The Alarm Was Off at 2:40 a.m.: Applying the Four Elements of Nursing Negligence to a Hip Fracture After an Unwitnessed Fall
[Student Name]
University of Phoenix
NSG/426: Integrity in Practice: Ethic and Legal Considerations
Week 3 Assignment
[Instructor Name]
[Date]
The patient, nurse, hospital and lawsuit are a composite written for a model paper. No real case is described.
Pneumonia brought a composite 81-year-old woman to a medical unit. On admission, her nurse scored her at high risk for falls because of her age, a previous fall, intermittent confusion at night and a diuretic. The care plan specified a bed exit alarm, hourly rounding, a low bed and assistance to the bathroom. At 2:40 a.m. on her third night, she was found on the floor beside her bed with a shortened, externally rotated left leg. The bed alarm was switched off. She had a hip fracture, underwent surgery and died of complications three weeks later. Her family sued. Whether the nurse was negligent would be decided less by what she remembered than by what her chart could prove. This paper applies the four elements of negligence to the case.
Duty
The first element is duty: the plaintiff must show that the nurse owed the patient a duty of care. Duty arises from the nurse-patient relationship, created when a nurse accepts responsibility for a patient's care (Brous, 2019a). The night nurse had accepted this patient in her assignment, so a duty clearly existed. The content of the duty is the standard of care, measured against how a careful nurse with comparable training would act in the same situation, shaped by professional standards, hospital policies and the patient's care plan.
Breach
The second element is breach: failing to meet the standard of care. Brous (2019b) explained that breach is usually established through expert testimony about what the standard required, along with hospital policies, the care plan and the medical record. Here, the care plan called for a bed exit alarm, hourly rounding and assistance to the bathroom, and the hospital's fall prevention policy required alarms for high-risk patients.
The chart showed a mixed picture. Hourly rounding was documented through 1 a.m., then not again until the fall. There was no documentation of why the alarm was off. The nurse testified that the patient had asked for it to be turned off because it woke her when she shifted in bed, and that she had meant to turn it back on after answering another patient's call light. That reason was not charted. A plaintiff's expert could argue that the standard of care required keeping the alarm on, or documenting a reasoned decision to change the plan and notifying the charge nurse, and that a ninety-minute gap in rounding breached the plan. The defense could argue that one busy night with competing demands does not make a reasonable nurse negligent, but without documentation, that argument depends on the nurse's memory.
Causation
The third element is causation: the breach must have caused the injury, both in fact and as a foreseeable consequence. Brous (2019c) described how causation is often the most contested element, because patients can be injured despite good care. The defense could argue that a confused patient determined to get up might have fallen even with the alarm on, since alarms alert staff but do not prevent falls. The plaintiff could argue that an active alarm would have summoned the nurse before the patient walked, that hourly rounding would likely have met her toileting need and that falls are the foreseeable harm that fall precautions exist to prevent. Because the precautions were chosen specifically to prevent this kind of fall, a jury could reasonably find that their absence contributed to it.
Harm
The fourth element is harm, also called damages. Brous (2020) noted that without actual injury, even a clear breach does not support a malpractice claim, and that damages can include medical costs, pain and suffering, lost earnings and, in wrongful death cases, losses to survivors. Here the harm is significant: a hip fracture, surgery, and death three weeks later. The defense might argue that her pneumonia and age, not the fracture, caused her death, which returns the dispute to causation. Harm is established; how much of it the fall caused would be argued.
Where Liability Attaches
Liability in such a case is rarely the nurse's alone. Under respondeat superior, the hospital is generally liable for the negligence of employees acting within the scope of their employment. The hospital may also face direct corporate liability if its own systems contributed, for example if staffing levels made hourly rounding unrealistic, if alarms could be silenced without a documented override or if the policy was not enforced. The nurse may be named individually, and a separate complaint to the board of nursing could examine her practice regardless of the lawsuit's outcome. In a system review, the hospital should ask not only what this nurse did but why the system allowed a high-risk patient's alarm to be off for ninety minutes without anyone knowing.
What the System Review Found
The hospital's own review, separate from the lawsuit, found that the unit's bed exit alarms could be silenced with a single button and gave no reminder to reactivate them, that the night shift had been short one nursing assistant that week and that two other patients on the unit had asked for alarms to be turned off because of noise in the same month. The review led to three changes: alarms that automatically reactivate after a short pause, a documented override field requiring a reason and the charge nurse's awareness, and quieter alarm tones in patient rooms with the loud alert routed to staff phones. These findings do not excuse the individual lapse, but they show why the analysis of negligence and the analysis of safety ask different questions.
Documentation Lessons
The case shows what documentation does. Complete, timely charting of rounding supported the nurse for the hours it covered. The gap in rounding and the absence of a note about the alarm left her explanation unsupported. Had she documented the patient's request, her decision to turn the alarm off briefly, her plan to reactivate it and her notification of the charge nurse, the record would have shown a reasoned judgment rather than an omission. Documentation cannot make an unreasonable decision reasonable, but it shows the reasoning behind reasonable ones.
Conclusion
Applying the four elements to a fall with injury shows how negligence is judged. Duty was clear. Breach turned on the care plan, the policy and gaps in the chart. Causation was contestable but supported by the purpose of the precautions. Harm was severe. Liability would likely fall on both the nurse and the hospital, with the system's design examined alongside the individual's choices. For nurses, the lesson is that the standard of care is set by plans and policies, and that the chart is the evidence of whether it was met.
References
Brous, E. (2019a). The elements of a nursing malpractice case, part 1: Duty. American Journal of Nursing, 119(7), 64-67. https://doi.org/10.1097/01.NAJ.0000569476.17357.f5
Brous, E. (2019b). The elements of a nursing malpractice case, part 2: Breach. American Journal of Nursing, 119(9), 42-46. https://doi.org/10.1097/01.NAJ.0000580256.10914.2e
Brous, E. (2019c). The elements of a nursing malpractice case, part 3A: Causation. American Journal of Nursing, 119(11), 54-59. https://doi.org/10.1097/01.NAJ.0000605380.52689.af
Brous, E. (2020). The elements of a nursing malpractice case, part 4: Harm. American Journal of Nursing, 120(3), 61-64. https://doi.org/10.1097/01.NAJ.0000656360.21284.50
How this NSG 426 Week 3 example is structured
The NSG/426 shelf page describes Week 3 as taking up negligence, documentation and where liability attaches to a nurse. The paper follows the four elements a plaintiff must prove, in order, because each element turns on different evidence and the chart speaks to each differently. The liability section explains how responsibility is shared among the nurse, the employer and the system, and the final section turns the analysis into documentation and practice lessons. Students search this week as NSG 426 Week 3, NSG426 Wk 3 or NSG/426 Wk 3; all three are the same assignment.
NSG/426 Week 3 questions, answered
What does NSG/426 Week 3 usually ask for?
The course shelf describes Week 3 as covering negligence, documentation and where liability attaches to a nurse. Many sections ask you to analyze a case using the elements of negligence or malpractice and discuss the role of documentation and the nurse's liability.
What are the four elements of negligence?
Duty, breach of duty, causation and harm (damages). The plaintiff must prove all four: that the nurse owed the patient a duty, failed to meet the standard of care, that the failure caused the injury and that the patient suffered harm.
If the hospital is sued, is the nurse protected?
Under respondeat superior, an employer is generally liable for the negligent acts of employees within the scope of employment, and hospitals usually defend and insure their nurses. Nurses can still be named individually, and conduct outside the scope of employment or professional misconduct can bring board of nursing action.
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