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Liability Landscape

October 1, 2006
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The Seriousness of Head Injuries by Linda Williams, RN
LIABILITY landscape

The seriousness of head injuries Falls are the leading cause of head injuries among the elderly. One of the most serious types of head injuries is a subdural hematoma, which consists of a collection of blood on the surface of the brain. The terms acute, subacute, and chronic reflect how long it takes blood to collect. Acute subdural hematomas usually result from a serious head injury, whereas chronic subdural hematomas can occur spontaneously or after a very minor head injury, especially in the elderly. These tend to go unnoticed for many days to many weeks.

A subdural hematoma is an emergency condition. According to the Washington Hospital Center in Washington, D.C., acute subdural hematomas are among the most lethal of all head injuries. They expand very rapidly, leaving little room for the brain, and are associated with brain injury. Treatment includes performing lifesaving measures, controlling symptoms, and minimizing permanent brain damage.

Healthcare providers should be prepared to seek medical attention following a signi-ficant head trauma or mental deterioration in the elderly. Please take the time to review the circumstances surrounding the following situation and make changes as necessary at your facility.

The Situation
A man was admitted to a nursing home following hospitalization for treatment of meningitis and hydrocephalus. His family chose the nursing home because he had briefly stayed there four years earlier while recovering from a right parietal craniotomy for tumor removal. At that time, he received physical therapy and was eventually discharged back to his home upon regaining some functional abilities. His family was pleased with the care and services that he received and wanted the same for him again.

Unfortunately, the man's brain tumor had reoccurred, leaving him with dizziness, loss of balance, and weakness on his left side. He had difficulty recalling things immediately, but seemed otherwise alert and oriented. A recent surgery had caused complications, so the family opted not to proceed with anymore aggressive measures because of his weakened state.

During his first week at the facility, the man rapidly developed more complications, including seizures and a blood clot in his left leg, so he was taken back to the hospital. He was treated at the hospital for four days and returned to the facility with orders for padded +-length siderails to provide a physical barrier during seizures and when independently moving in bed, since his hemiparesis made his movements jerky and erratic. He also was to be given an anticoagulant as a preventive measure for thromboembolic disease.

Over the next few days, the man's condition worsened. He reported experiencing double vision and became more and more restless while in bed. One morning, a phlebotomist (from a consultant lab company) walked into the man's room and found him struggling to sit on the edge of his bed. The phlebotomist assisted him in sitting upright and proceeded to draw his blood. When she was finished, she helped the man lie back down and left his room without raising the bed's siderails. Shortly thereafter, the man's bed alarm sounded and the staff found him lying on the floor after falling from his bed.

The staff arriving at the scene asked the man if he had struck his head, and he replied that he had. His head had no visible injury, but there were red marks on his back and shoulder, to which they applied ice packs. A staff nurse performed a head-to-toe assessment and found no other injuries, so they used a lift to put the man back in bed.

About this time, the nurse supervisor arrived and was informed of the incident. The supervisor performed a neurological check of the resident and found no change in his condition since his last admission assessment. She notified the man's spouse and physician about the incident and explained that there were no significant injuries. The physician ordered neurological checks to be done every 15 minutes for the first hour and hourly checks for the next four hours. The nurses were to immediately notify the physician if any changes occurred.

Within the next five hours, the therapists noticed the man was less focused during treatments and complained of nausea and a severe headache. One therapist notified the staff nurse, who stated that the man was not due for another pain reliever, so she encouraged him to lie down and rest until lunch. When lunchtime came, the man attempted to eat but became nauseated and vomited. He went back to sleep after telling the nurse, "The food must have disagreed with me."

Three hours later, the oncoming nurse arrived and was informed of the fall. The staff nurse told the oncoming nurse that the man's neurological checks were fine. Afterward, the oncoming nurse went to the man's room to assess him and found him unresponsive. About that time, the man's family entered his room for a visit. The man was immediately sent to the hospital, where he died later that day from a subdural hematoma.

The following day, the administrator and director of nursing conducted an investigation of the fall and determined that the phlebotomist had left the man's siderail down, which enabled him to fall out of bed when he became restless. They implemented a new policy that informed all independent contractors (on their requisition forms) when a particular resident had a siderail order.