When Magdalena Marrones relatives gathered for her funeral in Central Florida, they were told the matriarch of the family succumbed to ravages of old age at her upscale Orlando group home.
What they didnt know: Caregivers failed to give her life-saving heart medication for four days and then gave her the wrong drugs.
Not until days later did family members learn the details of the 82-year-old grandmothers final days.
No one called the family until the investigation, said grandson Kevin Marrone, 35. We all assumed it was natural.
Though state regulators found sweeping breakdowns and neglect leading to sanctions against Emeritus at Crossing Pointe, caretakers were never held responsible under Floridas elder-abuse law.
Citing a lack of evidence, the state attorney generals office dropped the case last year, even though state agents found caretakers failed to read Marrones charts and then gave her the wrong medication.
The attorney generals office said the state was unable to pinpoint a specific person at fault. Records tell a different story: The Department of Children & Families found that three people committed medical neglect contributing to her death.
The attorney general closed the case, concluding problems had been addressed by regulators. Not so. The home went on to break the law a dozen more times, including a critical lapse that left a man without psychiatric drugs for 10 days and a falsified report concealing the mistake.
Three decades after Marrone moved to Florida to spend her retirement years, her grandson said his family is still disappointed no one was held accountable in her death.
My family never felt justice, Kevin Marrone said in an interview last year.
Karen Lucas, a spokeswoman for Emeritus Senior Living, said she could not discuss details of the case because of a confidential settlement agreement between the ALF and Marrones family.
The problems began in August 2009 when the elderly grandmother returned to the facility from an extended hospital stay.
Marrone had been losing weight and suffering from complications of diabetes and other disorders, but after nearly two months at a nursing home, she appeared to be improving, DCF reports show. By the time she returned to the ALF where her husband, Anthony, was also residing, the fateful errors had begun.
At first, the home lost track of her chart, including orders from a doctor that she get crucial doses of medication, including Rythmol and Digoxin, every day to keep her heart beating regularly and reduce the risk of heart attack.
Four days later, a nurse realized Marrone had not gotten any drugs since she arrived, but then ordered the wrong prescriptions. Just hours after the first dosage was given, a medical technician found Marrone slumped in a wheelchair, foaming at the mouth, and her skin turning blue.
Minutes after she was rushed to the hospital, she was pronounced dead at 5:26 p.m., August 26, 2009. The cause of death: cardio-pulmonary arrest, records show.
Three weeks later, the case took another turn: A doctor working with the ALF declared Marrone died of ovarian cancer, hypertension, diabetes and dementia without mentioning the critical mistakes by the home in the days before she died, records show.
AHCA inspectors concluded the errors at the home caused Marrone to go without life-saving cardiac medications for 4 days.
Rudy Panganiban, the doctor who signed the death certificate, told The Miami Herald he reviewed a health assessment form in the wake of her death that said Marrone had cancer, so he wrote it on her certificate.
AHCA records describing that form completed just three months earlier list several diseases including diabetes and hypertension but make no mention of cancer.
Panganiban declined to respond to further questions.
Marrones death wasnt the only problem turned up at the home during AHCAs investigation.
Medical mistakes and maltreatment of wounds had sent at least four other residents to the hospital three for festering bed sores and one after getting drugs meant for another person. Three people were found languishing in the dementia ward with toenails curling around their toes, another claimed she hadnt been showered for two weeks. And an employee was caught forging a nurses signature on doctors orders.
AHCA concluded the facility showed a total collapse in the delivery of care to the residents.
As far as the death of Marrone, DCF put the blame squarely on the director of nursing; another nurse who gave her the wrong prescriptions; and an assistant director who was responsible for residents arriving from the hospital, state agents said.
Staff members admitted to DCF investigators that they thought Marrone had simply transferred from a different floor and had no idea she had come from a hospital.
There was mass miscommunication within the facility, a DCF agent wrote.
Months later, more violations were turned up by AHCA. Last year, the home gave up its license and converted into an independent living center, said Lucas, the spokeswoman for Emeritus.
Kevin Marrone said his grandfather, who suffered from dementia and died five months ago, was never told how his wife of nearly 50 years died.
We never really told him what happened, said his grandson. Its devastating.