Case 18303 (Stroke rehabilitation setting)

The faller, a 73 year old stroke survivor fell on Saturday, September 15, 2012 at 07:10. Like any other day, the faller woke up around 07:00 and used the call bell to call for assistance to go to the washroom. Because all seven nurses in the unit were partaking in the scheduled shift change and handover of responsibilities meeting, the personal care provider (PCP) attended to the faller. The PCP, who was 6 months pregnant, checked the transfer status posted above the faller’s bed before assisting her to the washroom. The instructions indicated assistance by at least one person. The PCP assisted the faller into her wheelchair then wheeled her into the washroom. The PCP parked the wheelchair perpendicular to the toilet, then she stood behind the wheelchair as the faller stood up independently and grabbed onto the bathroom grab bars. The faller tried to hold onto the grab bars as she pulled up her nightgown and pivoted around to sit on the toilet. She was cognizant of the fact that the PCP was six months pregnant and was concerned for the well-being of the mother and baby. She attempted to maneuver onto the toilet by herself and decided not to ask for further assistance because she was worried that she would hurt the PCP and her baby. The faller’s left knee buckled and she lost her balance. The faller was no longer able to hold onto the grab bars, and when she let go, she fell to her left side, hitting the wall, and then hitting the toilet with her head. She lay on the ground in front of the toilet and wheelchair while the PCP rushed outside the room to call for help. Three nurses ran to the scene and assisted the faller up. They helped her use the

washroom and returned her to bed where she was assessed for injuries. Only minor bruising on her left arm and pain in the left shoulder were observed but no head injuries or changes in level of consciousness were reported.

Multiple contributing factors were identified for this event and included deficiencies within all four levels of the Swiss Cheese Model of Accident Causation. These are discussed below:

• The faller had significant hemiparesis involving the left arm more than the left leg with limited ability to move either one. Her fingers remained flexed and she had no intrinsic movements in her hands and straightening her fingers caused her

considerable discomfort. She was not dysarthric (difficulty formulating words) and appeared not to have any significant perceptual deficits but was slow to respond. Due to a stroke affecting the basal ganglia, the faller had difficulty with decision-making abilities.

• The faller had significant muscle weakness and was left side hemiplegic. She had morning fatigue and was unsteady on her feet when she first rose from bed. The faller required the assistance of at least one other person for all transfers and ambulation.

• Although the PCP followed transfer instructions written on the transfer status chart posted above the patient’s bed, the chart did not specifically indicate that the faller needed assistance on her left side. Therefore, during the transfer from wheelchair to toilet, the PCP was positioned inappropriately, because she was standing behind the wheelchair and not on the faller’s left side. The transfer instructions were changed by the PT after the fall.

• Although the faller recognized that she needed more assistance on her left side and that the PCP was not in an optimal position to support her, she chose not to say anything because she was concerned about the well-being of the pregnant PCP. She stated that she did not want to unintentionally harm the PCP or her child if she happened to fall and, instead, decided to transfer herself to the toilet

independently.

• The PCP had not visited occupational health for modifications to her workload. Although the PCP felt comfortable performing her roles and responsibilities as usual, this information was not provided to the faller, who assumed, based on the physical appearance of the PCP, that she was incapable of performing her duties.

• Because the PCP did not approach occupational health for workload adjustments, the PCP was expected to perform transfers as usual.

• The organizational policy for workload adjustments does not distinguish between accommodation due to pregnancy, and accommodation due to disability or infirmity.

• During the morning shift change, all seven RNs participate in a mandatory shift change meeting whereby patient information from the night shift RNs is passed on to the day shift RNs. This report meeting took place from 07:00 to 07:30. During this time, there was only one PCP and one porter in the unit to assist 20 patients. If a patient requires assistance with transfers or ambulation, then he/she has to wait for either the PCP or porter or for the RN to be done with reports.