When Patients Fall: Navigating the Complex Terrain of Rights and Liability

Disclaimer

This article contains information based on my education, professional knowledge, and clinical experience. I am not an attorney; this content is for informational purposes only and should not be construed as legal advice.

Introduction

Falls remain one of the most common adverse events in healthcare settings. Hundreds of thousands of patients annually fall in hospitals and other healthcare facilities. Many healthcare professionals hear the phrase "patients have a right to fall" during their careers. This statement creates confusion about liability and responsibility. It suggests a false dichotomy between patient autonomy and safety obligations. Legal nurse consultants and attorneys face complex questions when examining fall cases. They must navigate between patient rights, provider duties, and institutional responsibilities. This article explores the legal and clinical realities of patient falls. We will examine what "right to fall" means in practice. We will discuss how to assess fall cases from nursing and legal perspectives properly. Understanding these nuances helps build stronger cases and provides clearer guidance for healthcare facilities, legal nurse consultants, and litigators.

A God-Given Right to Fall

Although this phrase has been used for many years, and its true origin is unknown to me, I know the first time I heard it used in litigation. It was during the criminal trial of Randi Noel McKinley, a Licensed Practical Nurse (LPN). Ms. McKinley had used a gait belt to secure a resident to a reclining medical chair. The resident subsequently died the next day. The medical examiner determined that the resident had died of natural causes and not, in fact, from being restrained the prior day. Ultimately, the jury found Ms. McKinley not guilty.

I will not discuss this nurse's actions any further because, to be honest, she has already been tried for her alleged crimes and found not guilty. I will talk about the prosecution stating, "A resident has the God-given right to fall." This statement was drawn from long-term care regulations, which address the right to autonomy, freedom from restraint, and dignified care. However, there is not a single regulation that states, "A patient/resident has the God-given right to fall."

Yes, a patient or resident has the rights listed above, and one could even say the patient may have a God-given right to fall. However, this right does not relieve a healthcare organization or healthcare professional of their duty to prevent falls and/or injuries from falls. The phrase creates a dangerous misunderstanding. It implies that falls are inevitable and nothing can or should be done to prevent them. This interpretation can lead to negligence. It can also lead to improper defense strategies in litigation.

Fall Assessment Tools: Limitations and Practical Applications

Most healthcare facilities use some form of fall risk assessment tool. Common examples include the Morse Fall Scale, the Hendrich II Fall Risk Model, and the St. Thomas Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY). These tools assign numerical scores based on risk factors and categorize patients as low, moderate, or high risk for falls.

These tools provide a starting point for assessment. However, they have significant limitations. Most importantly, they only identify the likelihood of a fall. They do not predict the severity of injury if a fall occurs. A frail elderly patient with osteoporosis scores the same as a physically fit patient of the same age with the same risk factors. Yet the potential for injury differs dramatically.

Another limitation is standardization itself. These tools cannot account for unique individual factors. They often miss environmental hazards specific to a facility. They rarely consider medication interactions that may increase fall risk. Many do not adequately address cognitive impairment as a risk factor.

Nurses must go beyond the score and assess each patient individually. Risk assessment should be an ongoing process, not a one-time event. Scores change as patient conditions change. A proper assessment considers mobility, cognition, continence, medication effects, a history of falls, and the physical environment. Only then can preventive measures be tailored appropriately.

Falls in Long-Term Care Settings

Falls in long-term care represent one of the most litigated areas in healthcare. This is unsurprising given the vulnerable population. About 50-75% of nursing facility residents fall each year. The rate is twice that of seniors living in the community. Falls lead to serious injuries, hospital transfers, and sometimes death.

Long-term care facilities face unique challenges in fall prevention. Residents live there for extended periods and have the right to mobility and autonomy. Many facilities struggle with staffing shortages, which limit supervision capabilities. The physical environment may not be optimally designed for fall prevention.

A problematic practice in long-term care is "intervention stacking." After each fall, staff add a new intervention to the care plan. No one reviews previous interventions for effectiveness, resulting in care plans with dozens of fall interventions. This approach creates an impossible standard of care. No staff can reasonably implement thirty different interventions for a single resident every time the resident rises to their feet.

Another critical issue I frequently encounter is care plans built on incorrect fall risk scores. Often, MDS coordinators build the care plan. However, they may not have been the nurse who assessed the resident upon admission or before admission. Many facilities use nurse liaisons or admission nurses for initial assessments. When the care plan is completed by a nurse who has not performed the assessment, this may lead to false scores.

I reviewed a case where a resident with multiple falls before arrival, a fact that would make the resident an immediate high fall risk, was scored as a low fall risk. Subsequently, this incorrect score was reflected in the care plan, and inappropriate interventions were made. Because this resident's care plan was based on an incorrect fall score, it was not individualized and violated the federal code. Ensuring the care plan adequately reflects the resident's actual risk and providing individualized interventions to address such risks is vital.

Consider this personal experience from my time as a Director of Nursing in a residential geriatric community. The resident had Parkinson's disease with a classic shuffling gait and forward-bent posture. The facility had carpeted hallways. The resident fell approximately once per shift. The resident enjoyed wandering through the facility. It brought the resident joy and calmed him. The resident's spouse was aware of this behavior and supported it. Upon reviewing the care plan, I discovered over forty fall interventions.

The solution was not more interventions. I held a care planning meeting with the resident's spouse. I discussed the diagnosis and its effects on gait and balance. I explained how dementia exacerbated these issues. I outlined potential injuries from falls, including intracranial bleeding, thoracic injuries, and hip fractures. We acknowledged that despite every intervention except physical restraints, falls continued.

We simplified the care plan dramatically. We only used essential interventions: shoes and socks while awake, gripping socks in bed, keeping the room free of clutter, and installing a night light. We then shifted focus to injury mitigation. The resident wore padded clothing like what football players wear. This included a padded vest for thoracic protection and padded compression pants for hip protection. I offered a helmet, which the spouse declined due to dignity concerns. This decision was documented with the spouse's signature. I thoroughly documented the care planning meeting and ensured our MDS coordinator updated the care plan accordingly. It is important to note that staff did not cease investigating each fall for a contributing factor. If a single factor could be identified, this was addressed with a new care plan intervention. However, every fall did not receive a new intervention – a fall was inevitable for this patient.

This approach balanced safety with dignity. It acknowledged reality while taking reasonable measures to prevent serious injury. Most importantly, it created a defensible standard of care.

Falls in Hospital Settings

Hospital falls present different challenges than those in long-term care. Patients are often acutely ill and may be disoriented by unfamiliar surroundings. Many receive medications that increase fall risk. Patients frequently overestimate their abilities and attempt to get up without assistance despite weakness or dizziness.

Hospital environments contribute to fall risk. Unfamiliar rooms, smooth floors, IV poles, and monitoring equipment create obstacles. Patients may be reluctant to call for assistance with toileting due to embarrassment. Staff are often busy with multiple high-acuity patients. This limits their ability to respond quickly to call lights.

Hospitals face a tricky balance. They must promote mobility to prevent complications of bed rest. Yet, they must protect vulnerable patients from falls. This tension sometimes leads to inappropriate use of physical restraints or medications. Both these approaches can increase fall risk and lead to other complications.

Most hospitals have robust fall prevention programs. However, they often limit or completely remove a nurse's autonomy. Standardization is important for adoption. However, patients do not fit into a box. Certain interventions are great for standardization, but nurses should be empowered to go beyond the standardized interventions and consider the patient's unique needs.

Successful hospital fall prevention programs emphasize multiple strategies. These include hourly rounding, bedside handoff, fall alert systems, low beds, non-slip footwear, and clear pathways. The most effective programs involve interdisciplinary teams, including nursing, physical therapy, pharmacy, and environmental services. They emphasize communication about fall risk at every handoff.

It is important to note that care plans, while integral to long-term care, are nonexistent in many acute care hospitals today. Care plans create consistency in care across providers. Hospitals need a robust system to communicate care needs across shifts, units, and disciplines. This communication is key in ensuring the proper interventions are in place for patients.

Without a structured communication system, critical information about fall risk and specific interventions may be lost during transitions. Hospitals should consider implementing standardized handoff tools that address fall risk factors and prevention strategies. Electronic health records can be leveraged to create fall prevention alerts that follow the patient throughout their hospital stay. Morning huddles and interdisciplinary rounds provide additional opportunities to discuss high-risk patients and reinforce fall prevention measures.

Foreseeability in LNC Review

We have all fallen at some point in our lives. Not every fall is preventable or foreseeable. Legal nurse consultants must determine whether the organization or staff knew or should have known, about fall risk. The key question is whether reasonable measures were taken based on this knowledge.

Common issues I encounter during chart reviews include the following.

Room clutter creates tripping hazards, which are particularly problematic when staff create them. Examples include equipment left in walkways, electrical cords running across walkways, or spills not promptly cleaned.

Improper positioning, such as patients left reclined in rolling chairs, increases the risk. These chairs move when patients shift their weight. Similarly, patients left upright wearing only socks on slippery tile floors face obvious hazards.

Medication-related risks are frequently overlooked. Many medications cause positional hypotension. This creates dizziness when standing. Others increase impulsivity, such as certain psychiatric medications. Some induce confusion or psychosis. Diuretics and laxatives increase the urgency to reach the bathroom. This often leads to hurried, unsafe movement.

Environmental factors include call lights placed out of reach, which forces patients to attempt self-care when they need assistance. Inadequate lighting, particularly at night, substantially increases fall risk.

Perhaps most concerning are cases where staff document confusion and weakness but implement no interventions. Patients with these conditions require strategies to alert staff when attempting to stand. Bed alarms, chair alarms, or more frequent checks are essential.

Additional foreseeable risks include inadequate staffing for high-risk patients. Some patients require one-to-one observation during periods of acute confusion, and others need assistance from two staff members for transfers. The healthcare organization assumes the risk when these resources are not provided despite the documented need.

The LNC must examine whether the assessment correctly identified risks. They must then determine if appropriate interventions were implemented and documented. Finally, they must evaluate whether staff responded appropriately to changes in conditions that increased fall risk.

Creating Defensible Fall Prevention Programs

Defensible fall prevention begins with individualized assessment. Generic approaches fail to address specific risk factors. Each patient's care plan should reflect their unique needs, including physical abilities, cognitive status, medication profile, and personal preferences.

Documentation must be thorough and consistent. This includes regular reassessment of fall risk. It should detail all interventions implemented and record patient responses to them. When interventions fail, documentation should explain the rationale for changes to the care plan.

Fall prevention requires an interdisciplinary approach. Physical therapists can assess mobility and recommend appropriate assistive devices. Pharmacists can review medications for fall risk. Environmental services can address hazards in the physical space. Physicians must be informed of fall risk and engaged in prevention strategies.

Staff education is critical. All caregivers must understand fall risk factors, receive proper transfer techniques training, know how to implement specific interventions, and, most importantly, communicate clearly about each patient's fall risk.

When falls occur despite prevention efforts, post-fall protocols become essential. These should include immediate injury assessment, trigger reassessment of fall risk, and prompt a root cause analysis to identify contributing factors. Based on these findings, the care plan should be revised.

Technology can enhance fall prevention efforts. Bed alarms, chair alarms, and wearable devices can alert staff to patient movement. Video monitoring allows observation without constant staff presence. Electronic medical records can flag high-risk patients and prompt reassessment.

Most importantly, organizations must foster a culture of safety. This means empowering staff to report risks, requiring leadership support for fall prevention initiatives, and demanding accountability for implementing interventions. A blame-free reporting system encourages

transparency when falls occur.

Conclusion

The phrase "patients have a right to fall" creates a false dichotomy between autonomy and safety. Patients indeed have rights to dignity, mobility, and freedom from unnecessary restraint. However, healthcare providers have duties to prevent foreseeable harm. These principles can and must coexist.

Legal nurse consultants play a crucial role in fall-related litigation. They evaluate whether assessments identified appropriate risks, determine whether interventions matched identified risks, and assess whether documentation supports the care provided. Their expertise helps attorneys understand the clinical nuances of each case.

For litigators, fall cases require careful analysis of clinical and regulatory standards. They must understand facility policies and how they align with state and federal regulations. They must evaluate staffing levels and resource allocation. Most importantly, they must determine whether the standard of care was met.

The best fall prevention programs balance safety with quality of life. They recognize individual differences among patients, implement targeted interventions rather than excessive restrictions, and document thoroughly without creating impossible standards. With this approach, healthcare providers can meet their ethical and legal obligations to those in their care.

AI Assistance Disclosure: This article was developed, in part, with the assistance of artificial intelligence tools. The author has reviewed and edited all content to ensure accuracy and alignment with the author's professional expertise and opinions.