Patient’s death after being dropped in the O.R. leads to safety changes at Ballad Health

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Greeneville, Tenn (WJHL) –  A Tri-Cities man who went to the hospital for hip repair surgery late last year, left the operating room with a broken neck.

That’s because immediately after surgery, he was dropped on the operating room floor and sustained injuries that later claimed his life.

That patient was Harold Landers, an 80-year-old husband and father of two sons from Greeneville, Tennessee.

“He was a happy person,” said Bertha Landers about her husband.  “He was good to everybody.”

Pictured: Bertha and Harold Landers

She says that didn’t change even when Alzheimer’s disease robbed her husband of his ability to live at home.

On November 7, 2018, Landers fell at the Greeneville nursing home where he was receiving care.

Bertha Landers says a doctor at Laughlin Memorial Hospital in Greeneville told her that surgery to repair a broken hip was her husband’s best option.

“I had hope of him being well enough to go back to the nursing home and well enough to be taken care of and live no telling how many years,” she said.

Right after surgery, Bertha Landers said the surgeon came to the room where she had been waiting and initially delivered good news.

“He was telling us the surgery went well and how things would be afterward,” she said.  “The doctor looks down at his phone and he said ‘I’ve got to go. I’ll be back in a few minutes.'”

When the surgeon returned, Landers said she immediately knew something was wrong.

“He dropped his head and said, ‘I don’t know how to tell you all this but… they dropped Mr. Landers and they have broke his neck,” Landers said.

Medical records provided to News Channel 11 by the Landers family include a physician’s note on the same day of the injury saying “during the process of reassembling the bed for transfer, the patient is reported to have slipped off the bed and fell to the floor striking his head.”

“It was kind of utterly disbelief,” said David Landers, one of Harold and Bertha Landers’ sons.  “I mean – who gets dropped in an operating room?”

Records show a CT scan revealed a fractured C2 vertebra and a small subdural hematoma, or bleeding on the brain.

Doctors in Greeneville decided Harold Landers needed to be airlifted to the trauma center at Holston Valley Medical Center in Kingsport.  

In Kingsport, family photos show Landers in a halo brace to secure the spinal fracture.   He was placed on life support and never regained consciousness, his family said.  

Pictured: Harold Landers

Eight days later, on November 16, 2018, Harold Landers died.

Back at Laughlin Hospital, now called Greeneville Community Hospital East, a Ballad Health hospital executive says Landers’ fall triggered rapid same-day action including staff meetings and re-training.

“There were several things that came together all at the wrong time that allowed this to happen,” said Dr. Mark Patterson, Chief Medical Officer at Laughlin at the time of the accident.   He’s now president of Ballad Health Medical Associates.

Patterson said the day of the fall, staff was re-trained on the proper use of the fracture bed, and he says he instituted a new policy creating a clear path for communicating who in the operating room has direct hands-on oversight of a patient at any given moment.

Patterson said caregivers and administrators at the hospital met to conduct what’s called a root cause analysis to identify where problems occurred.  “We evaluated what happened that evening to try to find every link in the chain that could have been a participant in what happened,” Patterson said.

Six days after Landers was injured in the operating room, the Centers for Medicare and Medicaid Services launched an investigation at Laughlin Memorial Hospital.

Pictured: Harold Landers

Through a public records request, News Channel 11 obtained an 80-page report that details the investigation.

As Harold Landers was being prepared for transfer from the operating room to the recovery room, the report says four hospital employees struggled with what’s called a fracture bed, a specialized piece of equipment designed for surgeries to repair fractures.

Source: Ballad Health

According to the report, the chief nursing officer described “technical difficulties” saying “there were no safety straps used for the patient during the procedure and the post was removed from in between the patient’s legs prior to the bed assembly for transfer…”   The report also describes a miscommunication between the providers as to who was monitoring the patient.

“The patient during that period of time was waking up from anesthesia,” Patterson told News Channel 11.  “During that event, while they were manipulating the table, he rolled and unfortunately came off of the table and impacted the back of his head and his neck.”

The CMS inspection concluded that “the facility failed to follow facility policy” and “failed to ensure a safe environment during a surgical procedure.”

The day after the inspection began, the Centers for Medicare and Medicaid services declared “Immediate Jeopardy” at Laughlin Hospital – its most serious sanction – meaning the hospital’s noncompliance had caused, or is likely to cause, injury harm impairment or death.

“It was human error that needed to be assisted through better training on a piece of equipment they may not have been as familiar with as we had hoped,” Dr. Patterson said.  

Pictured: Harold Landers

Records show Ballad Health’s action plan led CMS to remove the Immediate Jeopardy status on November 16th,  the day after it was declared and the same day Harold Landers died in Kingsport.

Since then, Patterson said Ballad Health ordered a safety review of and staff retraining on the use of every fracture bed of all manufacturing types at all its hospitals with strict oversight to continue for the next year.

“Every time the (fracture bed) equipment is used there is someone there to make sure the equipment is used appropriately and to document that it’s used appropriately,” Patterson said.

Patterson said he’s confident that plans are in place to prevent what happened to Harold Landers in Greeneville from happening to another patient.

“The whole team is devastated at the chain of events that occurred,” he said. “We wanted to make sure that, whatever chain of events led to this, we take care of every link in that chain.”

Harold Landers’ death certificate lists the cause of death as “acute traumatic spine fracture” related to a “fall in a healthcare facility.”

“It wasn’t supposed to be that way,” Bertha Landers said.  “Nobody should leave this world like he did, like he had to. He could have still been here today.”

Pictured: Harold Landers

The Landers family and Ballad Health have been negotiating cash settlement for the past several months.

Thursday morning, the attorney for the Landers family said a settlement had been reached.

The terms are confidential, but the Landers family released this statement:

“The Landers family believes Ballad Health has taken our situation very seriously, and we appreciate the steps Ballad Health has taken to make sure all their employees and doctors can learn from this incident.

Ballad Health says their mission is to honor those they serve. Their actions since this incident have shown they are living up to their mission by honoring our father and husband in minimizing the chance an accident like this would happen in the future.

Mr. Landers’ story is important, because it can be used to help others. While greatly saddened by the result of this accident, the family is grateful Ballad is trying to turn it into something to learn from.”

-Landers family attorney

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