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Birdwell v. Texarkana Memorial Hospital12/12/2003
he 6/11/98 - 6/16/98 admission, the nurse's notes indicate the patient was found on the side of the bed on one occasion, and on the floor on another. The second occasion, the patient was face down on the floor, appearing stunned, and initially nonverbal. The attending physician was notified of this accident. The attending physician acknowledged the fall and the resultant 5 x 5 cm hematoma during his examination of the patient on 6/16/98. Although no detailed neurological examination was documented, the attending physician did state there was "no other evidence of trauma from fall" (the nurse's notes did indicate a finger skin tear). The attending physician's discharge instructions included continued subcutaneous Heparin and "ice to scalp PRN". No diagnostic studies appear to have been ordered. The hospital's discharge instructions did not appear to include head injury precautions. The patient was discharged at 12:52 PM on June 16, 1998.
Mrs. Birdwell later the same day developed a significant change in mental status and was brought to the Emergency Room (at 21:39 PM) for evaluation. The patient was then re-admitted. Work up at that time included a CT Scan of the head, which revealed: 1) multiple intracerebral areas of hemorrhage with a small amount of subarachnoid blood. 2) probable old infarct of the right cortical region of the parietal lobe. 3) encephalomalacia in the left temporal lobe due to previous hemorrhage. Further work up included a CT Scan of the neck, which revealed: 1) intramuscular hematoma involving the right sternocleidomastoid (consistent with trauma). Several physicians during this hospital stay documented the etiology of the current multiple hemorrhages as "probably post-traumatic".
As a result of the fall and multiple intracranial hemorrhages, the patient was left obtunded and with a left hemiplegia. Mrs. Birdwell later developed Aspiration Pneumonia, ultimately requiring Endotracheal Intubation, and later tracheotomy. The patient also required a permanent feeding tube for nutritional support. Neurologically the patient showed some improvement prior to her discharge on 09/21/98.
With regard to the fall, it appears that some measures were taken to attempt to educate the patient regarding safety and to prevent falls. I have also reviewed the Wadley Regional Medical Center's Practice Guideline: Fall Precautions, and policy on use of restraints. The policy clearly states the standard of care is: "The patient will be provided an environment that is safe so that the patient is protected from injury during his/her hospital stay." The use of restraints is clearly outlined in the details of the policy. The patient's documented confusion, and inability to be taught, indicates a need for additional protection. The failure to provide this protection for Mrs. Birdwell was clearly below the medical center's own standard of care. Had additional measures been taken, the fall more likely than not could have been prevented. Due to the patient's documented history of Cerebral Bleeds, and the fact that the patient was receiving subcutaneous Heparin, it would have been prudent and within the standard of care to obtain a head CT Scan prior to discharge on 6/16/98. The attending physician did document that the patient had no evidence of trauma from the fall (other than a small hematoma). However, documentation of a thorough neurological examination would have been helpful.
It is evident from the documentation that the patient's debilitated condition as a result of the fall contributed to some of the adverse events late in the hospital course.
To comply with the expert report requirement, a plaintiff must only make a good faith attempt to provide a fair summar
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