Hospital On Probation After Multiple Bed Sore, Fall Incidents

A community hospital's probation has been extended after state investigators uncovered more than 30 new public health code violations, including one in which a 13-inch surgical instrument was left inside a patient’s abdomen for more than two weeks following surgery.

The state Department of Public Health had placed the hospital on a one-year probation in 2008, which should have been lifted on Feb. 8.

The 867-bed hospital was cited for multiple, systemic public health code violations, some of which resulted in the deaths of four patients. Since it was put on probation, the hospital’s top executives were replaced.

Among the 30 additional violations, five were defined as adverse events, one of which the hospital failed to report as required by state law.

The most common adverse events are patient falls resulting in serious disability or death, hospital-acquired bed sores, perforations during laparoscopic or endoscopic procedures, and the retention of foreign objects in patients after surgery.

According to DPH documents, one of the adverse events pertained to a patient who had been discharged from the hospital four days after abdominal surgery in January. The patient returned to the hospital emergency room a few days following his discharge, complaining of extreme stomach and back pain. A CT scan revealed that a 2-inch by 13-inch malleable ribbon retractor — a surgical instrument — had been left inside the patient, undetected by medical staff for more more 15 days following the surgery. The instrument was removed on Feb. 3.

The additional violations were discovered by investigators on unannounced visits to the hospital, some as recent as March 12. Those violations include the hospital’s failure to report a hospital-acquired bed sore (pressure sore, decubitus ulcer, pressure ulcer) that worsened considerably following the patient’s admission. The sore eventually required a surgical procedure.

In another violation, the hospital was cited for failing to properly assess a patient’s mental status after falling. Although the proper protocols were in place for the patient, who was identified as a fall risk, the patient was discovered sitting on the floor in the doorway of his room. Upon being discovered by staff, it was noted that the patient had a bump on the back of the head, was slightly nauseous and complained of a headache. The patient was helped back to his bed. However, within hours, the patient’s condition significantly deteriorated with a change in mental status and respiratory distress, requiring intubation. The patient was eventually transferred to the hospital’s intensive care unit. For more, read the story.


Robert W. Carter, Jr. is a Virginia attorney whose law practice is dedicated to protecting the rights of the victims of nursing home and assisted living neglect and abuse in Richmond, Roanoke, Norfolk, Lynchburg, Danville, Charlottesville, and across Virginia.

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