When vulnerable long-term care or rehabilitation patients are admitted following major surgery, post-operative care standards require rigorous monitoring and reliable safety equipment to prevent secondary injury. In this matter presented before the Patient’s Compensation Fund State of Louisiana, an 88-year-old post-hip joint replacement patient sustained a secondary periprosthetic fracture (a broken bone occurring around a surgical implant) after falling unattended from his bed. Despite documented fall risk factors—including post-anesthesia confusion, Alzheimer’s disease, agitation, and severe malnutrition—facility personnel failed to properly supervise the patient or ensure that his personal bed alarm functioned as designed.
Case Profile
The Claimant: 88-year-old vulnerable adult admitted post-hip joint replacement. Pre-existing conditions included severe malnutrition, Chronic Obstructive Pulmonary Disease (COPD—a chronic inflammatory lung disease causing obstructed airflow), chronic renal failure (long-term kidney damage), hypertension (high blood pressure), anemia (low red blood cell count), Alzheimer’s disease with behavioral disturbances, atherosclerotic cardiovascular disease (hardening of the arteries due to plaque buildup), and benign prostate hypertrophy (enlarged prostate). Required maximal assistance with transfers and was noted to have intermittent confusion and agitation post-surgery.
The Defendant: Rehabilitation hospital located in DeQuincy, Calcasieu Parish, Louisiana, operating under the oversight of the Patient’s Compensation Fund State of Louisiana.
Incident Dynamics: The patient was found on the floor suffering from severe pain during an unmonitored window of over one hour. Nurse notes indicated the magnetic patient alarm (PA) was off, while an internal hospital occurrence report stated the alarm failed to sound when the patient moved. Records indicated no staff checks occurred between 0130 hours and 0240 hours when the unwitnessed fall was discovered.
Injuries & Medical Taxonomy:
Periprosthetic Fracture (a break in the bone surrounding a prosthetic joint implant or replacement) requiring immediate discharge and transfer to an acute care facility.
Post-operative Agitation & Confusion (episodes of mental disorientation and restlessness following anesthesia and surgical stress).
Jurisdictional Basis: Medical Malpractice Claim submitted to the Patient’s Compensation Fund State of Louisiana (PCF Number: 2004-01007). Compliance standards evaluated under Title 42 of the Code of Federal Regulations (42 CFR § 483.25 and 42 CFR § 483.20).
Regulatory Breaches & Standard of Care Violations
- Failure to Maintain Equipment & Provide Adequate Accident Supervision (42 CFR § 483.25(h)): The facility failed to ensure the patient environment remained free of accident hazards and that the resident received adequate supervision and working assistance devices. The personal bed alarm failed to sound during the fall sequence, and video monitoring system promises were unfulfilled.
- Inadequate Care Plan Implementation (42 CFR § 483.20(k)): The facility utilized a generic, boilerplate care plan that failed to properly address the patient’s severe fall risks resulting from surgical recovery, dementia, and sedating medications. Preventive protocol measures such as routine bed checks, toileting programs, and bed alarm maintenance were omitted.
- Absence of Systematic Fall Prevention Policies: Depositions of facility leadership revealed that no administrative fall prevention policy or fall prevention committee existed at the facility at the time of the incident, despite a majority resident population over age 65.
Kenneth D. St. Pé, APLC
Board-Certified Medical Malpractice Attorney
700 St. John Street, Suite 401
Lafayette, LA 70501
Direct Line: (337) 534-4043
Consultation: Free & Strictly Confidential
Website: stpelaw.com
If you or a family member suffered a fall, fracture, or severe injury due to poor monitoring or equipment failure in a rehabilitation center or nursing facility, contact our legal team today for a confidential consultation.