Sunday, June 27, 2010 | 2 a.m.
Do No Harm: Hospital Care in Las Vegas
- Prologue: A breakthrough in transparency
- Reporting is the first of its kind in Nevada
- Health care can hurt you
- Accident took her life, his heart
- Fall proves fatal for elderly patient
- Inadequate care, unspeakable pain
- Scarred for life by mistake in surgery
- Where I Stand: Fascination and frustration in reporting on Las Vegas hospital care
- Editorial: Preventing harm
- Health care leaders discuss Sun report’s findings
- St. Rose Dominican Hospitals to post data on quality
- State presses hospitals for full accounting of preventable injuries
Harmful events glossary
See the results
Share your stories
A day before Morry Janovitz was scheduled to be discharged from Spring Valley Hospital Medical Center, he was found on the floor of his room — his forehead gashed, his neck broken.
Just that fast, the 82-year-old man who was recovering from pneumonia faced a dire prognosis. Emergency room doctors determined Janovitz had a “hangman’s fracture” — a break of the second cervical vertebra. It was a miracle he was alive.
A retiree who had moved to Las Vegas in 2001 with his wife, Pamela, Janovitz had been classified as a fall risk when he was admitted to the hospital. He required assistance to get into bed and to use the bathroom.
After surgery to fuse his neck, Janovitz’s fall-risk assessment was elevated, according to hospital records.
Medical staffs are supposed to take precautions to ensure falls don’t occur, but doctors and nurses say hospitals are often short-staffed. When falls occur and result in broken bones, state law considers them sentinel events — incidents in which a patient is harmed while under hospital care.
Two weeks after Janovitz’s first fall, he was again found on the floor of his room. This time his only injury was a bruised elbow.
But as his stay at Spring Valley dragged on, Janovitz developed a severe bedsore on his buttocks. The size of a fist, the open wound was blackened with dead flesh and caused excruciating pain.
Janovitz recovered from the pneumonia that brought him to the hospital but complications led to his death on March 21, 2009, three months after his initial fall.
A “statement of deficiencies” produced after an investigation by the Nevada State Health Division found Spring Valley had failed to protect Janovitz from falling and provide proper care for the subsequent bedsores.
The Sun’s analysis of Spring Valley’s inpatient records for 2008 and 2009 shows two cases of advanced-stage bedsores and 13 cases of falls that resulted in some type of trauma.
It’s unknown whether Spring Valley reported Janovitz’s falls because the state does not release patient names in connection with sentinel events.