Tucker Nursing & Rehabilitation Center complaint alleges pressure-injury and malnutrition neglect before resident’s death
The complaint alleges that Tucker Nursing & Rehabilitation Center failed to assess, prevent the worsening of, and treat an 83-year-old resident’s existing sacral and heel pressure injuries, and failed to respond to her sustained poor intake and weight loss, during a stay from November 2023 to March 2024. The resident lost more than 31 pounds during the stay, was later hospitalized with sacrococcygeal osteomyelitis and a sacral ulcer extending to bone, and died at home in June 2024 with protein-calorie malnutrition listed as the cause of death.
Overview
This page concerns a public complaint alleging that a skilled nursing facility in Tucker, Georgia failed to prevent the worsening of a resident’s pressure injuries and failed to address her malnutrition before her death.
Chronology
The complaint alleges as follows:
- The resident, an 83-year-old woman with hypertension, type 2 diabetes, chronic kidney disease, anemia, and dementia, was admitted to Emory Decatur Hospital on or about November 24, 2023 for generalized weakness.
- On or about November 29, 2023 she was discharged to Tucker Center for skilled nursing rehabilitation with significant pressure injuries to the sacral area and both heels, malnutrition, and incontinence documented at or near admission.
- Wound-care documentation during the stay reflected a stage 3 sacral wound that at times required debridement and bilateral heel wounds with necrotic tissue, and facility weight records reflected a decrease from 134.8 pounds to 103.3 pounds.
- The resident was discharged home on March 8, 2024, later presented to Emory Decatur Hospital with altered mental status and concern for worsening ulcers, and imaging documented sacrococcygeal acute osteomyelitis before an April–May 2024 discharge with hospice services.
- The resident died at home on June 8, 2024, and her death certificate lists protein-calorie malnutrition as the cause of death.
Alleged failures
The complaint alleges the following failures:
- The facility failed to accurately assess, document, and care-plan for the resident’s pressure-injury risk, with Braden scores that varied between “at risk” and “no risk” entries.
- The facility failed to implement and document an effective turning, repositioning, and offloading program and failed to consistently carry out or document ordered wound treatments.
- The facility failed to respond to sustained poor intake and profound weight loss, failed to ensure safe and coordinated discharge planning, and was understaffed because operational decisions were made on financial goals rather than patient safety.