Lawsuit Filed: Elderly Woman Suffers Paralysis, Chokes & Dies Due to Negligence at Sacramento Nursing Home

Sacramento, Calif. — Mary Castex, an 82-year-old woman with dementia, suffered a fall at home and was admitted to Kaiser Permanente South Sacramento Medical Center where she was discovered to have a thoracic spine fracture and scalp lacerations. During this hospitalization, Castex also suffered a sudden heart attack. She was then discharged to Eskaton Care Center Greenhaven for occupational, physical and speech rehabilitation therapy. It’s alleged that during her residency, Castex suffered multiple strokes which went undiagnosed and untreated by the facility, and left her paralyzed. Following hospitalization, Castex was readmitted to the facility and left unsupervised when she suffered a choke incident which she ultimately died from due to the facility’s alleged failure to seek emergent care.

Garcia, Artigliere & Medby filed a lawsuit against Eskaton Care Center Greenhaven for elder abuse, and negligent hiring and supervision.

“Mary suffered a choke incident without the facility performing any meaningful assessments and without notifying her family or physician, then simply left her to suffer the painful consequences,” said Attorney Stephen Garcia. “Based on her untreated, compounding injuries, it’s evident the facility’s wrongful withholding of care was on a chronic and systematic basis. The facility wrongfully withheld this required care to Mary due to their alleged refusal to provide services with a sufficient number of personnel on duty on a 24-hour basis in accordance with Mary’s resident care plans as required by federal law.”

Allegations and Background

Upon Castex’s admission to the Eskaton Care Center Greenhaven on November 3, 2016, the facility was well aware, through assessment information, family information, as well as physician notes and orders provided to the facility, that Castex suffered from dementia, coronary artery disease, atrial fibrillation and was taking Coumadin, hypertension, had a history of strokes with right sided residual weakness, dementia, and a history of falls with fractures, swallowing difficulties, and the inability to eat without assistance and supervision. Further, Castex required assistance with activities of daily living and therefore required special care and assistance, including 24-hour supervision and monitoring, assistance and monitoring with eating, medication administration, ambulation and transfers, the provision of safety and assistance devices to prevent accidents, assessment and reassessment as appropriate to determine increased choking risks, medication assessment and evaluation following alterations to medication regimen, assistance and monitoring with other activities of daily living, and the implementation of interventions to prevent choking and interventions to address choke incidents in a timely fashion.

On September 5, 2017, after months of near misses on falls which had been allegedly ignored by the facility, Castex fell out of bed while attempting to transfer from her bed to her wheelchair unsupervised and unassisted by the inadequately trained facility caregiver assigned to her care at the time.

When questioned regarding how Castex fell out of bed when she is paralyzed, the facility offered no account as to how it happened; they simply stated that they did not know. The facility did not take x-rays and transferred Castex for unrelated reasons. In an alleged effort to conceal their misconduct, the facility transferred Castex without recommendation for assessment for internal injuries even though Castex was on blood thinners.

On September 6, 2017, Castex was discharged back to the facility and upon her readmission, the facility was aware, through assessment information, family information, as well as physician notes and orders provided to the facility, that Castex suffered from conditions and limitations which rendered her at high risk for choke incidents, and therefore required special care and assistance, including 24-hour supervision and monitoring, assistance and monitoring with eating and medication administration, the provision of safety and assistance devices to prevent accidents, assessment and reassessment as appropriate to determine increased choke risks, medication assessment and evaluation following alterations to medication regimen, assistance and monitoring with other activities of daily living, and the implementation of interventions to prevent choke incidents and interventions to address choke incidents in timely fashion.

The month prior, on August 27, 2017, Castex was found by her son with a significant change to her mental condition. When he went to her room he found her in bed as usual. He said hello to her and she was unable to respond. He reached out to take her hand and she was unable to lift her arm to meet his hand. When asked to squeeze his hand, Castex was unable to. When asked what was wrong, Castex could not respond. Castex’s son then immediately went out to the nurse’s station and notified them about his mother’s change of condition. In response, the facility nurse stated Castex was “fine” and that she was “just tired.” Castex’s son told the nurse that his mother was not fine and that she may have suffered a stroke. When the nurse stated disbelief in this regard, Castex’s son requested her to check Castex. The nurse followed him back to Castex’s room. When asked if she was okay, Castex tried to say something but she could not be understood. The nurse then nodded and said “okay.” When Castex’s son asked the nurse what Castex said, the nurse said he didn’t know. Castex’s son then asked the nurse to call 911. The nurse refused, however. Only after Castex’s son told the nurse that he would call 911 himself were arrangements made to transfer Castex.

That same day, Castex was taken to Kaiser Hospital Sacramento and admitted for treatment of multiple strokes. During this stay, Castex’s son was informed that his mother was paralyzed due to the effects of the stroke. The hospital staff continued explaining that Castex would not have become paralyzed had facility transferred her sooner. Unfortunately, by the time Castex arrived at the hospital, it was past the window of treatment to prevent her from becoming paralyzed. Castex’s Speech Therapy records from this stay reflect recommendations for 1:1 supervision with eating.

On August 30, 2017, Castex was discharged back to the facility. On September 19, 2017, Dr. Kirill Berejnoi authored a facility interdisciplinary note reflecting a meeting date that same day. Therein, under Plan of Care, Dr. Berejnoi documented in pertinent part “Diet: NAS, LF, CCHO, Mechanical soft diet,” “weight: 128 lbs,” ”BP= 116/69, monitor.” In this same note, Castex’s Code Status was noted “full code.”

On September 23, 2017, Castex completed rehabilitation therapy at the facility. By this time, Castex’s level of needs with activities of daily living were documented as follows:

  • Bed Mobility: Max Assistance
  • Transfers: Max Assistance
  • Ambulation: Wheelchair Totally Dependent
  • Wheelchair Mobility: Totally Dependent
  • Feeding: Max Assistance
  • Grooming: Max Assistance
  • Upper Body Dressing: Max Assistance
  • Lower Body Dressing: Totally Dependent
  • Toileting: Totally Dependent
  • Sit to Stand: Max Assistance

In October 2017, the California Department of Public Health issued deficiencies against the facility for violating federal care of quality regulations when a “staff member rushed the care she was providing” and failed “to immediately consult with the resident’s physician and notify the resident’s Responsible Party (RP) when there was a significant change in condition” which resulted “in the physician being unable to intervene and prevent further decline in condition for Resident 1 and the RP being uninformed.”

On March 31, 2018, Castex suffered a choke incident after she was allegedly provided medications and left unsupervised by facility staff. By the time they returned to Castex’s room, she was unresponsive due to lack of oxygen from choking.

The entirety of issues then compounded when the facility was unable and incapable of taking prompt and corrective action to address the choke incident to ensure it did not fatally exacerbate Castex’s condition.

Moreover, the facility allegedly did not seek emergent care after they found Castex choking and unresponsive, and allowed Castex to die without oxygen in an attempt to cover up their misconduct. Further, Castex’s facility chart was replete with inaccurate and internally conflicting accounts as to how Castex suffered the choke incident, as the facility allegedly hoped that by concealing the true events regarding the choke incident, that their misconduct would never come to light. The facility’s efforts to conceal the choke incident through fraudulent charting is evidenced in the facility “Resident Progress Notes” from this day reflecting the following illogical chronology of events directly contradicting the factual realities existing at this time relating to Castex’s needs and conditions. Then, to compound this wrongful withholding of required care, the facility failed to report the “unusual occurrence” involving Castex to the Department of Public Health as required by 22 Code of Regulations §72541.