A 70-year-old male presented to the Emergency Department with complaints of severe lower back pain. The patient, who weighed 377 pounds, had a history of morbid obesity, chronic obstructive pulmonary disease, congestive heart failure, hypertension, and diabetes mellitus.
The emergency physician ordered an MRI, but the hospital’s MRI machine could only accommodate patients up to 350 pounds. A search of area MRI machines revealed that none were large enough to accommodate him. Since the patient had no neurological deficits, it was decided to admit the patient and treat him medically.
The admitting physician ordered a bedside commode but did not order fall precautions. When the patient was admitted to the floor, the nursing staff assessed him as a moderate fall risk (13 on a scale ranging from 5 to 30) due to his size, complaint of back pain, and treatment with narcotic pain medications. They did not, however, institute fall precautions. Additionally, this hospital did not have policies or procedures concerning the care of morbidly obese patients.
The next morning, the patient asked to use the bedside commode. He was assisted out of bed by a nurse and nursing assistant without incident. A few minutes later, the patient asked to be placed back in bed. Again, the nurse and nursing assistant helped him to stand. When the patient began to pivot toward the bed, it started rolling away. The nurse instructed the nursing assistant to go to the other side of the bed and hold it in place. When the assistant was on the other side, the nurse attempted to help the patient back to bed. The patient stated, “I am falling,” and was guided to the floor by the nurse. The patient’s left foot and ankle were underneath him. When the nurse asked if he was injured, he replied that he was fine. The patient was rolled onto a blanket and lifted back into bed by eight nurses and nursing assistants. He again maintained that he was not injured.
That evening, the patient began to complain of left ankle pain. The nurse examined the ankle and noted extensive bruising and swelling. The physician was notified. An x-ray showed a comminuted fracture of the left distal fibula. An orthopedic consult was obtained, and the patient required surgical repair via open reduction and internal fixation. After surgery, he was transferred to a nursing home for rehabilitation.
A few months later, the patient had additional surgery on the ankle, but he remained at the nursing home. He never regained mobility and remains bedfast. Prior to the admission to the hospital, he was fully mobile.
The plaintiff alleged that a failure to ensure safety from falls led to the patient’s fibula fracture and loss of mobility.
The plaintiff claimed that the nursing staff was negligent when assisting the patient out of bed by not taking into consideration that he was morbidly obese, had been assessed as a moderate fall risk, and was taking several pain medications. The plaintiff alleged that the nurse should have moved him with a mechanical lift (e.g., a Hoyer lift). If a lift was not available, a minimum of two nurses should have assisted the patient while another held the bed. The plaintiff also claimed that transferring the patient with the assistance of only one nurse was below the standard of care for a morbidly obese patient on pain medications and that this action led directly to the patient’s fall and subsequent poor outcome.
The defense for the hospital noted that the patient had been fully mobile prior to admission and had been admitted for less than 24 hours. The physician had not written orders for fall precautions. The patient’s lower extremities had been assessed the previous evening with no neurological deficits, and he had been able to move to the commode safely a few minutes earlier.
However, the defense was unable to find an expert who could fully defend the care in this case. One expert stated that the assistance of one nurse would have been within the standard of care had it not been for the combined risk factors of the patient’s morbid obesity and use of pain medications. These two factors should have been taken into consideration, and additional nurses should have assisted in transferring the patient.
Patient Safety/Risk Management Issues
Patient safety issues in this case include a lack of staff training and education on how to safely transfer morbidly obese patients and a failure to follow fall precautions for a patient identified as a fall risk.
The nurse and nursing assistant involved in the incident were seasoned and competent employees. They did not, however, stop to ask for additional help when the need to transfer this patient arose—and neither considered using a mechanical lift or assistive device. With one staff member holding the bed, only one person was left to assist the patient. It would have been safer to obtain additional help to transfer a medicated, morbidly obese patient who had been assessed as a moderate fall risk.
The absence of a hospital policy and procedure on caring for morbidly obese patients—including safe patient handling and mobility standards—was also a factor. Without written policies and procedures, the hospital staff was essentially without guidance on the proper way to care for morbidly obese patients. The absence of such guidance highlighted a perceived lack of proactive action by the hospital to train employees in the best care of the morbidly obese patient. It made this case difficult to defend.
Each year, the number of morbidly obese patients admitted to hospitals continues to rise. It is imperative that hospitals provide employees with training and guidance that specifically address caring for morbidly obese patients. Hospitals should develop policies and procedures for care of the morbidly obese and invest in equipment that makes caring for them easier and safer. These actions can help reduce avoidable injuries to both patients and staff.
The Joint Commission. Sentinel Event Alert 55: preventing falls and fall related injuries in health care facilities. September 28, 2015. www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-55-preventing-falls-and-fall-related-injuries-in-health-care-facilities/
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.