Daniel E. Holloway
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Wellstar Atlanta and Emory Decatur complaint alleges pressure-wound neglect before a patient’s death

The complaint alleges that a patient fell at home and was admitted to Wellstar Atlanta Medical Center with no skin wounds. About a month later, Emory Decatur Hospital accepted her for long-term acute care and found pressure injuries, including an unstageable sacral wound. The wound assessment did not change for three weeks, then was upgraded to a stage 4 pressure wound. She was discharged home still needing wound care, and she died about a year later. The filing alleges the two hospitals’ negligence proximately caused or contributed to her death.

System
Wellstar Health System, Inc.
Facility
Wellstar Atlanta Medical Center
Providers involved
Wellstar Health System, Inc. / Emory Healthcare, Inc.
Pattern
Alleged failure to prevent and then adequately treat pressure wounds across a hospital stay and a long-term acute care stay
Harm
Alleged stage 4 sacral pressure wound, prolonged wound treatment, and death

Overview

This page concerns a public complaint alleging that a hospital and a long-term acute care facility failed to prevent and treat a patient’s pressure wounds. The complaint alleges the neglect contributed to her death.

Chronology

The complaint alleges as follows:

  1. On February 10, 2020, the patient fell at home, was taken to Wellstar Atlanta Medical Center, and was diagnosed with a subdural hematoma.
  2. She had no skin wounds at admission, then underwent a craniectomy the next day and went into a coma on a ventilator.
  3. On March 10, 2020, Wellstar discharged her to Emory Decatur Hospital for long-term acute care.
  4. An admission assessment there found bilateral heel injuries and an unstageable sacral pressure wound measuring 3 by 2 centimeters.
  5. The wound assessment did not change for three weeks, then was upgraded to a stage 4 pressure wound on April 3, 2020.
  6. Emory discharged her home on April 6, 2020 with a tracheostomy and feeding tube, and she needed wound care for about ten more months.
  7. She died on March 6, 2021, and the complaint alleges the defendants’ negligence caused or contributed to her death.

Alleged failures

The complaint alleges the following failures:

  • Staff at both hospitals did not institute an appropriate care plan to prevent pressure injuries and did not take adequate measures to prevent them.
  • Staff failed to assess, monitor, and document her wounds and failed to obtain appropriate consultations.
  • Staff failed to notify the physician and family of a significant change in her condition and failed to document her care.
  • The two hospitals were chronically understaffed and failed to properly train their nursing staff.
  • The complaint pleads professional and simple negligence, vicarious liability, negligence per se, and violations of Georgia’s bill of rights for long-term care residents. It also pleads breach of contract, understaffing, joint enterprise, negligent hiring and supervision, and punitive damages, and attaches an expert affidavit under O.C.G.A. § 9-11-9.1.

Entities and tags

Wellstar Atlanta Medical CenterWellstar Health System, Inc.Emory Decatur HospitalEmory Healthcare, Inc.Subdural hematomaPressure woundsSacral woundDeKalb CountyPressure ulcersUnderstaffingFailure to monitorWrongful deathNursing careWound careLong-term acute care