Samples of Our Work

Conspicuously absent from the staff’s 5/24/06 care plan addressing skin breakdown was an intervention for turning and repositioning Plaintiff every two hours to help prevent the development of pressure ulcers. Turning and repositioning Plaintiff every two hours was not implemented until the 7/26/06 care plan, according to the chart. But by then, Plaintiff had already developed a severe bedsore on her right buttock. The staff’s failure to turn and reposition Plaintiff every two hours was particularly egregious in this case because staff knew that she could not turn and reposition herself. According to the staff’s own documentation, Plaintiff “needed extensive assistance with bed mobility and turning and repositioning”, per an assessment dated 5/8/06 (just two days after her admission).

In summary, the staff failed to keep Plaintiff’s skin clean and dry, and instead, she was left by staff in urine-soaked clothes and bed sheets for extended periods of time; staff failed to apply a barrier cream after each incontinent episode; they failed to timely apply a pressure relieving cushion to Plaintiff’s wheelchair; they failed to turn and reposition her every two hours; and they failed to document accurate weekly skin checks. As a result of these failures, Plaintiff developed a large and painful bedsore on her right buttock.

The staff’s failures continued even after Plaintiff developed said pressure ulcer, in that they failed to provide proper care and treatment to the pressure ulcer, and as a result, it became progressively worse. Staff first documented Plaintiff’s pressure ulcer on 7/20/06. A treatment order was obtained and the care plan was updated accordingly. However, as before, the care plan interventions were not consistently implemented by staff. For example, staff still was not keeping Plaintiff’s skin clean and dry after each incontinent episode. Staff still was not turning and repositioning Plaintiff every two hours. And staff failed to notify Plaintiff’s physician to obtain a new treatment order when her pressure ulcer became worse.Significantly, nowhere in the chart is Plaintiff’s right buttock bedsore staged. It is not staged in the wound care records, nor in the nurse’s notes, nor in Defendant’s transfer sheet at the time of discharge. The pressure ulcer should have been documented in the MDS assessments, which would have required staff to stage the pressure ulcer. However, the only MDS assessment in the chart was the one completed around the time of admission (when Plaintiff had no pressure ulcers). All subsequent MDS assessments were missing from the chart. However, Plaintiff’s right buttock pressure ulcer was staged by the nursing home that she transferred to when she left Defendant’s facility. The new nursing home performed a complete body check on the Plaintiff on 8/25/06, which is the day she transferred out of Defendant’s facility. The new staff documented Plaintiff’s right buttock pressure ulcer as a stage III. Defendant’s failure to document the stage of Plaintiff’s pressure ulcer, thereby concealing its severity, was not only egregious, it was reckless and wanton and constituted a conscious disregard or indifference to Plaintiff’s right to adequate and appropriate healthcare.Plaintiff’s stage III pressure ulcer was severe and it was painful. It was painful for her when she laid in her bed, and it was painful for her when she sat in her wheelchair. The staff, however, was not adequately monitoring Plaintiff’s pain from her decubitus ulcer; there is no documentation in her chart documenting this pain or treating it. Plaintiff also fell several times while at Defendant’s facility, which falls could, and should have, been prevented had the staff provided proper care. Defendant’s staff knew that Plaintiff was a fall risk, and they also knew she had poor balance and poor safety awareness, according to their own admission assessments. Notwithstanding the same, staff failed to address Plaintiff’s fall risk in the initial care plan, or the 5/16/06 care plan, or the 5/24/06 care plan. Defendant’s staff finally addressed fall risk in a 5/31/06 care plan update. At that time, staff documented that Plaintiff continually attempted to get out of bed and out of her wheelchair without the assistance of staff. This is documented throughout the nurse’s notes as well. As a result, alarms were applied to Plaintiff’s bed and her wheelchair. Staff, however, repeatedly failed to respond, or failed to timely respond, to Plaintiff’s alarms when they sounded. The nurse’s notes document, for example, that the family complained to staff that Plaintiff’s alarm would go off, but no staff ever came to assist her. The nurse’s notes also document Plaintiff’s roommate in the hallway calling for staff when Plaintiff’s alarm went off, again because staff failed to provide assistance when the alarms sounded. In addition to failing to respond to Plaintiff’s bed and chair alarms, the staff also repeatedly failed to assist her to the bathroom as needed. Plaintiff was unable to toilet herself and required the assistance of staff. She did not get that assistance. Further, staff failed to monitor Plaintiff sufficiently, given her known risk for falling and suffering injury.

Because the staff failed to respond, or timely respond, to Plaintiff’s bed and chair alarms, failed to assist her to the bathroom as needed, and failed to sufficiently monitor her, Plaintiff fell several times while at Defendant’s facility. Her first fall occurred on 8/8/06. She was found face down on the floor in front of her wheelchair. The wheelchair alarm was sounding. When staff finally arrived to assist her, Plaintiff was sent to the emergency room for evaluation and was diagnosed with a large scalp contusion to her right forehead; a contusion to her upper right arm; and a severe black eye. She was in pain.Plaintiff fell again about a week later, on 8/15/06. She was found on the floor in her room; her alarm was sounding; her roommate was in the hallway yelling for staff to help the Plaintiff. When staff finally arrived, Plaintiff explained that she needed to use the bathroom. According to the chart, staff documented that Plaintiff suffered no injuries as a result of this fall. Pictures taken by the family at the time, however, document significant bruising.Both of Plaintiff’s falls at Defendant’s facility should have, and could have been prevented, had the staff simply responded to Plaintiff’s bed and chair alarms, assisted her to the bathroom as needed, and monitored her sufficiently.

The care and treatment that Plaintiff received while at Defendant’s facility fell well below the prevailing standard of care, and also constituted a violation of her statutory nursing home residents’ rights, including but not limited to, the right to receive adequate and appropriate healthcare; the right to be free from abuse; and the right to be treated fairly and with the fullest measure of dignity. Defendant’s own documentation clearly shows that the staff was negligent in its care and treatment of Plaintiff throughout her stay there. As a result, Plaintiff suffered needlessly, both physically and emotionally. In short, during her stay at Defendant’s facility, Plaintiff received substandard care at the hands of an unsympathetic and indifferent staff, ill-equipped to meet her needs. As a result, Plaintiff’s family decided to take her out of Defendant’s facility; they had lost all confidence in the staff. Defendant’s facility had failed to provide the care and treatment that it had promised to provide to Plaintiff.

As a result of the above described failures on the part of Defendant’s staff, Plaintiff fell on August 6, 2009 and suffered serious injuries. Because staff failed to provide toileting assistance, she ambulated to the bathroom unassisted and when she attempted to get up from the commode, she fell. According to the 8/6/09 nurse’s note, when staff found her (it is unknown how long she had been lying on the floor), she had on “bedroom shoes” with food on the bottom which were “very slippery” as a result. Thus, not only had staff failed to keep the floor clean of food and other debris, they also failed to provide Plaintiff with non-skid footwear. When staff picked Plaintiff up from the floor, she immediately complained of pain in her left wrist and she was sent to the hospital for evaluation. Plaintiff’s son was notified. However, her son was told by staff that his mother had purportedly fallen “in the shower.”

At the hospital, the Plaintiff was in “severe pain,” per the Physician’s Clinical Report. The report also documented severe tenderness, swelling and a deformity consistent with a forearm fracture. An x-ray revealed two fractures: a fractured ulna, and a “severely displaced” fracture of the radius. Plaintiff’s arm was placed in a splint and she was told to follow-up with her orthopedic.

The Plaintiff saw her orthopedic the next day. According to a physician progress note dated August 7, 2009, the Plaintiff had an “obvious deformity in her wrist.” An x-ray showed a “95% displaced” radius fracture. The family opted against surgery, given Plaintiff’s age and medical condition. Plaintiff’s orthopedic concurred and felt that a closed reduction and casting was a better option for her. The orthopedic performed a closed reduction maneuver (i.e. he manually re-set the two fractured bones, causing the Plaintiff severe pain) and placed the Plaintiff’s arm in a splint. Even after the procedure, post-reduction x-rays still showed 20% displacement of the radius fracture, as well as a shortening of the wrist. Plaintiff thereafter continued to see her orthopedic over the next 7 months, during which time her left wrist and arm remained either in a cast or splint. During this time, the fractures never healed completely, and instead Plaintiff developed crepitus, and her wrist at the fracture site continued to tilt backwards over time with increased comminution, and ultimately the fracture site became “extremely shortened” and a permanent deformity developed at the wrist the size of a golf ball. See the color photos produced during pre-suit.

As a result, Plaintiff permanently lost the use of her left wrist, her physical and occupational therapy notwithstanding, which in turn required an increased level of assistance with all of her activities of daily living. Additionally, Plaintiff suffered from severe, chronic pain for which she required pain medication. At one point, the pain became so severe that she was switched to a narcotic pain medication (Vicodin). Further, according to the psychiatric notes in her chart, the Plaintiff was unable to sleep at night and became depressed due to the pain in her left wrist.

About 2 ½ months after Plaintiff fell, Defendant’s staff completed a Quarterly Resident Data Set dated 10/22/09. A fall risk assessment was also completed, but incorrectly. Under the category “any falls in the past 3 months”, staff assigned Plaintiff zero points, when in fact she had fallen just 2 months earlier (i.e. the fall in her bathroom discussed above), which would have added 2 points to the assessment. Further, under the category “predisposing diseases,” one of which was “fractures,” staff again assigned zero points, when in fact Plaintiff had two fractures in her left arm/wrist as a result of the fall in her bathroom, which would have added another two points to the assessment. Because of these errors on the part of staff, Plaintiff was not deemed to be a high fall risk, when she should have been. As a result, the care plan interventions that staff developed for fall risk failed to adequately address Plaintiff’s high risk of falling. Not surprisingly, Plaintiff fell again at Defendant’s facility on February 6, 2010. She was found on the floor of her room next to her rolling walker. According to the staff, she purportedly suffered no injuries and was not in any pain. Plaintiff fell again on 3/1/11 and again on 3/2/11. According to the staff, she purportedly suffered no injury from these falls either. However, the extent to which these falls aggravated Plaintiff’s fractures in her left arm/wrist is still being investigated. Thus, even after her first fall and resulting injuries, Defendant’s staff still was not properly addressing the Plaintiff’s high fall risk.

In addition to the 8/6/09 fall and the resulting permanent deformity of Plaintiff’s wrist, which she had to live with for the rest of her life, the Defendant is also responsible for the Plaintiff’s untimely death. For several weeks prior to her discharge from Defendant’s facility, Plaintiff had been complaining of abdominal pain and also of constipation, her abdomen was bloated, and she was continually vomiting—all classic symptoms of bowel obstruction, which the Defendant’s staff knew or should have known. Defendant’s staff, however, failed to timely and properly address Plaintiff’s bowel obstruction symptoms, even when Plaintiff’s son repeatedly advised the staff over several weeks of his mother’s continuing symptoms. Instead of sending Plaintiff to the hospital for evaluation, the staff’s response was to give her medication for the constipation and “monitor” her. Additionally, the staff failed to notify Plaintiff’s physician of her recurring small bowel obstruction symptoms. In bowel obstruction cases, timely diagnosis is essential to successful treatment. Plaintiff’s bowel obstruction symptoms, however, were not timely diagnosed or treated due to the failures of Defendant’s staff. Instead, Plaintiff died just six days after her admission to the hospital; according to her death certificate, the cause of death was “acute small bowel obstruction.”

The Defendant’s staff failed to adequately monitor Plaintiff’s medical condition, and further failed to timely notify Plaintiff’s physician of significant changes in her medical condition, including her recurring symptoms of bowel obstruction. This failure to adequately monitor Plaintiff is documented in the chart. There is a pattern in the nurse’s notes of large gaps of time where Defendant’s staff failed to chart anything on the Plaintiff in the nurse’s notes for weeks and months at a time. For example, Plaintiff was discharged from Defendant’s facility on July 15, 2011 when she was finally transferred to the hospital for the bowel obstruction at the insistence of her son. Prior to Plaintiff’s discharge, the following gaps appear in the nurse’s notes: a thirty-nine day gap from January 20, 2011 to March 1, 2011; an eighteen day gap from 3/24/11 to 4/12/11; a sixty-nine day gap from 4/21/11 to 6/30/11; and a thirteen day gap from 6/30/11 to 7/14/11. The latter two gaps in the nurse’s notes are particularly egregious because they are so close in time to Plaintiff’s discharge from Defendant’s facility, and they show that Defendant’s staff was not monitoring the Plaintiff during the last few weeks of her stay. The first episode of vomiting that was documented in the nurse’s notes occurred on 4/16/11. According to the nurse’s note, Plaintiff had “several episodes of vomiting” and was also complaining of constipation. In a nurse’s note dated 4/17/11, complaints of Plaintiff not feeling well were also documented. Both nurse’s notes further documented that Plaintiff would be “monitored.” However, no such monitoring occurred because just four days later, i.e. on 4/21/11, was the beginning of the sixty-nine day gap in the nurse’s notes discussed above. This repeated pattern of large gaps in the nurse’s notes is evidence of the staff’s continued failure to adequately monitor Plaintiff’s medical status and changes in her medical condition, which resulted in the staff’s failure to timely and properly address Plaintiff’s classic symptoms of bowel obstruction, including at the very least reporting her symptoms to her physician.

When the paramedics arrived to take Plaintiff to the hospital, Defendant’s staff failed to provide an accurate assessment of Plaintiff’s condition. For example, according to the EMS Report, staff advised the paramedics that Plaintiff had been vomiting “since last night,” when in fact she had been vomiting for the last couple of weeks. The Plaintiff’s son had advised the nurses at the nurse’s station at least a dozen times during the last few weeks of his mother’s stay that she was vomiting.

Second, Defendant’s staff advised the paramedics that Plaintiff was vomiting “light brown/clear” fluid with “no blood”, when in fact she had been vomiting dark brown fluid with blood, which was witnessed not only by Plaintiff’s son, but also by another family member. Also, according to the hospital’s infectious disease consult dated 7/16/11, Plaintiff was having “pretty severe hematemesis” (vomiting of bright red blood). Third, Defendant’s staff advised the paramedics that Plaintiff had been having “normal bowel movements,” when in fact both Plaintiff herself and her son had repeatedly advised Defendant’s staff that she was continually constipated. In fact, according to the hospital’s radiology report dated 7/16/11, Plaintiff had a “collapsed colon.”

When Defendant’s staff finally acknowledged the seriousness of Plaintiff’s bowel obstruction symptoms, they notified her doctor, who immediately ordered Plaintiff transferred to the hospital for evaluation and treatment. However, by that time it was too late. According to a hospital consult dated 7/17/11, Plaintiff’s abdomen was “markedly” distended and “guarded all over with rigidity,” and her pain level on a scale of 1-10 was a 10. She was also severely dehydrated, presumably from all the vomiting. Plaintiff’s symptoms of bowel obstruction continued at the hospital.An x-ray revealed a large abdominal mass, and Plaintiff was quickly diagnosed with a small bowel obstruction. Significantly, the hospital records also document a previous history of a large abdominal mass that was diagnosed in 2005. However in 2005, Plaintiff’s abdominal mass was timely diagnosed and treated, and she had abdominal surgery to remove the mass. The surgery was successful and Plaintiff went on to live another six years. However this time surgery was not a viable option because of the untimely diagnosis, due to Defendant’s failure to timely act on the Plaintiff’s obvious symptoms of bowel obstruction. Had Defendant’s staff adequately monitored Plaintiff’s condition and timely and properly reported her bowel obstruction symptoms, Plaintiff’s abdominal mass could have been surgically removed just as it was in 2005 and her small bowel obstruction avoided and her untimely death prevented.

The care and treatment that Plaintiff received while residing at Defendant’s facility fell well below the prevailing standard of care, and also constituted a violation of her statutory nursing home residents’ rights, including but not limited to, the right to receive adequate and appropriate healthcare, the right to be free from abuse, and the right to be treated fairly and with the fullest measure of dignity. The facility’s own documentation clearly shows that Defendant’s staff was negligent in its care and treatment of Plaintiff during her stay there. Further, the staff’s repeated failure to properly address Plaintiff’s fall risk, and more importantly, the staff’s failure to timely address Plaintiff’s obvious bowel obstruction symptoms, was so wanting in care that it constituted a conscious disregard or indifference to the Plaintiff’s rights and safety, entitling her to punitive damages.