Oozing, infected ulcers pocked the 80-year-old’s frail body, from her back to her heels, causing her organs to effectively shut down.
The comatose woman, a resident at Bernadette ACLF in Hallandale Beach, was rushed to the emergency room at Aventura Hospital, where she died eight days later on Sept. 12, 2013.
On Thursday, the owner of the assisted living facility stood before a Broward judge to answer for the death of the woman, identified in court records only as L.D.
In a rare criminal case, 64-year-old Gail Victor is charged with aggravated manslaughter of an elderly person.
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As of Friday morning, Victor did not have any court appearances scheduled. She remains in jail in Broward County on $20,000 bond.
L.D.’s agonizing end may bring fresh scrutiny to Florida’s ALF industry, which was the subject of an investigative series in the Miami Herald in 2011. Neglected to Death, which documented a string of deaths due to abuse and substandard treatment, described how the state failed to monitor shoddy operators and almost never criminally charged caretakers responsible for deaths.
At Victor’s bond hearing Thursday, Assistant Florida Attorney General Arielle Demby-Berger said Victor’s actions led to L.D.’s death.
“Under the care of Ms. Victor, her backside rotted away, her bones liquefied,” Demby-Berger said in court. “This was a horrendous manslaughter.”
Victor’s attorney, Peter Heller, could not be reached for comment Thursday.
Under the care of Ms. Victor, her backside rotted away, her bones liquefied. This was a horrendous manslaughter.
Arielle Demby-Berger, assistant attorney general
The arrest came after a lengthy investigation by Attorney General Pam Bondi’s Medicaid Fraud Control Unit.
“Victor, a licensed practical nurse, failed to adequately treat the victim’s ulcers, falsified nursing notes and did not properly document the size and stage of the ulcers,” the attorney general’s office wrote in a news release. “In addition, Victor concealed the extent and severity of the ulcers from others involved in the victim’s care.”
L.D. first came to Bernadette’s ACLF, 520 NW Second Ave., on Jan. 31 2013, with several health conditions, including diabetes, hypertension, dementia and Alzheimer’s, according to the Agency for Health Care Administration (AHCA).
By March, L.D., who used a wheelchair, had developed heel blisters. She was then taken to her primary doctor, who ordered wound care treatments through Comfort Zone Home Health Services, according to Victor’s warrant. Sharafat Shorunke was assigned to care for the wounds, but it was found that L.D. did not receive any treatment between March and August.
Victor never told Shorunke that L.D. had developed pressure ulcers on her buttocks and tail bone, investigators wrote in Victor’s warrant.
Meanwhile, the wounds worsened.
During an interview with investigators, Victor said “she did not inform any physicians, nurses or family members of the pressure ulcers to L.D.’s hips or sacrum.”
“Victor stated she hoped she could heal the pressure ulcers herself,” an investigator wrote.
Victor, who ultimately relinquished her nursing license, also admitted that she falsified notes regarding L.D.’s treatment, according to the warrant.
Despite lawmakers pushing for more oversight after the publication of Neglected to Death, not much has changed for the better over the past five years, said Brian Lee, executive director of Families for Better Care and formerly the ombudsman for Florida.
He said that while greater oversight is necessary, less is being provided because lawmakers didn’t want to target the good providers while going after the bad ones.
“It’s a great disservice to the residents,” Lee said. “The problems are still as bad as they ever were.”
He said AHCA has stepped in and shut down some bad facilities, but added that there is plenty of work to be done.
“Enforcement remains a mystery to many consumers,” Lee said.
After L.D.’s death, AHCA conducted an unannounced visit to Bernadette’s ACLF on Oct. 8, 2013, and found more troubling signs.
“Based on observation, interview and records review, the facility failed to provide care and services appropriate for the needs of a resident,” the agency wrote in a report.
If convicted, Victor could face up to 30 years in prison.
Her ALF has since been closed.
Miami Herald news partner CBS4 contributed to this report.