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Sunday, June 27, 2010 | 2 a.m.
Do No Harm: Hospital Care in Las Vegas
- Prologue: A breakthrough in transparency
- Reporting is the first of its kind in Nevada
- Health care can hurt you
- Accident took her life, his heart
- Fall proves fatal for elderly patient
- Inadequate care, unspeakable pain
- Scarred for life by mistake in surgery
- Where I Stand: Fascination and frustration in reporting on Las Vegas hospital care
- Editorial: Preventing harm
- Health care leaders discuss Sun report’s findings
- St. Rose Dominican Hospitals to post data on quality
- State presses hospitals for full accounting of preventable injuries
See the results
Share your stories
A day before Morry Janovitz was scheduled to be discharged from Spring Valley Hospital Medical Center, he was found on the floor of his room — his forehead gashed, his neck broken.
Just that fast, the 82-year-old man who was recovering from pneumonia faced a dire prognosis. Emergency room doctors determined Janovitz had a “hangman’s fracture” — a break of the second cervical vertebra. It was a miracle he was alive.
A retiree who had moved to Las Vegas in 2001 with his wife, Pamela, Janovitz had been classified as a fall risk when he was admitted to the hospital. He required assistance to get into bed and to use the bathroom.
After surgery to fuse his neck, Janovitz’s fall-risk assessment was elevated, according to hospital records.
Medical staffs are supposed to take precautions to ensure falls don’t occur, but doctors and nurses say hospitals are often short-staffed. When falls occur and result in broken bones, state law considers them sentinel events — incidents in which a patient is harmed while under hospital care.
Two weeks after Janovitz’s first fall, he was again found on the floor of his room. This time his only injury was a bruised elbow.
But as his stay at Spring Valley dragged on, Janovitz developed a severe bedsore on his buttocks. The size of a fist, the open wound was blackened with dead flesh and caused excruciating pain.
Janovitz recovered from the pneumonia that brought him to the hospital but complications led to his death on March 21, 2009, three months after his initial fall.
A “statement of deficiencies” produced after an investigation by the Nevada State Health Division found Spring Valley had failed to protect Janovitz from falling and provide proper care for the subsequent bedsores.
The Sun’s analysis of Spring Valley’s inpatient records for 2008 and 2009 shows two cases of advanced-stage bedsores and 13 cases of falls that resulted in some type of trauma.
It’s unknown whether Spring Valley reported Janovitz’s falls because the state does not release patient names in connection with sentinel events.
Ever pushed a nurse call button at a Las Vegas hospital? I have been a patient at one hospital, and visited people at 2 others. No one comes for at least 10 minutes - try telling an old man to wait to use the bathroom that long. He probably got sick of waiting and attempted to do it himself.
How does a hospital like that get their accreditation ? Obviously, this WAS NOT the 1st and won't be the last such situation.
jaycooke
Just like the articles says, it falls under being "understaffed" when no one answers those call buttons. The nurses and aides are too busy with others and there are not enough of them to take care of everyone. I saw it myself when I was a patient at Mountain View. I definitely needed help getting out of bed and with standing. Even had a nurse tell me when she saw that I could at least get my legs over the side of the bed (no small task), I can manage my own shower by myself! Of course, I agreed out of pride. Bad move. Almost landed on the floor because of the intense dizziness that overcame me from all the meds. The Ex and Big Sister went ballistic when they found out I was left alone in the shower and let the powers that be know it. Never happened again.
This is very common in nursing homes, too - neglect of the call buttons. When my Dad was alive and in a nursing home, several times he fell while trying to go to the bathroom by himself after using the call button to help him. It was also noted on the door of his room "Assistance Needed" but no one paid attention. My sister and I always felt the aides just didn't give a s*it enough to help all of the "residents" and just ignored the call buttons. And we believe never reported the accurate number of falls the residents took as required b law. Dad used to have unexplained bruises on him which used to piss us off. Most of those aides were also too damn fat to do anything anyway. They couldn't get their arms around the resident because their obese bodies got in the way. But there were a few aides that were wonderful.
These kinds of things do not just happen in Vegas hospitals but everywhere.
the quality, especially among UHS/VHS hospitals is horrid. I am calling for a BBB, JCAHO, State investigation. as a true and former insider, I can tell you that patients come last with them, after doctors and emt's. Local hospitals will compete with each other via perks such as lounges, food, computers, tv's, video games, and other amenities. i once asked an Admin at Centennial, "So, you mean to tell me that we encourage EMT's to come here if our food/snacks are better, even if Mountainview is closer, say, for a chest pain case?" "Yes." "Isn't that unethical?" "Sssssshhhhhhhhhhh........."