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