Case Study: Failure to supervise and monitor post-surgical patient leads to reinjury, permanent disability
Physical Therapist and Medical Malpractice
Case Study with Risk Management Strategies
Presented by HPSO and CNA
Total Incurred: Greater than $650,000
(Monetary amounts represent only the indemnity settlement and legal expense payments made on behalf of the individually insured physical therapist.)
Medical malpractice claims may be asserted against any healthcare provider, including physical therapists. This case study involves a physical therapist who was an employee of a physical therapy practice that operated in a non-hospital physical therapy clinic.
The patient was a 60-year-old female and four weeks post-bilateral total knee replacement. The patient was seen by our insured physical therapist (PT) for initial physical therapy evaluation and treatment. During the evaluation, the patient was on the recumbent bike for ten minutes and while getting off, she had problems getting her right leg over to dismount the bike and semi-fell, causing a re-tear to her tendon requiring surgical repair.
The patient contends that prior to the fall she informed the PT that she needed help getting off the bike because her legs felt weak. She exited the bike to her left and the PT was standing on the opposite side of the bike. The PT did not assist the patient off the bike. The patient claims that she lost his balance and stuck her left leg against the floor with sufficient force to rupture her left quadriceps tendon. Patient further claims that it took two individuals to assist her to a wheelchair in that she was unable to stand. She further contends that assistance was required to exit the bike and that she should have been wearing a safety belt. Had contact assistance been provided from the side of the bike she was dismounting her fall would not have occurred.
The insured PT denied that the patient requested assistance in getting off the bike. The PT stated that the patient walked into the facility with the assistance of a single point cane. Prior to getting on the bike, the patient walked around the facility with and without her cane independently. According to PT and a video of the incident, the patient’s right leg did catch on the bike frame causing the left knee to flex but she did not hit the ground. The PT then hooked his arm under her arm pits and helped her stand back up using minimal assistance.
Prior to exiting the bike, the video shows the patient’s lower her head to her hands (looking like an expression of fatigue) and shows the patient and insured having a dialogue. The video then shows that the patient appeared to have trouble lifting her right leg high enough to clear the bike frame. She did fall to her left but whether she hit the ground can’t be seen on the video.
As the PT was assisting the patient back onto the seat of the bike, his PT student (not an insured party), came into the room and after a few seconds both assisted her off the bike. It looks like the PT student helped push the right leg over the bike. The patient was given a walker and she walked a few steps without assistance. However, after about 10 steps the patient appeared to be having problems walking and even looked like she was going to fall. The PT student got her a chair and as she was sitting down the patient passed out. After several minutes the patient was transferred to a wheelchair and her spouse then took her home.
The following day the patient called her orthopedic surgeon for an appointment due to pain in her left leg. A MRI showed full thickness tear of the left distal quadriceps tendon 3.5 cm above the patellar insertion. A repair of the post left distal quadriceps was performed, and recovery was fraught with problems. Complications included arthrofibrosis of the right knee limiting range of motion requiring manipulation under anesthesia, soft leg cast for left leg x10 weeks, developed an extensive left leg DVT requiring anticoagulant therapy. Because of the presence of the DVT, and the inability to wait for the DVT to be fully absorbed because the knee would have become locked by scar tissue, a vein filter was placed to block the clot if it traveled. This added to her slow progress in increasing left leg range of motion, leading to a left knee manipulation under anesthesia.
Risk Management Comments
The defense team had PT experts review the case. The experts were marginally favorable to the defense where the facts supported the patient’s mobility and lack of complaints regarding fatigue. However, when the expert viewed the video he felt the actions of the PT did not meet the medical urgency the patient seemed to demonstrate. The expert felt that in the video the patient was showing signs of fatigue and stress once she exited the bike. However, it did not appear that the PT appreciated the patient’s condition.
The patient’s ability to ambulate with comfort was limited following this incident. Her surgeon declared her permanently disabled and unable to return to her former job as a manager for a large department store. Her work required her to kneel, squat, reach low places, and to work in environments where there is a danger of tripping. She can now only flex her knee to 90 degrees (120+ degrees is considered normal).
A consortium claim was filed by the patient’s husband along with the patient’s claim. Her husband described that he misses doing activities with his wife. They used to enjoy long walks and now she can’t walk very far. Going to the movies is also difficult because she has trouble bending her knee enough to sit in a theater seat.
Several attempts were made to mediate the claim, but the patient, her husband, and her attorney refused to settle for under $2,000,000. With the unreasonable expectations of the plaintiffs, defense team prepared for trial.
The jury trial lasted 11 days, three of those days included jury deliberation. The jury found in favor of the plaintiffs, which included past and future economic loss, past and future noneconomic loss and loss of spouse consortium.
The jury was interviewed after the trial and had positive feedback about the defense counsel and the defense experts, but they didn’t like the PT’s demeanor. They felt the insured was too nonchalant about the incident and they didn’t understand why he didn’t call 911 when the patient passed out. They also felt that the PT’s documentation was lacking and if he would have done a better job of documenting the incident, that may have changed their decision.
The jury had it in their mind that because it was the patient’s first visit to the facility, there should have been closer interaction between the patient and the PT. For example, the PT should have walked over and checked on her after she was on the bike about 10 minutes. They commented that the PT walked ahead of the patient before and after the accident, so they questioned how he could have been assessing the patient if he was walking ahead of her.
The claim wound up resolving for much less than the plaintiffs’ original demands, though the total incurred for the PT’s professional liability claim, including indemnity and defense payments, exceeded $650,000.
Risk Management Recommendations
- Treat patients with respect and compassion during their course of therapy.
- Recognize patients’ medical conditions, co-morbidities and any additional specific risk factors that may affect therapy. Examples of pre-existing conditions include:
- de-conditioning following extended hospitalization or recent surgery
- osteopenia and osteoporosis
- cardiac problems
- coagulation disorders requiring anticoagulant therapy
- pulmonary disease
- neurological impairments, dementia or behavioral health issues
- sensory loss involving heat/cold sensitivity, hearing, vision, speech or proprioception
- vestibular/balance disorders and fall risk
- side effects of medications
- Recognize nonverbal cues from the patient, such as grimacing or flinching, as well as physical distress signs, such as pallor or diaphoresis.
- Closely supervise and/or monitor patients during treatment, including frequent checks.
- Ensure that clinical documentation practices comply with the standards promulgated by physical therapy professional associations, state practice acts and facility protocols. The importance of complete, appropriate, timely, legible and accurate documentation cannot be overstated, whether records are in electronic or handwritten form. At a minimum, records should include:
- date, time and signature for each entry
- patient complaints, statements and ongoing concerns related to the treatment plan, such as progress and pain levels
- findings of initial and ongoing patient assessments
- results of diagnostic procedures
- patient responses to therapy
- discussions regarding diagnosis, treatment options and expected outcomes with the patient, family and healthcare team members
- patient education and discharge instructions, including assessment of the patient’s ability to demonstrate self-care and correctly repeat instructions
- objective facts related to any patient accident, injury or adverse outcome
- Avoid documentation errors that may weaken legal defense efforts in the event of litigation. The following documentation missteps can seriously compromise defensibility:
- Refrain from documenting subjective opinions or conclusions, as well as making any derogatory statement about patients or other providers in the record.
- Never remove any page or section from a health information record or alter a written or electronic medical record.
- If it is necessary to correct documentation errors or make a late entry, ensure that alterations conform to organizational policies and procedures.
- Contact your manager, risk manager or legal counsel for assistance with documentation concerns or questions related to regulatory compliance or potential liability.
- Respond immediately to any signs or symptoms of a medical emergency by determining the need for additional medical evaluation and obtaining emergency medical services as needed.
- Observe high-risk patients closely to prevent falls and/or fractures, and never leave them unattended.
- Utilize appropriate safety devices, such as gait belts, floor and treatment table pads and equipment alarms.
This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. This information is provided for general informational purposes only and is not intended to provide individualized guidance. All descriptions, summaries or highlights of coverage are for general informational purposes only and do not amend, alter or modify the actual terms or conditions of any insurance policy. Coverage is governed only by the terms and conditions of the relevant policy. This information is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., HPSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information.
Healthcare Providers Service Organization is a registered trade name of Affinity Insurance Services, Inc., a licensed producer in all states (TX 13695); (AR 100106022); in CA, MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services, Inc.; in CA, Aon Affinity Insurance Services, Inc., (CA 0G94493), Aon Direct Insurance Administrators and Berkely.