Case Précis Author: Professor Joseph Ibrahim, Monash University
This Residential Aged Care Communiqué case study looks at the increased clinical risks, and the need for heightened levels of supervision, when a patient is moved to a different location or when there is a change in the staff providing care to the patient. We also examine the practice of using bedrails for preventing falls.
This article was originally titled: “All that in just one hour”
Ms IC was a 91-year-old female resident in low-level care at a large metropolitan Residential Aged Care Service (RACS) for 4 years. Past medical history included a fractured hip. In September, Ms IC was admitted to an acute hospital following a series of five falls and diagnosed with a cerebrovascular event (stroke). One month later Ms IC was discharged from hospital and admitted into a new High Level Care RACS located on the same site as the low level care (LLC) RACS where she had previously resided.
Ms IC was admitted to the HLCRACS just after lunch. The discharge documents noted that she had had a stroke, multiple falls, was confused, could only be given grade two thickened fluid and was a high risk for falls.
On arrival Ms IC was met by the duty RN, given a given a cup of tea, had the bed rails put up and initial observations taken. The blood pressure was measured by a student nurse and recorded as 203/74mmHg. An hour later she was found by staff semi-conscious on the floor near her bed. A hoist was used to get Ms IC back into bed, and transfer to an acute hospital was organized. At the hospital the decision to withdraw active treatment was made and palliative measures implemented.
Ms IC died the following day.
The cause of death following an inquest was “traumatic subarachnoid haemorrhage and an acute and chronic subdural haematoma as a result of a fall.”
The coroner directed further investigation was required to determine
(a) whether the care provided was in accordance to professional standards; and
(b) what had been done to prevent a recurrence.
This included gathering of statements from the RACS staff and taking evidence in the courtroom at Inquest.
This occurred over 18 months after the death of Mrs IC. The coroner reported on three aspects of care: management of a high falls risk; management of special diet and response to abnormal high blood pressure reading.
The RACS staff indicated they were aware of the discharge summary notes that Ms IC was a High Risk for Falls and had special dietary needs. The falls harm minimisation approach was centred around the use of bed rails. The differences in the RACS staff statements made it very difficult to know the position of the bed rails. The Coroner concluded at least one of the bed rails must have been down.
The RACS had documented Ms IC was only to be given thickened fluids. However, they still gave her a welcome cup of tea.
The RN stated the progress notes documenting the high blood pressure were wrong and the student nurse had not completed the measurement. The coroner did not accept this version of events. Ms IC had not been seen for 45 minutes of the total 1 hour and five minutes she had in the facility.
It is important to note the two nurses on the roster were subpoenaed to give evidence at this inquest about the bed rails however they both said they had no recollection of the incident. “I find this situation to be most strange.”
The duty RN had given a statement the day after the incident and subsequently declined to be interviewed and gave evidence during the Inquest. The Coroner stated the RN was “not an open, clear, consistent witness and I could not describe the evidence as reliable”.
The RACS consisted of three separate facilities owned by one organisation. The two Low Care and one High Care facilities operated independently and did not transfer the residents’ records between each other. The approved provider had not completed any internal review of this event. The only response over the next eighteen months was two lines written on an “Accident Report” made on the day, by the RACS manager. There was no notation that the outcome was fatal; no enquiries of anyone present; or whether the staff had adhered to the falls policy.
Coroner’s Comments and Findings
The case was closed following an inquest. The coroner recommended the:
(1) Nursing Registration Board review the professionalism of the care provided by the RN who had admitted Ms IC.
(2) Commonwealth Department of Health and Aging (DoHA) review the response of the approved provider to the fatal fall.
(3) DoHA requires all RACS to undertake a Root Cause Analysis of all deaths and hospitalisations that occur following a traumatic event.
Looking back at this case, we all say, “thank goodness I was not there that day!” It is amazing how one hour, in an otherwise ordinary day so profoundly alters life for the resident, staff and the organisation. Two issues are worth commenting on.
First, we know whenever there is a transition of care there is an increased clinical risk. Whenever we change the location or staff providing care for residents we need a heightened level of supervision and monitoring.
Second, is the use of bedrails. Current practice is not to use bedrails at all. Instead, low beds and protection on-floor are solutions for falls harm minimisation. The assumption that bedrails protect residents from falls is widely disputed. Some argue bedrails increase the height from which a fall occurs if a resident goes over the top.