Georgia case library

Fulton Center for Nursing and Healing complaint alleges staff concealed a pressure ulcer before it reached the bone

The complaint alleges that a nursing home did not prevent or properly treat a resident’s pressure ulcers during a stay that began in August 2021. The resident used a feeding tube and could not communicate. Staff repeatedly told her son that her sacral wound was being treated and was healing. On September 11, 2023, her feeding tube became dislodged, and her medication and nutrition stopped for days while staff did not promptly arrange reinsertion. When she reached a hospital emergency room two days later, her son learned the wound had reached the bone.

System
Fulton Center for Nursing and Healing
Facility
Fulton Center for Nursing and Healing
Providers involved
Fulton Center for Rehabilitation LLC / ENSH Consulting LLC / Empire Care Centers LLC / YW Georgia 4 LLC / Starlight Healthcare Services LLC / YYES OP, LLC
Pattern
Alleged concealment of a worsening sacral pressure ulcer and delayed care after a feeding tube dislodged
Harm
Alleged Stage 4 sacral pressure ulcer requiring debridement

Overview

This page concerns a public complaint alleging that a Fulton County nursing home concealed a worsening pressure ulcer from a resident’s family.

Chronology

The complaint alleges as follows:

  1. The resident, then 75 and dependent on a feeding tube and a tracheostomy, was admitted to the facility on August 30, 2021.
  2. She developed pressure ulcers during her stay, and staff repeatedly told her son the wounds were unavoidable but were being treated and healing.
  3. In 2023, a sacral pressure ulcer worsened quickly, and staff told her son it remained small and was healing well.
  4. In early September 2023, her son noticed a foul smell and asked staff to have a physician examine her.
  5. On September 11, 2023, her feeding tube became dislodged, and her medication and nutrition stopped for days while staff did not promptly arrange reinsertion.
  6. On September 13, 2023, she was transferred to a hospital emergency room, where her son learned the sacral wound went down to the bone.
  7. Staff had reportedly required her son to leave the room when she was changed, which he says kept him from seeing the wound’s true severity.

Alleged failures

The complaint alleges the following failures:

  • Staff did not create or follow an adequate care plan to prevent and treat the resident’s pressure ulcers.
  • Staff did not notify her physician promptly when her feeding tube became dislodged.
  • The complaint alleges that staff records saying she reported no pain and sat on her own were “incorrect at best and fraudulent at worst.”
  • The complaint pleads professional and ordinary negligence and violations of long-term care residents’ rights. It also pleads negligent hiring, training and staffing, and imputed and direct liability, and attaches an expert affidavit under O.C.G.A. § 9-11-9.1.

Entities and tags

Fulton Center for Nursing and HealingFulton Center for Rehabilitation LLCSacral pressure ulcerPEG tubeStage 4 pressure ulcerFulton CountyPressure ulcersConcealment or records tamperingDelayed treatmentNursing-home neglectNursing home careWound careLong-term care