Summary
The patient was a 69-year-old male who was referred to physical therapy after undergoing a left total hip arthroplasty. Postoperatively, the patient was instructed by the hospital physical therapist to use a walker when ambulating. The patient had not previously used a walker. The patient initially completed home therapy and after two weeks transitioned to an outpatient clinic setting where he began treatment with our insured PT. During the initial evaluation, the PT observed that the patient was not using the walker properly and that he frequently abandoned the walker when navigating doorways. The PT conducted an extensive educational session teaching the patient about fall prevention, body mechanics and how to properly ambulate using a walker. She documented a detailed note regarding the education that was provided, and that the patient verbalized an understanding of the instructions and agreed to participate in the proposed treatment plan.
Two days later, the patient presented to the clinic for the second session and informed the PT that he was having difficulty using the walker at home. He reported that the wheels of the walker were getting trapped in the furniture and that he would often lose his balance when this occurred. The patient admitted that he would become frustrated and would end up carrying the walker or leaving it behind. In response to receiving this information, the PT repositioned the front wheels of the patient’s walker from the outside to the inside frame in order to decrease the walker’s outer dimension so that he would have more room to navigate tight spaces. The PT was aware that repositioning the wheels could potentially reduce the stability of the walker. However, after carefully assessing the situation and the patient’s fall risk, she determined that the benefits of moving the wheels outweighed the risks associated with the patient abandoning the walker. The PT explained the rationale for moving the wheels to the patient, re-educated the patient on how to ambulate properly with the walker and documented all patient education.
When the patient did not keep the next three scheduled appointments, the PT contacted the patient’s spouse. The spouse reported that the patient went to the emergency department as a result of falling at home while ambulating with the walker and was diagnosed with an acute spinal fracture. Conservative treatment was ordered, and the patient returned home in stable condition.
Risk Management Comments
Six months later, the patient (plaintiff) filed a lawsuit asserting that he suffered permanent injuries as a result of the fall and that the fall was caused by the PT’s negligence in repositioning the walker wheels. During discovery, the PT was deposed and testified that moving wheels to the inside frame of a front-wheeled walker is an acceptable practice used to decrease the outer dimension. The PT made a credible witness, testifying that she carefully weighed the risks and benefits and determined that the patient had a greater risk of falling from improper, inconsistent walker use. The physical therapy experts for the defense were supportive of the PT’s testimony and opined that the treatment was within the standard of care. The experts highlighted the fact that the PT appropriately documented an objective assessment and rationale for the actions taken.
The plaintiff initially testified that the PT did not inform him about the rationale for moving the wheels and that he did not receive instructions on how to properly ambulate with the walker. However, in cross-examination, the plaintiff admitted that he did in fact receive instructions regarding use of the walker, but that he did not adhere to them. He also admitted that he could not refute the PT’s documentation detailing the comprehensive education that was provided. While the plaintiff claimed to have a limited recollection of any discussions about the wheels, he again conceded that he could not deny what the PT had documented. The plaintiff also provided inconsistent details about the fall. Initially, he testified that the walker tipped over on its side and he fell backwards, but then later changed his testimony when confronted with the hospital documentation indicating that he told the emergency department triage nurse the day of the fall that he fell forward while attempting to answer the phone.
Resolution
The initial demand made by the plaintiff was for more than $400,000. However, the defense attorney believed that the PT’s complete documentation provided a strong legal defense. In addition, expert testimony supported the position that the insured PT had not breached the standard of care in her treatment of the patient and that the modification of the walker wheels was not the direct, proximate cause of the patient’s injury. Rather, the patient’s non-adherence was a contributing causative factor. Based upon this strong defense position, the defense attorney was able to negotiate a dismissal of the matter. The plaintiff attorney dropped the case.
Total Incurred: Expenses associated with the lawsuit proceedings were more than $90,000.
(Monetary amounts represent only the legal expense payments made on behalf of the PT and the physical therapy firm.)
Risk Management Recommendations for Physical Therapists:
- Be vigilant about protecting patients from falls and utilize evidence-based fall risk assessments and interventions when establishing a treatment plan. Consider the patient’s post-surgical diagnoses, home setting, cognitive status and willingness to adhere to the plan as part of the fall risk assessment process.
- Recognize medical conditions, co-morbidities and any additional risk factors that may affect patients’ fall risk, including:
- Diabetes
- Sensory loss involving heat/cold sensitivity, hearing, vision, speech, or proprioception
- Neurological impairments, dementia, or behavioral health concerns
- Cardiac problems
- Coagulation disorders
- Pulmonary disease
- Side effects of medications or dietary supplements
- Document all pertinent patient information in the patient healthcare information record in an objective, concise manner. Maintaining consistent, comprehensive, and timely documentation of services provided is one of the physical therapist’s primary professional responsibilities, as noted in Principle 7E of the American Physical Therapy Association Code of Ethics for the Physical Therapist. Consider the following recommendations, among others, when documenting physical therapy notes:
- Document patient assessments, observations, communications, treatments and patient education.
- Include the results of objective tests and measures and any evaluation of the patient’s fall risk and mobility, sensory, and cognitive status, if applicable.
- Delineate any educational materials, resources, or references provided to the patient and/or their caregivers, including recommendations for home safety.
- Record a summary of all telephone or email encounters (including after-hours calls), documenting the name of the person contacted, advice provided, and actions taken.
- Document reexaminations and revisions to goals/treatment plans, including data from repeated or new examination elements, to provide useful context for evaluating progress and modifying treatment plans.
Resources
- APTA-Geriatrics: Balance and SIG; National Fall Prevention Day Awareness Toolkit https://aptageriatrics.org/special-interest-groups/balance-falls/NFPAD/documents/Role%20of%20the%20Healthcare%20Providers%20in%20Fall%20Prevention%202020,%20Final.pdf
- APTA Code of Ethics for the Physical Therapist (2020); American Physical Therapy Association Code of Ethics for the Physical Therapist
Disclaimers
These case scenarios are illustrations of actual claims that were managed by the CNA insurance companies. However, every claim arises out of its own unique set of facts which must be considered within the context of applicable state and federal laws and regulations, as well as the specific terms, conditions and exclusions of each insurance policy, their forms, and optional coverages. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. These statements do not constitute a risk management directive from CNA. This material is for illustrative purposes and is not intended to constitute a contract. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation, encompassing a review of relevant facts, laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.
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