Begin (awarded message:

From: comglaint@ ointcommissionorg
Subject: Correspondence from The Joint Commission Office 01 Quality

Monitoring: 69

Date October 6, 2015 6:58:49 PM EDT
To

Tuesday, October 6, 2015

Stephanie Sinclair Hoben

Regarding: Lawnwood Regional Medical Center Heart Institute
Incident 

Dear Ms. Sinclair Hoben:

Recently. you contacted the Joint Commission about Lawnwood Regional Medical Center 81
Heart Institute, a Joint Commission accredited organization. We contacted the organization
regarding your concerns and asked for their written response. After our comprehensive review,
we have determined that their response is acceptable at this time. We will continue to monitor the
organization in the areas of your concern.

Our evaluation focuses on processes and policies that are required within our standards. In line
with our Public lnfonnation Policy. we cannot provide you with the urganizatiun's response.
However. we can provide the following infurmatiun:

. The standards areas that applied to your specific report are: Leadership. Provision of Care

To obtain general information about the organization's performance on key quality measures.
please refer to the organization 's Quality Report, which is available at The Joint Commission's
website and click Quality Check). To obtain a hard copy of the
repon, please contact our Customer Service Center at (630) 79275800 or write to:

Customer Service Center
"Hie Joint Cummission

One Renaissance Blvd.
Oakbmok Terrace, IL 60131

"Drank you for bringing your concerns to our attention. nus concludes our evaluation, but we
will keep your complaint on file and we will continue to track this organization's performance.

Please include the incident number indicated at the top of this letter on any future
correspondence regarding this matter.

Sincerely,

Office of Quality and Patient Safety

Begin furwarded message:

From: Stephanie Sinclair --

Subject: Complaint against Lawnwood Regional Medical Center and St.
Lucie Medical Center
Date: May 29. 2015 8:32:10 PM EDT

To: 

To Whom it May Concern:

I am writing to file an official complaint about the care at Lawnwood Medical Center in Ft. Pierce, FL, as well
as St. Lucie Medical Center in Port St. Lucie, FL. It has been a while since the following incidents
occurred, but the dismal medical treatment that my mother received ultimately resulted in a very painful death, one
that haunts my family to this day, which made it too difficult to full re-live in writing before now. However, I can
assure you that the issues raised here still problems at these hospitals and since I have several family members who
reside in St. Lucie County, Florida, I felt it was important to write, even if late. The following narrative is from her
medical records, which we can provide if needed.
On Aug. 8, 2012 my mother, Paula Schulte, was admitted to Lawnwood Regional Medical Center for her first
seizure since 2001, when she sustained a brain injury. She was admitted to their ICU due to the resulting intense
aphasia. Unfortunately, on 8/12/12 despite being diagnosed as a significant fall risk, her restraints were left off and
she fell and broke her right hip and wrist while attempting to get out of bed in an altered mental state. The medical
records show on Aug. 9, the hospital put anti-fall procedures in to place. These required: (1) a bed alarm be attached
and activated at all times to notify in the event of movement; (2) a “tethered device” be in place; (3) that the bed
rails (poles) be up at all times to prevent exit; and (4) on 8/11 soft blue wrist restraints to prevent her exit from the
bed. These orders were noted and required and in place during every series of rounds after being initiated.
Despite these precautions, which, when combined with the constant supervision of the ICU nurses, should have been
more than enough to keep a 64 year old, 90 pound woman in place, on 8/12 at 06:00, she is found slouched down in
her bed—an indication that the procedures were not being followed.
The incident report from later that same morning, 09:46 on 8/12, states that, “the patient is found lying on right
side next to bed,” and that the bed alarm was not on—This despite her being put on the fall risk protocols and those
having been found lacking or not in place earlier that day.
The Lawnwood hospital personnel subsequently x-rayed her cranium, right shoulder, right elbow, and right humerus.
All revealed no fracture. Her wrist and hip were, suspiciously, not x-rayed. The hospital reporting log from the next
three days indicates that my mother had a substantial rise in blood pressure, anxiety and pain complaints. She also
refused to eat. Her medications were increased and she was transferred to Emerald Nursing Home for rehabilitation
on 8/16 with doctor’s orders added to her fall risk procedures that a staff member (sitter) be with her around the
clock. Her hip and wrist here never looked into.
At Emerald Nursing Home, she had a round the clock sitter so we are sure she never fell there, she was
also fully cognizant at this point. However, on 8/18 the limited movement or her wrist, the wrong-looking angle of
her leg, and her constant pain prompted a physician at Emerald NH to finally x-ray Paula’s hip and wrist. This was a
full 6 days after her fall. The next day, on 8/19, the x-ray was read and, of course, both Paula’s hip and her wrist
were indeed broken. Her husband refused to have her sent back to Lawnwood Hospital so Paula was then sent to St.
Lucie Medical Center (SLMC).
Initial impressions upon Paula’s 8/19 intake at SLMC were of a broken hip and wrist. Their own x-rays confirmed
this. After a series of consultations, Dr. Gerald Shute performed a, “procedure for displaced rt femoral neck fracture
and displaced two-part rt distral radius fracture,” (sic). His procedure notes included mentioning that: “[Upon
opening] as indicated pt did have a significant amount of shortening of the femur… [I]t was felt that she would need
a significant amount of muscle releases from the proximal femur to bring her back out to the length due to the
shortening and the length of time that she had the fracture of the hip,” (sic).
Paula convalesced at SLMC until 8/29 where she was returned to Emerald Nursing Home
for continued rehabilitation. Drainage on her hip dressing was first noticed on 8/30. Complaints of confusion, pain,
upset stomach, anxiety are common during this time. On 9/1 swelling of the drainage area is noticed in addition to
the drainage itself. On 9/11, due to continuing drainage issues, Paula was taken back to St. Lucie Medical Center for
a consult with the surgeon, Dr. Shute on suspicion of an infection at the hip surgery site.

 On 9/12 Paula is taken back in to surgery. Dr. Shute at SLMC performs two procedures: (a) a “rt hip irrigation and
debridement, and arthrotomy”; and (b) “placement of antibiotic beads.” The culture taken revealed klebsiella and
pseudomonas found in a hematoma above and inside the new hip prosthesis, which would require antibiotic
treatment for the rest of her life.
She was treated with several additional antibiotics for this, including Cefepime 2GM/100ML NS twice a day for 45
days.
On 9/19 Paula is, once again, taken back to Emerald Nursing Home for rehabilitation. She remains there
almost one month, until 10/17. During this time she is increasingly confused and agitated. Paula also continues to
scream in pain during this time. The nurses’ notes interpret this as her being hostile, however, and the fact that, along
with this, her blood pressure continues to spike doesn’t merit action for a full week. Finally, a Dr. Pamer orders
Paula back to St. Lucie Medical Center on 10/17.
The 10/17 transfer notes indicate the EMT was told that Paula exhibited “a decline in mentation since
yesterday” and that she was “given Haldol for her bizarre behavior.” The intake report by SLMC states she was
“confused and yelling nonsense words.”
Upon re-entering SLMC, my mother is never placed into ICU, but in the farthest room from the nurses station and a
neurologist does not examine her until the following day. However, by then things got even worse. In the early hours
of 10/18, Paula was given a fresh IV injection of potassium chloride. The attending RN missed Paula’s vein and
infiltrated her arm musculature. She wasn’t checked closely again for nearly eight hours. The new shift RN
noticed what was by that time, Paula’s horrifically injured arm.
On the morning of 10/18, Orthopedic surgeon, Aaron Michael Trocchia’s consultation noted: “pt recently
just suffered from fluid infiltration into the left upper extremity by her IV this morning or the yesterday evening…
initial consult w/ pt assessed her as having compartment syndrome.. pt in substantial pain… substantial
ecchymoses…” His Plan states: “future possibility of skin grafts, substantial morbidity, loss of functionality.”
Further reports affirm the grim diagnosis of compartment syndrome.
It must be noted that upon the infiltration, Paula became nonresponsive and remained in a catatonic
state from which she never returned, though her body began to have visibly noticeable tremors at this time.
So instead of treating her declining mental state, she was re-entered into surgery to deal with another hospital
error.
The medical staff spoke at length with myself and my father about our only two options: amputation or
fasciotomy. The possibility of her surviving either procedure was described as slim given her rapidly declining
health. The family opted for the fasciotomy. The operative report filed on 10/18 by Dr. John Hruska decribed the
procedure: “fasciotomy both volar and dorsal compartments and drainage of severe hematoma… complete
degloving of forearm up to occluding the distal aspect of the elbow… extensive amount of dead space and degloving
with separation from that fascia…” Paula’s arm is to remain flayed open in an air-bubble cast for two weeks to let
the air dry out the chemically eroded musculature of her forearm.
When a neurologist from SLMC finally examined her, she was diagnosed with non-convulsive status
epilepticus and she was airlifted to Shands Hospital in Gainesville, Florida.
It was only at Shands that we learned that the non-convulsive status epilepticus was likely caused by the
Cefepime -- which would never have been prescribed had she not sustained a broken hip and then had the
prothesis get infected. According to the records from Dr. Denise Shaine (attached), “Cefepime can cause
seizures and encephalopathy in small, elderly women with chronic insufficiency and Mrs. Schulte has the
additional risk factors of previous seizure disorder due to head trauma.”
To complete this horrible story, my mother developed the devastating Stevens-Johnson syndrome, which we were
told was likely a reaction to either the Dilantin or Tobramycin used to treat non-convulsive status epileptics, both

 discondnued al Shands. Unlonunalely, ihe 513 had already sianed to cause she skin inside her mnuLh [0 slough off
and she dociors said ii was likely happening on her organs as well. It was al ihis dni Lhal we decided ID bring in
hospice, as her chances ol recovering lroni Lhal, given Lhe inlecdons and arm condilion, woidd likely only lead [0 a
shall painlid liie, even il she did recover {ml-l1 ihe seizures, which had linally slowed down. She died