Indiana Bulletin - February 2022

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20 The Bulletin February, March, April 2022 Think like an expert witness to avoid falls liability Georgia Reiner, MS, CPHRM An 88-year-old patient slips on the floor, falling and breaking his hip. Your immediate concern is getting him the help he needs, but you also wonder if you could be legally liable for what happened. By thinking like an expert witness, you can help determine if this concern is valid and whether you could have taken steps to avoid the situation in the first place. But first, you need to understand some background information. Falls facts From 2007 to 2016, the fall death rate for older adults in the United States increased by 30%, according to data from the CDC. Each year, 3 million older adults are treated in emergency departments (EDs) for fall injuries, and more than 800,000 people are hospitalized each year because of injuries related to a fall. These falls extract a high price—more than $50 billion for medical costs in a single year. Nurse professional liability claims involving falls are identified in the Nurse Professional Liability Exposure Claim Report: 4th Edition. The report notes that many of the closed claims analyzed in the report dataset which involved falls occurred because the nurse failed to follow fall-prevention policies and procedures. Further, the report states that falls most frequently occurred in inpatient hospital, surgical services, and aging services settings, as well as in patients’ homes. Given the statistics and the many places falls can occur, a fall is not an uncommon occurrence in a nurse’s career. A fall does not automatically mean the nurse is liable; for that to happen, key elements of malpractice need to be present. Elements of malpractice To be successful in a malpractice lawsuit, plaintiffs must prove four elements: 1. Duty. A duty existed between the patient and the nurse: The nurse had a responsibility to care for the patient. 2. Breach. The duty to care was breached; in other words, the nurse may have been negligent. To determine if negligence occurred, the expert witness would consider whether the nurse met the standard of care, which refers to what a reasonable clinician with similar training and experience would do in a particular situation. 3. Injury. The patient suffered an injury. Even if a duty existed and it was breached, if no injury occurred, it’s unlikely the lawsuit would be successful. Keep in mind, however, that injury can be defined as not only physical injury, but also psychological injury or economic loss. 4. Causation. The breach of duty caused the injury— the injury must be linked to what the nurse did or failed to do. This can be summed up in one question: Did the act or omission cause the negative outcome? Expert witnesses will consider these four elements as they review the case, and they’ll ask multiple questions (see Was there liability?). The questions primarily address prevention and what was done after the fall occurred. Prevention The following steps can help prevent falls and, if documented correctly, prove that the nurse took reasonable steps to protect the patient from injury: Take a team approach. Registered nurses, licensed practical/vocational nurses, and certified nursing assistants are ideal members for a team dedicated to creating a falls reduction plan for each patient. Assess the risk. Whether in the hospital, rehabilitation facility, clinic, or home, a comprehensive assessment is essential to identify—and then mitigate—falls hazards. This starts with assessing the patient for risk factors such as history of a previous fall; gait instability and lower-limb weakness; incontinence/urinary frequency; agitation, confusion, or impaired judgment; medications; and comorbid conditions such as postural hypotension and visual impairment. It’s also important to consider the environment, particularly in the home setting. For example, throw rugs are a known falls hazard. An excellent resource for assessing communitydwelling adults age 65 and older is the CDC’s STEADI (Stopping Elderly Accidents, Deaths & Injuries) initiative, which is an approach to implementing the American and British Geriatrics Societies’ clinical practice guideline for fall prevention. The initiative provides multiple resources for clinicians, such as a fall risk factors checklist with the categories of falls history; medical conditions; medications; gait, strength, and balance (including quick tests for assessing); vision; and postural hypotension. Keep in mind that assessment should be ongoing during the patient’s care because conditions may change. Develop a plan. Once the assessment is complete, the patient care team, including the patient and their family, can develop a falls-reduction plan based on the patient’s individual risk factors. The plan should address locations that are at greatest risk, such as bedside, bathrooms, and hallways, and detail action steps. Sample action steps include giving patients nonslip footwear, making sure call lights are within reach, removing throw rugs from the home, and providing exercises to improve balance. Communicate. It’s not enough to create a plan; communication is essential for optimal execution. All care team members, including patients and their families, need to be aware of the patient’s fall risk and the falls reduction plan. Communication also includes education. The STEADI initiative has falls prevention brochures for patients and family caregivers at www.cdc.gov/steadi/patient. html. Families often are underutilized as a resource for helping to prevent falls. They may know the best way to approach patients who are reluctant to follow fallsreduction recommendations and can take the lead to reduce home-related risks. The falls risk reduction plan, communication with others, and education provided should all be documented in the patient’s health record. If a fall occurs Despite nurses’ best efforts, a patient may fall. An expert witness will scrutinize how the nurse responded to the event. The following steps will help to reduce the risk of a lawsuit or the chances that a lawsuit is successful: Assess the patient. Examine the patient for any obvious physical or mental injuries. For example, check vital signs; look for bleeding, scrapes, or signs of broken bones; ask the patient about pain; and check mental status. Do not move the patient if a spinal injury is suspected until a full evaluation can be made. Be particularly alert for possible bleeding if the patient is taking anticoagulants. When appropriate, ask patients why they think they fell and continue monitoring at regular intervals. Communicate assessment results. Notify the patient’s provider of the fall and results of the assessment. The provider may order X-rays for further evaluation. Remember to mention if the patient is taking anticoagulants, particularly in the case of a potential head injury, so the appropriate scans can be ordered. Revise the plan. As soon as possible after the fall, work with the team to reassess risk factors, revisit the falls reduction plan, and revise the plan as needed. For example, footwear may need to be changed, the amount of sedatives the patient is receiving may need to be reduced, or more lighting may need to be added to a hallway. It’s important that actions are taken to prevent future falls. Document. Each step should be documented in the patient’s health record, especially all assessment results and provider notifications. The expert witness can then see that the nurse followed a logical progression, with thorough evaluation and follow-up. Never alter a patient’s health record entry for any reason, or add anything to a record that could be seen as self-serving, after a fall or other patient incident. If the entry is necessary for the patient’s care, be sure to accurately label the late entry according to your employer’s policies and procedures. Reducing risk Unfortunately, patient falls are not completely avoidable. However, developing a well-conceived prevention plan can help reduce the risk, and taking appropriate actions after a fall can help mitigate further injury. Both prevention and post-fall follow up not only benefits patients, but also reduces the risk that the nurse will be on the losing side of a lawsuit. Article by: Georgia Reiner, MS, CPHRM, Senior Risk Specialist, Nurses Service Organization (NSO) RESOURCES Bono MJ, Wermuth HR, Hipskind JE. Medical malpractice. StatPearls. 2020. www.ncbi.nlm.nih.gov/books/ NBK470573. Centers for Disease Control and Prevention. Important facts about falls. www.cdc.gov/homeandrecreationalsafety/falls/ adultfalls.html. Centers for Disease Control and Prevention. STEADI: Materials for healthcare providers. 2020. www.cdc.gov/steadi/ materials.html. Was there liability? If a patient falls, an expert witness will likely want to know the answers to the following questions (developed by Patricia Iyers) when deciding if liability may exist: Before the fall: • Was the patient identified as being at risk for falls? How was that risk communicated to others? – What medications did the patient receive? Do they have side effects that may increase the risk of a fall? – Were there specific conditions present that could increase the risk of a fall? • Were measures implemented to prevent falls? – Was the patient capable of using the call light and was it used to call for assistance? – Was the bed in the lowest position? – Were the lights on in the room or under the bed to help light the area at night? – Was the patient given antiskid slippers? Immediately after the fall: • How soon was the individual found after he had sustained a fall (it’s not always possible to establish an exact time)? • What was done at the time of the fall? • Was the patient appropriately monitored after the fall to detect injuries? • What did the assessment (including vital signs) reveal? • Did the nurse communicate the findings to the patient’s provider? • Were X-rays ordered and performed? • Was there an injury? If so, how soon was it treated? • If the patient hit their head, was the chart reviewed to determine if mediations included an anticoagulant? If on anticoagulant, was this information communicated to the provider so head scans could be performed to check for cranial bleeding? Following up after a fall: • Was there a change in mental status after the fall? • Were additional assessments and monitoring done as follow up? • Was the patient’s risk for falls reassessed after the fall and the plan of care revised to minimize the risk of future falls? CNA, NSO. Nurse Professional Liability Exposure Claim Report: 4th Edition. 2020. www.nso.com/ nurseclaimreport. Dykes PC, Adelman J, Adkison L, et al. Preventing falls in hospitalized patients. Am Nurs Today. 2018;13(9):8- 13. https://www.myamericannurse.com/preventingfalls-hospitalized-patients. Iyer P. Legal aspects of documentation. In: KG Ferrell, ed. Nurse’s Legal Handbook. 6th ed. Wolters Kluwer; 2015. Van Voast Moncada L, Mire GL. Preventing falls in older persons. Am Fam Physician. 2017;96(4):240-247. https://www.aafp.org/afp/2017/0815/p240.html. Disclaimer: The information offered within this article reflects general principles only and does not constitute legal advice by Nurses Service Organization (NSO) or establish appropriate or acceptable standards of professional conduct. Readers should consult with an attorney if they have specific concerns. Neither Affinity Insurance Services, Inc. nor NSO assumes any liability for how this information is applied in practice or for the accuracy of this information. This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. The individual professional liability insurance policy administered through NSO is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to service@nso.com or call 1-800-247-1500. www.nso.com.
February, March, April 2022 The Bulletin 21 Drink Less, Live More Rachel Pritz, RN, MSN Certified Coach, Certified Enneagram Coach I was driving to my job as a nurse manager one day and I started day dreaming. What if I got into a car accident, just a small one of course, but one that would require other people to take care of me for a change. I pulled into work and woke up from my day dream in horror. This wasn’t normal and how did I even get to this place in life anyway? I was drinking a bottle of wine most nights to “get through life” and this had become problematic. As I got unstuck from over-drinking, I started talking to about it on stages and with the teams I coached. At first, it was vulnerable and scary. Then, people started coming to me and messaging me after saying “me too.” While there is comfort in knowing you aren’t alone, it was also a little frightening to know how many of us in healthcare were out there. It’s a lot and more than I’d ever imagined. What drew you to this read? I am lucky to have a very close friend that is also a practicing clinical psychologist. She recently shared insights and takeaways from the authors on her practice blog and mentioned them to me the last time she came to visit. I knew right away it was something I wanted to better understand and possibly share with nurses. This book is available on Audible which is a win for me so that I can multitask. I had a road trip planned and it was the perfect length to accompany me on my ride. You know it is going to be good if Brene Brown calls it a “total game changer.” The audio version comes with a printable PDF for working through stressful decisions (cost/benefit analysis) and additional supportive worksheets. I liked the idea of exercises in addition to the content so that I could hopefully apply the methodology to my own life events. What have you learned from this author? One of my key takeaways, early in my listening was that we are all on a journey. Wellness is not an end destination but is an ongoing process that requires attention and purposeful action. The authors focus on how to respond, moving fluidly, through life and the stress response cycle. Why, if so, do you recommend this book to other nurses? I recommend this book to nurses, really to any female. I do not recommend the book to readers that identify as male as it is written specifically for females, or individuals that identify as female. I appreciate that the authors clearly state this in the beginning. I think many of the actions and processes can be applied to males, however Nagoski and Nagoski take into consideration that male brains (or individuals that identify as) can function differently than females, hence some of these items may not come into play or be as useful. A favorite section includes the authors referring to our own “mad woman in the attic”, the importance of connecting with your inner voice, and how to build the relationship in our favor. If you have an inner voice that consumes you, this may be just the book for you. I recommend this book as we are all spread thin and overwhelmed. Stress and stressors are compounding and occurring non-stop, even more so today that last year and the year before. Nagoski and Nagoski guide the reader to move fluidly through stress and stressful circumstances by preventing us from being stuck in a negative state. We can process suffering if we know why we are responding in this way. Meaning is good for us. “People with greater sense of meaning and purpose in life experience better health and are more likely to access preventive health care services to protect that health… A meta-analysis of the relationship between purpose in life and health found It makes sense. You have a hard day, or night, at work and come home exhausted. You just want to turn off your brain and relax. A global pandemic and all that has come with it both professionally and personally, hasn’t made this easier. Not only do you have all the to-do’s and the emotional toll of being a healthcare professional, but you also have so many responsibilities outside of work. Kids, aging parents, family drama, relationship struggles, etc. We’ve normalized drinking as a way to cope with all the stressors that are thrown our way. But, what if you got curious about the deeper why behind the drinking? Is this behavior working for you or is it causing you harm? What are the emotions and thoughts behind the drinking? Healthcare professionals everywhere have been told to practice more self-care as the answer to their burnout and exhaustion. I remember being told this too. But what if society sold us a bag of lies about what self-care really is? It’s so much deeper than bubble baths and chardonnay. In fact, when I was swimming in chardonnay that was the exact opposite of self-care. Here are some of the strategies I used to help dig me out of the pit of despair. I call it radical self care. Nothing radical about it, but it does take time and daily intention. If you truly want to get to the ISNA’s Bookshelf Burnout: The Secret to Unlocking the Stress Cycle by Emily Nagoski, PhD and Amelia Nagoski, DMA that greater sense of purpose is associated with 17% lower risk of all-cause mortality.” (Nagoski & Nagoski, 2019, Chapter 3, 08:19). This book is truthful, easy to read/listen to, and helpful as we process our current environment and everyday stress. The book barely mentions happiness, but realistically focuses on how to cultivate joy by working through your stress, because we all have it. Most importantly we all have the power to persevere. How will you apply what you have learned? • Nagoski and Nagoski have helped me put labels on and define stress. They have also shed light on how to separate stressors from my response to stress. This is foundational material in monitoring my stress cycles. • Thinking through the concept of stressors and response to stress as components of a cycle will help remind me to close the gap and to work through either or both cause and the outcome of stressors in which are in and out of my control. • A reminder to not be hard on myself while on this journey and to not use obtaining wellness as a check off or end game. • This was a great reminder that I am in control of how I let stress affect me. Stress is inevitable but how I manage it is in my control. • The authors reminded me that adversity or overcoming difficulties and stressful circumstances can help me define my own meaning in life, moving me through coping onto thriving. Post traumatic growth builds strength and supports handling additional difficulties that will come my way if I am completing my stress cycles. • We make our own meaning to life, which requires focus and intention. It’s what sustains us. Just like wellness, it is an ongoing journey. What is your next book or reading material in your queue? I’d like to hear or read more from Kristin Neff about Compassion. She has a Ted Talk that gets referenced frequently and authored two books, Self-Compassion: The Proven Power of Being Kind to Yourself, and Fierce Self- Compassion. I’ve also recently started Moral Resilience, written by Cynda Hylton Rushton, which I am enjoying and moving through quickly. Interested in sharing a recent book, podcast, article, or show? Email me katie@indiananurses.org root cause of any harmful numbing behavior, here are some ways to do it: • Therapy/Coaches • Podcasts/Audiobooks • Self-awareness work (I used the Enneagram) • Exercise • Healthy eating • Spirituality • Meditation (I use a guided version) • Deep connections with other humans • Belonging, not just fitting in • Healthy boundaries • Understanding thoughts and emotions and making space to process them • Asking for (and at times hiring) help Ultimately, I decided to stop blaming everyone else around me and to take accountability for the life I’d created. No one was stopping me from doing all of the above, but me. Not my work, my boss, my partner, my kids, my parents. No one else was responsible but me. My favorite definition of self-care is creating a life you don’t have to regularly escape from. Think about what you are escaping and where you might need help. This is a personal journey and my guidance might not match what you need. But the good news here is you already know what you need if you can just quiet the noise around you. Here’s what I’ve learned after going from drinking a bottle of wine per night, to only drinking when I really want to, which is rare. • I sleep better - yes, alcohol can get you to sleep, but you don’t get quality sleep. • I have much less anxiety. Hangxiety is a real (and chemical thing). • My mood is better. • Alcohol numbed the more negatively perceived emotions. But it also numbed all the good stuff. • Alcohol added no value in my life. • I’ve lost weight. Calories aren’t the only biological reason for this. • Shaming yourself doesn’t work. Self-love does. I thought my journey out of over-drinking would only impact my drinking. Turns out, this healing and empowering journey fixed a whole lot of problems in my life. When we get to the root cause, that’s when the magic happens. Rachel Pritz, RN, MSN www.rachelpritz.com Instagram: @indyenneagram Facebook: Rachel Pritz Life Coaching LinkedIn: Rachel Pritz Disclaimer: If you believe you are an addict or alcoholic I encourage you to seek help.
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Indiana Bulletin - February 2022

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