A.G. Rhodes - Atlanta complaint alleges pressure-ulcer neglect and understaffing before a resident’s death
The complaint alleges that a nursing home failed to prevent, assess, and treat a resident’s pressure ulcers during her residency. Weekly skin assessments and Braden risk scores were repeatedly inaccurate or incomplete. The reopened sacral wound had no dressing, and it had no wound-care orders for six days after a hospital stay. The wound progressed from unstageable to an infected stage IV pressure ulcer with osteomyelitis. Understaffing driven by budget decisions is alleged to have contributed to the neglect. The complaint alleges that the resident died of sepsis from the wound. Her daughter brings this wrongful-death and negligence action.
Overview
This page concerns a public complaint alleging that a nursing home did not prevent, assess, or properly treat a resident’s pressure ulcers before her death.
Chronology
The complaint alleges as follows:
- Admitted to A.G. Rhodes - Atlanta on November 1, 2021 with intact skin, she received a Braden score of 16, not an accurate 12.
- By December 9, 2021 she developed skin breakdown, but many later weekly assessments recorded her skin as intact.
- The sacral wound reopened without a dressing on March 27, 2023, and she was hospitalized on March 31, 2023 with sepsis and hypernatremia.
- She returned to the facility on April 6, 2023, and no wound-care orders were entered for six more days.
- On or about July 20, 2023, her air mattress was found deflated due to a reported power shortage. Staff then placed her on a gel overlay, which the complaint says was not an adequate pressure-relief surface.
- A wound culture reported on July 23, 2023 showed four bacteria, and an antibiotic was ordered. No nursing notes monitored her response to it.
- She was hospitalized July 31, 2023 with an infected stage IV sacral wound and osteomyelitis, and died of sepsis on February 27, 2024.
Alleged failures
The complaint alleges the following failures:
- The facility failed to accurately assess the resident’s pressure-ulcer risk and did not create an individualized prevention care plan.
- Staff did not conduct weekly skin assessments consistently and did not revise her care plan with appropriate interventions as her skin worsened.
- Staff left the reopened sacral wound without a dressing and did not obtain wound-care orders after she returned from the hospital.
- The facility did not keep her air mattress adequately inflated. Staff did not monitor and document her vital signs and fluid intake from July 26 to 31, 2023.
- The defendants made operational and budget decisions driven more by their financial goals than by residents’ needs. The facility was chronically understaffed.
- The complaint pleads professional, gross, and simple negligence, negligence per se, and vicarious liability against the defendants. It also pleads breach of contract, joint enterprise, negligent hiring, retention, and supervision, and failure to provide sufficient trained staff. The complaint pleads violations of the Georgia Bill of Rights for Long-Term Care Residents and other nursing-home statutes. It pleads wrongful death, punitive damages, and attorney’s fees, and attaches an expert affidavit under O.C.G.A. § 9-11-9.1.