Daniel E. Holloway
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Memorial Health complaint alleges pressure injuries and absent nursing records after a T5-T6 spinal dislocation

The complaint alleges that a patient admitted to Memorial Health University Medical Center after a single-vehicle crash on April 1, 2024 with a T5-T6 spinal dislocation and no feeling or movement in either leg developed pressure injuries during the admission. A sacral pressure injury was first recorded in the chart on April 10, 2024, and the hospital record contains no nursing notes and no nursing assessments. On her transfer to Select Specialty Hospital on April 20, 2024 the patient was noted to have eight pressure injuries, including a Stage III sacral wound.

System
Memorial Health University Medical Center
Facility
Memorial Health University Medical Center
Providers involved
HCA Health Services of Georgia, Inc. / Savannah Health Services, LLC d/b/a Memorial Health University Medical Center / Select Specialty Hospital
Pattern
Alleged failure to turn, reposition, and document skin care for an immobile patient after a traumatic spinal injury
Harm
Alleged pressure injuries including a Stage III sacral wound, with malnutrition and dehydration

Overview

This page concerns a public complaint alleging that nursing care and documentation at Memorial Health University Medical Center did not prevent pressure injuries in an immobile patient after a traumatic spinal injury.

Chronology

The complaint alleges as follows:

  1. The patient arrived by EMS at the Memorial Health University Medical Center emergency department on April 1, 2024 after a single-vehicle crash, in critical condition.
  2. CT imaging that day showed an acute dislocation of the T5-T6 vertebral facets, multiple rib fractures, and small bilateral pneumothoraces, and she could not feel or move either leg.
  3. She underwent a T3-T7 spinal fusion on April 2, 2024 and a tracheostomy on April 11, 2024.
  4. A dietitian’s note of April 11, 2024 records a pending wound-care consult and a sacral pressure injury first cited in the record on April 10, 2024.
  5. Wound-care orders for the sacrum, right ankle, and right heel were entered on April 11 and 12, 2024, and the heel order was discontinued on April 18, 2024.
  6. The wound-care note itself is not present in the hospital record, which contains no nursing notes or nursing assessments.
  7. The patient was transferred to Select Specialty Hospital on April 20, 2024, where eight pressure injuries were recorded, including a Stage III sacral wound and unstageable wounds of the right ankle and scalp.

Alleged failures

The complaint alleges the following failures:

  • Staff failed to turn and reposition the patient every two hours or to document turning and repositioning.
  • Staff failed to provide hydration, nutrition, basic hygiene, and supervision, and to assess her risk of skin breakdown.
  • Orders for turning, repositioning, and offloading were not followed and skin integrity, wound care, and nursing assessments were not documented.
  • The complaint pleads ordinary negligence, professional negligence with an expert affidavit under O.C.G.A. § 9-11-9.1, loss of consortium, and punitive damages.

Entities and tags

Memorial Health University Medical CenterSavannah Health Services, LLCHCA Health Services of Georgia, Inc.Select Specialty HospitalPressure injuriesDeep tissue injurySacral pressure injuryT5-T6 dislocationSpinal fusionNursing documentationChatham CountyPressure ulcersDocumentation failuresHospital nursingWound careCritical careTrauma careSpine surgery