Lucy was admitted to a Riverside nursing home and promptly developed weakness, nausea, and diarrhea and blood was taken. Her appetite was also in decline and she didn't want to eat. Before her test results came back, she tested positive for Covid-19 (asymtomatic) and was moved out of her room and down the hallway to the "Red Zone" for Covid patients.
Her blood tests revealed dehydration and induced kidney failure and an order was made for two days of normal saline. But the facility never carried the order out. For the next two weeks, Lucy did not get proper hydration (or nutrition), and, and in addition to worsening kidney failure, developed a large decubitus ulcer on her buttocks.
After only a month in the nursing home, Lucy was discovered in rapid decompensation, and was lethargic and had difficulty breathing. She was transported via ambulance to a nearby hospital and diagnosed with severe sepsis, hypotension, acute respiratory failure, acute COPD exacerbation, lactic acidosis due to septic shock (from her infected sacral wound), leukocytosis, severe metabolic acidosis, acute kidney injury and suspect chronic kidney disease. She was also noted as having a “bleeding large size sacral ulcer.”
Lucy died the following day. Her death certificate listed the cause of death as cardiopulmonary arrest, septic shock, acute heart failure, Non-St-Elevation myocardial infarction and several other significant conditions contributing to death: acute renal failure, atrial fibrillation, and severe protein calorie malnutrition.
Ben was admitted into a Riverside nursing home for physical and occupational therapy following a hospitalization for high blood pressure. Prior to his admission, his rehabilitation potential was noted as “excellent” and his initial assessment by a physician noted his rehabilitation potential as “good.”
Shortly after admission, the nursing home doctor prescribed Bactrim DS (“double strength”) twice a day for Ben to treat a suspect urinary tract infection. The recommended dose for Bactrim DS to treat a urinary tract infection is 1 Bactrim DS per day. Moreover, Bactrim DS is contraindicated in patients with decreased renal function as it can cause acute kidney injuries. Despite knowing that plaintiff had decreased renal function, the doctor prescribed Bactrim DS twice a day for plaintiff.
Approximately 1 ½ hours after Bactrim DS was administered to Ben, the nursing home staff reported to he had a blister on his left anterior foot. A common allergic reaction to Bactrim DS is blistering. Two days later, the blister on Ben’s left foot was noted as being large, and within a week it was noted as being the “size of a fist,”
Despite being told of the worsening blister, the doctor never discontinued the Bactrim DS and never even bothered to perform an assessment on the patient. The doctor admitted that he did not like caring for patients like Ben because he did not get paid for it. When the blister worsened, the family insisted that Ben be transferred to the emergency room.
After a medical work up, physicians determined that the wound on Ben’s lower extremity was at risk for infection and that such an infection could be limb threatening for Ben. Over the following weeks, Ben's left foot became infected with black toes and gangrene. Ben was required to undergo a left above the knee leg amputation.
Mary was 87 years old, and had been diagnosed with Alzheimer’s disease. She required assistance with all of her activities of daily living, including feeding, hydration, hygiene, rotation/turning, ambulation, and other care. She was also bedridden.
The US Food and Drug Administration has long warned that the use of bed rails may pose unwarranted hazards to patient safety, especially patients with memory impairment such as dementia and Alzheimer’s disease. The use of bed rails to restrain individuals like Mary is highly dangerous, strongly disfavored, and likely illegal. And while bed rails might be inexpensive and convenient for staff, they dramatically increase the risk of injury to patients, including the risk of entrapment and asphyxiation.
At Mary's nursing facility, instead of providing her with fall prevention measures, such as lowering her bed and placing a landing mat next to her bed, the home chose to use bed rails as a physical restraint, despite the laws and regulations prohibit them.
On the day Mary died, a nursing home caregiver entered her room and found her lower body on the floor, with her head and neck wedged between the bed rail and the mattress. Caregivers freed her neck from its position and laid her on the floor but failed to call 911 for more than an hour. Mary was declared dead at the facility having asphyxiated.
Edward D. died at the age of 82, only five weeks after he was taken by ambulance from his San Bernadino nursing home to San Gorgonio Memorial Hospital for treatment of a fractured right hip.
A month before his arrival to his nursing home, Edward was recorded by a physician as suffering from mild cognitive impairment and as sometimes confused and disoriented. He was independent in bed mobility, transfers and walking in his room, but required extensive assistance for dressing, toilet use, and personal hygiene. He was also considered at risk for falls because of side effects of medications he was taking for confusion. He would wander and was considered a high fall risk.
Despite the dangers related to Edwards and his poor safety judgment, no one was around when he was violently thrown to the ground by another male resident, in the open corridor, causing a displaced right femoral neck fracture requiring surgical repair. As is well known, a hip fracture to individuals of Edwards’s age and condition often marks the beginning of the end. H was transported to San Gorgonio afor surgery, afterwhich his health declied rapidly.
While there are documented episodes of acting out, at no time was the family notified that he committed an act of physical abuse toward another resident. In his lawsuit, it was alleged that the resident who attacked Edward was a known abuser. The case was settled for an undisclosed sum.
In 2015, 88-year-old Margaret suffered a fall in her home and underwent surgery to repair her fractured hip. She was admitted into a San Diego skilled nursing facility for rehabilitation. Upon her admission, a skin breakdown assessment was performed rating Margaret at "high risk" for skin wounds.
A care plan was implemented, but no followed, and within 10 days Margaret had five wounds: Two on her bottom, and one on each thigh. A physician ordered a low air loss mattress for her but the nursing did not fax the request over to the medical supplier for over a week. Margaret pressure sores worsened.
Despite the fact that Margaret was not improving, and was still in need of skilled nursing care, the nursing home initiated her discharge process due to a lapse in her Medicare coverage, even though she had two additional weeks. She was moved to an assisted living facility and upon admission was deemed to need “full assist with almost everything.”
At her new facility, Margaret was essentially bedbound. Her family and friends, who visited on a daily basis, never saw staff attempt to get her out of bed, or even rotate her. As a result, her sores deteriorated. Only two days after her admission, a San Diego home health agency was engaged and on the first admission found Margaret’s wounds to be “unstageable” and reminded the staff of the importance of turning her and making sure her diaper was always changed promptly. The assisted living facility failed to comply.
When the home health nurse arrived a week later, she was shocked by what she saw. In an email recovered by Southern California Nursing Home Law Group, the nurse wrote, “I go back after last week to this! I was like whooooa…..” Her family was informed of the worsening wound and insisted that Margaret be taken to the hospital for evaluation.
Upon her admission to the ER, photographs were taken of her wounds, and she was found to have a necrotic stage IV pressure sore to her coccyx and a necrotic pressure sore to her right ischial with significant odor and drainage. Over the course of the next several months, Margaret underwent several painful debridement procedures to try and help heal her wound, but none of these treatments were successful. Margaret died two months later with her Death Certificate listing her Stage IV pressure sore as an underlying cause of her death.
Despite being 96 years, Ray was a remarkably active man, sometimes too active for his age. When he was admitted to his Orange County assisted facility, he was rated as a high fall risk, requiring one staff person for bathing, bed mobility, dressing, eating, personal hygiene and oral care, toilet use, and transfer. He was also noted in his physical therapy assessment to have “impaired” safety awareness and “some confusion noted with remembering."
On July 15th at approximately 11:50 a.m., Ray was found on the floor in his room complaining of pain on the back left of his head. Staff called 911, and Ray, who was noted as being unable to stand and walk, was transported by EMS to Providence Mission Hospital. Ray was noted to be "verbally confused." A CT of Ray’s head showed no acute bleed or stroke. A CT of his cervical spine showed no fracture or dislocation. With no injury found, Ray was sent back from the hospital to the assisted living facility.
Four days later, on July 19th, Ray suffered a second fall, when he was again found on the floor of his room and suffering from a severe laceration over his left eyebrow. Ray was again transferred again to Providence Mission Hospital where a CT scan and an MRI revealed a massive brain bleed. Two days later, Ray underwent a frontal craniotomy for evacuation of hematoma and placement of subdural drain. Unfortunately, his condition continued to worsen and he died the following day on July 25th.
In the months before her premature death, Sharon, age 74, had moved out of her longtime family home and into an assisted living facility in San Diego, which is owned and operated by a local woman. Sharon wasn’t sick, but age and memory impairment required that she get assistance with her activities of daily living, such as getting in and out of bed. Because of her infirmities, Sharon was also at elevated risk for skin breakdown.
Despite this knowledge, caregivers at the assisted living facility and its owner, failed to take precautions to prevent Sharon from developing skin ulcers, and at one point left Sharon in her bed for more than an entire month, leading to a bedsore on her coccyx that became so deep that it exposed bone. Worse, as the bedsore deteriorated, the facility owner actively concealed the condition from the Sharon's family, falsely telling them she was qualified to treat the wound and actively discouraging them from transferring Sharon to a hospital where she could receive appropriate care.
The owner was motivated by money to keep Sharon in the facility, knowing that if she was sent to a hospital or skilled nursing facility she would not be allowed to return. As a result, Sharon did not get the life-saving healthcare she required, the bedsore worsened, and ultimately caused her death. As a result of this deficient care, assisted living facility received multiple Class “A” citations from the State of California for neglect.
Eunice was 88 years old and used a walker when she wandered undetected from the “memory care unit” of a licensed residential care facility in San Diego. She traveled nearly 75 feet to an open concrete stairway, where she tumbled down the stair and was found, hours later, with severe injury.
Caregivers testified how Eunice “got out somehow,” explained that they “didn’t know” how she could have gotten out and had no idea how long she had been outside. Later, the Executive Director of the assisted living facility, later said that the “back gate alarm” sounded and two caregivers went outside to take a look but didn't see anything.
Much of the immediate statements to the family by the facility contradicted what the nursing home put in its own Unusual Incident Report. In that report, it contended that staff members “found resident outside laying on the ground” after she “was up ambulating, lost balance and fell to the ground.” There was no mention of an alarm or of stairs, and to state that Eunice “lost balance and fell” implied that the fall was witnessed – it wasn’t.
Eunice's injuries were severe. Upon arrival to the hospital it was quickly realized that she was a true trauma patient. A CT of the cervical spine revealed an acute spinous process fracture at C4. X-rays of the left elbow revealed a complex comminuted olecranon fracture (in several pieces) and an x-ray of the left hip showed a left femoral neck fracture with shortening of the leg.
At Sharp Memorial, she was seen by several physicians. A spinal surgeon recommended closed management of the cervical fracture, which require a neck brace for many weeks. Her left elbow fracture was cast, and she underwent operative repair of her left hip fracture, requiring a unipolar hemiarthroplasty (or replacement of the hip joint). Eunice tolerated the procedure remarkably well and healed as well as anyone would expect for a woman of her advanced age. That doesn’t mean, of course, this incident did not cause her intense discomfort and pain.
Despite a diagnosis of dementia, Deanna and her husband of 75 years had been living at a coastal Orange County assisted living facility, moving there in 2012. At the facility, Deanna sat in a chair mostly, but could walk to the bathroom with a walker, shower (with help), and would eat in the dining room with her husband and the other residents. She had a quality of life that allowed her independence and allowed her to share a life and a bed with her husband.
That all changed in 2013, for what was to be short, rehabilitative stay at a nearby nursing home. Upon admission, Deanna was rated as at risk for developing pressure ulcers, though she had no ulcers present, and had no history of ulcers. On her Care Area Assessments – the comprehensive assessment of Deanna performed 10 days after her admission – she is noted to be at risk for skin breakdown, and that a care plan will be developed to minimize that risk. Within a week after her admission, Deanna was moved from her regular room to a private room for isolation because of a diagnosis of C. Diff. In her new room, there is no evidence anywhere that any precautions were taken to relieve any pressure the bedridden Deanna might place on her heels. On her Care Area Assessment form it is noted that she “needs special mattress or seat cushion to reduce relieve pressure,” but there is no evidence one was ever provided.
During her second week at the nursing home, a CNA reported that Deanna had an intact “fluid filled blister” on her right heel approximately 9 x 4.5 cm in size, “R heel kept elevated.” The following day, a different staff member discovered a “blood filled blister” on Deanna’s left heel, and stated (for the first time) that she retracts her legs against “pillow and bed” despite offloading with pillows. The wounds on her heels rapidly grew and soon were unmanageable. By her third week, she could not take steps, and would scream in pain just in the transfer from bed to wheelchair. Her physical therapy was terminated, and three days later it was determined that it was too painful to continue to even try standing.
Her heel wounds became necrotic and needed surgical repair, which was extremely painful and disabling. Because of her age and her wounds, it became unlikely that she would ever walk again. She became bedbound, and her health deteriorated. She was placed on hospice care, where she resided for the duration of her case.
Art was a fire inspector who was still working at age 72. After decades in the profession, a bad back requires surgery, which Art underwent at Tri-City Hospital. The surgery was uneventful, and it was recommended he spend a few weeks in a rehabilitation facility for recovery and therapy. Art, and his doctors, expected him to make full recovery.
Upon admission to a Vista, California nursing home, Art was rated as being at “High Risk” for falls due to problems with standing, balance and decreased muscular coordination. He also had some post-anesthesia confusion. Caregivers failed or refused to recognize Art’s cognitive deficits and the dangers they posed. Over his first 10 days in the nursing facility, Art fell three times, each time found on the floor either by visitors, or by caregivers.
Because of the sudden decline, there was concern that Art may have suffered a stroke or injured his cervical spinal cord. MRIs were ordered for both the brain and cervical spine. The MRI of Art’s cervical spine was startling. It revealed significant spinal cord compression at C3-6 with a large disc herniation at C4-5. This cervical spine injury was believed to be the explanation for Art’s significant neurological decline the cause of which was attributed to his falls at the skilled nursing facility.
After his third fall, Art was transferred back to the hospital and was noted to have several new neurological deficits which deteriorated rapidly. Art had developed an increased weakness in his left hand, including tingling and numbness; he had decreased strength and range of motion, and decreased balance and coordination; and he had developed a severe lean to the left and backwards. Art had to undergo two additional spinal surgeries, and never fully recovered and moved into an assisted living facility permanently.
Bob became a resident of his San Bernardino skilled nursing facility after suffering a massive stroke. Though only 60, he required help with all activities of daily living due to his diagnoses of respiratory failure, cognitive deficits, encephalopathy, diabetes, and congestive heart failure.
Unbeknownst to Bob or his family, another resident by the name of Frank was admitted to the same nursing home. Frank had a history of violence and mental illness, which it was alleged the nursing home was aware of. Specifically, the nursing home was warned by Frank’s caregiver, prior to his admission, that he was prone to acts of violence and posed a risk to other residents.
After Frank's admission, the nursing facility learned firsthand about this violence, as Frank threatened nurses, acted violently toward nursing staff, and broke a television set. Despite these violent outbursts, Frank was allowed to continue residing in the facility.
One early morning in June, a nurse heard loud thumping sounds in the area of Bob’s room but did not investigate the cause of the sound. Later, a nurse delivering medications happened to look into Bob’s room and saw Frank beating him with a toilet seat. The nurse ran to Bob’s bed and found him covered in blood, blood gushing from his head and chest, and noticed the toilet seat covered in blood as well. Bob was rushed to the hospital where he had life-threating injuries, including a severe brain injury, and required life supporting care to survive. Thankfully, he survived the acute phase of his injury and is still recovering but has been told he will never return to his pre-attack baseline.
On July 3, David was transferred to Alvarado Hospital from his nursing home, where he had had a Foley catheter placed. It was expected that he would recuperate at nursing home for a few days, before returning to the board and care facility he was living at full time. Upon admission, the admitting physician issued a pre-printed order to change the catheter on the 6th day of every month or as needed. David was also prescribed Coumadin, a blood thinner.
Only three days after his admission to the nursing home, and only six days after a urinary catheter had been placed at Alvarado Hospital, a caregiver attempted to change David's urinary catheter. The caregiver failed to properly chart this catheter change or to follow-up on David's chart following this change. It was not until just before her shift ended that she noticed there was no urine in David's catheter bag, and removed the catheter that was inserted approximately four hours earlier. When the catheter was withdrawn, David began to bleed profusely through his penis. Caretakers attempted to stop the bleeding by applying pressure to the area, but David continued to bleed, saturating several towels.
After about 30 minutes of unsuccessful efforts to stop the bleeding, caregivers at the nursing home called 911. When medics arrived, David had lost a tremendous amount of blood, and complained of severe pain in his penis.
Paramedics transported David to the hospital, where, upon arrival, he was admitted in serious condition. Attempts to reinsert a urinary catheter by emergency room nurses were unsuccessful, and a urologist was summoned to take over the care. A cystoscopy was performed revealing severe trauma to David’s urethra.
The urologist was able to stop the bleeding and accurately place a new catheter, but not without a tremendous amount of pain. Shortly after David stabilized he acquired an E Coli infection (with fecal contaminant) as a result of the trauma and his health declined rapidly. Within 48 hours of his arrival at the hospital from the nursing home, David became septic and died.
Harold, 76, was living at home before contracting a UTI that put him in the hospital for what was to be a temporary stay. His rehab potential was good, and the plan was to send him home after some rehab at a skilled nursing facility. Once in a nursing home, however, his condition deteriorated, and by the end of his second month he was in far worse condition than he was when he entered.
Remarkably, instead of retaining Harold, or sending him to a higher level of care, Mr. Richie was sent to a lower level of care; a residential care facility for the elderly (assisted living) that was totally incapable of caring for him. In just over a month, because of poor care, his condition deteriorated rapidly, especially his skin. By the time he was transferred to the hospital he had numerous Stage IV skin wounds and was severely malnourished. So horrendous was his condition that the hospital suspected neglect, and made a complaint to the California Department of Social Services on its own.
Harold died one month later, with decubitus ulcer and malnutrition being listed as contributing causes.
Esther was 92 years old when she passed away. At the time of her death, she suffered from end stage Alzheimer’s Disease, and could not walk, speak, or perform any of her activities of daily living on her own. Though she was frail, she did not require any hospitalizations in the five years prior to her death.
In the final years of her life, Esther lived with her daughter in the San Diego County that was built by Esther and her husband in 1960. Because of her advancing age and her progressing Alzheimer’s Disease, Esther's daughter retained the services of a home care agency to provide in-home care services to Esther five days a week.
Several weeks after starting care, Esther was being care for by a caregiver named Monica, who was new and untrained. Unbeknownst to the home care agency, Esther's daughter set up surveillance cameras inside the home. The recorded video showed Esther sliding down in her wheelchair, and Monica becoming frustrated as she tried to adjust Esther. Monica jerked the wheelchair back and forth, causing Esther to violently slam from side to side.
When Esther's daughter came home from work that afternoon, her mother was in bed with bloody elbows. Further examination revealed that Esther had suffered a broken femur during the event. After an examination at the hospital, the decision was made to put Esther on hospice care, and she died a few days later.
Mary was 92 and lived independently before she fell and fracture her hip. She was given surgery, and then transferred to a Hemet nursing home for rehabilitation. In her 30 days at the facility, it was below the legally required 3.5 hours ppd (per patient per day) for 10 of those days. Mary's condition declined and she developed a Stage 4 bedsore that went unnoticed by staff. By the time she received appropriate care, she was infected and had developed sepsis. She died three weeks after her discharge from the Hemet facility.
Domingo grew up in Tijuana, came to the United States as a teen, and made a life for himself doing the kinds of jobs immigrants in his situation do – working in restaurants and hotels, busing tables and cleaning rooms. He know the value of hard work, and was rarely without a job. By his late 50s Domingo began to have health problems. A fall near his home resulted in a broken leg, which resulted in a surgery and suspected stroke, and by the age of 59, Domingo found himself living in San Diego nursing home.
Domingo developed a wound on his left heel that went ignored for over eight weeks. When it was finally dealt with, it was 8 x 7 cm and necrotic. He was taken to Scripps Chula Vista where doctors were aghast at his condition. Within days it was determined that his leg could not be saved and his leg was amputated above the knee.
Mel was 84 and ended up in his Ventura assisted living facility as Alzheimer’s disease slowly robbed him of his ability to take care of himself. After a short hospitalization, Mel suddenly had difficulty walking, so his wife had him taken to Ojai Memorial Hospital. After he was stable, Mel's family made the decision they had been fretting for years and placed him in a board-and-care facility designed for the "memory impaired."
Upon admission, Mel was placed in a room with two twin beds (he had a roommate). His Alzheimer’s disease had advanced to a point where he had difficulty performing most of his activities of daily living, but he was not yet incapacitated by the disease, and his general health was otherwise excellent. He could ambulate with assistance and was able sit up on his own, and he could feed himself with his fingers.
Exactly two weeks after Mel's admission to the board and care, caregivers entered his room to wake him up and get him ready for breakfast. When they entered, they found Mel with his head close to the floor, but his legs still up on the bed. His neck had become wedged between a 5 ½ inch gap between the side of the bed and the edge of the dresser. Mel was obviously dead.
The caregivers lifted Mel's body off the floor, placed it on the bed and called 911. Paramedics arrived and declared him dead at the scene, and the Medical Examiner was called. An autopsy confirmed that the death was caused by Strangulation Asphyxia.
A 69-year-old nursing home resident in North County San Diego required transportation to dialysis three times per week. A transportation company was engaged to take her there, mainly because it could accommodate her wheelchair.
After one dialysis session, the driver assisted the patient back to the transport van, but failed to belt her in. When the van took a turn, the patient was thrown from her wheelchair inside the van and fractured her femur. Upon arrival back at the nursing home, an ambulance was called, and the patient was rushed to the hospital where the fracture was diagnosed.