When she heard he fell in the hospital, she assumed it was because he didn't know his limitations. Defied doctor's orders. Tried to do too much. She learned later that wasn't the case. At all. She learned that when her dad drove himself to the ER because of edema in his legs, no one asked him if he had a history of falls, which he did. He fell once at home two weeks prior and another time five weeks earlier when he was brought by ambulance to the same ER after falling while attempting to hold a heavy door open for "an elderly woman." The daughter was amused when her 86-year-old father described a co-patron of the Senior Cafe as "elderly".
She learned more, having to begrudgingly remove the daughter hat in favor of the attorney/successor-in-interest hat. Upon review of his medical records,* she confirmed that no Morse fall risk or assessment was performed or assigned. This was not SOC (standard of care), she thought (and her expert confirmed), but perhaps not egregious. Until she read on. She learned he may have been on the ground for up to 90 minutes. That the RNs didn't do their requisite one-hour or "four eyes in four hours" rounding. (Not necessarily their fault; the hospital had a pattern and practice—elder abuse and neglect legal parlance—of being chronically understaffed as set forth in a scathing National Union of Healthcare Workers Report dated April 2016 that the daughter found online.) She had been trained to look under rocks, to pay keen attention to detail, to hear the words the hospital claims adjuster wasn't saying. She learned they gave her father meds they were supposed to HOLD because he was "less than 100 systolic." Meds that would make him dizzy, what with his dangerously low bp (blood pressure). She learned they belatedly fabricated an entry in his chart. (Maybe they forgot every entry is time-stamped?) That pissed her off. Still, she looked for a way to let them off the hook.
Until she read that he was found "on back, head in laundry hamper."
Laundry. Hamper.
Laundry. Hamper. filled with soiled linens from the telemetry floor. Many rooms. Lots of laundry. Toxic hazards. Which is why hospitals are supposed to keep hampers in hallways. They are not to be in a patient's room, much less an elderly patient's room, much less an elderly patient who should have been assessed as a high fall risk.
With that, she drafted nine California Code of Civil Procedure Section 364 Notice of Intent to Sue letters, laced with mixed emotions, chief among them determination and sadness, unable to shake the visual of her father on the ground, head in hamper, with a newly broken hip. Five days before he required hip replacement surgery. Six weeks before he died.
Prematurely.
* She stared at the stack of medical records for six months before she could bring herself to read them. It took three requests, but the hospital finally produced all categories of records (as initially requested). Perhaps they thought she wouldn't know the difference. They thought wrong.
She learned more, having to begrudgingly remove the daughter hat in favor of the attorney/successor-in-interest hat. Upon review of his medical records,* she confirmed that no Morse fall risk or assessment was performed or assigned. This was not SOC (standard of care), she thought (and her expert confirmed), but perhaps not egregious. Until she read on. She learned he may have been on the ground for up to 90 minutes. That the RNs didn't do their requisite one-hour or "four eyes in four hours" rounding. (Not necessarily their fault; the hospital had a pattern and practice—elder abuse and neglect legal parlance—of being chronically understaffed as set forth in a scathing National Union of Healthcare Workers Report dated April 2016 that the daughter found online.) She had been trained to look under rocks, to pay keen attention to detail, to hear the words the hospital claims adjuster wasn't saying. She learned they gave her father meds they were supposed to HOLD because he was "less than 100 systolic." Meds that would make him dizzy, what with his dangerously low bp (blood pressure). She learned they belatedly fabricated an entry in his chart. (Maybe they forgot every entry is time-stamped?) That pissed her off. Still, she looked for a way to let them off the hook.
Until she read that he was found "on back, head in laundry hamper."
Laundry. Hamper.
Laundry. Hamper. filled with soiled linens from the telemetry floor. Many rooms. Lots of laundry. Toxic hazards. Which is why hospitals are supposed to keep hampers in hallways. They are not to be in a patient's room, much less an elderly patient's room, much less an elderly patient who should have been assessed as a high fall risk.
With that, she drafted nine California Code of Civil Procedure Section 364 Notice of Intent to Sue letters, laced with mixed emotions, chief among them determination and sadness, unable to shake the visual of her father on the ground, head in hamper, with a newly broken hip. Five days before he required hip replacement surgery. Six weeks before he died.
Prematurely.
* She stared at the stack of medical records for six months before she could bring herself to read them. It took three requests, but the hospital finally produced all categories of records (as initially requested). Perhaps they thought she wouldn't know the difference. They thought wrong.
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