Grady Memorial Hospital complaint alleges inadequate monitoring before brain-injured patient’s fall and cardiac arrest

The complaint alleges that physicians at Grady Memorial Hospital transferred a 19-year-old patient with a severe brain injury from the ICU to a general floor. He remained tachycardic and showed impaired safety awareness and impulsivity in therapy sessions. Nursing staff did not properly monitor him or ensure fall precautions, including a sitter, were always in place. On February 3, 2022, he was found on the floor in cardiac arrest. The complaint alleges his fall caused additional trauma to his brain before he went into cardiac arrest. He was resuscitated with CPR and underwent emergency repeat brain surgery for a worsening subdural hemorrhage. The complaint alleges prolonged oxygen deprivation during the arrest caused a catastrophic anoxic brain injury and his persistent vegetative state.

System: Grady Health System
Facility: Grady Memorial Hospital
Providers involved: Grady Memorial Hospital Corporation / The Fulton-DeKalb Hospital Authority d/b/a Grady Health System / Emory Healthcare, Inc. / Emory University / The Emory Clinic, Inc. / Morehouse Healthcare, Inc. / The Morehouse School of Medicine, Inc. / Jason Sciarretta, M.D. / Emily Smith, M.D. / Deepika Koganti, M.D. / Kahdi Udobi, M.D. / Alicia Edwards, NP / Tesfanesh Tellore, RN / Cardell Sudlow, RN, CM / Toyin Adigun, RN / Derianne Jones, RN / Christiana Udofia, RN
Pattern: Alleged failure to properly monitor a brain-injured patient after his transfer from the ICU to a general floor
Harm: Alleged fall, cardiac arrest, and a resulting anoxic brain injury with persistent vegetative state

Overview

This page concerns a public complaint alleging inadequate monitoring after a brain-injured patient’s transfer to a general floor, before his fall and cardiac arrest.

Chronology

The complaint alleges as follows:

The patient was admitted to Grady Memorial Hospital’s surgical ICU on January 22, 2022, with a right subdural hematoma from a head injury.
His condition worsened on January 23, 2022, and neurosurgeons performed an emergency decompressive hemicraniectomy with evacuation of the hematoma.
Dr. Jason Sciarretta took over his ICU care on January 31, 2022, noting tachycardia that morning after an extubation and reintubation.
On February 1 and 2, 2022, therapy notes described him as impulsive. On February 1, he could not tolerate standing for more than a few minutes because of rising heart rate.
On February 2, 2022, Dr. Sciarretta ordered his transfer from the ICU to a general floor, and Dr. Emily Smith and Dr. Kahdi Udobi agreed.
A 5:00 p.m. nursing flowsheet on February 3, 2022 recorded two of four bed side rails up and the bed alarm on.
He was later found on the floor of his room without a pulse and was resuscitated with CPR.

Alleged failures

The complaint alleges the following failures:

The complaint alleges the physician defendants breached the standard of care by transferring him to a general floor without adequate monitoring.
The complaint alleges the nursing defendants breached the standard of care by failing to properly monitor him. It alleges they did not ensure fall precautions, including a sitter, were always in place.
The complaint alleges his fall caused additional trauma to his brain before he went into cardiac arrest.
The complaint alleges prolonged oxygen deprivation during the arrest caused a catastrophic anoxic brain injury and his persistent vegetative state.
The complaint pleads medical malpractice against the physician and nurse-practitioner defendants and nursing negligence against the nurse defendants, with expert affidavits under O.C.G.A. § 9-11-9.1.

Entities and tags

Grady Memorial HospitalGrady Health SystemThe Fulton-DeKalb Hospital AuthorityEmory Healthcare, Inc.Morehouse Healthcare, Inc.Subdural hematomaDecompressive hemicraniectomyAnoxic brain injuryPersistent vegetative stateFulton CountyFailure to monitorFallsBrain or spine injuryCritical care medicineNeurosurgeryTrauma surgeryNursing