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Grady and Emory complaint alleges pressure-injury care failures before sepsis death

The complaint alleges that a patient admitted to Grady Memorial Hospital after a fall and orthopedic surgery was left sitting in a chair for extended periods without repositioning or pressure-relieving cushions, leading to a sacral pressure injury. According to the complaint, the patient later was transferred to Emory University Hospital Midtown, where wound-care providers allegedly used inadequate treatment rather than sharp or enzymatic debridement. The complaint alleges that the wound progressed to a Stage 4 injury with osteomyelitis, sepsis, septic shock, respiratory failure, and death.

System
Grady Health System and Emory Healthcare
Facility
Grady Memorial Hospital
Providers involved
Grady Memorial Hospital Corporation / Emory Healthcare, Inc. / Emory University Hospital Midtown
Pattern
Alleged failure to reposition and treat a post-surgical patient with a progressing sacral pressure injury
Harm
Alleged Stage 4 sacral pressure injury, osteomyelitis, sepsis, septic shock, respiratory failure, and death

Overview

This page concerns a public complaint alleging that providers at Grady Memorial Hospital and Emory University Hospital Midtown failed to prevent and properly treat a severe sacral pressure injury in a post-surgical patient.

Chronology

  1. According to the complaint, the patient was admitted to Grady Memorial Hospital on July 13, 2023 after a fall and underwent surgery for patellar and femoral fractures.
  2. The complaint alleges that from July 16 through July 21, 2023, the patient was left sitting in a chair for extended periods, up to 11 hours, without repositioning or cushions.
  3. According to the complaint, a sacral wound was first recognized by staff on July 24, 2023.
  4. The complaint alleges that the patient was discharged to a rehabilitation center on July 30, 2023.
  5. According to the complaint, the patient was transferred to Emory University Hospital Midtown on August 2, 2023 for chest pain, and the sacral wound was noted to have fibrinous exudate.
  6. The complaint alleges that a wound-care nurse ordered triad hydrophilic paste on August 3, 2023, which the complaint characterizes as inadequate for the wound condition.
  7. According to the complaint, the wound later was documented as a non-healing Stage 4 injury with necrotic tissue and CT imaging showed osteomyelitis.
  8. The complaint alleges that the patient died on September 24, 2023 due to sepsis, septic shock, and respiratory failure.

Alleged failures

  • The complaint alleges that Grady Memorial Hospital staff failed to follow protocols for pressure-ulcer prevention.
  • The complaint alleges that staff failed to turn or reposition the patient or provide a cushion while she was sitting for extended periods.
  • The complaint alleges that Emory Healthcare providers used autolytic debridement when the standard of care allegedly required enzymatic or sharp debridement.
  • The complaint alleges that providers failed to provide timely hygienic measures after incontinent episodes, contributing to bacterial invasion of the wound.
  • The complaint alleges that the development and progression of the sacral pressure injury caused fatal sepsis.

Entities and tags

Grady Memorial Hospital CorporationGrady Memorial HospitalEmory Healthcare, Inc.Emory University Hospital MidtownSacral pressure injuryStage 4 pressure injuryOsteomyelitisSepsisSeptic shockDebridementPressure ulcersFailure to repositionInadequate wound careFailure to monitorWrongful deathWound careNursingOrthopedic surgeryRehabilitationHospital medicine

Questions this example answers

What does the Grady and Emory pressure injury complaint allege?

The complaint alleges that a patient admitted to Grady Memorial Hospital after a fall and orthopedic surgery was left sitting in a chair for extended periods without repositioning or pressure-relieving cushions, leading to a sacral pressure injury. According to the complaint, the patient later was transferred to Emory University Hospital Midtown, where wound-care providers allegedly used inadequate treatment rather than sharp or enzymatic debridement. The complaint alleges that the wound progressed to a Stage 4 injury with osteomyelitis, sepsis, septic shock, respiratory failure, and death.

Who is identified in this public case example?

This public case example identifies Grady Memorial Hospital Corporation, Emory Healthcare, Inc., and Emory University Hospital Midtown. It also tags the source-supported entities Grady Memorial Hospital Corporation, Grady Memorial Hospital, Emory Healthcare, Inc., Emory University Hospital Midtown, and Sacral pressure injury.

What alleged failures are summarized here?

The complaint alleges that Grady Memorial Hospital staff failed to follow protocols for pressure-ulcer prevention. The complaint alleges that staff failed to turn or reposition the patient or provide a cushion while she was sitting for extended periods. The complaint alleges that Emory Healthcare providers used autolytic debridement when the standard of care allegedly required enzymatic or sharp debridement.