This elder abuse/neglect case arose from blunt force traumatic injuries sustained by a 99 year old resident at a Confidential Skilled Nursing Facility in Monterey, California.
The elderly female resident lived at the skilled nursing facility for two years before her injuries. While a resident she was assessed to have mild dementia, confusion, poor judgment, occasional agitation, was a fall risk, and in need of supervision. Her attending physician wrote orders that she be monitored for attempts to leave the facility. She was wheelchair bound, however, was able to propel her wheel chair, albeit slowly. Her adult daughter would visit her mother almost daily for lunch. On more than one occasion the daughter advised both the administrator and the Director of Nursing of that she was concerned that her mother was in a state of agitation and confusion and that her mother may attempt to leave the facility and become harmed. The daughter was verbally assured that her mother would be taken care of.
On the date of the injuries, the resident was left unsupervised on the front porch of the skilled nursing facility. The building is built on the side of a hill and the driveway in front of the facility slopes steeply downward. Somehow the resident was able to wheel herself through the front gate and into the parking area, where she lost control of the wheel chair and it careened down the driveway to a point where it overturned, throwing her to the ground. She sustained bilateral knee fractures, a left distal femur fracture, multiple abrasions and lacerations of her lower and upper extremities, two black eyes, and forehead lacerations. These injuries, combined with her advanced age, resulted in her eventual death at a hospice center in Monterey.
The Department of Health Services investigated the incident, and determined that (1) a "forensic pathologist coroner's examination report documented cause of death as multiple blunt force injuries, sustained during an unsupervised mishap in her wheelchair"; and, (2) "the facility failed to provide adequate supervision to prevent the death of the patient who went out the front gate, rolled down the steep driveway and fell face first on the asphalt. Patient [ ] suffered serious harm from a wheelchair fall that resulted in her death. The accident could have been prevented with adequate supervision."