State inspection says poor nursing at University of Louisville Hospital endangered three patients out of 24 cases reviewed

A state inspection of the University of Louisville Hospital has found that shortcomings in nursing endangered three patients.

“A dozen nurses and doctors also told state inspectors that nursing and other staff shortages put patients at risk, according to the state’s 30-page report,” reports Andrew Wolfson of The Courier-Journal.

The report was released Monday by KentuckyOne Health, the chain that manages the hospital. Its CEO, Lisa Shannon, told Wolfson that “tremendous improvements” have since been made at the facility and its patients are safe. “Chief Nursing Officer Shari Kretzschmer said in the briefing that the hospital hired 55 nurses in May and June but still has 70 openings, all of which have been posted,” Wolfson reports.

“But the report from the Cabinet for Health and Family Services Office of Inspector General presents an unsavory picture of a facility in which nurses are overloaded with patients and patients who should be treated in intensive care are backed up in the emergency department,” Wolfson writes. “One nurse told inspectors that medications are passed out late and dressing changes passed on to the next shift, creating infection concerns; another said nurses frequently had to go from room to room searching for equipment because rooms aren’t stocked with emergency equipment.”

Wolfson says the report “seemed to confirm” charges made last month by a leading surgeon, Dr. J. David Richardson, that “cuts in nursing and other staff had caused a “major patient safety issue” for seriously ill and injured patients.” His comments to The Courier-Journal prompted the inspection, which reviewed care of 24 patients and found that three were endangered.

“In the one that appeared the most serious, a critically ill patient who should have been treated in intensive care instead was seen in a regular emergency department room, and when he began to vomit during an intubation, no suction equipment was available in the room,” Wolfson writes. “The report said a nurse had to scavenge in other rooms for the device, wasting precious time. The room should have been restocked after the previous patient by an ER technician, but there was no technician working that day, according to the report. A physician said the patient’s safety also was compromised because the nurse could not provide appropriate monitoring because she had to care for three other patients and because the emergency department was very busy.”

Another patient said he didn’t receive timely pain medication and became incontinent after waiting for help to use the bathroom. A third “fell out of bed and suffered minor cuts to his mouth and head because his bariatric mattress was flush with the bedrail,” Wolfson writes. “The report said a contributing factor was that the unit was down a nurse because one assigned to it had accompanied another patient to a CT scan.”

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