Am i potentially liable for this incident?

  1. Hi
    I was hoping to solicit feedback regarding an incident that occurred this weekend at work (subacute/LTC facility). I was supervising RN on duty. The pt in questions' primary nurse is also a RN.
    Pt had a fall event @ 1am. Physical assessment revealed a hematoma with scant bleeding to the back of the head. The pt denies pain, mental status is baseline, neurochecks are unremarkable. I paged the physician for the primary nurse with no response. Neurochecks were done as protocol throughout shift and remained unremarkable with pt voicing no complaints and no change from baseline. The physician was paged 3 times and never responded.
    I notified the family because of the nature of the incident. I explained the nature of the incident, our interventions, and we were awaiting for physician return call for further orders. The next of kin was accepting of this.

    I endorsed to the next shift to continue to try to reach the physician and continue neurochecks as protocol.

    When i returned to work i was notified the pt was sent to the ER and was found to have a subdural hematoma. The family was understandably upset and holding our facility liable. I do not know if they have any intent to take any legal action.

    My question is, am I legally liable for this pt's case? I'm not sure where culpability lies as I was supervising RN, however the pt's primary nurse is also a RN. In a worst case scenario if this case did end up in court, would I be held partially accountable for this case? I did not document in the notes, as again the primary nurse was a RN, who did her own assessment and documentation although she noted I, the supervisor, was aware and I was the one paging the physician. In a case such as this, if the supervisor holds the same license as the primary nurse, are both seen as responsible legally?

    Thank you.
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  2. 13 Comments

  3. by   dishes
    You should speak to your liability insurance provider about your involvement, IMO you are culpable. It would be easy for a lawyer to find experts witnesses who could argue that a reasonable and prudent nurse would send an elderly patient who fell and hit their head to the ER to rule out subdural hematoma. There are greater risk factors for this patient population to sustain a subdural hematoma and the signs and symptoms may be harder to detect due to pre-existing conditions.
  4. by   dream'n
    I understand that the family is upset, but do you think you acted like a prudent nurse? If the assessments and vitals were negative and charted often and the patient was always neurologically intact, I don't see where you could of done much differently. The Dr. never called back and you had no abnormal findings to report anyway, except for a hematoma which I'm assuming did not worsen throughout the shift. Hopefully the patient was not on blood thinners as that would make this a different case altogether. You can not tell the future, do not have a CT in the facility, and can't send every patient fall to the ER. If the hematoma was small and the fall was not hard, I doubt I would have sent the patient to the ER if all other assessments were negative, although I would watch them carefully. But check your policies at your employer for the actual protocols. It's hard for me to Monday quarterback your actions though as I don't work in your setting and am not recently familiar with LTC norms. In acute care, we have Drs always available and would have been able to notify one of them. And our CT is right downstairs.
  5. by   LovingLife123
    Do you need an order from the physician to send to the ER? While not every fall can be sent to the ER, a fall and hit to the head should be. Was this patient on any blood thinners? Most elderly are.

    The patient may have look fine on Neuro assessments but that doesn't mean there isn't a slow bleed in there.

    All head injuries in the elderly should get checked. I would contact my malpractice insurance.
  6. by   NooNieNursie
    Quote from dream'n
    I understand that the family is upset, but do you think you acted like a prudent nurse? If the assessments and vitals were negative and charted often and the patient was always neurologically intact, I don't see where you could of done much differently. The Dr. never called back and you had no abnormal findings to report anyway, except for a hematoma which I'm assuming did not worsen throughout the shift. Hopefully the patient was not on blood thinners as that would make this a different case altogether. You can not tell the future, do not have a CT in the facility, and can't send every patient fall to the ER. If the hematoma was small and the fall was not hard, I doubt I would have sent the patient to the ER if all other assessments were negative, although I would watch them carefully. But check your policies at your employer for the actual protocols. It's hard for me to Monday quarterback your actions though as I don't work in your setting and am not recently familiar with LTC norms. In acute care, we have Drs always available and would have been able to notify one of them. And our CT is right downstairs.


    It was really tough call. I couldnt justify a 911 EMS transfer as the pt is stable.
    Some physicians become extremely irate if you make a judgment call in non emergent situation like transfer to ER for CT. I've many times had MDs refuse an ER transfer even if pt on a weak bloodthinner if pt is otherwise stable.

    I also was not direct caregiver for this pt. I was only supervising RN which was another factor i considered, there was another primary RN reporting to me.

    I have no knowledge if pt intends to proceed. My understanding is the proximate nurse is directly responsible. Also for facility to be liable delay of care must result in harm to pt. Since the pt was stable and suffered no change of condition, opting for a 911 EMS transport didnt seem like good step. Now if the pt was reporting pain, if the minor bleeding or hematoma worsened, or if neurological deficits from baseline occurred, i would have obviously called 911.

    TBH i do think I did what was appropriate, i'm just concerned this may end up in court room because that's the nature of medicine and society. My main question is,would I be considered responsible for the actions that night, or would it only be the primary RN?
  7. by   dishes
    Quote from NooNieNursie
    My main question is,would I be considered responsible for the actions that night, or would it only be the primary RN?
    I think your main question shows you lack an understanding of how medical legal cases work, to get a clearer idea you should discuss the case with your liability insurance provider. A liability provider can help you to understand that everyone involved with a patient sentinel event is questioned (and can be subpoenaed). If when questioned, a nurse comes across as someone who abdicates their own responsibility in a incident and places all the blame on other colleagues, it will not go down well.
  8. by   dream'n
    Quote from NooNieNursie
    It was really tough call. I couldnt justify a 911 EMS transfer as the pt is stable.
    Some physicians become extremely irate if you make a judgment call in non emergent situation like transfer to ER for CT. I've many times had MDs refuse an ER transfer even if pt on a weak bloodthinner if pt is otherwise stable.

    I also was not direct caregiver for this pt. I was only supervising RN which was another factor i considered, there was another primary RN reporting to me.

    I have no knowledge if pt intends to proceed. My understanding is the proximate nurse is directly responsible. Also for facility to be liable delay of care must result in harm to pt. Since the pt was stable and suffered no change of condition, opting for a 911 EMS transport didnt seem like good step. Now if the pt was reporting pain, if the minor bleeding or hematoma worsened, or if neurological deficits from baseline occurred, i would have obviously called 911.

    TBH i do think I did what was appropriate, i'm just concerned this may end up in court room because that's the nature of medicine and society. My main question is,would I be considered responsible for the actions that night, or would it only be the primary RN?
    Basically a successful lawsuit against a nurse depends upon two criteria: Did the nurse act prudently and if not, did the patient suffer damages as a result. As the RN Supervisor you could be held as responsible, along with the facility, Doctor, and primary nurse. Anyone can try to sue anybody for anything, but that doesn't mean they'll be successful.

    I understand how hard it can be at night, with the Dr not answering, in a non-hospital setting, usually with no other nurses present, and with an iffy situation occurring. That is one of the moments that our critical thinking is truly tried. Whenever I've encountered these type of situations, I make the best decision I possibly can. I reason out every possible scenario, check policies, err on the cautious side if still unclear on a course of action, and make sure that I can defend my decision making process logically to God and the BON.

    After that, I know that I did the best I could at the time. No one can do more than their best. Learn about what to do next time if this happens and move on. You did the best you could.
  9. by   NooNieNursie
    Quote from LovingLife123
    Do you need an order from the physician to send to the ER? While not every fall can be sent to the ER, a fall and hit to the head should be. Was this patient on any blood thinners? Most elderly are.

    The patient may have look fine on Neuro assessments but that doesn't mean there isn't a slow bleed in there.

    All head injuries in the elderly should get checked. I would contact my malpractice insurance.
    For an emergent transfer of course we call 911. This does not require a Dr's order.

    To get a CT scan to head when pt is otherwise stable, that requires a drs order. Now some Dr will give nurses room to make those judgment calls, but some Dr's will refuse to order a CT to the head after the fall unless pt is on coumadin, eliquis, xarelto, lovenox, heparin, etc. I've seen Dr order CT's after a fall to be done days later, as well.

    If i had just sent the pt w/o a physician order, and lets say pt sustained injury during transport or in ER, then i would have been liable for that. I'm sure the Dr would have thrown me under bus (as Dr is trying to do now, throw me under bus for NOT sending him out w/o order, bcuz HE decided to turn off his pager all night).

    I want to emphasize this pt had a primary RN doing neurochecks all night and was reported to be stable, no change in hematoma, no change in condition, no report of pain. How can i order a 911 EMS transfer for a stable pt? And again, getting a CT to the head require a MD order. I could have just assumed MD would be okay with that (and that was probable), but its also *possible* he wouldn't be, and there is always a small risk with anything, even pt transfer to ER. I've seen pts get injured during transport as well.


    If i had the legal authority to order diagnostic tests and transfers i would have of course ordered this pt to get a CT then. I do not have that ability, I am a nurse not a MD, and the pt was not unstable requiring 911 EMS call.

    The only thing i could have done differently was call the medical director. In hindsight i should have done that. But again, the pt was stable, as per report from the primary RN who was the one actually assessing and monitoring this pt.
    Last edit by NooNieNursie on Oct 18
  10. by   litbitblack
    Everyone involved can be held liable - the attorneys just need to add your name to it. If you documented what you observed you should be fine. All head injuries are not sent to the ER. There have been times when the MD's do not call back and I usually ask the family what do they want to do. If they say send them then I send them. I have to have an order to send to the ER if family doesn't decide or can not be contacted.
  11. by   Been there,done that
    Quote from NooNieNursie
    For an emergent transfer of course we call 911. This does not require a Dr's order.

    To get a CT scan to head when pt is otherwise stable, that requires a drs order. Now some Dr will give nurses room to make those judgment calls, but some Dr's will refuse to order a CT to the head after the fall unless pt is on coumadin, eliquis, xarelto, lovenox, heparin, etc. I've seen Dr order CT's after a fall to be done days later, as well.

    If i had just sent the pt w/o a physician order, and lets say pt sustained injury during transport or in ER, then i would have been liable for that. I'm sure the Dr would have thrown me under bus (as Dr is trying to do now, throw me under bus for NOT sending him out w/o order, bcuz HE decided to turn off his pager all night).

    I want to emphasize this pt had a primary RN doing neurochecks all night and was reported to be stable, no change in hematoma, no change in condition, no report of pain. How can i order a 911 EMS transfer for a stable pt? And again, getting a CT to the head require a MD order. I could have just assumed MD would be okay with that (and that was probable), but its also *possible* he wouldn't be, and there is always a small risk with anything, even pt transfer to ER. I've seen pts get injured during transport as well.


    If i had the legal authority to order diagnostic tests and transfers i would have of course ordered this pt to get a CT then. I do not have that ability, I am a nurse not a MD, and the pt was not unstable requiring 911 EMS call.

    The only thing i could have done differently was call the medical director. In hindsight i should have done that. But again, the pt was stable, as per report from the primary RN who was the one actually assessing and monitoring this pt.

    If i had just sent the pt w/o a physician order, and lets say pt sustained injury during transport or in ER, then i would have been liable for that. I'm sure the Dr would have thrown me under bus (as Dr is trying to do now, throw me under bus for NOT sending him out w/o order, bcuz HE decided to turn off his pager all night).
    Damned if you do, damned if you don't. Fact is.. you could not get direction. Send the patient out for proper evaluation. Based on NURSING assessment the patient was stable... but the patient needed to be evaluated by a physician.

    Best of luck with this mess.
  12. by   NooNieNursie
    Quote from litbitblack
    Everyone involved can be held liable - the attorneys just need to add your name to it. If you documented what you observed you should be fine. All head injuries are not sent to the ER. There have been times when the MD's do not call back and I usually ask the family what do they want to do. If they say send them then I send them. I have to have an order to send to the ER if family doesn't decide or can not be contacted.
    Exactly which is why i contacted the daughter, i was very clear he has evidence of swelling/with brusing on head but is otherwisestable. We are waiting for MD to return call.
    She was like "Oh, ok, i'll be there during day"

    Later i received endorsement they were furious.

    I had the primary RN chart the MD notifications as well as notification of family.

    I was hoping the family would demand an ER transfer where i could justify my actions as family request for emergent transfer. But they didnt. They still ended up blaming our facility and the MD. To my knowledge they did not blame the nursing staff, but in legal cases, that can easily change if they contort i violated a policy/procedure.

    My facility did NOT have policy procedure manual on unit. However, my director has verbally told me if pt is stable after fall event and evidence of head injury our only policy is to initiate neurochecks and contact MD. Pretty sure that does not hold up in court, however.

    My director told me my actions were appropriate and i followed procedure, but i am pretty sure she will say anything to get me to take the more "cost effective" solution (not transfering pts). If i am in violation of procedure, thats on the RN license on the floor.
  13. by   LovingLife123
    Quote from NooNieNursie
    For an emergent transfer of course we call 911. This does not require a Dr's order.

    To get a CT scan to head when pt is otherwise stable, that requires a drs order. Now some Dr will give nurses room to make those judgment calls, but some Dr's will refuse to order a CT to the head after the fall unless pt is on coumadin, eliquis, xarelto, lovenox, heparin, etc. I've seen Dr order CT's after a fall to be done days later, as well.

    If i had just sent the pt w/o a physician order, and lets say pt sustained injury during transport or in ER, then i would have been liable for that. I'm sure the Dr would have thrown me under bus (as Dr is trying to do now, throw me under bus for NOT sending him out w/o order, bcuz HE decided to turn off his pager all night).

    I want to emphasize this pt had a primary RN doing neurochecks all night and was reported to be stable, no change in hematoma, no change in condition, no report of pain. How can i order a 911 EMS transfer for a stable pt? And again, getting a CT to the head require a MD order. I could have just assumed MD would be okay with that (and that was probable), but its also *possible* he wouldn't be, and there is always a small risk with anything, even pt transfer to ER. I've seen pts get injured during transport as well.


    If i had the legal authority to order diagnostic tests and transfers i would have of course ordered this pt to get a CT then. I do not have that ability, I am a nurse not a MD, and the pt was not unstable requiring 911 EMS call.

    The only thing i could have done differently was call the medical director. In hindsight i should have done that. But again, the pt was stable, as per report from the primary RN who was the one actually assessing and monitoring this pt.

    If you had sent the patient to the ER, the ER physician would have ordered the head CT. The patient had a hematoma already. I don't know why you are relying on the Neuro assessment so much. A lot of times, those changes are late changes, meaning the damage is done. And to be perfectly honest, I don't expects you guys in LTC to be Neuro experts and pick up subtle changes.

    My last terminal wean was a guy who fell, hit his head, thought he was fine. Took a nap, friends found him covered in vomit hours later. He was done at that point. The bleed was too massive.

    Neuro is tricky and unpredictable. Take it from me. You are worrying too much about liability instead of the fact this pt should have been sent your the ER.

    Like I said before, call your malpractice carrier.
  14. by   Been there,done that
    Quote from LovingLife123
    If you had sent the patient to the ER, the ER physician would have ordered the head CT. The patient had a hematoma already. I don't know why you are relying on the Neuro assessment so much. A lot of times, those changes are late changes, meaning the damage is done. And to be perfectly honest, I don't expects you guys in LTC to be Neuro experts and pick up subtle changes.

    My last terminal wean was a guy who fell, hit his head, thought he was fine. Took a nap, friends found him covered in vomit hours later. He was done at that point. The bleed was too massive.

    Neuro is tricky and unpredictable. Take it from me. You are worrying too much about liability instead of the fact this pt should have been sent your the ER.

    Like I said before, call your malpractice carrier.
    a guy who fell, hit his head, thought he was fine. Took a nap, friends found him covered in vomit hours later. He was done at that point. The bleed was too massive.

    Neuro is tricky and unpredictable.

    Exactly. There is NO TIME to wait. We have been taught that a patient with a suspected concussion needs immediate studies. OP did not follow prudent nursing action.

    Screw protocol.

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