*This Case of the Month is based on an inquest report from the Office of the Chief Coroner. The Ontario Ministry of Health and Long-Term Care has asked that we share this story with our members.*

Situation

A 91-year-old woman was admitted to a long-term care home in the winter 2010. She suffered from Alzheimer-type dementia, alcoholism, hypertension, and a left hip fracture. She developed shingles with postherpetic neuralgia in 2012, causing left thigh pain.

In 2012, after conducting an assessment, the physiotherapist involved in her case deemed her a high risk of falls because of poor trunk control, weakness, decreased sensation, cognitive impairment and poor judgment.

As a result, a seat-belt like restraint was recommended when she was in a wheelchair, along with a fall mat, bed alarm and two bed rails. The seat belt was assessed by the health product representative to ensure that it was properly fitted.

In the summer of 2012, it was noted that the patient was agitated and “acting strangely.” A new order was written for two, three-quarter length bed rails. Consent was obtained to use the bed rails from the family.

In the fall of 2013, the patient had an unwitnessed fall from her bed. Both side rails were up and there was a fall mat on the opposite side of bed from where she fell. It appeared that she slipped between the rail at the far end of the bed and fell to the floor. The patient was placed back in her bed.

The next morning, she complained of severe left hip pain and was transferred to an acute care hospital. X-rays revealed a fracture of the right superior pubic ramus, as well as a fractured left acetabulum. Orthopedics advised that the acetabular fracture was inoperable.

In discussion with the patient’s family, it was agreed the she would return to the long-term care home and be given medication for pain and agitation, and oxygen to ease her breathing.

The woman died four days later in the long-term care home.

Consequences

The deceased’s family expressed concerns about the staffing on the evening of the fall to the long-term care home. An investigation found that staffing on the night of the fall was within the legislative requirements. There was no direct evidence that staffing was an issue in this case.

Her cause of death was determined to be complications of pelvic fracture due to a fall from a bed, with a contributing factor of Alzheimer’s dementia. It was ruled an accident by the Coroner.

Questions for Physiotherapists to Think About

When a patient is harmed, we should all pause and reflect on ways to potentially improve practice.When considering using any kind of restraint with a patient in your care, ask yourself:

• What are the risks associated with using a particular restraint?
• What factors contribute to patients who have dementia becoming more agitated?
• Are there alternatives to restraints that can be used with this particular patient? What are your options?