Daniel E. Holloway
Email me about your case
Georgia case library

Fulton Center complaint alleges stage 4 pressure ulcer and fatal sepsis

The amended complaint alleges that an elderly resident at Fulton Center for Rehabilitation developed pressure ulcers, including a stage 4 sacral wound that the filing says was not identified until it was advanced. Facility staff failed to implement turning, repositioning, nutrition, hygiene, and monitoring measures, and medical providers failed to timely transfer the resident for emergency care despite signs of sepsis. The resident died shortly after hospital transfer.

System
Empire Care Centers
Facility
Fulton Center for Rehabilitation
Providers involved
Fulton Center for Rehabilitation / Kristen Shea, N.P. / Willie E. Landrum, M.D. / Lytani Wilson, M.D. / Medical Director Services, PC / Skilled Facility Health Care Solutions, Inc.
Pattern
Alleged failure to monitor and treat worsening pressure ulcers in a skilled nursing facility
Harm
Alleged stage 4 sacral pressure ulcer, sepsis, and death

Overview

This page concerns a public amended complaint alleging that Fulton Center for Rehabilitation and related providers failed to prevent, identify, and treat pressure ulcers before the resident developed fatal sepsis.

Chronology

The complaint alleges as follows:

  1. The resident was admitted to Fulton Center for Rehabilitation in 2017 for long-term care with no initial skin breakdown.
  2. Pressure ulcers appeared on both fifth lateral toes in October 2020.
  3. An outside wound specialist treated the toe wounds during November 2020 and noted worsening at various points.
  4. December 2020 activities-of-daily-living flow sheets contained major documentation gaps for bed-mobility assistance.
  5. A stage 4 sacral pressure ulcer was first observed on January 6, 2021 despite its severity.
  6. The sacral wound was later documented as mostly necrotic, and the resident was not transferred to a hospital at that time.
  7. A nurse practitioner noted an infected sacral wound, tachycardia, and acute mental-status change on January 19, 2021.
  8. The resident was transferred to a hospital emergency room on January 20, 2021 and died from sepsis shortly afterward.

Alleged failures

The complaint alleges the following failures:

  • The facility failed to develop and implement an individualized care plan for the resident’s risk of skin breakdown.
  • Staff failed to perform and document turning and repositioning every two hours.
  • Providers failed to timely identify the sacral pressure injury before it reached stage 4.
  • The nurse practitioner and attending physician failed to immediately transfer the resident to the hospital when signs of sepsis were present.
  • Chronic understaffing contributed to neglect of the resident’s nutrition, hygiene, and wound-care needs.

Entities and tags

Fulton Center for RehabilitationEmpire Care CentersStage 4 pressure ulcerSacral pressure ulcerSepsisSkilled nursing facilityWound careTurning and repositioningPressure ulcersNursing-home neglectFailure to monitorDelayed treatmentWrongful deathSkilled nursing careGeriatricsNursing home care