Sedated JCMC patient falls in operating room after someone 'looked away'

JOHNSON CITY, TN (WJHL) - Mountain States Health Alliance CEO Alan Levine says he takes responsibility for an 89-year-old woman's fall off a stretcher inside a Johnson City Medical Center operating room last year that left her with a black eye, a broken nose, an arm tear and a cut on her face.

"We treat 61,000 patients a year. We can get it right 60,999 times. The one time something bad happens, that's a 100% failure rate for that patient and so we take that very seriously," Levine said. "I take responsibility for it. It rests with me."

Melba Lowe went in for a routine endoscopy (widely considered a safe procedure) at JCMC on July 15, 2016, according to her medical records. For the last year, her family says they've searched those medical records and even hired an attorney, hoping to find out exactly what led to Lowe's fall from a stretcher while sedated in the operating room.

"It's been a year and we still don't know what happened to her," Lowe's discouraged daughter Karen Mazzei told us when we first sat down with her in July. "We would like to know what happened to her."

MSHA has maintained an "unfortunate accident" led to the woman's injuries. A health system spokesperson insisted the fall was not the result of a mistake. MSHA, in a statement, assured us the care team was "attentive and working appropriately," but our investigation found someone took their eyes off of the woman.

Mazzei said she remembers what her mom's doctor told her family after the "incident."

"(He) acted totally and sincerely sorry, but I would too," Mazzei said. "All of a sudden she was falling off the table, he tried to catch her, he couldn't support the weight and she hit the floor. We all just sort of stared at each other with our mouths open kind of like, 'What? She fell off the table?'"

The worst part for Mazzei and her brother Frank Huff is that their mother passed away less than three weeks later. Her death certificate lists her cause of death as cardiopulmonary arrest, respiratory failure and sigmoid colon carcinoma, which doctors discovered during a colonoscopy two days after the fall, according to a letter from MSHA's attorney to the family. Mazzei said she made a promise to her mother before she passed away.

"I promised her that I would look into this," Mazzei said. "I'm not going to break a promise to my mother."

Since her mother's medical records only included a handful of vague mentions of the fall and her attorney could only secure confirmation of an "unfortunate fall," Mazzei asked us for help.

Not long after we got involved, the health system set up a meeting at JCMC with the family. Mazzei said representatives listened more than they talked, but shared one important detail.

"They did tell us that from now on someone will be standing right there at the patient and will not turn away," Mazzei said.

Initially, MSHA would not confirm to us that someone looked away. In a statement, the health system said the patient, under moderate sedation, shifted or moved as the procedure ended and as the anesthesiologist turned off her medication. MSHA added the woman's side bed rail was down because staff needed to access her and when she moved, the people next to her were unable to prevent the fall.

"Multiple staff members were positioned adjacent to Ms. Lowe," a MSHA spokesperson said. "Ms. Lowe's fall was an unfortunate accident that occurred even though the care team was attentive and working appropriately."

Eventually, after multiple interview requests, Levine agreed to an on-camera interview and that's when we learned the full story.

"My understanding is there were several nurses, this is one of those instances where somebody looked away and the patient shifted and the patient fell," Levine said. "It's possible that they can follow the procedures and things can still go wrong and sometimes in those cases you realize there's nothing we could've done in that case."

"If someone looked away, couldn't it have been prevented had that person been looking at the patient?" we asked.

"Yes, I would imagine so, but standing here I don't know why they looked away," Levine said. "They might have turned away to look to get an instrument or something. That's the part where you have to learn and try to adapt and make sure the rest of the team hears what happened and (knows) here is how you can prevent it in the future."

Levine said every time something goes wrong the health system opens an internal investigation, creates a corrective action plan and alerts the board. In this case, he said the investigation concluded the people in the operating room followed every procedure.

"When something bad happens, we have to be willing to talk about it," he said. "An organization becomes great when they recognize that they're not perfect. Besides the patient and the family, no one is more devastated when something happens to a patient than the nurses and doctors that are caring for that patient."

"It seems unreasonable to expect a sedated patient in an operating room could fall. Aren't there enough protections in place to prevent that?" we asked.

"In this case, no," he said. "Obviously there weren't."

Levine told us MSHA takes safety seriously and added its hospitals are among the safest in the country.

"If something occurs, we take steps to re-educate them to make sure we learn from what happened," Levine said. "We want to get better. We want to be the best."

MSHA sent out a news release on August 2, 2016 touting some of JCMC's national rankings. Lowe died the next day.

Her children hope now that their search for answers is complete their mother is resting peacefully knowing they kept their promise.

"I guess I feel like I've taken care of her now as best I could," Mazzei said. "I can rest better. Hopefully she can too."

Following Lowe's fall, medical records show staff treated her for her injuries. The health system reports it did not discipline any employees as a result of this situation. Levine said there are always consequences when warranted, but added MSHA doesn't want its nurses or doctors to withhold information during an investigation or lose confidence in their abilities.

"We don't want to see good people, good nurses, good doctors lose confidence or lose confidence that we're going to support them when a mistake occurs, but we want them to learn from it when something happens that they don't intend," he said. "Because I believe in them and because I believe they want to do the right thing, I have to have confidence that when something does happen they're going to do an honest assessment and try to learn from it and then share with their colleagues. I really believe that does happen."

Despite this situation, the family felt so grateful for some of the care their mom received, they thanked five JCMC nurses by name in their mom's obituary.

Copyright 2017 WJHL. All rights reserved.

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