Case Summary: Examination of Neglect and Legal Accountability in Elder Care

In a significant legal action concerning the care of an Alzheimer’s patient within an elder care facility, the lawsuit unfolds detailing the events leading to the tragic passing of the patient due to inadequate care and oversight. Admitted to the facility for 24/7 monitoring due to his tendency to wander, the patient experienced a series of neglectful incidents, ultimately leading to a severe fall that significantly contributed to his demise. This case brings to light the facility’s failure in adhering to essential care standards, notably in supervising high-risk patients and effectively managing their medical conditions.

The case was resolved before trial for a confidential amount.

Critical Aspects of the Case:

  • Initial Care and Observations: Upon admission, the facility identified the patient as a fall risk, yet subsequent actions and preventive measures proved grossly insufficient.
  • Sequence of Neglectful Events: A pattern of neglect surfaced through multiple incidents, including unaddressed injuries and serious infections, culminating in a fatal fall that occurred due to improper transportation within the facility.
  • Understaffing and its Repercussions: Evidence indicates that the facility’s chronic understaffing, especially of registered nurses, compromised the quality of care, directly impacting the patient’s health outcomes.
  • Financial Misconduct: The facility’s management practices, specifically the diversion of funds away from staffing and care provisions, highlight a concerning prioritization of profit over patient welfare.


The applicable standard of care required the defendants to comply with the Omnibus Budget Reconciliation Act (OBRA) of 1987 and the [Redacted State] Rules of Department of Health and Senior Services Division 30—Division of Regulation and Licensure Chapter 85—Intermediate Care and Skilled Nursing Facility.

The applicable standard of care mandates the nursing home to adhere to the Omnibus Budget Reconciliation Act (OBRA) of 1987. Specifically, § 483.20(k) requires the nursing home to:

Develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being; and

A comprehensive care plan must be prepared by an interdisciplinary team that includes the attending physician, a registered nurse with responsibility for the resident, and periodically reviewed and revised by a team of qualified persons after each assessment.

Furthermore, § 483.25(h)(2) of OBRA mandates that the nursing home ensure “[e]ach resident receives adequate supervision and assistance devices to prevent accidents.” The guidance to surveyors clarifies that the intent of this provision is for the facility to identify each resident at risk for accidents and/or falls and adequately plan care and implement procedures to prevent accidents. An accident is defined as an unexpected, unintended event that can cause a resident bodily injury.

An “Avoidable Accident” is described as an incident that occurred because the facility failed to identify environmental hazards and individual resident risk of an accident, including the need for supervision; and/or failed to evaluate/analyze the hazards and risks; and/or failed to implement interventions, including adequate supervision consistent with a resident’s needs, goals, plan of care, and current standards of practice, to reduce the risk of an accident; and/or failed to monitor the effectiveness of the interventions and modify the interventions as necessary in accordance with current standards of practice.

An “Assistive Device” refers to any item, such as fixtures (e.g., handrails, grab bars) and devices/equipment (e.g., transfer lifts, canes, and wheelchairs), that is used by or in the care of a resident to promote, supplement, or enhance the resident’s function and/or safety.

“Supervision/Adequate Supervision” is defined as an intervention and a means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents, defined by the type and frequency of supervision based on the individual resident’s assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident.

The explanatory language for F-tag 323 under this regulation calls for evaluation and analysis data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. This process includes interdisciplinary involvement, communicating the interventions to all relevant staff, assigning responsibility, providing training as needed, documenting interventions, and ensuring that the interventions are put into action.

Proper actions following a fall are outlined, including ascertaining if there were injuries and providing necessary treatment, determining what may have caused or contributed to the fall, addressing the factors for the fall, and revising the resident’s plan of care and/or facility practices as needed to reduce the likelihood of another fall.


The resident, an Alzheimer’s patient, was admitted to the facility at the end of August 2018 for full-time care due to a tendency to wander, necessitating constant monitoring. Facility records identified him as a fall risk, yet implemented limited precautions to mitigate this risk. Concerns were raised early on when the resident displayed signs of leaning to one side and had visible injuries, prompting a request for hospital evaluation.

Subsequent to this, the resident was hospitalized for a urinary tract infection and pneumonia. Upon his return to the facility and during a transition to hospice care, an incident occurred where the resident, improperly transported in a wheelchair (contrary to needing a gurney), stood up, fell, and sustained a severe injury. Despite the facility’s awareness of his condition and the need for supervision, adequate measures were not in place to prevent this fall.

This incident underscores a failure in the facility’s duty to provide adequate supervision and care, particularly for a resident with known risks and a recent change in mental condition, who had not received a comprehensive reassessment upon his return.


The facility’s staffing levels are central to the case, with allegations pointing towards a failure to meet both federal and state requirements for adequate staffing. This deficiency is linked directly to the quality of care and the outcomes for residents, with a clear association established between staffing ratios and the incidence of care-related problems.

Federal and State Staffing Requirements: Regulations stipulate sufficient staffing to maintain or achieve the highest possible physical, mental, and psychosocial well-being of each resident, based on individual assessments and care plans.

Direct Relationship Between Staffing and Resident Outcomes: Studies and analyses, including those from CMS, have identified specific staffing levels below which the risk of quality problems significantly increases.

Facility’s Actual Staffing Levels: Data revealed that the facility provided significantly less RN time per resident per day than expected by CMS, highlighting a substantial shortfall in registered nursing care during the period in question.


The facility’s financial practices have raised concerns, particularly the allocation of funds away from staffing and towards other financial priorities. This section discusses how the defendants’ decisions to limit spending on necessary staffing, despite the obvious need, demonstrate a disregard for the well-being of residents, potentially motivated by financial gain rather than care quality.

Impact of Financial Decisions: The redirection of funds that could have supported sufficient staffing levels is cited as a contributing factor to the inadequate care and supervision provided to residents, including the plaintiff’s decedent.

Legal Considerations for Financial Misconduct: The case explores the legal implications of these financial decisions, arguing that such practices could warrant punitive damages due to the deliberate disregard for resident safety and well-being.

Legal Framework and Standards:

The case is framed within the obligations set forth by the Omnibus Budget Reconciliation Act (OBRA) of 1987 and state-specific health service regulations, underscoring the facility’s non-compliance with mandated care standards. Legal arguments emphasize the facility’s known deficiencies and the systemic nature of the neglect, supported by historical staffing and financial practices.

Litigation and Settlement Dynamics:

With a focus on addressing the extensive neglect and the patient’s suffering, the legal team advocates for a settlement that not only compensates for the loss but also mandates significant operational changes within the facility to prevent future incidents of similar neglect.

The case was resolved before trial for a confidential amount.