Neglected to Death

State orders Miami assisted living facility to close

State health regulators are shutting down a Miami assisted living facility where caregivers illegally tied a frail elderly woman to a wheel chair — forcing her to sit on a life-threatening wound.

The state Agency for Health Care Administration has ordered that the San Martin De Porras ALF pay $20,000 in fines and close its doors. The home, at 1840 NW 15th St. in Miami, has 12 licensed beds.

The rare license revocation is in response to a February 2012 complaint to the health care agency. When inspectors arrived at the facility, they found a woman, identified only as Resident 1, tied to a wheelchair, struggling to get up.

Worse, the woman was being forced to sit on a pressure sore, exacerbating what was already a severe wound, records say.

“This resident,” a nurse testified at trial, “was in imminent danger.”

The administrator of San Martin De Porras did not respond to calls for comment.

The order, dated June 3, gives San Martin De Porras 30 days to complete the closure, “for the sole purpose of allowing the safe and orderly discharge” of the ALF’s residents. It also forbids the home from accepting any new residents.

The charge stems from a visit in Feb. 27, 2012, by health care inspectors.

Resident 1, records say, was “trying to get up, but unable to because she was restrained with two lap belts around her legs and abdomen.” Florida law bans the use of such restraints at an assisted living facility.

The woman, records show, should not have been at the ALF to begin with. Suffering from seizures, diabetes, psychosis, pain and two pressure sores, she needed to be in a skilled nursing home, AHCA records say. The woman also did not have the required medication on hand to treat her ailments.

Carla Mayorga, a registered nurse who testified on behalf of AHCA at a hearing, said Resident 1’s pressure sore, located near her buttocks, had become so severe that it “could eventually lead to [the] death of the resident.”

Mayorga said Resident 1 also was not receiving any medication for her seizure disorder, and her blood was not being monitored to control her diabetes. Both the untreated seizure disorder and the diabetes, Mayorga testified, “could put her at risk for death.”

“The resident was diabetic, and she did not have her insulin, and she was not receiving her psychotic medication and they were not following doctor’s orders,” Mayorga testified. “It was an immediate danger to her.”

Mayorga’s inquiry into the woman’s health was hampered, records say, because the woman’s medical records had previously been shredded.

Resident 1’s daughter, who was identified in records only by her first name, Margarita, testified, however, that family members were quite satisfied with their mother’s care, adding the facility “treated her mother like their own mother,” records say.

The home’s administrator, Marcario Huaitlalla, testified that in 12 years of managing the home, he had “never had a problem before with any other clients.”

“I admit I made a mistake,” Huaitlalla testified. “I re-admitted her to the facility because the daughter asked me to do so.

“This is my living and I dedicate about 24 hours of my day, and this is my only means of income, and this is my only job,” Huaitlalla testified. “I am 55 years old, and for me to lose this job would put me in a very severe position financially. It would be hard for me to find a job.”

The ALF had been criticized by health regulators for other lapses, as well, in recent years.

This February and March, AHCA faulted the facility for having inadequate staff. Last August, the agency cited the home for allowing a staff member to sleep in the closet of a room shared by two residents, which violated a state law forbidding staff members and their families from sleeping in the same rooms as residents. In March 2010, the home was cited for sloppy record-keeping and with failing to help residents take their medications, as required, and failed to keep proper medication records.

The home also was faulted in 2010 for failing to allow a resident access to his own clothes, “so as to maintain individuality and personal dignity.”