Case Summary: A Case of Neglect in Senior Care


This is the tragic case of an elderly resident’s decline and subsequent death due to neglect at a senior care facility. Despite clear medical and nutritional directives aimed at preventing and treating pressure ulcers, the facility’s gross understaffing and disregard for established protocols led to the resident’s suffering. Detailed medical evaluations point to the facility’s failure to implement essential care practices, resulting in the resident’s hospitalization due to severe, untreated pressure ulcers, compounded by an unrelated choking incident. The facility, previously cited for similar care deficiencies, displayed a systemic failure to provide the necessary and legally mandated level of care, directly contributing to the resident’s painful and preventable death.

Key Points of Concern:

  • The resident, an 83-year-old individual, succumbed to complications from pressure ulcers that were inadequately managed by the care facility.
  • Notable incidents leading to the hospitalization include the development of Stage IV pressure ulcers and an emergency arising from a choking incident, contrary to dietary recommendations.
  • Expert medical evaluations uniformly criticize the facility for:
    • Chronic understaffing during the critical period of the resident’s care.
    • Significant delays and neglect in following physician, wound care specialist, and nutritionist orders.
    • A disturbing lack of adequate record-keeping, including missing meal intake and wound care documentation.
  • The facility has a history of regulatory citations significantly exceeding state averages, with previous violations closely mirroring the current incident’s circumstances.

The case was resolved before trial for a confidential amount.