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Deficiencies at Grady Memorial Prompt CMS Review

Margaret Dick Tocknell, for HealthLeaders Media, October 18, 2011

As noted in the 52-page survey report, Grady's current deficiencies fall into three broad categories: patient rights, nursing services, and physical environment. All of the deficiencies are related to the Sept 6 patient death.

According to the report findings the patient was admitted" to receive treatment for seizures and alcohol withdrawal." On the ninth day of the patient's hospitalization physician orders "revealed the patient was to be on 1:1 monitoring." However, on Sept. 6 there were "no available sitters for the 11p.m to 7 a.m. shift." Instead, staff was going to check on the patient "as often as possible." A registered nurse noticed that the patient was missing around 1:50 p.m. and that the patient's room window was open. The RN "looked out the window and saw something on the street." Accompanied by the charge nurse, the RN "went downstairs and found the patient's body on the street."

The survey report noted these issues that contributed to the deficiencies:

  • The patient's unit was understaffed during 20 of 21 shifts from Sept. 1 to Sept. 7.
  • No documented evidence of the patient having a sitter in either the nursing notes or the patient's plan of care.
  • No sitter observation or hand-off forms were included in the patient's records.
  • No protocol for assessing the safety of patient room windows was in effect.

It also identified steps the hospital has already taken to correct the deficiencies:

  • Staff has been added to the medical-surgical units.
  •  Overtime has been authorized for unlicensed staff to work as sitters.
  • Education and training sessions have been implemented for sitters regarding safety and compliance to sitter documentation logs
  • All 566 of the hospital's operable windows have been inspected and 21 were found unlocked. Standard screws were replaced with tamper-proof screws.
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