Brand New Nurse Leaves Elderly Patient Alone Resulting in Brain Damage
The following excerpt from a Notice of Intent to File Claim, or more commonly called, “Notice of Intent to Sue,” is a recent case that the litigators at Erlich, Rosen, Bartnick & Cook, P.C., have begun on behalf of one of our clients. If you wish to discuss a medical malpractice claim please contact ERBC at either www.ERBClaw.com or 1-877-453-2840 for a free consultation.
Factual Basis For Claim
Plaintiff, age 75, was hospitalized on October 24, 2006 at a local hospital through the emergency department for a rapid heart rate. Plaintiff was admitted to the floor for observation and medication. A Braden scale fall-risk assessment was initially done by the nursing staff and found Plaintiff to be at low risk for a fall and found her able to independently utilize her bathroom.
On October 27, 2006, Plaintiff was found on the bathroom floor by the nursing staff after apparently sliding off the commode and landing on the floor. Plaintiff did not appear to be injured as a result of this fall and was returned to her bed. This event did, however, put the nursing staff on notice that she was, indeed, a fall risk patient. Following this incident, Plaintiff was still allowed her bathroom privileges without assistance by the nursing staff until 8:00 p.m. on October 28, 2006 when the nurse on duty upgraded her restrictions and activities to bed rest only.
On October 29, 2006, the activity assessment filled out by the nursing staff restricted Plaintiff to bed rest with one assist for activities including bathroom privileges and activities of daily living. Plaintiff also received Norflex (100 mg) and Oxycodone (10mg) during the afternoon of October 29, 2006. According to the medical records provided by Defendant hospital, Defendant Nurse who had only been a nurse for six weeks began caring for claimant when her shift began at 7:00 p.m. on October 29, 2006. The nursing notes indicate that Defendant Nurse saw plaintiff on one occasion at 9:00 p.m. on October 29, 2006 and, in the records, limited her activity to bed rest with one assist for activities. The nurse also noted that at 9:00 p.m. on October 29, 2006, Plaintiff was eating dinner in her bed with her family at her bedside.
Plaintiffs’ family members left her room at approximately 10:00 p.m. that evening. The next notation found in Plaintiff’s medical records indicate there was no contact with Plaintiff by any medical personnel at Defendant hospital following Defendant Nurse’s 9:00 p.m. notation until a notation by Defendant Nurse dated October 30, 2006 at exactly 12 Midnight. The 12 Midnight notation indicates that Plaintiff had increased confusion than her prior assessments, was forgetful at times, having a hard time expressing herself, had vomited once, and that they were awaiting results of a CT scan of her brain!
The radiology records and neurosurgery dictation notes indicate that the CT scan was done on a STAT basis shortly before 1:30 a.m. on October 30, 2006 following a fall by Plaintiff out of her bed at which point and time, she apparently struck her skull. The radiology and neurosurgery records call into question the voracity of Defendant Nurse’s midnight nursing note as to both the timing and content of her notation. Counsel for Plaintiff has received the medical records for this time period from Defendant hospital from two separate record requests asking for all records concerning the events of October 29, 2006 and October 30, 2006. None of the medical records received from both record requests contain any nursing notes, physician notes, or any other documentation whatsoever contemporaneously describing the facts and circumstances of Plaintiff’s fall which occurred between 10:00 p.m. on October 29, 2006 and 1:30 a.m. on October 30, 2006. Several notations from different disciplines at Defendant hospital following this time frame refer to Plaintiff having slipped and fell out of her bed and striking her head as the cause of the subdural hematoma, (brain bleed), which was ultimately diagnosed and surgically treated following the CT scan of October 30, 2006 at 1:30 a.m.
No records have been produced, despite the two separate requests, which indicate exactly when Plaintiff fell, which hospital personnel responded to her fall, where she fell, how she fell, and what was done for her following the fall. The medical records mysteriously end at 9:00 p.m. on October 29, 2006 with Plaintiff eating dinner in her bed and pick up again after midnight on October 30, 2006 after she has fallen, gone to radiology for a CT scan of the brain, and returned to her room.
Since it is reasonable to assume that Plaintiff did not get up off of the floor by herself, walk down to radiology, ask for a CT scan of her brain be performed, and then walk back to her room only to be found by Defendant Nurse resting in her bed with signs and symptoms of confusion and forgetfulness, the only logical conclusion that can be drawn is that Defendant hospital personnel have altered, removed and/or doctored the medical records to conceal their negligence surrounding the facts and circumstances of Plaintiffs’ life-threatening injury.
Following the results of the CT scan of her brain done at 1:30 a.m. on October 30, 2006, Plaintiff was transferred to the ICU and monitored with serial CT scans. She began to bleed subdurally in her brain and an emergency craniotomy was performed on October 30, 2006 to drain the subdural hematoma, (brain bleed), which, according to the medical records from Defendant hospital, generated after the fact, was caused by her falling and striking her head. Plaintiff was hospitalized at Defendant hospital for three weeks until November 21, 2006 at which time she was transferred to a rehabilitation center for further medical attention. As a result of the negligence of Defendant Nurse and the staff at Defendant hospital, Plaintiff is no longer able to live independently as she had before her fall and subdural hematoma injury and now suffers from permanent cognitive and physical limitations.
