Daniel E. Holloway
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Emory Midtown complaint alleges a failed catheter and a pressure ulcer that worsened at Wellstar before death

The complaint alleges that a 93-year-old patient developed a pressure ulcer after five days at Emory University Midtown Hospital in July 2021. Nurses allegedly did not prevent her from lying on a wet bed for five days or properly use her external catheter. After transfer to Wellstar Atlanta Medical Center South for a kidney injury, staff did not follow wound-care orders or obtain an ordered wound culture. An old dressing remained on her wound past discharge. She went home on hospice care, and an unstageable wound was found on July 30, 2021. The filing alleges she died on August 4, 2021, in extreme pain caused by the failure to prevent an extreme pressure sore.

System
Emory Healthcare
Facility
Emory University Midtown Hospital
Providers involved
Emory Healthcare, Inc. / Emory University / Wellstar Health System, Inc.
Pattern
Alleged failure to manage a urinary catheter and follow wound-care orders for a worsening pressure ulcer
Harm
Alleged unstageable pressure ulcer, pain, and death

Overview

This page concerns a public complaint alleging that hospital nurses did not properly manage a catheter and pressure-ulcer wound care before the patient’s death.

Chronology

The complaint alleges as follows:

  1. The 93-year-old patient was admitted to Emory University Midtown Hospital on July 2, 2021, for fatigue and a urinary tract infection.
  2. On July 4, 2021, a family member found urine pooling between her thighs. Her PureWick catheter appeared not to be suctioning urine.
  3. She was discharged to a rehabilitation facility on July 7, 2021. A wound-care nurse there found a small open area on her sacrum and a heel injury the next day, July 8, 2021.
  4. On July 12, 2021, she was transferred to Wellstar Atlanta Medical Center South for a kidney injury and dehydration. Her pressure injuries showed no change in measurements.
  5. A wound-care order on July 21, 2021, called for dressing changes three times a week or as needed. The complaint says a dressing dated July 13, 2021, shows the order was not followed.
  6. She went home on hospice care on July 27, 2021. On July 30, 2021, the dressing dated July 13 was found intact; underneath was an unstageable wound.
  7. She died on August 4, 2021.

Alleged failures

The complaint alleges the following failures:

  • The complaint says there is no indication Emory nurses changed the PureWick device during her stay. Its directions call for changing it every eight hours.
  • Staff at Wellstar Atlanta Medical Center South did not follow a physician’s order for wound care and did not obtain an ordered wound culture.
  • Wellstar staff did not perform routine assessments and were not aware of the wound’s stage at discharge. The hospice nurse recorded a hospital nurse’s report of ’at least a stage 2-4.’
  • The filing alleges that she died while suffering extreme pain caused by the failure to prevent the pressure sore.
  • The complaint pleads professional negligence and vicarious liability against the hospital defendants, vicarious liability against unnamed entities, breach of contract, and damages. It attaches an expert affidavit under O.C.G.A. § 9-11-9.1.

Entities and tags

Emory University Midtown HospitalEmory Healthcare, Inc.Emory UniversityWellstar Atlanta Medical Center SouthWellstar Health System, Inc.Pressure ulcerPureWick catheterDeKalb CountyPressure ulcersNursing careWound careHospital medicine