Daniel E. Holloway
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Budd Terrace at Wesley Woods complaint alleges fall-risk assessment and supervision failures before brain injury

The complaint alleges that a 69-year-old resident of Budd Terrace at Wesley Woods was rated a low fall risk even though the admitting physician documented a need for fall and delirium precautions and records showed she needed extensive help with walking and was totally dependent for transfers and bathing. Physical Therapy rated her a fall risk and Occupational Therapy told the charge nurse that staff needed to increase vigilance, but no further fall-prevention measures were added. She sustained an unwitnessed fall three days after admission, suffered facial fractures and bleeding in the brain requiring emergency surgery, and records of the fall were incomplete.

System
Budd Terrace at Wesley Woods
Facility
Budd Terrace at Wesley Woods
Providers involved
Emory North Clifton, Inc. f/k/a Wesley Woods Center of Emory University, Inc. d/b/a Budd Terrace at Wesley Woods / HCR Manor Care Services, LLC / ProMedica Health System, Inc. / Emory Healthcare, Inc. / Northside Hospital / Wellstar North Fulton Hospital
Pattern
Alleged low fall-risk rating and generic care planning for a dependent skilled-nursing resident
Harm
Alleged unwitnessed fall, facial fractures, intracranial bleeding, and emergency craniectomy

Overview

This page concerns a public complaint alleging that a skilled-nursing facility rated a resident a low fall risk and did not act on therapist warnings before an unwitnessed fall.

Chronology

The complaint alleges as follows:

  1. The resident was admitted to Budd Terrace at Wesley Woods on June 10, 2024 after a hospital stay for a urinary tract infection.
  2. The admitting physician documented a need for fall and delirium precautions, while nursing documented a low fall risk and a generic fall care plan.
  3. Physical Therapy rated the resident a fall risk on June 11, 2024 with a dynamic gait index score of 3/24.
  4. Occupational Therapy told the charge nurse on June 12, 2024 that staff needed to increase vigilance to prevent a fall.
  5. The resident sustained an unwitnessed fall on June 13, 2024 and was taken by EMS to Northside Hospital with intracranial hemorrhage and facial fractures.
  6. She was transferred to Wellstar North Fulton Hospital, underwent an emergency craniectomy, and remained hospitalized until July 8, 2024.

Alleged failures

The complaint alleges the following failures:

  • The low fall-risk rating was inaccurate given documented dependence on staff for transfers, bathing, and dressing.
  • The care plan left out steps such as frequent rounds, non-slip footwear, scheduled toileting, and increased supervision.
  • Fall risk was not reassessed after the therapy findings and the June 12, 2024 warning.
  • Fall documentation was incomplete and the discharge Minimum Data Set stated there had been no falls since admission.
  • The complaint pleads professional negligence, negligent hiring, retention and training, violations of the Georgia Bill of Rights for Residents of Long-term Care Facilities, and punitive damages, with an expert affidavit under O.C.G.A. ยง 9-11-9.1.

Entities and tags

Budd Terrace at Wesley WoodsEmory North Clifton, Inc.HCR Manor Care Services, LLCProMedica Health System, Inc.Emory Healthcare, Inc.Northside HospitalWellstar North Fulton HospitalUnwitnessed fallSubarachnoid hemorrhageCraniectomyFallsNegligent hiring or supervisionFailure to monitorNursing-home neglectDocumentation failuresSkilled nursing careLong-term careNursing home careFall preventionNursing