Our Recent Cases

An 88-year old man was admitted to the hospital with respiratory compromise. The patient required respiratory support and was placed on a ventilator. In order for the patient to receive diagnostic testing at the hospital, the patient’s ventilator was placed in “stand by” mode, during which the ventilator was not providing oxygen.

A medical transport company was lifting a wheelchair-bound patient into the transport vehicle. The patient was placed on a hydraulic lift, which elevated the patient from the ground into the air. The medical transport company did not properly secure the patient’s wheelchair or supervise the patient.

An elderly, female nursing home patient with dementia and a history of exit-seeking behavior was admitted to a nursing home’s secure/locked unit to protect her from falls, wandering, and elopement. After a short period on the secure/locked unit, the nursing home moved the patient to a portion of the facility that was not locked. On the unlocked unit, the patient was noted to be “going down to the back doors trying to get out” and to have “went out the front doors,” without supervision.

An elderly nursing home patient was admitted to a nursing home as a high fall risk. The patient was initially provided with a bed alarm, but the bed alarm was withdrawn by the nursing home shortly after the patient arrived at the facility without any notice to the patient’s family. The patient’s family noticed during a later visit, the patient did not have either a fall alarm in his wheelchair or in his bed.

An elderly nursing home patient, known by the facility to be at high risk for falls, fell three times within a seven-hour period just days after admission to the nursing home. As a result of the third of the three falls, which occurred when the patient was left unsupervised in his wheelchair without a chair fall alarm, the patient sustained a displaced left hip fracture. The hip fracture required open reduction internal fixation surgery.

An elderly, immobile nursing home patient was allowed to fall from her bed to the floor while being repositioned during incontinence care. The nursing home aide responsible for the fall turned the patient away from her to the opposite side of the bed, left the patient on her left side, and required the patient, who had sustained a stroke with right-sided compromise, to use her right hand to hold onto the repositioning bar/rail of the bed for safety. The aide then turned away from the patient, an…

A 76-year-old female nursing home patient was transferred to Berkshire Health & Rehabilitation Center, a nursing home in Vinton, Virginia operated by Medical Facilities of America, Inc. The patient had severe respiratory disease on admission. The nursing home permitted the patient’s oxygen saturation to dip to 63%.

An elderly female nursing home patient was totally dependent upon staff for transfers. The patient was transferred using a hoyer lift, which is a full mechanical lift that suspends the patient in a sling as the patient is transferred from one seating surface to another. During a transfer with a hoyer lift, the nursing home allowed the patient to fall and sustain an impacted fracture of her left shoulder.

An elderly female nursing home patient was permitted to fall from her bed to the floor. The nursing home claimed it was changing the patient’s bed sheets while the patient remained in bed. The patient was turned away from the aide who was making the bed and positioned on her side at the edge of the bed.

While hospitalized, a middle-aged male patient developed what was initially described by the hospital as a large bruised area on his buttock with no skin breakdown. Within one week thereafter, the hospital described the wound as a very large purple bruise on his coccyx (low back) and buttock area with sloughing. The patient also developed a large purple area over his left heel.