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San Mateo resident Trudy Maxwell, 93, died Aug. 29 in the hospital after being served Ecolab Ultra Klene by Atria San Mateo staff two days earlier. The incident at the assisted living and memory care at 2883 S. Norfolk St. occurred Aug. 27 when Trudy and two other residents were mistakenly served the liquid as juice, according to an Atria press release.
The death shocked her family and led them to call for management restructuring, more staffing and specific training to ensure the tragedy doesn’t happen to another family.
“This shouldn’t have even been possible,” her son James Maxwell said. “It isn’t just that someone made a mistake. It should never have been possible.”
According to the lawsuit, an employee left a container of Ecolab Ultra Klene in the kitchen area, while another employee staffing the cafeteria took it and filled a separate container with the liquid inside. Another employee allegedly took the separate container with Ultra Klene and poured it into cups for residents to drink.
Maxwell was in pain and had severe damage to her mouth, throat and esophagus before her death. Atria employees also allegedly waited 30 minutes before calling 911.
“Overall, they have completely shirked responsibility for what happened,” plaintiff lawyer Niall McCarthy said. “There has been no apology issued to the family, and there hasn’t been a complete and accurate recitation of facts.”
Law firm Cotchett, Pitre and McCarthy filed the lawsuit for the Maxwell family. The lawsuit alleges negligence and bad decisions from Atria staff and that the company had been misleading and downplaying the incident. The lawsuit names Atria San Mateo, Atria Senior Living and Atria San Mateo administrator Jennifer Duenas.
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According to the lawsuit, Atria put out a misleading press release calling the substance “dishwashing liquid” when it knew it was industrial cleaner, misrepresented facts about a similar Atria Park Walnut Creek incident days earlier, and Atria employees misled first responders into thinking the patients drank the liquid themselves.
Atria Senior Living issued a statement Thursday about the lawsuit.
“Our residents will always be our top priority,” the statement said. “We devote significant resources to ensure our staff are thoroughly trained and able to meet our residents’ needs at all times. We take this incident very seriously. We’re continuing to work with authorities and the Department of Social Services to fully review and assess the incident. Our hearts remain with the residents affected, their families and loved ones.”
McCarthy called for wide-reaching policy changes, noting Atria has not announced any policy changes based on the incidents. He called the death entirely avoidable if Atria followed state laws or had taken action after the first incident in the East Bay.
“There is no indication that anything has changed or will change, so that’s one of the main purposes of this lawsuit,” McCarthy said.
The lawsuit said Atria cut costs and care, including failing to insufficiently train or vet new employees, resulting in temporary workers who knew little about the residents or safety training and protocol. Work was also shift-based, resulting in few pre-shift meetings to update employees on residents’ needs during the prior shift. The family said Atria’s care for Trudy had a continuing pattern of concerning behavior, like failing to change undergarments. They had also sent written complaints to Atria staff before the incident. The lawsuit said Stanford doctors, in July, revealed to the family Maxwell had broken her hip twice within the last six months, something the family was unaware of. Atria housing costs for Maxwell were more than $7,000 a month.
The lawsuit also noted Atria San Mateo received 12 violations of California’s Code of Regulations and Health and Safety Code in the past five years. Four violations were Type A citations that present an immediate risk to health and safety. Atria is a national senior living company that operates 45 senior living communities in California for 4,000 families daily, including several in the Bay Area. In 2020, Atria Park was named in a wrongful death lawsuit that accused it of failing to supervise and assist an 86-year-old woman with Alzheimer’s disease who fell several times.
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