A sixty-nine-year-old woman underwent back surgery. Subsequently, she was admitted to a rehabilitation center. Upon admission, the woman was assessed as having a high fall risk based on her history of multiple falls, chair-bound status, poor vision, current medications, and predisposing conditions. The admission assessment noted that the woman required two-person assists with transfer and extensive assistance from the staff for her activities of daily living. Physical and occupational therapy assessments further documented the conditions that placed the woman at a high risk of falling, but noted she had good rehabilitation potential.
About a month after her admission, testing indicated that the woman had deep vein thrombosis (DVT) in her bilateral lower extremities. Her treating physician ordered bed rest for forty-eight hours and prescribed Coumadin and Lovenox, anticoagulants that prevent the blood from clotting, to treat the DVT and prevent complications such as pulmonary embolism. The physician also ordered that the woman's International Normalized Ratio (INR) levels be checked every Monday and Friday to monitor the effects of the Coumadin and Lovenox.
Two days later it was noted that the woman had slight edema and redness of her right thigh. The physician ordered that the woman continue to receive Coumadin and Lovenox. Later that day, tests showed that the woman had an INR of 1.18, which was slightly below the therapeutic range of 2.00 to 3.00. She also had a prothrombin time, which is a measure of how long it takes a person's blood to clot, of 13.9 seconds, which was above the normal range of 9.8 to 12.9 seconds. Three days later, a blood test indicated that the woman’s INR was within the normal range but her prothrombin time was 29.6 seconds. Even though the woman's INR was within the normal range, the woman continued to receive Lovenox injections. Despite the woman's physician's orders that her INR be checked every Monday and Friday, the woman's INR was not checked again during her stay at the rehabilitation center.
Three days after the last INR test, a nurse’s note stated that the woman had tried to go back to bed by herself, was unable to balance, and sat down on the floor. The woman’s physician was notified and x-rays were ordered to evaluate the woman’s lower back. About seven hours later, a nurse noted that there were no delayed injuries from the fall and the x-rays showed no signs of fracture.
The following day, a nurse noted that there were no delayed injuries from the fall, but the woman was restless, and had a knot on her lower right buttock with purple bruising covering the area. The next day, a nurse noted that the woman had a hemotomal bump on her buttocks, but no bleeding. Later that day, the woman was described as pale with labored breathing and was transferred to a medical center.
Upon admission to the medical center, the woman was assessed with tachycardia, anemia, extreme weakness, and altered mental status. Additional testing revealed she was suffering from traumatic retroperitoneal hematoma secondary to anticoagulation. She had an INR of 4.9 and a prothrombin time of 51.6 seconds. She was noted as having severe abdominal pain and bruising as well as large bruises on her buttocks, upper legs, pubis, and perineum that were caused by trauma. The woman was admitted to the intensive care unit and was intubated, sedated, and placed on mechanical ventilation. She received multiple blood transfusions and fresh frozen plasma in an attempt to correct her coagulopathy. The attending physician described the woman as being over anti-coagulated. She was also diagnosed with acute renal failure. She experienced failure of multiple organs. She died two days after admission to the medical center from respiratory failure, retroperitoneal bleeding, acute renal failure, and multiple organ failure. A subsequent autopsy concluded that the woman died from blunt force injury associated with Coumadin therapy.
The woman’s estate filed a health care liability suit against the rehabilitation center and the woman’ treating physician while she was a resident at the rehabilitation center. The complaint alleged that the rehabilitation center breached the applicable standards of care by failing to maintain adequate supervision, staffing, and assistance to prevent avoidable falls; failing to develop and maintain a care plan consistent with the woman's needs and history; failing to properly analyze accidents and conduct a sufficient post-fall evaluation; failing to know the rationale for and the effects of medications that were being administered; and failing to timely transfer the woman to the hospital. The estate filed an expert report in support of its claims. The expert discussed each of the theories of liability based on actions or omissions by the rehabilitation center that fell into two categories: (1) failing to prevent the woman from falling and (2) failing to properly monitor and transfer the woman to the medical center after her fall.
The rehabilitation center filed objections to the expert report. Specifically, the rehabilitation center argued that the report failed to adequately address any breach of the applicable standard of care by the rehabilitation center and sufficiently identify and describe causation. The rehabilitation center also filed a motion to dismiss.
The 116th Judicial District Court, Dallas County, Texas, overruled the rehabilitation center’s objections to the expert report and denied its motion to dismiss.
The Court of Appeals of Texas, Dallas, affirmed. The court held that the trial court did not abuse its discretion by determining the report was a good faith effort to comply with the statutory requirements and by denying the rehabilitation center's motion to dismiss.
The trial court did not abuse its discretion by determining the report was a good faith effort to comply with the statutory requirements and by denying the rehabilitation center's motion to dismiss. The report adequately addressed both breach of the applicable standard of care and causation as to the rehabilitation center's conduct after the woman's fall. The expert in his report set out a chain of events linking specific breaches of the applicable standard of care to the ultimate injury. The court found that the trial court could have reasonably determined the report adequately identified the manner in which the care rendered by the rehabilitation center failed to meet the applicable standard of care and explained the causal relationship between that failure and the injury, harm, or damages claimed.
The Court of Appeals of Texas, Dallas, affirmed the trial court’s overruling of the rehabilitation center’s objections to the expert report and denial of its motion to dismiss.
See: Nexion Health at Garland, Inc. v. Townsend, 2015 WL 3646773 (Tex. App. June 12, 2015) (not designated for publication).
See also Medical Law Perspectives, December 2013 Report: Thicker Than Water: Liability When Blood Clots Cause Injury or Death
See also Medical Law Perspectives, March 2014 Report: Blood Draws, Testing, Transfusions: Venipuncture Injury, Inaccurate Results, Tainted Blood - The Liability Risks
See also Medical Law Perspectives, May 2013 Report: Drugs, Dosage, and Damage: Physician Liability for Prescribing or Administering Medication
See the Medical Law Perspectives April 2, 2015, Blog: Use of Jury Instruction on Foreseeability in Medical Negligence Case