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Hospital refuses to record injury my Mom sustained while a patient

SC68

Junior Member
#1
What is the name of your state (only U.S. law)? California

Why won't the hospital put in my Mom's records/medical chart that she fell from hospital bed and sustained black eye which also led to bruising on her neck while in hospital?

My Mom who is 90 years old and in pretty good health was taken by ambulance to a hospital, it was determined that she had a urinary tract infection. The hospital admitted her. Sometime during the night my mom received a black eye and a bruised neck. the following morning after being admitted when my siblings and I arrived at the hospital to visit my Mom, that's when we noticed the black eye. When we asked what happened, the nurse said that at some point during the night my Mom fell from her bed and that they found her on the floor. When we tried to get more information and asked to speak to the nurse that was on duty caring for my Mom that night the hospital nurses that were there said they didn't know which nurse was on duty.

My family members and I made several attempts at finding out which nurse was on duty caring for my Mom when the injury happened so that we could speak with her in order to find out what happened, but we still haven't been able to speak with her or even know her name. Then the nurses said began to tell us that they couldn't give us any more information about my Mom. When we finally were able to speak to the doctor and asked him about my Mom's black eye he said, "Did she receive the black eye at home?". We told the doctor no she did not receive the black eye at home. The doctor said that there was no record in my Mom's chart of her having any black eye. We asked why my Mom's injury, black eye, wasn't recorded in her chart or by the hospital anywhere, he said he couldn't tell us anymore information.

My Mom now has fluid on the brain. The hospital is suggesting that the fluid on her brain could be a symptom of dementia. My siblings and I scheduled and had a meeting with hospital doctors, nurses and floor manager and they still haven't recorded in my Mom's hospital records that she fell from her bed while in the hospital and sustained a black eye, they have verbally admitted that the fall happened at the hospital, but they will not put it in writing.

The hospital has told us that they have done several CT Scans. I asked a nurse, exactly what is my Mom being treated for and the nurse said that she was only being treated (given antibiotics) for the urinary tract infection.

Then why the CT Scans? My Mom was admitted into the hospital on Monday January 29th, taken by ambulance from her home and is still in the hospital. I believe it was the floor nurse manager that said that when my Mom is discharged to come home she will need home nursing care and that she doesn't know if my Mom's insurance (my Mom only has Medi-Care) will cover it as there may be additional health insurance coverage needed.

On Saturday February 3rd during one of my visits a hospital social worker came into my Mom's room and told me that my Mom could be discharged and taken home, that all her tests (that she couldn't tell me specifically which tests were done) came back and that my Mom was good to go home, all they needed was for someone to sign her out. The social worker said that the hospital was recommending my Mom be taken to a rehab facility in order to receive physical therapy and to regain some strength, but that she (the social worker) said that she thought my Mom could be discharged taken home and have the physical therapy done at home.

My Mom was sedated during this conversation with the hospital social worker, I told the social worker that my Mom didn't look well enough to be discharged and going home and that I wanted to speak with my Mom's doctor because he would know more about my Mom's condition than she would and that I would not be signing my Mom out as I didn't know her condition.

This hospital would not tell us very much, hardly anything about my Mom's condition the whole time my Mom has been in the hospital as they said and stated repeatedly they couldn't unless one of the family members had a Power of Attorney for my Mom and then this social worker was telling me I could sign her out...how could that be, willing to let me sign my Mom out when before they said I had no authorization to get answers or make any decisions on my Mom's behalf per her condition?

My Mom has been under sedation most of the time she's been in the hospital and it's been hard to get answers directly from her regarding the treatment she's been receiving by the staff during her stay.

As far as I know the hospital still hasn't recorded her fall and the injury my Mom sustained from it in her chart. The hospital won't show us her chart anyway so we can't be sure of anything they're telling us, they just believe we should take their word and that's that.
 
Last edited:


cbg

I'm a Northern Girl
#2
Unless your mother has given her written and signed permission otherwise, the hospital is prohibited by Federal law from showing you her chart.
 

SC68

Junior Member
#3
Why do you suppose the hospital has refused to record the fall in her chart? They have told many different family members this. We all have pictures of my Mom's black eye and bruised neck.
 

SC68

Junior Member
#4
How is the hospital planning on explaining CT Scan billing if my Mom was only being treated for urinary tract infection? (rhetorical)
 
#5
Why do you suppose the hospital has refused to record the fall in her chart? They have told many different family members this. We all have pictures of my Mom's black eye and bruised neck.
You don't know they haven't since you told the doctor about it.

How is the hospital planning on explaining CT Scan billing if my Mom was only being treated for urinary tract infection? (rhetorical)
That is up to them and neither you nor your mother needs to worry about it unless medicare refuses to pay for it.
 

quincy

Senior Member
#6
What is the name of your state (only U.S. law)? California

Why won't the hospital put in my Mom's records/medical chart that she fell from hospital bed and sustained black eye which also led to bruising on her neck while in hospital?

My Mom who is 90 years old and in pretty good health was taken by ambulance to a hospital, it was determined that she had a urinary tract infection. The hospital admitted her. Sometime during the night my mom received a black eye and a bruised neck. the following morning after being admitted when my siblings and I arrived at the hospital to visit my Mom, that's when we noticed the black eye. When we asked what happened, the nurse said that at some point during the night my Mom fell from her bed and that they found her on the floor. When we tried to get more information and asked to speak to the nurse that was on duty caring for my Mom that night the hospital nurses that were there said they didn't know which nurse was on duty.

My family members and I made several attempts at finding out which nurse was on duty caring for my Mom when the injury happened so that we could speak with her in order to find out what happened, but we still haven't been able to speak with her or even know her name. Then the nurses said began to tell us that they couldn't give us any more information about my Mom. When we finally were able to speak to the doctor and asked him about my Mom's black eye he said, "Did she receive the black eye at home?". We told the doctor no she did not receive the black eye at home. The doctor said that there was no record in my Mom's chart of her having any black eye. We asked why my Mom's injury, black eye, wasn't recorded in her chart or by the hospital anywhere, he said he couldn't tell us anymore information.

My Mom now has fluid on the brain. The hospital is suggesting that the fluid on her brain could be a symptom of dementia. My siblings and I scheduled and had a meeting with hospital doctors, nurses and floor manager and they still haven't recorded in my Mom's hospital records that she fell from her bed while in the hospital and sustained a black eye, they have verbally admitted that the fall happened at the hospital, but they will not put it in writing.

The hospital has told us that they have done several CT Scans. I asked a nurse, exactly what is my Mom being treated for and the nurse said that she was only being treated (given antibiotics) for the urinary tract infection.

Then why the CT Scans? My Mom was admitted into the hospital on Monday January 29th, taken by ambulance from her home and is still in the hospital. I believe it was the floor nurse manager that said that when my Mom is discharged to come home she will need home nursing care and that she doesn't know if my Mom's insurance (my Mom only has Medi-Care) will cover it as there may be additional health insurance coverage needed.

On Saturday February 3rd during one of my visits a hospital social worker came into my Mom's room and told me that my Mom could be discharged and taken home, that all her tests (that she couldn't tell me specifically which tests were done) came back and that my Mom was good to go home, all they needed was for someone to sign her out. The social worker said that the hospital was recommending my Mom be taken to a rehab facility in order to receive physical therapy and to regain some strength, but that she (the social worker) said that she thought my Mom could be discharged taken home and have the physical therapy done at home.

My Mom was sedated during this conversation with the hospital social worker, I told the social worker that my Mom didn't look well enough to be discharged and going home and that I wanted to speak with my Mom's doctor because he would know more about my Mom's condition than she would and that I would not be signing my Mom out as I didn't know her condition.

This hospital would not tell us very much, hardly anything about my Mom's condition the whole time my Mom has been in the hospital as they said and stated repeatedly they couldn't unless one of the family members had a Power of Attorney for my Mom and then this social worker was telling me I could sign her out...how could that be, willing to let me sign my Mom out when before they said I had no authorization to get answers or make any decisions on my Mom's behalf per her condition?

My Mom has been under sedation most of the time she's been in the hospital and it's been hard to get answers directly from her regarding the treatment she's been receiving by the staff during her stay.

As far as I know the hospital still hasn't recorded her fall and the injury my Mom sustained from it in her chart. The hospital won't show us her chart anyway so we can't be sure of anything they're telling us, they just believe we should take their word and that's that.
Your mother is lucky to have you advocating for her, SC68.

It is not uncommon for those in a hospital to become disoriented, and an elderly (or any) patient might get up in the middle of the night to use the bathroom and misjudge the height of the bed, causing a fall. If the call button is not within reach, a patient can stay on the floor until someone checks patients' rooms.

Whatever the cause of a fall, however, the fall should be charted, especially if there was an injury and subsequent treatment.

I suggest you speak to an attorney in your area for advice.
 

LdiJ

Senior Member
#7
If it were my mom, I would happily sign her out of the hospital and promptly take her to another hospital for evaluation. I would pay for it out of my own pocket if necessary.

I agree with Quincy that people can become disoriented and fall from bed. The hospital's whitewashing of that event disturbs me.
 

quincy

Senior Member
#8
If it were my mom, I would happily sign her out of the hospital and promptly take her to another hospital for evaluation. I would pay for it out of my own pocket if necessary.

I agree with Quincy that people can become disoriented and fall from bed. The hospital's whitewashing of that event disturbs me.
It is possible (probable?) that the hospital had the mom sign a patient agreement form that advised in advance of medicine side effects (e.g., possible dizziness) and the importance of using call buttons when wanting to leave the bed and the risk of falls.

Because the number of patient falls in hospitals is so high, hospitals are being trained in fall-prevention measures. But these preventive measures are often only as good as the patients who choose to follow hospital recommendations.

I do not (necessarily) see any hospital fault in the fall itself (based on the little that has been provided in the way of information) but the fall and injury should have been noted.
 

LdiJ

Senior Member
#9
It is possible (probable?) that the hospital had the mom sign a patient agreement form that advised in advance of medicine side effects (e.g., possible dizziness) and the importance of using call buttons when wanting to leave the bed and the risk of falls.

Because the number of patient falls in hospitals is so high, hospitals are being trained in fall-prevention measures. But these preventive measures are often only as good as the patients who choose to follow hospital recommendations.

I do not (necessarily) see any hospital fault in the fall itself (based on the little that has been provided in the way of information) but the fall and injury should have been noted.
That is exactly what disturbs me about the whole thing.
 
#11
Furthemore unless mom gives them permission or they have guardianship of her or a power of attorney, the hospital cannot talk to OP and her siblings or show them her chart. OP hasn't stated that she has guardianship or is the POA for her mother.
 
#12
What is the name of your state (only U.S. law)? California

Why won't the hospital put in my Mom's records/medical chart that she fell from hospital bed and sustained black eye which also led to bruising on her neck while in hospital?....
This hospital would not tell us very much, hardly anything about my Mom's condition the whole time my Mom has been in the hospital as they said and stated repeatedly they couldn't unless one of the family members had a Power of Attorney for my Mom and then this social worker was telling me I could sign her out...how could that be, willing to let me sign my Mom out when before they said I had no authorization to get answers or make any decisions on my Mom's behalf per her condition?
You are assuming that the fall was not recorded. You don’t actually know that to be the case since you have not had access to her records to find that out. It may be that it was recorded. The federal law known as the Health Insurance Portability and Accountability Act (HIPAA) includes a health records privacy rule that prohibits covered entities (health insurers and most medical care providers, including hospitals) from disclosing protected health information (PHI) to persons other than the patient except where allowed by the rule. As it applies here, the hospital would need to have written consent from your mother consenting to the release of her medical information to you before the hospital may let you see the records. Some states have their own medical record privacy laws. In those states the medical provider must follow the stricter of the two laws.

The laws regarding who may make health care decisions for your mother is set by state law, not federal law. If your mother is legally competent to make decisions concerning her care, then she is the primary person to make her own health care decisions. A hospital could also accept health care decisions by a person to whom she has granted that authority in a power of attorney, however, though it would not be compelled to do so.

If she is not legally competent then the hospital would look first to whomever she granted authority in a durable health care power of attorney to make those decisions and if no such power of attorney exists then it would be her spouse or next of kin who would make those decisions. The problem is that if it is simply the next of kin the hospital has to do a balancing act to provide the next of kin with enough information to make decisions without disclosing PHI in violation of HIPAA and/or state law. That may be what is going on here and would explain why the hospital is telling you a few things but not not letting you see the full medical records.
 

quincy

Senior Member
#13
We (and the OP) don't know that it wasn't noted.
Right. We don't know that there is not a record of the fall and injury. We were only told that an attending physician said nothing was noted on the chart.

An oft-quoted estimate is that there are 700,000 to 1,000,000 falls by patients in US hospitals every year. These falls are keeping some health care malpractice attorneys busy.

Here is a link to one of many reports on patient falls and how hospitals can work to prevent them:

http://www.hpoe.org/Reports-HPOE/2016/preventing-patient-falls.pdf

I think that SC68 should speak with an attorney who can meet with the mom to discuss the circumstances that led to her injuries. A personal review of the incident by an attorney can better help the mom determine if proper precautions were taken to prevent (as much as possible) a fall and if the standard of care was met.

My feeling is that it probably was and that the fall was - unfortunately - one of the more common risks that patients face when hospitalized (along with sepsis).
 

xylene

Senior Member
#14
HIPPA compliance does not explain away facial injuries.

You don't need to be a healthcare compliance officer to know when people are circling the wagons and looking to CYA.
 
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