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Elderly Woman Overmedicated, Suffers Multiple Falls & Fractured Pelvis

Garcia & Artigliere

San Jose, Calif. — Renee Ortiz, an elderly woman suffering from a history of mental illness and a high risk for falls, was admitted to Amberwood Gardens for required care and services. While a resident of the facility, Ortiz allegedly suffered significant injuries, including overmedication, unnecessary restraints and multiple entirely preventable falls, including one on March 4, 2018, that caused a fractured pelvis and was left untreated by facility staff. According to the lawsuit, the facility did not have the resources or trained staff available to provide the care and supervision they described to Ortiz’s family prior to her admission. As a result of Ortiz’s falls and related injuries, her physical and mental health rapidly declined, and she suffered needless pain and suffering.

Garcia & Artigliere filed a lawsuit against Amberwood Gardens for elder abuse, and negligent hiring and supervision.

“Amberwood Gardens knew full well that it didn’t have the resources or trained staff available to provide the required care and supervision promised to Renee’s family,” said Attorney Stephen Garcia. “These promises were made for the sole purpose of increasing the headcount of paying residents in order to fulfill the financial goals management set by the facility. Rather than correcting understaffing and substandard care deficiencies, which were regularly documented by the State of California’s Department of Health Services, facility management allowed these violations to continue at the expense of resident health and safety.”

Allegations and Background

Prior to being admitted into Amberwood Gardens, it’s alleged the facility was aware of Ortiz’s history of mental illness since young adulthood, including Bipolar disorder, schizophrenia, and depression. Ortiz was also known to have been in and out of multiple institutions over the years, suffering from arthritis throughout her body, battling with self-medicating and addiction to opiates, a chronic obstructive pulmonary disorder, chronic bronchitis, hypertension, and heart disease. Further, Ortiz was known to require oxygen assistance for significant portions of the day and had a known history of falls related to diagnoses in 2017 of cerebral ataxia leaving her crippled and with a balance problem due to clubbed feet. She was also known to be on medications which caused her to be chronically disoriented. In addition, Ortiz’s overall condition caused her to be feeble and weak and resulted in her having an unsteady gait. Accordingly, Ortiz required 1:1 supervision and monitoring when ambulating and transferring.

Throughout her stay at the facility, it’s alleged Ortiz was never provided a low bed, and floor mats or alarms were never put in place on and near her bed. Nor did the facility have sufficient nursing staff as required by California and federal law to ensure that Ortiz received the supervision, care, and monitoring required by her increasing needs during her residency.

Instead of providing Ortiz the care she required and deserved to address her fall safety needs, the facility allegedly repeatedly and unnecessarily overmedicated and chemically restrained her. This physical abuse was used for the convenience of facility staff, each of whom was responsible for the provision of care for far more residents than was possible, thereby leading to the wrongful withholding of required care.

Predictably, Ortiz suffered from addiction and was diagnosed as Opioid Dependent on June 14, 2017, as confirmed in the facility chart. By this time, Ortiz could only walk a few steps and was dependent upon a walker or wheelchair.

In September 2017, Ortiz experienced a significant change of condition and her breathing difficulties progressively worsened. When she requested to be transferred to a hospital, facility staff allegedly refused. It was only when Ortiz’s daughter confronted staff regarding her respiratory conditions and risk factors, did facility staff transfer Ortiz to the hospital. By this time, Ortiz had blood in her sputum.

When Ortiz arrived at the hospital, she was diagnosed with pneumonia. In addition, Ortiz had contracted Methicillin-resistant Staphylococcus aureus on her arms, legs, and lips.

In January 2018, Ortiz was weaned off her pain medications. During this time, her personality changed completely and she became very depressed. Because Ortiz was having difficulty with pain management, her daughter took her to a medication management specialist. After a couple of weeks, Ortiz’s condition improved before she again started falling and having memory issues.

On March 4, 2018, Ortiz suffered a fall in the facility, fracturing her pelvis. This same week, Ortiz had already suffered three prior falls. She was taken to Good Samaritan Hospital in San Jose. Extreme bruising was present upon arrival on her face, arm, and hip. After receiving four days of treatment, Ortiz was returned to the facility.

In April 2018, a friend of Ortiz named “Lisa” came to visit her at the facility. After finding Ortiz lethargic and her oxygen level at 80, she notified Ortiz’s daughter, who was out of town at the time. The following day, at approximately 10:00 pm, the facility called Ortiz’s daughter notifying her that they had called 911 and made the decision to send Ortiz to Kaiser Hospital.

Upon arrival at Kaiser Hospital, Ortiz was in cardiac arrest. By this time, Ortiz had been placed on Do Not Resuscitate status. Unfortunately, the facility unsafely and disorderly discharged Ortiz, and as a result, the multiple resuscitation attempts were made until Ortiz was revived.

On April 8, 2018, Ortiz was found by her daughter non-responsive with noticeably unusual behaviors. Several hours later, at approximately 6:00 p.m., Ortiz starting having spasms. Her arms were flailing all over the place and her face was twitching. At approximately 10:30 p.m. that same night, Ortiz passed away.

It’s alleged Stephen Hooker (Administrator), Phillip A. Greene (Administrator), Mildred Canlas (Director of Nursing) and many other facility staff, including certified nursing assistants, registered nurses and licensed vocational nurses, were unfit to perform their job duties. This unfitness created a risk to elder and infirm residents of the facility, including Ortiz.


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