When a nurse checked in on Gloria Shavers at 1:20 a.m., she was sitting on the side of her hospital bed watching TV.
Less than an hour later, the 60-year-old patient had fallen to her death from an 11th-floor window of Grady Memorial Hospital.
Grady didn’t have enough staff that night to provide the one-on-one monitoring a doctor said Shavers needed. And a window that should have been locked was open, according to a federal investigative report obtained by The Atlanta Journal-Constitution.
The report, which details Grady’s failures in Shavers’ Sept. 6 death, has triggered federal regulators to call for a full survey of the Atlanta hospital. That means inspectors will show up unannounced in the coming weeks. It also means that if problems persist, Grady’s Medicare funding could be in jeopardy.
Grady’s problems were “determined to be of such serious nature as to substantially limit [Grady’s] capacity to render adequate care,” the Centers for Medicare & Medicaid Services, a federal health-care regulator, wrote in a letter delivered last week to Grady corporate board chairman Pete Correll.
Grady said it’s aware of the findings and is taking action to fix the problems. Spokesman Matt Gove declined to comment on the inspection results, but he said each of Grady’s windows have since been checked, closed and locked. Tamper-proof screws have also been added
Of the 566 operable windows checked, 21 were found unlocked. Windows in patient rooms are designed to be opened only by technicians, according to the hospital.
It’s unclear why a window in Shavers room was open. One administrator saw a screw on the floor under the window; a hand print was on the pane, the inspectors’ report shows. The retractable arm that allows the window to open no more than 6-8 inches was also broken.
Two weeks earlier, Shavers was rushed to Grady after having a seizure at a MARTA station and spent time in the intensive care unit before being transferred to the neurological unit on the 11th floor, said David Wolfe, an attorney representing Shavers’ family.
A doctor had ordered that Shavers — “who had been showing signs of confusion” — be monitored one-on-one by a sitter. Sitters observe patients to ensure their health and safety.
“When someone goes into a facility to be cared for, you expect that at the very least they’ll be safe there,” Wolfe said. “She was supposed to have a sitter and didn’t.”
Family members said Shavers, who worked with her niece cleaning homes and office buildings, had been feeling stronger and was looking forward to coming home, Wolfe said.
According to the report, Shavers had a sitter until 11:30 p.m. but there were no sitters available for the 11 p.m. to 7 a.m. shift. Staff planned to check on her as often as possible. A review of the unit revealed 20 of 21 shifts were understaffed from Sept. 1 to Sept. 7.
Following Shavers death, Grady’s chief nursing officer held an emergency meeting with the nursing leadership team to review sitter policy. The chief nursing officer authorized overtime to unlicensed staff to work as sitters and an increase in the number of nursing assistants, among other changes.
While hiring more staff is good, it’s equally important to have a working system that allows people to deliver safe care 100 percent of the time, said Jim Conway, a senior fellow at the Institute for Healthcare Improvement, a Massachusetts-based nonprofit focused on promoting quality patient care.
For more than a decade, there has been growing frustration over patient safety and quality of care, and agencies such as the Centers for Medicare & Medicaid Services have started to take more action, Conway said.
“Every one of these tragedies provides an extraordinary opportunity for learning and improvement,” Conway said.
It’s not clear when the more extensive survey will take place at Grady or when results will be made public. Once complete, Grady will have to submit a plan of correction. Meanwhile, its accreditation and Medicare payments aren’t affected.
It’s not uncommon for Centers for Medicare & Medicaid Services to issue a notice that a hospital could lose its Medicare funding but it’s very rare for that to actually happen, said Millman, who is with the regulatory agency. Medicare funding for some hospitals is as much as 40 percent of its revenue, often hundreds of millions of dollars.
“Hospitals are important to the community,” she said. “They are very interested in getting anything that is amiss corrected.”
About the Author
