Physical Therapy Case Study: Unwitnessed fall of a stroke patient during a physical therapy session.

Summary of Facts

The insured physical therapist (PT) was an independent contractor providing services to patients in an acute care hospital setting. He was assigned to treat a 65-year-old married woman who had been admitted after an acute ischemic stroke caused by complete occlusion of the right internal carotid artery. Imaging showed a large right middle cerebral artery distribution infarct involving the right parietal region, basal ganglia, and thalamus. Her medical history included coronary artery bypass graft surgery and hypertension.

The patient had significant left-sided weakness and was receiving physical, occupational, and speech therapy in preparation for transfer to an inpatient rehabilitation facility. As part of secondary stroke prevention, she was receiving a triple antithrombotic regimen. An initial PT evaluation was completed, and the patient participated in the initial PT session without complication. The following day, at the start of the second PT session, the patient reported a severe headache rated 10 out of 10. The patient’s nurse administered pain medication, and the patient agreed to participate in a shortened PT session. Treatment included bed mobility transfers, and rolling exercises using the bed rails. She required tactile and verbal cues when sitting without support because she tended to fall backward, but she did not demonstrate instability when seated with support.

Shortly after the session began, the patient stated that she needed to use the bathroom. The PT assisted her with a pivot transfer from the wheelchair to the commode in the patient’s bathroom, positioned the wheelchair nearby, and remained at her side. The patient sat upright, remained balanced and requested privacy. The patient was alert and oriented and agreed not to stand without assistance. The therapist instructed her to use the call bell when finished and stated that she would remain in the room outside the bathroom door. After stepping out, the therapist crossed the room to connect her computer to a power source. The outlet was approximately seven feet from the bathroom. Within seconds, the therapist heard a loud noise, returned immediately, and found the patient on the floor. The patient was alert after the incident, apologized for falling, and initially denied striking her head. Nursing staff assisted with returning her to bed, and the patient was evaluated by the resident physician. The neurologic examinations were documented as being at baseline and since the patient denied hitting her head, imaging studies were not ordered. Of note, shortly after the resident left, the patient told the nurse that she may have hit her head, but that she was not sure.

Approximately one hour later, the patient experienced two episodes of emesis and then became unresponsive. She was intubated and transferred to the intensive care unit. Imaging demonstrated a massive acute subdural hematoma with substantial midline shift and herniation. Surgery was not considered a viable option, and the patient subsequently was terminally extubated and expired the next day.
 

Risk Management Comments

Plaintiff's allegations

One year after the patient’s death, her husband filed a lawsuit naming the hospital and the PT. The plaintiff alleged that the hospital was vicariously liable for the PT’s care and for failing to have appropriate policies in place for fall prevention during physical therapy treatment. In the Complaint, the plaintiff alleged the following departures from the standard of care specifically against the PT:

• Failure to adequately assess the patient’s fall risk and to implement appropriate fall prevention interventions.
• Failure to communicate an appropriate fall-prevention plan to nursing staff.
• Failure to provide the supervision necessary to prevent the patient from falling or to break the fall to avert serious injury.

The plaintiff relied on an order in the medical record directing that the patient not be left unattended in the bathroom. The plaintiff also cited documentation in the healthcare information record suggesting that the patient struck her head during the fall. The proximity between the unwitnessed fall and the diagnosis of the subdural hematoma was central to the plaintiff’s causation theory. The plaintiff’s neuroradiology expert opined that the hemorrhage identified after the fall was new and that prior imaging did not show evidence of a subdural bleed. This opinion supported the plaintiff’s position that the bathroom fall caused the fatal intracranial hemorrhage.
 

Defense Experts

Physical therapy expert

The defense physical therapy expert concluded that the therapist’s care met the applicable standard of care. The expert emphasized the following points:

• The patient required physical therapy for post-stroke mobility deficits, but the record did not identify a specific inability to sit safely on a bed, chair, wheelchair, or toilet when appropriately positioned.
• Although there was a physician order to not leave the patient unattended in the bathroom, there was no indication that continuous hands-on assistance was required.
• The patient had previously completed transfers with reasonable success, and the therapist appropriately assisted with the toilet transfer before giving limited privacy.
• The therapist provided a safety instruction not to stand, kept the patient near a grab bar and call bell, and remained only a few feet away. The standard of care did not require uninterrupted physical contact during toileting.
• Determining if the cause of the fall was due to the patient reaching for something, attempting to stand or if she was experiencing an evolving neurologic event was speculative, as the patient did not have a clear recollection of the event. Even if the therapist had remained inside the bathroom, the evidence did not establish that she would have been positioned closely enough to prevent the fall.

The absence of new clinical findings, i.e. evidence of head trauma, immediately after the incident supported the position that the fall itself did not produce an acute injury.
 

Neurosurgery / neurology experts

The defense neurosurgical and stroke experts supported the defense’s causation theory and opined that the patient’s antithrombotic medications and anticoagulated state created a significant risk of spontaneous intracranial bleeding. In their view, the triple therapy likely caused a nontraumatic subdural hematoma that began before the fall event and then rapidly progressed.

• The severe 10-out-of-10 headache before the therapy session was identified as a possible sign that intracranial bleeding was already underway.
• The experts found no clinical or imaging evidence of a scalp injury, skull injury, soft-tissue trauma, or brain contusion that would be expected if the patient had sustained a traumatic head injury.
• The patient initially denied hitting her head, and the fall reportedly occurred toward the side opposite the location of the subdural hematoma.
• The experts opined that the evolving hemorrhage may have precipitated the fall, rather than the fall causing the hemorrhage.
• The stroke expert also noted that straining during toileting could increase intracranial vascular pressure and potentially contribute to bleeding in a vulnerable patient.

 

Neuroradiology expert

The defense neuroradiology expert described the subdural hematoma as an acute, massive hemorrhage producing substantial midline shift and herniation. The expert opined that the event was unsurvivable and that it was not an extension of the original ischemic stroke.

On retrospective review, the expert identified no radiographic evidence of bony injury, scalp or soft-tissue trauma, or cerebral contusion. Based on the absence of traumatic findings and the patient’s antithrombotic therapy, the expert concluded that the fall did not cause or contribute to the subdural hematoma. The expert believed the hemorrhage likely began before the fall, and that the developing bleed may itself have contributed to the patient falling from the toilet.

The experts supported the causation defense that the patient developed a nontraumatic subdural hematoma in the setting of a severe ischemic stroke and related antithrombotic therapy. The bleed was likely evolving prior to the fall and the although the fall was temporally associated with the subdural hematoma, it did not cause or worsen it.

 

Resolution

This matter proceeded to trial and resulted in a defense verdict. The defense attributed the result primarily to two factors. First, expert testimony offered a plausible causation explanation that the subdural hematoma was related to the patient’s antithrombotic treatment and had begun before the bathroom event, with no imaging evidence of traumatic head injury. Second, the physical therapist’s detailed documentation of the patient’s status, transfer, instructions, prompt response, and post-fall care helped demonstrate diligence and supported the defense that her conduct did not cause the patient’s death.

A significant challenge was the close timing between the fall, the patient’s deterioration, and the diagnosis of the hemorrhage. The defense addressed that challenge by distinguishing temporal association from the clinical post fall assessment and diagnostic imaging findings to support the theory that the intracranial bleed preceded the fall.
 

Risk Management Considerations for Physical Therapists

Although this case resulted in a successful outcome, the following recommendations are provided as a resource and review for physical therapists:

• Assess fall risk using a multifactorial approach and implement individualized patient interventions to reduce the likelihood of falls and related injuries in alignment with the American Physical Therapy Association (APTA) guidelines. Consider the patient’s age, mobility status, presenting diagnosis, cognitive status and willingness to adhere to the plan as part of the fall risk assessment process.
• Perform a comprehensive assessment in order to recognize underlying medical conditions, co-morbidities and any additional risk factors that may affect patients’ fall risk and/or their ability to participate in the physical therapy treatment plan, including but not limited to orthopedic conditions/surgery, diabetes, sensory loss, vision and hearing loss, neurological impairments, dementia, age-related risks, cardiopulmonary disease and side effects of medications.
• Seek opportunities for continuing education regarding handling patient emergencies. Emergencies are infrequent and therefore training regarding first aid care is essential.
• Document all pertinent patient information in the healthcare information record in an objective, concise manner. Maintaining consistent, comprehensive, and timely documentation of services provided is the best defense in the event of a professional liability claim. 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 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.
  • Document and summarize any telephone or email encounters from patients (including after-hours calls), detailing 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.
  • Refrain from altering the healthcare information record and enter late entries only when pertinent to patient care.

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The information, examples and suggestions presented in this material have been developed from sources believed to be reliable as of the date they are cited, but they should not be construed as legal or other professional advice. CNA, Aon, Affinity Insurance Services, Inc., NSO, or HPSO accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All products and services may not be available in all states and may be subject to change without notice. Certain coverages may be provided by a surplus lines insurer. Surplus lines insurers do not generally participate in state guaranty funds, and insureds are therefore not protected by such funds. The claims examples are hypothetical situations based on actual matters. Settlement amounts are approximations. Certain facts and identifying characteristics were changed to protect confidentiality and privacy. Any references to non-CNA, non-Aon, AIS, NSO, and HPSO websites are provided solely for convenience, and CNA, Aon, AIS, NSO and HPSO disclaim any responsibility with respect to such websites. “CNA” is a registered trademark of CNA Financial Corporation. Certain CNA Financial Corporation subsidiaries use the “CNA” trademark in connection with insurance underwriting and claims activities. This material is not for further distribution without the express consent of CNA. Copyright © 2026 CNA. All rights reserved.

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Created: 11/2026