Atlanta Medical Center South complaint alleges no fall precautions before a sedated patient fell and hit his head
The complaint alleges that staff at Atlanta Medical Center South admitted a 62-year-old patient with schizophrenia under Georgia’s involuntary-commitment law on December 26, 2017. He also had stroke-related paresis, and staff ordered checks every fifteen minutes. Behavioral-unit staff then started sedating medications, including Zyprexa and as-needed Ativan, without addressing his known fall risk from paresis and wheelchair use. On the morning of December 28, 2017 staff found him on the floor of his room after he fell going to the shower. No staff member was present. The complaint alleges the failure to order continuous observation or fall precautions caused his fall and head injury.
Overview
This page concerns a public complaint alleging that psychiatric-unit staff did not order fall precautions before an at-risk patient fell and hit his head.
Chronology
The complaint alleges as follows:
- The patient, 62, arrived by ambulance at the Atlanta Medical Center South emergency department around 3:02 p.m. on December 26, 2017. He had auditory and visual hallucinations and stroke-related right-sided paresis requiring a wheelchair.
- Gregory C. Lunceford, M.D. examined him and found an acute exacerbation of schizophrenia. At 7:57 p.m., he ordered the patient’s admission to the psychiatric unit. His order noted a Georgia Form 1013 signed by another physician and required checks every fifteen minutes.
- He left the emergency department for the behavioral unit around 9:54 p.m. that night.
- On December 27, 2017 a treating physician’s history and physical noted his stroke history, wheelchair use, and paresis. Staff started him on Zyprexa and as-needed Ativan for anxiety.
- On the morning of December 28, 2017 staff found him on the floor of his room. He had fallen and hit his head while going to the shower, and no staff member was present.
- A progress note that morning described him as newly somnolent, with slurred speech and disorganized thinking. By December 29, 2017 he was severely lethargic and difficult to arouse.
Alleged failures
The complaint alleges the following failures:
- Staff did not continuously observe the patient or place him on fall precautions despite his known paresis and wheelchair use.
- Dr. Lunceford did not enter an order for continuous observation or notify other staff that the patient needed fall precautions.
- Staff administered Zyprexa and as-needed Ativan without accounting for their sedating effects on a patient already at risk of falling.
- The filing alleges that these failures caused the patient’s fall and head injury on December 28, 2017.
- The complaint pleads negligence, gross negligence, and reckless conduct against the defendants, and attaches an expert affidavit under O.C.G.A. § 9-11-9.1.