To prevent falls, hospitals keep elderly in bed

Dorothy Twigg was living on her own, cooking and walking without help until a dizzy spell landed her in the emergency room. She spent three days confined to a hospital bed, allowed to get up only to use a bedside commode. Twigg, who was in her 80s, was livid about being stuck in a bed with side rails and a motion sensor alarm, said Melissa Rowley, her cousin and caretaker.

“They’re not letting me get up out of bed,” Twigg protested in phone calls, Rowley recalled.

In just a few days at the Ohio hospital, where she had no occupational or physical therapy, Twigg grew so weak that it took three months of rehab to regain the ability to walk and take care of herself, Rowley said. Twigg repeated the same pattern — three days in bed in a hospital, three months of rehab — at least five times in two years.

Falls remain the leading cause of fatal and nonfatal injuries for older Americans. Hospitals face financial penalties when they occur. Nurses and aides get blamed or reprimanded if a patient under their supervision hits the ground.

But hospitals have become so overzealous in fall prevention that they are producing an “epidemic of immobility,” experts say. To ensure that patients will never fall, hospitalized patients who could benefit from activity are told not to get up on their own — their bedbound state reinforced by bed alarms and a lack of staff to help them move.

That’s especially dangerous for older patients, often weak to begin with. After just a few days of bed rest, their muscles can deteriorate enough to bring severe long-term consequences.

“Older patients face staggering rates of disability after hospitalizations,” said Kenneth Covinsky, a geriatrician and researcher at the University of California-San Francisco. His research found that one-third of patients 70 and older leave the hospital more disabled than when they arrived.

The first penalties took effect in 2008, when the Centers for Medicare and Medicaid Services declared that falls in hospitals should never happen. Those penalties are not severe: If a patient gets hurt in a hospital fall, CMS still pays for the patient’s care but no longer bumps up payment to a higher tier to cover treatment of fall-related conditions.

Still, Covinsky said that policy has created “a climate of fear of falling,” where nurses “feel that if somebody falls on their watch, they’ll be blamed for it.” The result, he said, is “patients are told not to move,” and they don’t get the help they need. To make matters worse, he added, when patients grow weaker, they are more likely to get hurt if they fall.

Congress introduced stiffer penalties with the Affordable Care Act, and CMS began to reduce federal payments by 1% for the quartile of hospitals with the highest rates of falls and other hospitalacquired conditions. That’s substantial because nearly a third of U.S. hospitals have negative operating margins, according to the American Hospital Association.

Nancy Foster, the AHA’s vice president of quality and patient safety policy, said these policy changes sent “a strong signal to the hospital field about things CMS expected us to be paying attention to.”

Limiting patient mobility “certainly is a potential unintended consequence,” she said. “It might have happened, but it’s not what I’m hearing on the front line. They’re getting people up and moving.”