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Fulton Center complaint alleges stage 4 pressure ulcer and fatal sepsis

The amended complaint alleges that an elderly resident at Fulton Center for Rehabilitation developed pressure ulcers, including a stage 4 sacral wound that the filing says was not identified until it was advanced. The complaint alleges that facility staff failed to implement turning, repositioning, nutrition, hygiene, and monitoring measures, and that medical providers failed to timely transfer the resident for emergency care despite signs of sepsis. According to the complaint, the resident died shortly after hospital transfer.

System
Empire Care Centers
Facility
Fulton Center for Rehabilitation
Providers involved
Fulton Center for Rehabilitation / Kristen Shea, N.P. / Willie E. Landrum, M.D. / Lytani Wilson, M.D. / Medical Director Services, PC / Skilled Facility Health Care Solutions, Inc.
Pattern
Alleged failure to monitor and treat worsening pressure ulcers in a skilled nursing facility
Harm
Alleged stage 4 sacral pressure ulcer, sepsis, and death

Overview

This page concerns a public amended complaint alleging that Fulton Center for Rehabilitation and related providers failed to prevent, identify, and treat pressure ulcers before the resident developed fatal sepsis.

Chronology

  1. According to the complaint, the resident was admitted to Fulton Center for Rehabilitation in 2017 for long-term care with no initial skin breakdown.
  2. The complaint alleges that pressure ulcers appeared on both fifth lateral toes in October 2020.
  3. According to the complaint, an outside wound specialist treated the toe wounds during November 2020 and noted worsening at various points.
  4. The complaint alleges that December 2020 activities-of-daily-living flow sheets contained major documentation gaps for bed-mobility assistance.
  5. The complaint alleges that a stage 4 sacral pressure ulcer was first observed on January 6, 2021 despite its severity.
  6. According to the complaint, the sacral wound was later documented as mostly necrotic, and the resident was not transferred to a hospital at that time.
  7. The complaint alleges that a nurse practitioner noted an infected sacral wound, tachycardia, and acute mental-status change on January 19, 2021.
  8. According to the complaint, the resident was transferred to a hospital emergency room on January 20, 2021 and died from sepsis shortly afterward.

Alleged failures

  • The complaint alleges that the facility failed to develop and implement an individualized care plan for the resident’s risk of skin breakdown.
  • The complaint alleges that staff failed to perform and document turning and repositioning every two hours.
  • The complaint alleges that providers failed to timely identify the sacral pressure injury before it reached stage 4.
  • The complaint alleges that the nurse practitioner and attending physician failed to immediately transfer the resident to the hospital when signs of sepsis were present.
  • The complaint alleges that chronic understaffing contributed to neglect of the resident’s nutrition, hygiene, and wound-care needs.

Entities and tags

Fulton Center for RehabilitationEmpire Care CentersStage 4 pressure ulcerSacral pressure ulcerSepsisSkilled nursing facilityWound careTurning and repositioningPressure ulcer neglectFailure to monitorDelayed hospital transferSepsis managementWrongful deathSkilled nursing careGeriatricsNursing home care

Questions this example answers

What does the Fulton Center pressure ulcer sepsis complaint allege?

The amended complaint alleges that an elderly resident at Fulton Center for Rehabilitation developed pressure ulcers, including a stage 4 sacral wound that the filing says was not identified until it was advanced. The complaint alleges that facility staff failed to implement turning, repositioning, nutrition, hygiene, and monitoring measures, and that medical providers failed to timely transfer the resident for emergency care despite signs of sepsis. According to the complaint, the resident died shortly after hospital transfer.

Who is identified in this public case example?

This public case example identifies Fulton Center for Rehabilitation, Kristen Shea, N.P., Willie E. Landrum, M.D., Lytani Wilson, M.D., Medical Director Services, PC, and Skilled Facility Health Care Solutions, Inc. It also tags the source-supported entities Fulton Center for Rehabilitation, Empire Care Centers, Stage 4 pressure ulcer, Sacral pressure ulcer, and Sepsis.

What alleged failures are summarized here?

The complaint alleges that the facility failed to develop and implement an individualized care plan for the resident’s risk of skin breakdown. The complaint alleges that staff failed to perform and document turning and repositioning every two hours. The complaint alleges that providers failed to timely identify the sacral pressure injury before it reached stage 4.