Daniel E. Holloway
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Northside Hospital complaint alleges a bed alarm was off before a fall-risk patient fell and suffered a fatal hematoma

The complaint alleges that hospital nurses did not maintain fall-risk precautions for a patient who had been assessed as a high fall risk. He was admitted for pneumonia after a fall at home. A nurse scored his fall risk at 85 on the night of December 20 to 21, 2022, and documented “forgets limitations” as a fall risk. His bed alarm was off when he got out of bed and fell at about 2:38 a.m. A CT scan about eighty minutes later found a new subdural hematoma that had not been present days earlier. His condition declined, and he died on December 22, 2022.

System
Northside Hospital, Inc.
Facility
Northside Hospital
Providers involved
Northside Hospital, Inc. / Kenyanna Ledgister, RN
Pattern
Alleged failure to maintain fall-risk precautions, including a bed alarm, for a high-fall-risk hospital patient
Harm
Alleged fall causing a subdural hematoma and death

Overview

This page concerns a public complaint alleging that hospital nurses did not keep a high-fall-risk patient’s bed alarm on. He fell in his room and developed a fatal subdural hematoma.

Chronology

The complaint alleges as follows:

  1. The patient was admitted to Northside Hospital on December 17, 2022 after a fall at home, and was treated for pneumonia.
  2. Nurses assessed him throughout his stay as a high fall risk, with daily Morse Fall Scale scores above 51.
  3. On the night of December 20 to 21, 2022, Kenyanna Ledgister, RN scored his fall risk at 85. She documented “forgets limitations” as his mental-status fall risk.
  4. At about 2:38 a.m. on December 21, 2022, the patient got out of bed and fell onto the floor. His bed alarm was off at the time.
  5. Staff then increased his bed rails from two to four and turned the bed alarm on.
  6. A CT scan at about 3:57 a.m. found a new 5-to-6-millimeter subdural hematoma that had not appeared on imaging from December 17, 2022.
  7. Neurosurgery was consulted but did not recommend intervention given the patient’s advanced age. He declined neurologically and died on the evening of December 22, 2022.

Alleged failures

The complaint alleges the following failures:

  • Nurse Ledgister and hospital staff did not maintain fall-risk precautions, including keeping the bed alarm on, for a patient scored as a high fall risk.
  • His daily fall-risk scores placed him at high risk, so high-risk fall precautions, including a bed alarm, should have been in place.
  • The filing alleges that the fall caused the subdural hematoma that led to the patient’s death.
  • The complaint pleads nursing malpractice against Northside Hospital, Inc. and Nurse Ledgister, and seeks wrongful-death and estate damages. It attaches an expert affidavit under O.C.G.A. § 9-11-9.1.

Entities and tags

Northside HospitalKenyanna Ledgister, RNSubdural hematomaFall-risk precautionsBed alarmMorse Fall ScaleDeKalb CountyFallsDelayed or missed diagnosisWrongful deathHospital medicineNursing