Woman Dies At Sacramento Skilled Nursing Facility, Part 3 of 20

It is worth noting that situations similar to those described in this elder abuse case could just as easily occur at any of the healthcare facilities in the area, such as Kaiser Permanente, UC Davis Medical Center, Mercy, Sutter, or any skilled nursing facility.

(Please also note: the names and locations of all parties have been changed to protect the confidentiality of the participants in this personal injury case and its proceedings.)

All witnesses also will agree that when Ms. Hill became entirely immobile after her September 2 hip fracture, she was at increased risk for developing pressure sores. After September 2, Ms. Hill was putting constant pressure on her sacral area either in bed or in her geri chair. This reality required facility staff to reposition her every two hours, check her skin every shift, and use pressure relieving devices while she was in bed or in the chair. According to the documentation, the facility did none of these things. It did not update the care plan — which is the “blue print” for action – to instruct care providers to reposition Ms. Hill. On the overwhelming number of shifts, there is no reference whatsoever to Ms. Hill being repositioned. Aside from one weekly summary (which itself is fraught with assumptions and mistakes), there is not a single reference to Ms. Hill’s skin being inspected. There is no evidence that any pressure relieving devices were used with Ms. Hill.

For more information you are welcome to contact Sacramento personal injury lawyer, Moseley Collins.

The jury will learn that understaffing at the facility was the underlying cause of Ms. Hill being warehoused after her fall on September 2. In the days after her fall, Station 4 was staffed by a single Licensed Vocation Nurse and several CNAs. The LVN thus was responsible for overseeing over 40 Alzheimer’s patients. The supervising nurse that usually was also working was off September 3, 4, and 5, as was the Director of Nurses.

This left these LVNs unsupervised, understaffed, and wholly incapable of attending to the care needs of Ms. Hill or the other 40 patients to whom she was assigned. The jury will learn that, based on its own calculations, the facility was staffed at a level that violated California law regarding staffing on the days following Ms. Hill’s September 2 fall.

On September 10, 2007, at 7:45 p.m., Ms. Hill was discharged from Universal to Kaiser Hospital. When she was admitted to the floor at Kaiser five hours and fifteen minutes later (September 11, at 1:00 a.m.), a head to toe inspection was performed and Kaiser staff documented her to have a Stage II pressure sore. Thereafter, autolitic debriding was initiated and the wound become more exposed. On September 15, 2007, Ms. Hill was discharged from Kaiser to National Care Center. National personnel were not able to eliminate the wound and it progressed to a Stage IV. On October 11, 2007, Ms. Hill died. Her treating physician, Robert Goldberg, identified the cause of death as sepsis due to an infected sacral wound. (See Part 4 of 20.)

For more information you are welcome to contact Sacramento personal injury lawyer, Moseley Collins.

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