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Elderly Woman Suffers Severe Infection

Garcia & Artigliere

North Hollywood, Calif. — Carole Bondi, a 77-year-old woman, was admitted to Windsor Gardens Healthcare of the Valley after a laminectomy to receive wound care to the surgical site. Over the next several weeks, on a daily and systematic basis, it’s alleged the defendants withheld required care from Bondi in direct violation of the facility’s own policies and procedures. According to the lawsuit, Bondi’s injuries predictably compounded when the facility failed to report and respond to emerging, worsening signs once an infection developed in her surgical wound site. Bondi was then forced to take oral antibiotics for 14 days and receive wound treatment twice a day to prevent worsening of the infection due to the facility’s negligence.

Garcia & Artigliere filed a lawsuit against Windsor Gardens Healthcare of the Valley for elder abuse, and negligent hiring and supervision.

“Carole’s injuries would not have occurred had Windsor Gardens Healthcare of the Valley simply adhered to applicable rules, laws, and regulations, as well as the acceptable standards of practice governing the operations of a skilled nursing facility,” said Attorney Stephen Garcia. “In fact, after Carole’s residency, the State of California’s Department of Public Health stepped in on December 11, 2017, to conduct an unannounced complaint investigation of the facility specifically regarding ‘Infection Control’ based upon Carole’s alleged injuries. The facility was then issued a deficiency for the substandard care provided to and leading to Carole’s injuries, including failing to reassess her lower back incision site as indicated in the facility’s Plan of Care.”

Allegations and Background

Bondi was admitted to Windsor Gardens Healthcare of the Valley’s care and custody on October 18, 2017. The facility physician’s order form dated October 18, 2017, indicated to remove the dressing from Bondi’s incision site on October 23, 2017, and required a surgical consult on October 31, 2017.

The facility Care Plan developed for Bondi on October 18, 2017, for potential/actual impairment to skin integrity from lumbar surgery, had a goal for her skin to heal without complications. The approaches included monitoring and documenting location, size, and treatment of the skin injury, and reporting to Bondi’s physician any abnormalities, failure to heal and signs and symptoms of infection.

The facility Minimum Data Set dated October 30, 2017, indicated Bondi was alert, oriented and required extensive one-person assistance with activities of daily living including transfers, ambulation, personal hygiene, bathing, etc.

The facility Medicare Skilled Documentation forms completed by the facility’s licensed nurses dated from October 19, 2017, through November 1, 2017, did not address Bondi’s incision site status from October 24, 2017, to November 1, 2017. The forms indicated Bondi’s dressing to the surgical incision site was to be removed on October 23, 2017 but did not indicate the dressing was removed as ordered.

The facility Nursing Notes dated October 23, 2017, at 6:42 p.m. reflect the facility’s Licensed Vocational Nurse 1 (“LVN 1”) documentation that there were no significant changes to Bondi’s surgical site without bleeding or drainage. The facility Non-Pressure Skin Condition Report dated October 23, 2017, indicated Bondi’s incision site was healed. There were no further facility Nursing Notes documenting the status of Bondi’s surgical incision site in the progress notes until October 31, 2017.

The facility Physician’s Progress Note from Bondi’s surgeon dated October 31, 2017, indicated her lumbar incision site had erythema, tenderness, and the dressing had dried blood and a putrid smell; however, Bondi’s surgeon documented that he had not been notified of the condition of the wound by the facility’s nursing staff. According to the Discharge Notes, Bondi was discharged from the facility to a lower level of care on November 2, 2017.

During an interview with the facility’s LVN 2 and concurrent record review on December 11, 2017, at 2:20 p.m., the facility’s LVN 2 stated there was no incision assessment after the dressing removal on October 23, 2017.

During an interview with the facility’s Director of Nursing (DON) and record review on December 11, 2017, at 3:26 p.m., the facility’s DON verified there was no documented evidence the licensed nurses monitored the condition of Bondi’s incision site. The facility’s DON further stated the licensed nurses needed to monitor the surgical wound daily after the dressing was removed.

It’s alleged the injuries suffered by Bondi while a resident of the facility was the result of the facility’s plan to cut costs at the expense of their residents. Integral to this plan was the practice and pattern of staffing the facility with an insufficient number of service personnel, many of whom were not properly trained or qualified to care for the elders and/or dependent adults, whose lives were entrusted to them. The “understaffing” and “lack of training” plan was designed as a mechanism to reduce labor costs and predictably and foreseeably resulted in the abuse and neglect of many residents.


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