Daniel E. Holloway
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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. 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 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

The complaint alleges as follows:

  1. The patient was admitted to Grady Memorial Hospital on July 13, 2023 after a fall and underwent surgery for patellar and femoral fractures.
  2. 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. A sacral wound was first recognized by staff on July 24, 2023.
  4. The patient was discharged to a rehabilitation center on July 30, 2023.
  5. 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. A wound-care nurse ordered triad hydrophilic paste on August 3, 2023, which the complaint characterizes as inadequate for the wound condition.
  7. The wound later was documented as a non-healing Stage 4 injury with necrotic tissue and CT imaging showed osteomyelitis.
  8. The patient died on September 24, 2023 due to sepsis, septic shock, and respiratory failure.

Alleged failures

The complaint alleges the following failures:

  • Grady Memorial Hospital staff failed to follow protocols for pressure-ulcer prevention.
  • Staff failed to turn or reposition the patient or provide a cushion while she was sitting for extended periods.
  • Emory Healthcare providers used autolytic debridement when the standard of care allegedly required enzymatic or sharp debridement.
  • Providers failed to provide timely hygienic measures after incontinent episodes, contributing to bacterial invasion of the wound.
  • 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 monitorWrongful deathWound careNursingOrthopedic surgeryRehabilitationHospital medicine