In the State Court of Gwinnett County

State of Georgia

WILLIE EVA SAMPSON, as Guardian of DOROTHY ANN ANTHONY,

                  Plaintiff,

— versus —

DOCTORS HOSPITAL OF AUGUSTA, LLC

HCA HEALTH SERVICES OF GEORGIA, INC.

HCA HEALTH SERVICES OF TENNESSEE, INC.

ADAM M. ROSS, MD

JONATHAN PRESTON, MD

JAMES A. CATO, MD

EKMINE WIJESINGHE, MD

JDG CIRCLE INPATIENT SERVICES LLC

CSRA MEDICAL ASSOCIATES

JOHN/JANE DOE 1-10,

                  Defendants

CIVIL ACTION

FILE NO. ___________

JURY TRIAL DEMANDED

Plaintiff’s Complaint for Damages

Nature of the Action

1.             This medical malpractice action arises out of medical services negligently performed on Dorothy Anthony in October and November 2018.

2.             This case concerns a “pressure wound” that developed over Dorothy’s sacral area while she was a patient at Doctors Hospital of Augusta (DHA). The wound developed because of neglect by the staff at DHA, and it progressed under DHA’s negligent care to the point that the wound became a severe, incurable “stage 4” wound that caused Dorothy to go into life-threatening septic shock and that has left her with permanent, serious injuries, chronic bone infections, and a risk of premature death.

3.             Pursuant to OCGA § 9-11-9.1, the Affidavits of Christopher Davey, MD, and Judith Climenson, RN, are attached hereto as Exhibits 1-2. This Complaint incorporates the opinions and factual allegations contained in those affidavits.

4.             As used in this Complaint, the phrase “standard of care” means that degree of care and skill ordinarily employed by the medical profession generally under similar conditions and like circumstances as pertained to the Defendant’s actions under discussion.

Parties, Jurisdiction, and Venue

5.             Willie Eva Sampson and Dorothy Anthony are citizens of Georgia. Ms. Sampson is the older sister, and guardian, of Dorothy Anthony.

6.             Defendant Doctors Hospital of Augusta, LLC (“DHA”) is a Delaware limited liability company registered to do business in Georgia. DHA’s Registered Office is in Gwinnett County. DHA may be served through their Registered Agent, C T Corporation System, at 289 S Culver St, Lawrenceville, GA, 30046-4805.

7.             DHA participates in owning the hospital that operates under the name “Doctor’s Hospital of Augusta” at 3651 Wheeler Road in Augusta, Georgia.

8.             DHA participates in operating the hospital that operates under the name “Doctor’s Hospital of Augusta” at 3651 Wheeler Road in Augusta, Georgia.

9.             DHA participates in supervising the management of the hospital that operates under the name “Doctor’s Hospital of Augusta” at 3651 Wheeler Road in Augusta, Georgia.

10.          DHA is subject to the personal jurisdiction of this Court.

11.          DHA is subject to the subject-matter jurisdiction of this Court in this case.

12.          DHA has been properly served with this Complaint.

13.          DHA has no defense to this lawsuit based on undue delay in bringing suit — whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

14.          Pursuant to OCGA §§ 14-2-510, 14-3-510, and 14-11-1108[1] DHA is subject to venue in this Court because (a) it maintains its registered office in Gwinnett County.

15.          In October and November 2018, DHA was an employer or other principal of the nursing staff at Doctors Hospital of Augusta who were involved in the treatment of Dorothy Anthony in October and November 2018.

16.          However, if any other entity was a principal of those nurses, each such entity is hereby on notice that but for a mistake concerning the identity of the proper party, the action would have been brought against it.

17.          Defendant HCA Health Services of Georgia, Inc. (“HCA-GA”) is a Georgia corporation with its Registered Office in Gwinnett County. HCA-GA may be served through their Registered Agent, C T Corporation System, at 289 S Culver St, Lawrenceville, GA, 30046-4805.

18.          HCA-GA participates in owning the hospital that operates under the name “Doctor’s Hospital of Augusta” at 3651 Wheeler Road in Augusta, Georgia.

19.          HCA-GA participates in operating the hospital that operates under the name “Doctor’s Hospital of Augusta” at 3651 Wheeler Road in Augusta, Georgia.

20.          HCA-GA participates in supervising the management of the hospital that operates under the name “Doctor’s Hospital of Augusta” at 3651 Wheeler Road in Augusta, Georgia.

21.          HCA-GA is subject to the personal jurisdiction of this Court.

22.          HCA-GA is subject to the subject-matter jurisdiction of this Court in this case.

23.          HCA-GA has been properly served with this Complaint.

24.          HCA-GA has no defense to this lawsuit based on undue delay in bringing suit — whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

25.          Pursuant to OCGA §§ 14-2-510, 14-3-510, and 14-11-1108 HCA-GA is subject to venue in this Court because (a) it maintains its registered office in Gwinnett County.

26.          In October and November 2018, HCA-GA was an employer or other principal of the nursing staff at Doctors Hospital of Augusta who were involved in the treatment of Dorothy Anthony in October and November 2018.

27.          However, if any other entity was a principal of those individuals, each such entity is hereby on notice that but for a mistake concerning the identity of the proper party, the action would have been brought against it.

28.          Defendant HCA Health Services of Tennessee, Inc. (“HCA-TN”) is a Tennessee corporation registered to do business in Georgia. HCA-TN has its Registered Office in Gwinnett County. HCA-TN may be served through their Registered Agent, C T Corporation System, at 289 S Culver St, Lawrenceville, GA, 30046-4805.

29.          HCA-TN participates in owning the hospital that operates under the name “Doctor’s Hospital of Augusta” at 3651 Wheeler Road in Augusta, Georgia.

30.          HCA-TN participates in operating the hospital that operates under the name “Doctor’s Hospital of Augusta” at 3651 Wheeler Road in Augusta, Georgia.

31.          HCA-TN participates in supervising the management of the hospital that operates under the name “Doctor’s Hospital of Augusta” at 3651 Wheeler Road in Augusta, Georgia.

32.          HCA-TN is subject to the personal jurisdiction of this Court.

33.          HCA-TN is subject to the subject-matter jurisdiction of this Court in this case.

34.          HCA-TN has been properly served with this Complaint.

35.          HCA-TN has no defense to this lawsuit based on undue delay in bringing suit — whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

36.          Pursuant to OCGA §§ 14-2-510, 14-3-510, and 14-11-1108 HCA-TN is subject to venue in this Court because (a) it maintains its registered office in Gwinnett County.

37.          In October and November 2018, HCA-TN was an employer or other principal of the nursing staff at Doctors Hospital of Augusta who were involved in the treatment of Dorothy Anthony in October and November 2018.

38.          However, if any other entity was a principal of those individuals, each such entity is hereby on notice that but for a mistake concerning the identity of the proper party, the action would have been brought against it.

39.          Non-Defendant HCA Healthcare, Inc. (“HCA Inc.”) is the ultimate corporate parent of Defendants DHA, HCA-GA, and HCA-TN.

40.          HCA Inc. is a publicly traded for-profit corporation.

41.          In 2019, HCA Inc. operated 184 hospitals, comprised of 179 general, acute care hospitals; three psychiatric hospitals; and two rehabilitation hospitals. In addition, HCA Inc. operated 123 freestanding surgery centers.

42.          HCA Inc.’s facilities are located in 21 states and England.

43.          In 2019, HCA Inc. had nearly 280,000 employees, including 98,000 registered nurses.

44.          HCA Inc. has a market capitalization of over $45 billion.

45.          In 2019, HCA Inc. had revenues of over $51 billion, and net income of over $3.5 billion.

46.          DHA, HCA-GA, and HCA-TN are not under-resourced entities.

47.          DHA, HCA-GA, and HCA-TN have the resources to operate medical facilities properly.

48.          DHA, HCA-GA, and HCA-TN have the resources to provide appropriate treatment for their patients, including Dorothy Anthony.

49.          Defendant Adam M. Ross, MD is a citizen of Georgia. He may be served at his residence: 944 Heard Ave, Augusta, GA 30904-4165 in Richmond County.

50.          Dr. Ross is subject to the personal jurisdiction of this Court.

51.          Dr. Ross is subject to the subject-matter jurisdiction of this Court in this case.

52.          Dr. Ross has been properly served with this Complaint.

53.          Dr. Ross has no defense to this lawsuit based on undue delay in bringing suit — whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

54.          Pursuant to OCGA 9-10-31, Dr. Ross is subject to venue in this Court because his co-defendants are subject to venue in this Court.

55.          At all times relevant to this Complaint, Dr. Ross acted as an employee or agent of JDG Circle Inpatient Services, LLC.

56.          At all times relevant to this Complaint, Dr. Ross acted as an employee or agent of DHA.

57.          At all times relevant to this Complaint, Dr. Ross acted as an employee or agent of HCA-GA.

58.          At all times relevant to this Complaint, Dr. Ross acted as an employee or agent of HCA-TN.

59.          At all times relevant to this Complaint, Dr. Ross acted as an employee or agent of HCA-TN.

60.          Defendant Jonathan Preston, MD is a citizen of Georgia. He may be served at his residence: 458 Timber Wolf Trail, Augusta, GA 30907-8948.

61.          Dr. Preston is subject to the personal jurisdiction of this Court.

62.          Dr. Preston is subject to the subject-matter jurisdiction of this Court in this case.

63.          Dr. Preston has been properly served with this Complaint.

64.          Dr. Preston has no defense to this lawsuit based on undue delay in bringing suit — whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

65.          Pursuant to OCGA 9-10-31, Dr. Preston is subject to venue in this Court because his co-defendants are subject to venue in this Court.

66.          At all times relevant to this Complaint, Dr. Preston acted as an employee or agent of JDG Circle Inpatient Services, LLC.

67.          At all times relevant to this Complaint, Dr. Preston acted as an employee or agent of DHA.

68.          At all times relevant to this Complaint, Dr. Preston acted as an employee or agent of HCA-GA.

69.          At all times relevant to this Complaint, Dr. Preston acted as an employee or agent of HCA-TN.

70.          At all times relevant to this Complaint, Dr. Preston acted as an employee or agent of HCA-TN.

71.          Defendant JDG Circle Inpatient Services, LLC (“JDG”) is a Georgia limited liability company. JDG’s Registered Office is in Cobb County. JDG may be served through their Registered Agent, CSC of Cobb County, Inc. at 192 Anderson Street SE, Suite 125, Marietta, GA, 30060.

72.          JDG is subject to the personal jurisdiction of this Court.

73.          JDG is subject to the subject-matter jurisdiction of this Court in this case.

74.          JDG has been properly served with this Complaint.

75.          JDG has no defense to this lawsuit based on undue delay in bringing suit — whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

76.          Pursuant to OCGA 9-10-31, JDG is subject to venue in this Court because their co-defendants are subject to venue in this Court.

77.          In October and November 2018, JDG was an employer or other principal of Dr. Ross and of Dr. Preston in October and November 2018.

78.          However, if any other entity was a principal of Dr. Ross or Dr. Preston, each such entity is hereby on notice that but for a mistake concerning the identity of the proper party, the action would have been brought against it.

79.          Defendant James A. Cato, MD is a citizen of Georgia. He may be served at his residence: 3210 Walton Way Ext, Augusta, GA 30909-3119.

80.          Dr. Cato is subject to the personal jurisdiction of this Court.

81.          Dr. Cato is subject to the subject-matter jurisdiction of this Court in this case.

82.          Dr. Cato has been properly served with this Complaint.

83.          Dr. Cato has no defense to this lawsuit based on undue delay in bringing suit — whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

84.          Pursuant to OCGA 9-10-31, Dr. Cato is subject to venue in this Court because his co-defendants are subject to venue in this Court.

85.          At all times relevant to this Complaint, Dr. Cato acted as an employee or agent of CSRA Medical Associates, P.C.

86.          At all times relevant to this Complaint, Dr. Cato acted as an employee or agent of DHA.

87.          At all times relevant to this Complaint, Dr. Cato acted as an employee or agent of HCA-GA.

88.          At all times relevant to this Complaint, Dr. Cato acted as an employee or agent of HCA-TN.

89.          At all times relevant to this Complaint, Dr. Cato acted as an employee or agent of HCA-TN.

90.          Defendant Ekmini Wijesinghe, MD is a citizen of Georgia. She may be served at her residence: 215 Ryan Ln, Evans, GA 30809-4031.

91.          Dr. Wijesinghe is subject to the personal jurisdiction of this Court.

92.          Dr. Wijesinghe is subject to the subject-matter jurisdiction of this Court in this case.

93.          Dr. Wijesinghe has been properly served with this Complaint.

94.          Dr. Wijesinghe has no defense to this lawsuit based on undue delay in bringing suit — whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

95.          Pursuant to OCGA 9-10-31, Dr. Wijesinghe is subject to venue in this Court because her co-defendants are subject to venue in this Court.

96.          At all times relevant to this Complaint, Dr. Wijesinghe acted as an employee or agent of CSRA Medical Associates, P.C.

97.          At all times relevant to this Complaint, Dr. Wijesinghe acted as an employee or agent of DHA.

98.          At all times relevant to this Complaint, Dr. Wijesinghe acted as an employee or agent of HCA-GA.

99.          At all times relevant to this Complaint, Dr. Wijesinghe acted as an employee or agent of HCA-TN.

100.       At all times relevant to this Complaint, Dr. Wijesinghe acted as an employee or agent of HCA-TN.

101.       Defendant CSRA Medical Associates (“CSRA”) is a Georgia Professional Corporation with its Registered Office in Richmond County. CSRA may be served through their Registered Agent, Lee W Prather, 3540 Wheeler Road, Suite 210, Augusta, GA, 30909,.

102.       CSRA is subject to the personal jurisdiction of this Court.

103.       CSRA is subject to the subject-matter jurisdiction of this Court in this case.

104.       CSRA has been properly served with this Complaint.

105.       CSRA has no defense to this lawsuit based on undue delay in bringing suit — whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

106.       Pursuant to OCGA 9-10-31, CSRA is subject to venue in this Court because their co-defendants are subject to venue in this Court.

107.       At all relevant times, CSRA was an employer or other principal of Dr. Cato.

108.       At all relevant times, CSRA was an employer or other principal of Dr. Wijesinghe.

109.       However, if any other entity was a principal of Dr. Cato or of Dr. Wihesinghe, each such entity is hereby on notice that but for a mistake concerning the identity of the proper party, the action would have been brought against it.

110.       Defendants John/Jane Doe 1-10 are those yet unidentified individuals and/or entities who may be liable, in whole or part, for the damages alleged herein. Once served with process, John/Jane Doe 1-10 are subject to the jurisdiction and venue of this Court.

111.       This Court has subject matter jurisdiction, and venue is proper as to all Defendants in this Court.

Pressure Wounds Generally[2]

A well-known problem

112.       The problem of pressure wounds has been known for centuries. One textbook on pressure wounds notes that “The bedsore problem is ancient and has never been far removed from the daily concerns of those whose business it is to deal with chronic disease.”[3] 

113.       Pressure wounds are known by various terms, including “bedsore,” “decubitus ulcer,” “pressure ulcer,” and “pressure injury.”

114.       The facts concerning pressure ulcers are well-known. Indeed, most of the general discussion in this document is taken directly from basic medical textbooks.

115.       Pressure wounds occur mainly, but not exclusively, in the elderly, bedridden, and severely ill.

What pressure wounds are, and what causes them

Generally

116.       The skin, the largest organ in the body, is a major part of the body’s defense against disease and infection.

117.       A break in the skin may allow toxins to enter the body, causing infection.

118.       A pressure wound is a localized injury to the skin and/or underlying tissue, usually over a bony prominence.

119.       Pressure wounds are the end result of an inadequate nutrient blood supply to the tissues.

120.       Pressure on the tissue which partially or completely occludes the capillaries impedes the inflow and outflow of blood.

121.       When this occurs for an extended period of time, tissue ischemia and hypoxia result. That is, tissue loses blood flow and, with loss of blood, loses the oxygen supply necessary for the tissue to live.

122.       Pressure wounds may kill skin tissue, kill muscle tissue, injure blood vessels, and impair lymphatic circulation.

123.       Pressure wounds may also cause infection and sepsis.

Incontinence, skin irritation, and wounds

124.       Skin irritation may contribute to, or develop in conjunction with, pressure wounds. 

125.       Urinary and fecal incontinence can irritate skin and make the skin more likely to break down.

126.       The most common skin damage associated with incontinence is perineal dermatitis.

127.       Patients with mobility impairment and incontinence are at higher risk for pressure wound formation and are more likely to have delayed healing of existing lesions. 

Types & stages of pressure wounds

128.       The back of the head, shoulders, elbows, hips, buttocks, and heels are the most commonly affected sites for pressure wounds.

129.       Pressure wounds are commonly classified in four stages, as follows.

130.       Stage 1: Pressure-related alteration of intact skin, as compared with adjacent/opposite body area. May include changes in (one or more): skin temperature (warmth/coolness), tissue consistency (firm/boggy/mushy), induration (swelling), or sensation (pain/itching). Stage 1 wounds are reversible, if pressure is relieved (by frequent turning, positioning, and pressure-relieving devices). 

131.       Stage 2: Loss of epidermis with damage into dermis (partial thickness tissue loss); appears as shallow crater/blister with red/pink wound bed, with no sloughing. May also appear as an intact or ruptured serum-filled blister or abrasion. Healing may require several weeks after pressure is relieved, often by maintenance of a moist environment.

132.       Stage 3: Subcutaneous tissues involved (full-thickness tissue loss); subcutaneous fat may be visible (no bone, tendon, or muscle exposed). May show undermining or tunneling. Healing may require months after pressure is relieved (e.g., by debriding with wet-to-dry dressings, surgery, or proteolytic enzymes).

133.       Stage 4: Extensive damage to underlying structures; full thickness tissue loss, with exposed bones, tendons, or muscles. (Wound possibly appearing small on surface, but with extensive tunneling underneath.) Slough or eschar may be present. Usually foul-smelling discharge. Healing may require months or years, and may requires skin “flap” surgery.

134.       Nonstageable: A pressure wound may be unstageable when the base of a full-thickness wound is covered by slough and/or eschar.

135.       “Tunneling” refers to one or more channels within or underlying an open wound.

136.       Pressure wounds may occur within 12 to 24 hours in a compromised patient. The wound begins deep in the tissue and may not be observed on the skin surface for several days. Signs of an evolving pressure wound are nonblanching erythema (redness that does not lighten when pressed), pain, and induration (swelling).

Risk factors

137.       The following factors put a patient at risk of skin breakdown and pressure wounds. This is not an exhaustive list.

a.    Immobility, low level of activity (lying/sitting in one position for extended periods of time, paralysis)

b.    Inadequate nutrition

c.     Incontinence of urine or feces; possibly other external moisture

d.    Impaired mental status, alertness, or cooperation; heavy sedation and/or anesthesia; mental illness, intellectual impairment

e.     Advancing age, friable skin

f.      Diabetes

138.       Patients with a past history of skin breakdown are particularly vulnerable.

139.       Skin breakdown is a particular problem in an obese patient.

The danger of pressure wounds

140.       The most significant complication of a pressure wound is infection.

141.       Early in the evolution of a deep pressure wound, a surface area of demarcation appears. Initially, the surface is sealed by an eschar, contiguous with surrounding normal skin. The wound at this stage is either sterile or has a low bacterial content. 

142.       A stage of liquefaction then occurs with separation of the necrotic tissue from surrounding viable tissue. In this process, bacterial counts rise, often producing sepsis from the undrained wound. 

143.       Severe infection is found in the patient with underlying illness such as the elderly and diabetics, and/or in otherwise healthy patient in whom the extent of infection has spread beyond the adjacent tissue.

144.       Osteomyelitis — infection in the bone — can occur.

145.       Infection in pressure wounds is a common and potentially life-threatening complication.

146.       Infection may lead to sepsis.

147.       Sepsis is the primary cause of death from infection and thus requires early recognition, urgent attention, and prompt treatment.

148.       Sepsis, septic shock, and multiple organ failure are major causes of morbidity and mortality in the United States.

149.       Pressure injuries are a known cause of sepsis and death.

The importance of prevention

150.       Stage 3 or 4 pressure wounds are difficult to treat successfully.

151.       After treatment, stage 3 or 4 pressure wounds often recur.

152.       Where flap surgery is required, the flap may fail. The tissue stretched or sewn over the pressure wound may die because of lack of adequate blood supply.

153.       Infections related to pressure wounds may recur after treatment.

154.       Because of the difficulty of treatment of pressure wounds, it is critical to prevent pressure wounds from arising in the first place.

Treating pressure wounds

155.       The extent of treatment needed depends on the degree of the wound.

156.       For stage 3 or 4 pressure wounds, treatment may require including debridement, wound drains, vacuum devices, or skin flap or graft surgery.

157.       Pressure wounds will not heal unless necrotic debris is first removed. Necrotic (dead) tissue creates a physical barrier that prevents tissue repair and provides an ideal medium for bacterial colonization.

158.       Removal of necrotic tissue is called “debridement.”

159.       Sharp debridement involves cutting away necrotic tissue with a scalpel or scissors, exposing living tissue. This can be very painful.

160.       All patients with full-thickness loss of soft tissue will require varying degrees of surgical wound care. This may be limited to debridement.

161.       It may be necessary to perform debridement in the operating room for those patients in whom major debridements are planned.

162.       Severe wounds may require surgery to cover the area of the pressure wound with skin from an adjacent area or, less often, from elsewhere in the body.

163.       A skin flap is healthy skin and tissue that is partly detached and moved to cover a nearby wound.

164.       Reconstruction with flaps is major surgery.

165.       Postoperatively, prolonged periods of immobilization and assiduous nursing care to prevent pressure on the operative site or additional secondary areas of breakdown are imperative for success. 

166.       Where a pressure wound developed because of negligent care in the same hospital where the surgery is performed, the postoperative care may be performed by the same staff that allowed the wound to develop in the first place.

The medical community’s focus on preventing pressure wounds

167.       Pressure wounds are preventable with simple measures available in any modern medical facility; and yet these wounds still occur with disturbing frequency.

168.       For these reasons, the medical community has for many years made it a priority to prevent pressure wounds.

169.       The National Pressure Ulcer Advisory Panel, a national medical organization, was created in 1987 — 33 years ago — specifically to advocate for serious attention to pressure wounds.

170.       The Joint Commission — a hospital accreditation agency — has for years identified pressure wounds as a “sentinel event” that requires an “immediate” investigation.

171.       A “facility-acquired” pressure wound is a sentinel event which must be reported to the appropriate authorities. If a stage III, IV, or nonstageable wound/ulcer develops within a facility, this usually must be reported to the Health Department and investigated.

172.       The Centers for Medicare & Medicaid Services, the largest funder of healthcare in the United States, has declared a stage 3 or 4 pressure wound as a “never event.” That is, a “serious and costly error in the provision of health care services that should never happen.”

173.       The National Pressure Ulcer Advisory Panel issues guidelines to assist medical facilities in preventing and treating pressure wounds.

174.       Written guidelines and protocols for decubitus ulcer prevention and treatment are used in most institutions. 

Responsibilities of nurses in preventing & treating pressure wounds

Part of basic nursing

175.       Nurses have been identified as the patient’s first line of defense in the prevention of pressure wounds. Because they are involved in total care of the patient, nurses have assumed the responsibility for care of the patient’s skin.

176.       Nurses have become the primary care givers for the prevention of pressure wounds.

177.       Nurses in any area of a hospital know, or should know, how to prevent pressure wounds, and are responsible for doing so. 

Examine and assess risk

178.       Because there are known predisposing factors to pressure wounds, the first requirement is to identify the patient at risk and to take preventive measures.

179.       Nurses are responsible for identifying the patients at greatest risk. 

180.       The patient must be assessed as to their general health, their nutritional status, mental responsiveness, mobility, bowel and bladder function, as well as the specifics of treatment programs in certain circumstances, e.g., fracture management and spinal injuries.

181.       Because pressure wounds usually occur within the first 10 days of admission to an acute care institution, assessment should be performed on admission.

182.       Any acute deterioration of the patient’s clinical status requires immediate reassessment.

183.       Several methods are used to predict the risk of pressure wound development. Two of these are the Braden Scale and the Norton Scale.

184.       The condition of urinary incontinence, or similar conditions, is included in the major risk assessment tools for predicting risk of pressure wound development.

185.       Skin assessment should be performed routinely and systematically. It should be done daily.

Prevent harm from incontinence and immobility

Generally

186.       It is an important nursing responsibility to prevent skin breakdown and, if it occurs, to report it immediately and treat it as ordered.

187.       Frequent and effective skin care is essential to keep the skin intact and remove dirt, excess oil, and harmful bacteria.

188.       Everyone’s face, underarms, skin folds, and perineal area need daily cleansing.

189.       Body fluids, such as perspiration, vomitus, urine, and feces, are generally acidic and are very irritating to the skin. They must be removed immediately.

190.       Many older people, people confined to bed, and people who are ill have very fragile (friable) skin. These clients need special skin care, to prevent skin breakdown.

191.       A number of protective devices, special products, and procedures are available to protect the skin.

192.       It is particularly important to protect bony and skin prominences (e.g., elbows, heels, coccyx, shoulder blades, backs of the ears, back of the head). This is vital for the immobile client.

193.       It is the nurse’s responsibility to inspect the skin during baths and other routine daily care.

194.       If any reddened or irritated areas are noted, they must be reported immediately. If these areas are treated quickly, actual skin breakdown can often be avoided.

195.       Perineal care, bathing the genitalia and surrounding area, is given to all clients. Some patients may be embarrassed, but regular perineal care is part of total patient care, even if a patient is of the opposite sex.

196.       A group of procedures, called the Skin Bundle, are implemented to prevent skin breakdown in clients at risk.

197.       Alleviation of pressure is essential.

198.       Nurses should encourage all clients to move themselves as much as possible.

199.       For a patient at risk for pressure wound development, the nurse should turn and reposition the client every 2 hours, elevate bony prominences with pillows, and limit the amount of linens under the client.

Incontinence

200.       Urinary incontinence affects millions of Americans.

201.       Fecal incontinence affects many of the hospitalized elderly.

202.       The patient who is incontinent of urine or stool must have meticulous skin care, to prevent skin breakdown.

203.       Prevention of incontinence related to restricted mobility involves, for example, providing urinals or bedpans within easy reach, use of a bedside commode, or scheduled toileting programs may resolve the incontinence.

204.       The most successful behavioral management strategies for the frail cognitively impaired patient typically at risk of pressure wounds include prompted voiding and scheduled toileting programs. Both strategies are caregiver-dependent and require a motivated care giver to be successful. Scheduled intake of fluid is an important underlying factor for both strategies.

205.       Incontinence containment strategies imply the need for a check-and-change schedule for the incontinent patient so wet linens and pads may be removed in a timely manner.

Notify physician immediately if a wound starts to develop

206.       Nurses should act to prevent pressure wounds on their own initiative, without direct orders to do so by a physician.

207.       However, when a nurse sees evidence of a pressure wound, the nurse must notify the physician chiefly responsible for the patient.

208.       It is an important nursing responsibility to report skin breakdown immediately and treat it as ordered.

Responsibilities of attending physicians in preventing & treating pressure wounds

209.       While nurses face their own independent responsibility to prevent pressure wounds, the physician with primary responsibility for the patient (the attending physician) remains responsible for the patient.

210.       The attending physician is responsible for overseeing and supervising the care of the patient.

211.       In the hospital setting, generally a hospitalist is assigned as the patient’s attending physician, with primary authority and responsibility for supervising and coordinating the patient’s medical treatment — though various consulting physicians may also become involved in evaluating or treating the patient.

212.       Medical students are taught about pressure wounds.

213.       Hospitalists in particular are taught about pressure wounds, partly because their practice focuses on a hospital inpatient population, for whom pressure wounds present a particular risk.

214.       The attending physician’s responsibility includes ensuring that necessary actions are taken to prevent the patient from developing a pressure wound.

215.       Generally, hospitals have policies — often with standard order sets — for preventive actions for patients at high risk of a pressure wound.

216.       Regardless of whether such a standard order set exists, the attending physician is responsible for monitoring the patient’s status and for entering orders to effectively prevent or treat a pressure wound.

217.       In the event that the patient develops a stage 1 or 2 pressure wound, the attending physician faces an urgent responsibility to order treatment for the wound and to prevent it from worsening into a stage 3 or 4 wound.

218.       The attending physician’s responsibilities include entering orders to ensure that nurses take appropriate actions to treat pressure wounds, or to order consults from other physicians as needed.

Responsibilities of hospital administration

219.       The administration of a hospital interacts with the medical and nursing staff.

220.       The administration creates policies, procedures, and protocols for the medical and nursing staff to follow.

221.       The administration provides medical record systems for the medical and nursing staff to use.

222.       The administration provides communication systems for the medical and nursing staff to use.

223.       Through their actions concerning these systems and policies, the hospital administration affects the safety of patients, for better or worse.

224.       The patient may suffer — perhaps fatally — if a gap in responsibility exists, so that no physician supervises and coordinates medical treatment of the patient.

225.       The hospital administration is responsible for ensuring that authority and responsibility for patient care is clearly defined.

226.       The hospital administration must not allow a patient to go without a physician with overall responsibility for supervising and coordinating medical treatment.

227.       Hospital administration is responsible for implementing procedures to reduce or eliminate known, serious risks to patient safety.

228.       Hospital administration is responsible for implementing procedures to reduce or eliminate the risk of a stage 3 or 4 pressure wound from developing in the hospital.

229.       The medical staff of a hospital generally is led by a medical director appointed by the overall hospital leadership. The medical director’s role is to evaluate clinical performance and to enforce hospital policies related to quality care.

230.       A hospital’s administration generally includes a committee or other body responsible for reviewing quality improvement matters — responsible for identifying problems in the treatment of patients, and fixing them.

231.       Licensed hospitals are required to have a compliance and performance improvement program in place. This requirement is also a key aspect of the Medicare conditions of participation for hospitals that wish to be a Medicare provider.

232.       In 1999 the Institute of Medicine (IOM) produced To Err Is Human: Building a Safer Health System. This publication raised awareness about adverse outcomes by reporting that almost 100,000 people were dying each year as a result of medical errors and misadventures in the healthcare system. Its recommendations focused on accountability.

233.       In 1984, peer review organizations (PROs) were established to review Medicare admissions in terms of medical necessity with appropriate medical treatment, proper coding for billing, and quality of service.

234.       The PRO reviews gave rise to the concept that many adverse outcomes were due to system failures rather than individual failures.

235.       Many errors are the result of miscommunication or lack of communication among healthcare providers and staff.

236.       Health team members must develop critical thinking skills and communicate their concerns to the appropriate people when patient safety is at stake.

237.       Miscommunications must be investigated and systemic changes must be implemented to promote effective communication.

238.       Several organizations exist to help hospital administrative staff protect and improve patient safety by designing safe systems.

239.       To establish a culture of safety, a healthcare organization must make safety a top priority, involving teamwork on the part of both staff and patients, transparency, and accountability.

240.       In 2002, The Joint Commission initiated annual national patient safety goals (NPSGs). Accredited entities report specific measures on these NPSGs.

241.       Quality Improvement Organizations (QIOs): These organizations emphasize prevention, early detection, and proper management of services that are high cost and/or have a high potential for errors and adverse outcomes. QIOs also assist in the implementation of safety measures and evidence-based clinical management guidelines.

242.       IHI AND ISMP: A number of other organizations also focus on safety in the healthcare environment. The Institute of Health Initiatives (IHI) and the Institute of Safe Medication Practices (ISMP) have provided leadership and programs for patient safety and improved patient outcomes.

Financial incentives and patient dumping

243.       If a patient’s skin breaks down after admission to a medical facility, the facility is considered to be responsible.

244.       In most cases, third-party payors, including CMS, will not reimburse the facility for costs incurred related to a stage 3 or 4 pressure wound that was not present when the patient was admitted.

245.       Stage 3 or 4 pressure wounds require costly care.

246.       Patients who develop pressure wounds not only require more nursing care, they also need special, more costly, mattresses and/or bed systems.

247.       Faced with a patient who requires costly care — and for which the hospital receives no money, because the hospital is responsible for the harm and its necessary treatment — the hospital has a financial incentive to dump the patient onto some other facility (a nursing home, for example).

248.       “Patient dumping” is a well-recognized problem in the United States.

Before Dorothy Anthony’s October 2018 Admission

249.       Dorothy Anthony was 58 years old in October 2018. She suffers from Down Syndrome and has been cared for by family members. As of October 2018, Dorothy had also been diagnosed with dementia.

·      DH1 – 31[4]

250.       On January 24, 2018, a family member took Dorothy to the DHA ER because of flu symptoms that had lasted for three days. PA Omar Queensbourrow discharged Dorothy home later that day, with prescriptions for Influenza A and bronchopneumonia.

·      DH3b – 577-83

251.       About three weeks later, on February 16, 2018, a family member took Dorothy to the Outpatient Wound Center, because of wounds on both of Dorothy’s heels and on her lower back. NP Laura Cox and Dr. Shawn Fagan noted a stage I wound to both heels, and a “pressure wound to the sacrum, stage II” due to extended immobility for pneumonia and flu.

·      DH3b – 575

252.       A family member took Dorothy to the Wound Center eight times over the next 7-1/2 months, to follow up on Dorothy’s heel and sacral wounds.

·      DH3b – 572 (2/27/2018 visit)

·      DH3b – 564 (3/13/2018 visit)

·      DH3b – 560 (3/27/2018 visit)

·      DH3b – 556 (4/26/2018 visit)

·      DH3b – 552 (5/17/2018 visit)

·      DH3b – 547 (6/19/2018 visit)

·      DH3b – 542 (8/7/2018 visit)

·      DH3b – 540 (10/4/2018 visit)

253.       On the fifth follow-up visit, on May 17, 2018, NP Elizabeth Riordan and Dr. Fagan noted that the wound on Dorothy’s right heel wound was still present, but that the wounds on her left heel and on her sacral area had healed. The right-heel wound measured 2 x 1.5 x 0.2 cm.

·      DH3b – 552

254.       On June 19, 2018, Dorothy’s older sister, Ms. Willie Eva Sampson, took Dorothy for a follow-up visit at the Wound Center. PA Jeanine Linehan-Burack and Dr. Fagan again noted that Dorothy’s sacral wound and left heel had resolved. The right heel wound now measured 1.3 x 0.5 cm.

·      DH3b – 547

255.       On August 7, 2018, Dorothy’s younger sister took Dorothy to the Wound Center to follow up on Dorothy’s right-heel wound. At this point, that wound measured 1 x 0.5 cm.

·      DH3b – 542

256.       About two months later, on October 4, 2018, a family member took Dorothy back to the Wound Center. The wound on Dorothy’s left heel had returned, and the right-heel wound had worsened. The right-heel wound now measured 2 x 1 x 0.1 cm. The left-heel wound measured 2 x 1 x 0.1 cm. Both were unstageable.

·      DH3b – 540

257.       A stage 2 wound is superficial, but the healed stage 2 sacral wound demonstrates that despite suffering from diabetes and Down Syndrome, Dorothy was capable of healing a wound — if properly cared for.

Dorothy’s October 15, 2018 Admission

ER Visit: October 15 — Monday

258.       On October 15, 2018, Dorothy’s sister took Dorothy to the Doctor’s Hospital ER, for what turned out to be about an 8-1/2 month stay in the hospital.

259.       The extended stay was made necessary largely because, while Dorothy waited for placement in a nursing home, a Stage IV pressure wound developed on Dorothy’s sacral area, and Dorothy became septic.

260.       On October 15, 2018, Dorothy’s sister took Dorothy to the Doctor’s Hospital ER because Dorothy was having trouble walking, was not talking, was acting confused, and was occasionally shaking — after having fallen and hit her head about three weeks earlier.

·      DH1 – 9

Inpatient Admission: October 15

261.       In the ER, testing revealed no acute cause of Dorothy’s altered mental status.

·      DH1 – 16

262.       The ER physician, Dr. Kenneth Grotz, discussed the case with a hospitalist. They decided to admit Dorothy for observation, noting that Dorothy’s dementia might be worsening. Dr. Grotz noted that Dorothy might need to be placed in a nursing home. The decision to admit Dorothy was made around 1456 hrs. (That’s when Dr. Grotz signed his Emergency Provider Report.)

·      DH1 16

263.       Dr. Grotz noted the wounds on Dorothy’s heals, and noted that the Wound Care service would be consulted during Dorothy’s admission.

·      DH1 – 11, 16

264.       A couple hours later, at 1631 hours on October 15, Nurse Thriza Eje conducted an Admission Health History.

·      DH2 – 78-82.

265.       In the Admission Health History, Nurse Eje noted that Dorothy had suffered a recent decline in mobility or ambulation, that her legs were weak, and that she needed assistance both with ambulation and with hygiene. Nurse Eje also noted that Dorothy had recently lost weight due to a loss of apetite and was at risk of malnutrition.

·      DH2 – 79-81

266.       The Admission Health History included an Integumentary (i.e., skin) section. That section did not include a Braden scale or other formal screening for risk of pressure wounds.

·      DH2 – 80-81

267.       At 1640 hours (apparently as part of the same Admission Health History “activity”), Nurse Eje filled out a risk-assessment form. This form did include a “skin risk” section. In that section, Nurse Eje noted that Dorothy was unable to ambulate, unable to comprehend and follow directions, and that Dorothy had an existing wound. Nurse Eje documented that Dorothy was at risk of impaired skin integrity.

·      DH2 – 81

268.       At about the same time, at 1641 hours, Nurse Eje filled out a Daily Care Routine form, indicating that “bed rest” had been ordered for Dorothy.

·      DH2 – 82

269.       This skin risk assessment created requirements for the hospital administration, the nursing staff, and the attending physicians.

270.       The hospital administration was responsible for implementing measures that prompted, facilitated, and required appropriate preventive measures in light of the skin risk assessment.

271.       Such measures could consist of a standard order set available to be entered manually or automatically in response to the skin risk assessment. Such measures could consist of policies requiring specific preventive measures for at-risk patients — combined with training and supervision to ensure the policies were implemented reliably. A range of specific measures would suffice, so long as the measures reliably prompted, facilitated, and required appropriate measures.

272.       Dorothy’s medical records indicate, however, that the hospital administration had not in fact implemented measures that prompted, facilitated, and required appropriate preventive measures in light of the skin risk assessment.

273.       This skin risk assessment did not trigger orders to prompt or require actions to prevent a pressure wound from developing. For example, the skin risk assessment did not trigger an order for regular repositioning, to avoid prolonged pressure over bony prominences (like the sacrum, or an order for regular skin checks to assess whether a pressure wound was developing, or an order to assist Dorothy in ambulating and building strength, to avoid lying in the same position for lengthy periods.

274.       Nurse Eje and any other nurse who learned of the October 15 skin risk assessment was responsible: (1) for initiating preventive measures that nurses could undertake on their own initiative (e.g., frequent repositioning), and (2) for ensuring that Dorothy’s attending physician was aware of the facts relevant to the skin risk, and requesting appropriate orders.

275.       Dorothy’s medical records indicate, however, that neither Nurse Eje nor any other nurse on October 15 took any such steps.

276.       Each of Dorothy’s attending physicians was responsible for familiarizing himself or herself with Dorothy’s condition — including the factors that put Dorothy at risk for another pressure wound. Each of Dorothy’s attending physicians was similarly responsible for entering orders for appropriate preventive measures.

277.       The hospitalist who agreed to admit Dorothy was Dr. Ekmine Wijesinghe. Dr. Wijesinghe wrote a Hospitalist History & Physical at approximately 1720 hours on October 15.

·      DH1 – 24-30

278.       Dorothy had a variety of abnormal lab results, and Dr. Wijesinghe diagnosed Dorothy with metabolic encephalopathy — a potentially reversible brain disorder caused by systemic illnesses such as diabetes, liver disease, kidney failure, or heart failure.

·      DH1 – 24-30

279.       Dr. Wijesinghe planned to address potential causes of the metabolic encephalopathy, and also to obtain a physical therapy and/or occupational therapy evaluation.

·      DH1 – 29

280.       Even without notification by a nurse, Dorothy’s attending physicians could easily learn of the key factors that put Dorothy at risk of another pressure wound — namely, (a) current wounds on her heels and a prior wound on her sacral area, (b) weakness and immobility, (c) dementia with loss of comprehension, and (d) a daily care plan for bedrest.

281.       Based on these factors, Dorothy’s attending physicians were responsible for entering orders for measures to prevent another pressure wound from developing on Dorothy.

282.       Dorothy’s medical records indicate, however, that Dr. Wijesinghe entered no such orders on October 15.

October 16, 2018 — Tuesday

283.       Tuesday, October 16, was Dorothy’s first full day at the hospital.

284.       At about 1333 hours that day, the Wound Care service evaluated Dorothy. NP Jennifer Hardy Casella examined Dorothy and noted the heel wounds. NP Casella noted that Dorothy had no wound over her sacrum: “Sacrum with no breakdown noted.”

·      DH1 – 36-38

285.       NP Casella’s assessment and plan included measures to address Dorothy’s heel wounds. NP Casella also included a reference to “pressure reduction measures” including repositioning every two hours. The note did not specifically say whether that recommendation applied to Dorothy’s whole body or only to her heels.

·      DH1 – 38

286.       Later that day, however, Nurse Samantha James noted the wounds on Dorothy’s heels and stated that pillows were being used as positioning aids — though the note does not specify whether the repositioning was limited to Dorothy’s heels or applied to her whole body.

·      DH2 – 92

287.       Later that night, at 2215 hours, Nurse James noted that she found Dorothy soaked in urine.

·      DH2 – 94

288.       Dorothy’s incontinence increased the risk of skin breakdown and a pressure wound.

289.       When the nursing staff became aware of Dorothy’s incontinence, they should have notified the attending physician(s) and implemented measures to prevent pressure wounds. These measures should have included (a) some form of effective incontinence care (perhaps only a bedpan and a toileting schedule), (b) repositioning every two hours, and (c) skin and continence/hygiene checks every two to four hours.

290.       In the same note in which Nurse James recorded Dorothy’s incontinence, Nurse James also noted that she spoke to Dr. Graham and that new orders were placed (apparently for Gabapentin, a medication). Nurse James did not record a discussion with Dr. Graham about Dorothy’s incontinence, the increased risk of skin breakdown, or the need for action to prevent another pressure wound.

·      DH2 – 94

291.       The medical records indicate that at no point on October 16 did the attending physicians order — nor did the nursing staff independently implement — regular repositioning, effective incontinence care, or regular skin/continence checks.

October 17, 2018 — Wednesday

292.       Wednesday, October 17, was Dorothy’s second full day at the hospital.

293.       Late that morning, Courtney Spencer, an occupational therapist, went to Dorothy’s room for a therapy session.

·      DH2 – 95

294.       Occupational therapists and occupational therapy assistants help people participate in the things they want and need to do through the therapeutic use of everyday activities (occupations). Common occupational therapy interventions include helping people recovering from injury to regain skills, and providing support for older adults experiencing physical and cognitive changes.

·      A42

295.       Dorothy has Downs Syndrome and dementia, and Ms. Spencer found that Dorothy had difficulties performing simple actions. But Ms. Spencer found that the difficulties were more cognitive than physical, and with encouragement Dorothy could be induced to perform requested actions.

·      DH2 – 95

296.       That night, at 2010 hours, Nurse Samantha James again noted that Dorothy had pillows as a positioning aid. This note, however, added that Dorothy was also in a specialty bed.

·      DH2 – 101

297.       Later that night — apparently sometime between 2141 hours and 0143 hours — Nurse James again found Dorothy soaked in urine. Nurse James wrote that the “entire bed” was “saturated” with urine.

·      DH2 – 103

298.       This was the second night in a row that Dorothy had been found with a large amount of urine in the bed. This second discovery indicated that Dorothy had a serious incontinence problem that was not going to fix itself. Further, that Dorothy was twice found with a large amount of urine in her bed indicated that Dorothy had been left for long stretches without attention to her toileting needs. Typically, a single instance of incontinence would not produce enough urine to saturate a bed.

299.       In this same note by Nurse James, she wrote that Dorothy was unable to assist with turning in the bed.

·      DH2 – 103

300.       By this time — the night of October 17 — the nursing staff and the attending physicians knew or should have known that Dorothy was at high risk of another pressure wound.

301.       The nursing staff and attending physicians knew or should have known that Dorothy needed support and encouragement to become as ambulatory and mobile as possible, to avoid prolonged pressure over bony prominences (like the sacrum).

302.       The nursing staff and attending physicians knew or should have known that if Dorothy were to remain in bed for long periods, the nursing staff was required to reposition Dorothy every two hours.

303.       The nursing staff and attending physicians knew or should have known that Dorothy needed effective continence and hygiene assistance.

304.       The impairment of Dorothy’s mobility or ability to assist treatment providers would make it more difficult to take care of Dorothy.

305.       The hospital should have been capable of providing Dorothy the care she needed. According to their website, Doctors Hospital of Augusta is a full-service hospital, including an inpatient rehabilitation service treating, among others, stroke patients with brain injuries and cognitive impairments.

306.       However, if the hospital was not capable of providing Dorothy the care she needed, then in that case the nursing staff, the attending physicians, and the hospital administration had a duty to inform Dorothy’s caretakers (her family) of their inability to care for Dorothy properly.

307.       In that case, Dorothy’s family would have an opportunity to seek alternative care. And the hospital would also have had a duty to work diligently and urgently to facilitate that.

308.       At this point — October 17 — various providers had discussed with Dorothy’s family the idea of transferring Dorothy to a skilled nursing facility. However, the medical records do not indicate that anyone told Dorothy’s family that the hospital was incapable of caring for Dorothy properly.

October 18, 2018 — Thursday

309.       The next morning, October 18, at approximately 0940 hours, Nurse Regina Scott applied an external urinary catheter to Dorothy. Nurse Scott noted that the reason for the catheter was prolonged immobilization. As indicated by a later nurse note, the external catheter was apparently a PureWick device.

·      DH2 – 107

·      DH2 – 113

310.       As compared to internal catheters, external catheters pose less risk of causing infections, but greater risk of leaking.

311.       The pictures below are taken from the internet for illustration only. They are not from Dorothy’s medical records.

312.       That same morning, Dr. Jonathan Preston wrote a Discharge Summary noting that Dorothy was stable and was being discharged to a skilled nursing facility (SNF), but noted that the discharge was pending placement. The Discharge Summary identified Dr. Preston as Dorothy’s attending physician.

·      DH1 – 1

313.       On the morning of December 18 at 1045 hours, Caroline Pitts, MST, entered a note that read “Number of times incontinent urine: 1. Diapers count: 1.”

·      DH2 – 108

314.       Later that day at around 1454 hours, April Conway, an occupational therapist, came to Dorothy’s room for a therapy session. Ms. Conway noted that Dorothy remained generally uncommunicative. Ms. Conway indicated that some family member was there, and that Ms. Conway educated the family member on positioning and pressure sore prevention.

·      DH2 – 108

October 19, 2018 — Friday

315.       On October 19, Trista Caddell, a physical therapist, went to Dorothy’s room for a therapy session. Ms. Caddell noted that Dorothy’s limitations seemd to be more due to her dementia. However, Ms. Caddell wrote that during the session, Dorothy said she needed to go to the bathroom. With assistance, Dorothy walked to the bathroom and used the toilet. Dorothy then needed assistance with post-toileting hygiene.

·      DH2 – 117

316.       A little later that day, NP Jennifer Casella from the Wound Care service came to assess Dorothy. NP Casella noted Dorothy’s heel wounds but did not identify any sacral wound.

·      DH1 – 1160-62

317.       On October 19, Dorothy’s attending physicians still did not order — and the nursing staff still did not provide — regular repositioning or other movement to prevent pressure wounds. The systems put in place by hospital administration did not prompt, facilitate, and require them to do so.

October 20, 21, 22, 23 — Saturday, Sunday, Monday, Tuesday

318.       On Wednesday, October 24, 2018, Nurse Amanda Walden would identify a stage 2 wound — a small wound with broken skin — on Dorothy’s sacral area.

·      DH2 – 157

319.       We see no entries in the medical record for the four days before that wound was noted — October 20, 21, 22, and 23 — that shed light on the development of the wound.

320.       However, on these days — October 20, 21, 22, and 23 — Dorothy’s attending physicians still did not order — and the nursing staff still did not provide — regular repositioning or other movement to prevent pressure wounds. The systems put in place by hospital administration did not prompt, facilitate, and require them to do so.

October 24: Stage 2 Wound Discovered

321.       On Wednesday, October 24, while cleaning Dorothy after another episode of urine incontinence, Nurse Amanda Walden identified a stage 2 sacral wound on Dorothy.

·      DH2 – 157

322.       Generally, a stage 2 wound can be treated and healed with only moderate difficulty.

323.       But if not treated diligently, a stage 2 wound can worsen into a stage 3 or 4 wound that can be very difficult to treat and can cause serious harm — including infection, sepsis, and death.

324.       When Nurse Walden identified a new stage 2 sacral wound on Dorothy, Nurse Walden should have immediately notified Dorothy’s attending physician and requested orders for treatment.

325.       The records indicate that Nurse Walden did not do so.

326.       Particularly because Dorothy had both a sacral wound with broken skin and urine incontinence, the nursing staff should have initiated (and the attending physician should have ordered) two-hour incontinence checks.

327.       But the records reveal no new measures, ordered or implemented, for regular repositioning of Dorothy or any additional incontinence checks.

October 25-30: Wound Worsens

328.       On Thursday, October 25, Nurse Samantha James identifies a wound on Dorothy’s sacrum, and identified it as moisture-related.

·      DH2 – 169

329.       A short time later, Nurse James noted that Dorothy had another episode of incontinence with a large amount of urine.

·      DH2 – 171

330.       The records do not indicate that Nurse James notified Dorothy’s attending physician of Dorothy’s sacral wound and requested orders for treatment.

331.       Nor do the records indicate that Nurse James initiated regular repositioning of Dorothy or any additional continence and hygiene measures.

332.       On Friday, October 26, NP Casella from the Wound Care service checked on Dorothy. NP Casella again noted the pressure wounds on Dorothy’s heels, but did not even mention the wound on Dorothy’s sacrum.

·      DH1 – 1154-56

333.       This indicates a failure of the hospital’s systems for communication between the nursing and Wound Care staffs (as well as between the nursing and medical staffs).

334.       On the nursing-staff side, this failure involved both Nurse Walden as well as Nurse James. The lack of communication did not reflect merely an individual failing of a particular provider.

335.       That same day, Friday, October 26, physical therapist Trista Caddell came to Dorothy’s room to work with Dorothy. Ms. Caddell noted that she found Dorothy soaked with urine, with three pads beneath Dorothy saturated. Ms Caddell noted the open wound on Dorothy’s sacrum.

·      DH2 – 177

336.       Ms. Caddell spoke to Dorothy’s nurse and said that Dorothy needed a strict turning schedule, frequent checks for incontinence issues, and to be assisted with a bedpan on a schedule.

·      DH2 – 177

337.       The nurse Ms. Caddell spoke to was Houedan Agbatchi. Nurse Agbatchi noted the conversation and paged Dr. James Cato, Dorothy’s attending physician at the time, and informed him of Dorothy’s sacral wound. Dr. Cato issued no orders for any prevention or treatment measures.

·      DH1 – 666 (re. Dr. Cato)

·      DH2 – 177

338.       In his Hospitalist Progress Note for October 26, 2018, Dr. Cato made no mention of Dorothy’s sacral wound.

·      DH1 – 666-68

339.       At no time on Friday, October 26, were any new measures ordered or implemented for repositioning or for effective continence/hygiene assistance.

340.       On Saturday, October 27, Nurse Abgatchi again noted the sacral wound on Dorothy.

·      DH2 – 181

341.       At no time that day were any new measures ordered or implemented for repositioning or for effective continence/hygiene assistance.

342.       On Sunday, October 28, Nurse Abgatchi again noted the sacral wound on Dorothy.

·      DH2 – 188

343.       The same day, Nurse Amber Yoder also noted the sacral wound on Dorothy.

·      DH2 - 192

344.       At no time that day were any new measures ordered or implemented for repositioning or for effective continence/hygiene assistance.

345.       On Monday, October 29, Nurse Abgatchi again noted the sacral wound on Dorothy.

·      DH2 – 197

346.       The same day, Nurse Yoder also noted the sacral wound on Dorothy.

·      DH2 – 201

347.       At no time that day were any new measures ordered or implemented for repositioning or for effective continence/hygiene assistance.

348.       On Tuesday, October 30, NP Casella from the Wound Care service checked on Dorothy. Again NP Casella apparently did not know about, or independently discover, the sacral wound on Dorothy.

·      DH1 – 1151-53

349.       Later that day, at 1030 hours, Nurse Mirisha Coleman noted the sacral wound on Dorothy.

·      DH2 – 205

350.       At 1301 hours, Nurse Chelsey Haines noted that she had applied a Mepilex dressing to the wounds on Dorothy’s heels, but omitted any mention of the sacral wound on Dorothy.

·      DH2 – 208

351.       Later, at 2033 hours, Nurse Coleman wrote that Dorothy was “approved for placement but waiting re-evaluation per government due to Down Syndrome….No safety issues noted.”

·      DH2 – 208

352.       Nurse Coleman’s two notes from 1030 hours and 2033 hours are inconsistent. A sacral wound is a safety issue. These two notes suggest that Nurse Coleman may have entered some notes by blindly copying and pasting prior notes.

353.       Blind copying and pasting of medical records is a known problem in hospitals and can create safety risks for patients.

·      A43

·      A44

·      A45

354.       When medical personnel are responsible for documenting their own current assessment of the patient, it is improper and potentially dangerous to blindly copy and paste prior assessments that do not reflect the new, current assessment.

355.       At no time on Tuesday, October 30, were any new measures ordered or implemented for repositioning or for effective continence/hygiene assistance.

October 31: Stage 3

356.       On Wednesday, October 31, Nurse Nedjy Marius noted the wound on Dorothy’s sacrum as a stage 2 wound. Nurse Marius changed the dressing.

·      DH2 – 212

357.       Later that day, Nurse Marius wrote “Will remind day shift to call physician to put a consult for wound in the buttock. Dressing was applied to prevent contact from fecal.”

·      DH2 – 213

358.       A short time later, Nurse Thriza Eje described the sacral wound on Dorothy as a stage 3 and as “red/moist/bumpy/granulation.”

·      DH2 – 214-15

359.       Nurse Eje’s note marks a serious worsening of the wound. A stage 3 pressure wound is a serious wound, that is difficult to treat and creates a serious risk of infection and further deterioration.

360.       The physician should have been notified immediately, and the wound-care service should have been consulted immediately.

361.       That did not happen.

362.       At no time on Wednesday, October 31, were any new measures ordered or implemented for repositioning or for effective continence/hygiene assistance.

November 1-5: Wound worsens

363.       On Thursday, November 1, again Nurse Marius recorded a note saying “Wound on her buttock need to be addressed. Dressing on her buttock changed during bath.”

·      DH2 – 221

364.       This note refers to a Foley catheter being in place in Dorothy. The medical records provided to Dorothy’s caretaker are poor-quality and difficult to search, but this is the earliest reference we find in the records to a Foley catheter being inserted into Dorothy.

365.       From the records, we don’t see when this Foley was inserted, who ordered it, who inserted it, or why it was ordered.

366.       These are important details that should be included in the medical records, because a Foley catheter creates a risk of infection. In the event of complications related to the Foley, it may be important for physicians to know these details. Failure to include these details violates the standards for medical record-keeping.

·      A46 (re. Foley and infection)

·      A47 (re. record-keeping)

367.       Whatever the specific purpose for inserting the Foley catheter, that catheter would assist with urine incontinence.

368.       However, because a Foley creates a risk of infection, it should not be used for incontinence assistance unless more conservative measures prove ineffective — after being applied diligently.

369.       From the medical records, it appears that conservative measures to avoid incontinence were not applied diligently.

370.       At 0806 hours, Nurse Eje again described the sacral wound as a stage 3.

·      DH2 – 223

371.       Later, however, LPN Marsha Raycroft described the sacral wound as “pre-stage 1.”

·      DH2 – 227

372.       At no time on Thursday, November 1, were any new measures ordered or implemented for repositioning.

373.       On Friday, November 2, Nurse Amanda Walden noted the sacral wound at around 0908 hours but reported that she could not identify the skin alteration level or stage.

·      DH2 – 230

374.       At 1241 hours, Nurse Chelsey Haines reported checking the wounds on Dorothy’s heels but did not mention the sacral wound.

·      DH2 – 231

375.       At around 1840 hours, Nurse Amanda Walden noted abnormal urine: “Foley to bedside urine with cloudy, foul smelling urine – MD aware. U/A culture sent to micro as ordered by Dr. Preston.”

·      DH2 – 234

376.       At around 2145 hours, Nurse Marsha Raycroft noted that she had informed a physician that Dorothy had low blood pressure. IV fluids were started, with a plan to begin an antibiotic after cultures were obtained.

·      DH2 – 236

377.       At no time on Friday, November 2, were any new measures ordered or implemented for repositioning.

378.       However, four days later, on November 6, Dorothy would be found with a large, infected stage 4 sacral wound. The infection noted on November 2 was likely caused, in whole or in part, by the sacral wound — rather than being a urinary tract infection related to the Foley catheter.

379.        On Saturday, November 3rd, Dr. Jonathan Preston ordered that the Foley catheter be removed.

·      DH2 – 241

·      DH1 – 638-642 at 640

380.       While the removal of the Foley would remove one source of new infections, it would also increase the risk of incontinence-related skin breakdown — thus requiring additional diligence in preventive measures.

381.       At around 2041 hours, Nurse Marsha Raycroft noted the sacral wound but reported that she could not identify the skin alteration level or stage.

·      DH2 – 242

382.       At no time on Saturday, November 3rd, were any new measures ordered or implemented for repositioning or for effective continence/hygiene assistance.

383.       On Sunday, November 4th, at around 1824 hours Nurse Regina Scott noted the sacral wound as stage 3 and reported that she had changed the dressing on the wound.

·      DH2 – 245

384.       A short time later, around 1931 hours, Nurse Scott noted that the dressing on the sacral wound had been changed twice that day. She also reported that Dorothy had a low-grade fever.

·      DH2 – 248

385.       At no time on Sunday, November 4th, were any new measures ordered or implemented for repositioning or for effective continence/hygiene assistance.

386.       On Monday, November 5th, at around 0745 hours Nurse Deborah Sargent reported that Dorothy had been incontinent of a large amount of urine.

·      DH2 – 250

387.       At around 1039 hours, physical therapist Mark Clayton noted that Dorothy’s upper back was wet from sweat, and that he had changed the underpads on Dorothy’s bed.

·      DH2 – 254

388.       At no time on Monday, November 5th, were any new measures ordered or implemented for repositioning or for effective continence/hygiene assistance.

November 6: Stage 4

389.       On Tuesday, November 6th, Nurse Deborah Sargent noted that she had given Dorothy a complete bedbath and changed the bed linens. Nurse Sargent recorded that the dressings remained dry and intact.

·      DH2 – 258

390.       At approximately 1038 hours, NP Kimberly Linticum from the Wound Care service went to Dorothy’s room. NP Linticum saw the wound on Dorothy’s sacral area and characterized it as unstageable with surrounding erythemia (reddening of skin) and abscess formation.

·      DH2 – 1145-47

391.       PA Shellie Lutz and Dr. Robert Mullins, both from the Wound Care service, got involved.

392.       Within about an hour of NP Linticum’s assessment, Dr. Mullins examined Dorothy. Under Dr. Mullins’ supervision, NP Linticum dictated a History & Physical on behalf of Dr. Mullins.

·      DH2 – 31-33

393.       Dr. Mullins noted that Dorothy had been wearing a diaper that was heavily soiled with urine, that the sacral wound emitted a “very foul odor,” that the wound had necrotic (dead) tissue, and that the wound required debridement not at bedside but in the operating room. Dr. Mullins also noted that Dorothy had an infection that was “fairly complex” and that there was concern that the wounds were contributing to the infection.

·      DH2 – 31-33

394.       One of the Wound Care staff called Ms. Sampson, Dorothy’s older sister and caretaker. Ms. Sampson came to the hospital to see Dorothy. She took pictures of the wound.

395.       At 1709 hours, Dr. Mullins began surgical debridement of the wound in the operating room. With the wound excised, Dr. Mullins was able to stage the wound. It was a stage 4. Dr. Mullins noted that he was excising the wound in preparation for a flap surgery — a flap 15 x 18 cm (6 x 7 inches) large. Dr. Mullins cut away tissue down to and including the muscle.

·      DH1 – 1200-01

396.       After the debridement, a tissue culture from the sacrum tested positive for proteus/e-faecalis.

·      DH3a - 10

397.       Proteus species are a Gram-negative, facultative bacilli that colonize the gastrointestinal tract and are a source of nosocomial infection within hospitals and long-term care facilities.

·      A48, pg 3.

398.       E. faecalis can cause endocarditis and sepsis.

·      A49, pg 2

399.       When Dorothy was admitted to the hospital back on October 15, her white blood cell count — a key marker for infection — was at the low end of normal: 5.64 K/uL.

·      DH1 – 12-13

400.       On November 6, Dorothy’s white blood cell count was extremely high: 34.86 K/uL.

·      DH1 – 75

401.       After surgery, Dorothy was taken to the Intensive Care Unit, where NP Jennifer Key and Dr. John Keeley diagnosed Dorothy as being in septic shock.

·      DH1 – 41-48

402.       The condition Dorothy was found in on November 6 — a large, infected, putrid stage 4 wound with substantial necrosis, and in septic shock — does not develop instantaneously.

403.       The wound had of course developed over several days.

404.       The odor from the wound was likely noticeable for at least one day, and probably for multiple days.

405.       Sepsis likely took a day or more to escalate to septic shock.

406.       By November 6, Dorothy was in extremis. The wound, including the sacral infection, was likely incurable at that point, and the infection and septic shock well could have killed Dorothy.

Dorothy’s condition and treatment since the sentinel event

407.       Dorothy has suffered a complicated, difficult course since the stage 4 sacral wound was diagnosed and first treated. We do not recite Dorothy’s course in detail here, but only address some of the more notable events.

November 6, 2018, through July 11, 2019 discharge

408.       Overview: Before the wound developed on Dorothy’s sacral area, she had been fit to discharge as soon as space opened up at a nursing home. After the wound developed and Dorothy suffered infection and sepsis, Dorothy remained in the hospital for another eight months, until July 11, 2019. Before then, however, on March 21, 2019, the hospital sent Dorothy off to a nursing home. The nursing home sent Dorothy right back, because Dorothy’s sacral wound was too extensive for the nursing home to care for.

409.       From 11/14/2018 to 11/22/2018, Dorothy was treated with an IV Antibiotic course of Zosyn/Zyvox to treat the bone infection.

·      DH3a – 10

410.       From 11/22/2018 to 12/02/2018, Dorothy was treated with an IV Antibiotic course of Ampicillin to treat the bone infection.

·      DH3a – 10

411.       From 12/10/2018 to 12/17/2018, Dorothy was treated with IV Antibiotic course of Zyvox/Levofloxacin to treat the bone infection.

·      DH3a - 10

412.       On November 12, 2018, a percutaneous endoscopic gastrostomy (PEG) tube was placed into Dorothy.

·      DH1 – 1173-74

413.       A PEG tuge is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate.

414.       On December 7, 2018, Dorothy was given a colostomy, after multiple incidents of fecal incontinence that threatened to contaminate the sacral wound. (Picture for illustration only; not from Dorothy Anthony’s medical records.)

·      DH1 – 1202-03 (colostomy op note)

·      DH1 – 34-35 (colostomy consultation note)

·      DH2 – 496 (bowel incontinence)

·      DH2 – 618 (bowel incontinence)

415.       On February 12, 2019, Dr. Mullins performed a fasciocutaneous flap surgery, creating a 13 cm x 14.5 cm flap.

416.       The records currently available do not include photographs from the operation performed on Dorothy. The following photos are taken from Wong, Chin-Ho, Bien-Keem Tan, and Colin Song. “The perforator-sparing buttock rotation flap for coverage of pressure sores.” Plastic and reconstructive surgery 119.4 (2007): 1259-1266 (available at https://www.waesthetics.com/pdf/published/28.pdf). The operation indicated in the photograph likely differed from the operation performed on Dorothy, but the photograph nevertheless may give some idea of the surgery Dorothy underwent.

417.       On March 21, 2019, the hospital discharged Dorothy and sent her to Amara nursing home. The nursing home immediately sent her back, because the sacral wound was too extensive for them to care for.

·      DH3c – 177

418.       Shortly after Dorothy was sent back to the ER, PA Ansley Coffee of the Wound Care service examined Dorothy, under the direct supervision of Dr. Mullins. PA Coffee reported that “near the end prior to discharge she [Dorothy] was just lying on a silver burn pad.” PA Coffee also noted that Dorothy had a very deep open wound near the perineum and rectum — “very deep past a finger length of the surface.”

·      DH3c – 182-84

419.       On March 25, 2019, a bone culture grew Acinetobacter/e-faecalis.

·      DH3a – 10

420.       From March 26 to May 6, Dorothy was treated with a course of Merrem, an antibiotic.

·      DH3a – 10

421.       By April 2, 2019, the flap had failed.

·      DH3c – 232

422.       From 6/6/2019 to 6/12/2019, Dorothy was treated with an IV Antibiotic course of Zyvox/Zosyn.

·      DH3a – 10

423.       From 6/19/2019 to 6/24/2019, Dorothy was treated with an IV Antibiotic course of doxycycline.

·      DH3a – 10

424.       From 6/24/2019 to 6/28/2019, Dorothy was treated with an IV Antibiotic course of Zyvox/Zosyn.

·      DH3a – 10

425.       From 6/28/2019 to 7/05/2019, Dorothy was treated with an oral antibiotic course of Augmentin.

·      DH3a – 10

426.       On July 11, 2019, the hospital discharged Dorothy to her home.

·      See DH3c – 132; 384

After July 11, 2019

427.       Since being discharged in July 2019, Dorothy has continued to have a difficult course, with multiple hospital admissions. Here again we do not recite the events in detail.

428.       On July 25, 2019, a family member took Dorothy to the ER worried about an infection, because Dorothy had dark urine and a fever. Dorothy was discharged the same day.

·      DH3c – 138, 149

429.       On August 7, 2019, Ms. Sampson took Dorothy to the Wound Clinic for one of a continual series of outpatient visits. At this visit, NP Jennifer Casella and Dr. Zaheed Hassan noted that the sacral wound had significant necrotic tissue and slough. They admitted Dorothy to the hospital, to be treated by Dr. Mullins for surgical debridement and excision of the wound, and to be managed for possible infection.

·      DH3b – 701-03

·      DH3b – 704

430.        On this admission, a bone culture from Dorothy’s sacrum was positive for e-faecalis.

·      DH3a – 10

431.       Dorothy ended up staying in the hospital for about a month. The hospital discharged her on September 9, 2019.

·      DH3b – 699-700

432.       From August 14 to September 9, Dorothy was treated with an IV antibiotic course of Unasyn (ampicillin/sulbactam).

·      DH3a – 10

433.       From September 9 to October 7, Dorothy was prescribed oral Amoxicillin.

·      DH3a – 10

434.       Over the next several months, the Wound Center followed Dorothy on an outpatient basis.

·      DH3b – 682 (10/15/2019)

·      DH3b – 680 (11/5/2019)

·      DH3b – 675 (11/9/2019)

·      DH3b – 670 (11/25/2019)

·      DH3b – 668 (12/9/2019)

·      DH3b – 663 (12/18/2019)

·      DH3b – 654 (1/6/2020)

·      DH3b – 652 (1/27/2020)

·      DH3b – 647 (2/18/2020)

·      DH3b – 637 (3/19/2020)

435.       On April 9, 2020, a family member took Dorothy to the Wound Center for an outpatient visit. The sacral wound was exposed, with bone showing, and there was tunneling at the top of the wound.

·      DH3b – 632

436.       On May 1, 2020, a family member took Dorothy to the ER. Dr. John Rumbaugh admitted Dorothy because the sacral wound had more bone exposure, and it also contained necrotic tissue and produced serous discharge.

·      DH3a – 6-7

437.       On May 5, 2020, Dr. Bounthavy Homsombath debrided the sacral wound on Dorothy.

·      DH3a – 17

438.       On May 11, 2020, NP Denise Hamrick and Dr. Jack Austin from the Infectious Disease service consulted on Dorothy’s case. Dr. Austin concluded that Dorothy likely had chronic osteomyelitis. He concluded that another course of IV antibiotics was unlikely to help. He recommended oral antibiotics, an MRI to identify the extent of the bone infection, and possibly further resection of bone tissue.

·      DH3a – 15

439.       The hospital discharged Dorothy on May 21, 2020.

·      See DH3a – 18

440.       On May 26, 2020, a family member took Dorothy to the ER with concerns about her wounds leaking.

·      DH3a – 3, 4

Schedule of Providers from October 15 – November 6, 2018

Hospitalists (from Hospitalist Progress Notes)

October 16: Adam M. Ross, MD; Mari Mangasha, MD (DH1 – 692)

October 17: Adam M. Ross, MD; Mari Mangasha, MD (DH1 – 690)

October 18: ???

October 19: Adam M. Ross, MD (DH1 – 687)

October 20: Adam M. Ross, MD (DH1 – 684)

October 21: Adam M. Ross, MD (DH1 – 681)

October 22: Adam M. Ross, MD (DH1 – 678)

October 23: Adam M. Ross, MD (DH1 – 675)

October 24: Adam M. Ross, MD (DH1 – 672)

October 25: Adam M. Ross, MD (DH1 – 669)

October 26: James A. Cato, MD (DH1 – 666)

October 27: James A. Cato, MD (DH1 – 663)

October 28: James A. Cato, MD (DH1 – 660)

October 29: Jonathan Preston, MD (DH1 – 657)

October 30: Jonathan Preston, MD (DH1 – 654)

October 31: Jonathan Preston, MD (DH1 – 651)

November 1: Jonathan Preston, MD (DH1 – 647)

November 2: Jonathan Preston, MD (DH1 – 643)

November 3: Jonathan Preston, MD (DH1 – 638)

November 4: Jonathan Preston, MD (DH1 – 633)

November 5: Adam M. Ross, MD (DH1 – 629)

November 6: Adam M. Ross, MD (DH1 – 624)

—————

441.       As CMS has declared, the development of a new pressure wound in a hospital is a “never event.” The development of a stage 2 wound in a patient known to be at high risk — like Dorothy Anthony — reflects negligent care, but in itself need not cause serious, lasting harm.

442.       It is shocking, however, for a stage 2 wound to develop, be noted by multiple nurses and therapists, be brought to the attention of physicians, and yet to worsen to a stage four wound.

443.       The administration and the providers at Doctors Hospital failed Dorothy Anthony — grossly.

444.       The failure cannot be blamed on a couple negligent individuals. Too many nurses and physicians were involved. Too many days went by without proper action. That demonstrates a larger, systemic problem at Doctors Hospital — a problem with the systems put in place (or not put in place) by the hospital administration.

445.       Indeed, the records indicate that at least some of the nurses and physical therapists understood the seriousness of the sacral wound and made some effort to communicate it to the rest of the team, so that they would treat Dorothy appropriately. Yet it didn’t happen. That indicates a system failure for which the hospital administration is responsible.

446.       The facts revealed in the medical records establish the standard of care, causation, and damages opinions stated in the “Summary of Principal Opinions” above.

447.       Finally, as Dr. Jack Austin noted, Dorothy likely now suffers chronic osteomyelitis. The infections are likely to continue recurring, putting Dorothy at risk of sepsis and premature death.

Count 1 – Professional Negligence (all Defendants)

448.       Plaintiff incorporates by reference, as if fully set forth herein, all preceding paragraphs of this Complaint.

449.       The Defendants are liable for professional negligence pursuant to OCGA Title 51 and Georgia common law.

450.       The Defendants and their agents violated their standards of care as to the following tasks and requirements:

a.    Administrative Task & Requirement: The standard of care requires the hospital administration to implement patient safety measures to prompt, facilitate, and require measures to prevent pressure wounds from developing, and to treat wounds if they do develop.

Violation: The DHA administration violated this requirement by failing to implement measures that prompted, facilitated, and required appropriate steps to prevent pressure wounds and to treat them properly if they develop.

Causation: This violation led to neglect that allowed a stage 2 pressure wound to develop on Dorothy Anthony’s sacral area, and then led to further neglect that allowed the wound to develop to a stage 4 wound.

Damages: This violation caused pain, debridements, flap surgery, infections, long-term hospital stay, permanent disabilities.

b.    Administrative Task & Requirement: The standard of care requires the hospital administration to implement measures to prompt, facilitate, and require communication between nurses and physicians concerning patients’ high-risk status for pressure wounds and for patients’ actual development of pressure wounds.

Violation: The DHA administration violated this requirement by failing to implement measures that prompted, facilitated, and required necessary communication about pressure wound risk and development.

Causation: This violation led to neglect that allowed a stage 2 pressure wound to develop on Dorothy Anthony’s sacral area, and then led to further neglect that allowed the wound to develop to a stage 4 wound.

Damages: This violation caused pain, debridements, flap surgery, infections, long-term hospital stay, permanent disabilities.

c.    Attending Physician Task & Requirement: The standard of care requires the attending physicians to identify patients at high risk of developing pressure wounds, and ensure the nursing staff are taking appropriate preventive measures — including frequent repositioning and continence care.

Violation: The hospitalist staff — Dr. Adam Ross, Dr. James Cato, Dr. Jonathan Preston, and Dr. Ekmini Wijesinghe — violated this requirement by failing to identify Dorothy Anthony as being at high risk of developing a pressure wound, and by failing to enter orders or otherwise ensure that the nursing staff were taking appropriate preventive measures, including frequent repositioning.

Causation: This violation led to neglect that allowed a stage 2 pressure wound to develop on Dorothy Anderson’s sacral area, and then led to further neglect that allowed the wound to develop to a stage 4 wound.

Damages: This violation caused pain, debridements, flap surgery, infections, long-term hospital stay, permanent disabilities.

d.    Attending Physician Task & Requirement: The standard of care requires the attending physicians to order effective treatment for a pressure wound.

Violation: The hospitalist staff — Dr. Adam Ross, Dr. James Cato, and Dr. Jonathan Preston — violated this requirement by failing to enter orders for effective treatment of the pressure wound that developed over Dorothy Anthony’s sacral wound.

Causation: This violation led to neglect that allowed the wound to worsen into a stage 4 wound.

Damages: This violation caused pain, debridements, flap surgery, infections, long-term hospital stay, permanent disabilities.

e.    Nursing Task & Requirement: The standard of care requires the nursing staff to take appropriate steps to prevent development of pressure wounds, including frequent repositioning and continence care.

Violation: The nursing staff violated this requirement by failing to take appropriate steps to prevent another pressure wound from developing on Dorothy.

Causation: This violation led to neglect that allowed a stage 2 pressure wound to develop, and then further neglect that allowed it to develop into a stage 4 wound.

Damages: This violation led to pain, debridements, flap surgery, infections, long-term hospital stay, permanent disabilities.

f.     Nursing Task & Requirement: The standard of care requires the nursing staff to notify attending physicians of the development of a pressure wound and request treatment.

Violation: The nursing staff violated this requirement by failing to notify attending physicians of the development (and worsening) of a pressure wound on Dorothy’s sacral area.

Causation: This violation led to neglect that allowed a stage 2 pressure wound to develop, and then further neglect that allowed it to develop into a stage 4 wound.

Damages: This violation led to pain, debridements, flap surgery, infections, long-term hospital stay, permanent disabilities.

g.    Nursing Task & Requirement: The standard of care requires the nursing staff to routinely assess the skin of an at-risk patient and document the skin status accurately.

Violation: The nursing staff violated this requirement by failing to assess Dorothy’s skin, and by failing to document her skin status, diligently and accurately.

Causation: This violation led to neglect that allowed a stage 2 pressure wound to develop, and then further neglect that allowed it to develop into a stage 4 wound.

Damages: This violation led to pain, debridements, flap surgery, infections, long-term hospital stay, permanent disabilities.

h.   Nursing Task & Requirement: The standard of care requires the nursing staff to address incontinence effectively and assist with hygiene as needed to prevent skin breakdown and infection.

Violation: The nursing staff violated this requirement by failing to address Dorothy’s incontinence and hygiene disabilities.

Causation: This violation led to neglect that allowed a stage 2 pressure wound to develop, and then further neglect that allowed it to develop into a stage 4 wound.

Damages: This violation led to pain, debridements, flap surgery, infections, long-term hospital stay, permanent disabilities.

451.       The corporate Defendants — DHA, NHA-GA, NHA-TN, JDG, CSRA — are vicariously liable for the negligence of their employees or other agents, because the agents acted within the scope of their agency for the respective corporate Defendants.

452.       Dorothy Anthony, through her Guardian, is entitled to recover from all Defendants for all damages caused by the Defendants’ professional negligence.

Damages

453.       Plaintiff incorporates by reference, as if fully set forth herein, all preceding paragraphs of this Complaint.

454.       As a direct and proximate result of the Defendants’ conduct, Plaintiff is entitled to recover from Defendants reasonable compensatory damages in an amount exceeding $10,000.00 to be determined by a fair and impartial jury for all damages Plaintiff suffered, including physical, emotional, and economic injuries.

455.       WHEREFORE, Plaintiff demands a trial by jury and judgment against the Defendants as follows:

a.             Compensatory damages in an amount exceeding $10,000.00 to be determined by a fair and impartial jury;

b.             All costs of this action;

c.              Expenses of litigation pursuant to OCGA 13-6-11;

d.             Punitive damages; and

e.              Such other and further relief as the Court deems just and proper.

October 15, 2020

Respectfully submitted,

/s/ Lloyd N. Bell                    

Georgia Bar No. 048800

Daniel E. Holloway

Georgia Bar No. 658026

BELL LAW FIRM

1201 Peachtree St. N.E., Suite 2000

Atlanta, GA 30361

(404) 249-6767 (tel)

bell@BellLawFirm.com

dan@BellLawFirm.com

Thomas D. Trask

Georgia Bar No.

TRASK LAW FIRM

One Atlantic Center

1201 W. Peachtree Street NW

Suite 2300

Atlanta, GA 30309

(404) 795-5010

trask@trasklawfirm.com

Attorneys for Plaintiff

[1] OCGA §§ 14-2-510 and 14-3-510 provide identical venue provisions for regular business corporations and for nonprofit corporations:

“Each domestic corporation and each foreign corporation authorized to transact business in this state shall be deemed to reside and to be subject to venue as follows: (1) In civil proceedings generally, in the county of this state where the corporation maintains its registered office…. (3) In actions for damages because of torts, wrong, or injury done, in the county where the cause of action originated, if the corporation has an office and transacts business in that county; (4) In actions for damages because of torts, wrong, or injury done, in the county where the cause of action originated.”

These same venue provisions apply to Professional Corporations, because PCs are organized under the general “Business Corporation” provisions of the Georgia Code. See OCGA § 14-7-3. These venue provisions also apply to Limited Liability Companies, see OCGA § 14-11-1108, and to foreign limited liability partnerships, see OCGA § 14-8-46.

[2] The Defendants themselves likely do not need assistance in answering the allegations contained in the general discussion of pressure wounds, provider responsibilities, etc. However, for the benefit of others who may be involved in answering the allegations: The general discussion here draws from the following texts (although many other texts address the topics, too):

·       European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). 2019.

·       Griffin, Donald, ed. Hospitals: What they are and how they work. Jones & Bartlett Learning, 2011.

·       Parish, Lawrence C., Joseph A. Witkowski, and John T. Crissey, eds. The decubitus ulcer in clinical practice. Springer Science & Business Media, 2012.

·       Rosdahl, Caroline Bunker, and Mary T. Kowalski, eds. Textbook of basic nursing. Lippincott Williams & Wilkins, 2008 (Chapters 50 & 58).

[3] Parish, The decubitus ulcer in clinical practice (2012).

[4] Along with this Complaint, we are serving copies of the medical records we have received from Doctors Hospital of Augusta. The page references here are to Bates numbers in those records. We include the page references to make it easier for the Defendants to answer these allegations. The page references are not intended as part of the allegations, but only as an aid to the Defendants, to make it easier to answer the allegations.