Risk Management

Elderly Patient Falls from Wheelchair Following a Dilated Exam

By Ryan Bucsi, OMIC Senior Litigation Analyst

ALLEGATION: Failure to assess fall risk and to warn patient of effects of dilating drops on visual accuity.

DISPOSITION: Case dismissed following patient’s death from causes unrelated to injuries sustained in fall.

Case Summary

An elderly patient underwent a dilated examination by an optometrist at an OMIC insured ophthalmology group. She was unaccompanied and used an electric wheel- chair. As she was leaving the building following the exam, staff gave her a pair of sunglasses and asked if she required assistance to her car; she declined. Shortly thereafter, some staff members were eating lunch outside the office when they heard a loud crash. They found the patient lying on the steps with her head bent into the stairs. Apparently, she had misjudged the stairs for the wheelchair ramp upon exiting the building.

An ambulance was called, and the patient was admitted to the ICU where a CT scan displayed a small intra-parenchymal contusion. She remained neurologically intact and was not felt to be an appropriate candidate for rehabilitation service at the hospital. Instead, she was discharged nine days later and admitted to a long-term skilled nursing facility where she received care for a rotator cuff tear on her right shoulder. She was subsequently discharged from the skilled nursing facility and was followed by a neurologist. The neurologist noted that her double vision had gradually subsided and that her memory for recent and remote events was unaffected. The patient remained independent in all activities of daily living. She died of an unrelated illness during the investigation of her claims.

Analysis

Staff at the OMIC-insured facility certainly did the right thing by providing sunglasses, offering assistance, and documenting the patient’s refusal of it. In retrospect, however, it is clear that the patient was a poor judge of her own need for help. Moreover, the offer of help did not prevent the plaintiff attorney from alleging that more proactive care in the form of a fall risk assessment was required. Indeed, this patient had several risk factors, including her advanced age, wheel- chair use, unaccompanied status, and a decline or alteration of vision due to dilating drops.

Furthermore, the wheelchair ramp and stairs leading out of the building were the same color, and it was arguably difficult to distinguish between the two, even with good vision. The lawsuit also alleged a failure to warn since the patient was not told of the risk of a fall or the danger of operating machinery, i.e., driving a motorized wheelchair, while her vision was impaired.

Risk Management Principles

Falls are the most common type of accident in the hospital setting and the fifth leading cause of death among persons over age 65.1 Ophthal- mologists routinely treat elderly individuals with physical limitations, motility impairment, and poor visual acuity. When these same individuals are administered dilating drops, the known side effects—decreased visual acuity, photophobia, lack of accommodation, glare, blurred vision, and decreased contrast threshold and contrast visual acuity—can prove to be much more than they can safely handle.

Fall prevention requires assessment, assistance, supervision, and surveillance. Assistance to and from the office and when getting up from a chair should specifically be offered or supplied to the elderly, handicapped, and/or visually impaired. Thorough evaluation of all of a patient’s risk factors as well as an evaluation of the general surroundings should be performed in assessing each patient’s risk for an accident following a dilated examination. Utilizing color schemes that maximize the differences between floors, steps, walls, and ramps can decrease the likelihood of a patient fall and injury.

In addition to assessing patients for fall risk, ophthalmologists and/or their staff should also obtain informed consent for dilating drops and offer patients sunglasses. While this case involved a fall, patients and other injured parties have also sued ophthalmologists when patients whose eyes were dilated were involved in motor vehicle accidents after leaving the ophthalmologist’s office. See the Risk Management Hotline article in this issue as well as OMIC’s risk management recommendations and sample consent form at www.omic.com.