Questions remain after family of bruised, battered 94-year-old Alzheimer's patient wins lawsuit

Complaints against memory care facility substantiated four times since 2016

SAN ANTONIO – A Bexar County Justice of the Peace last month awarded a San Antonio family $1,500 plus court costs after a 94-year-old woman with Alzheimer's was injured at a far West Side memory care facility last summer.

The woman's daughter, Linda Smith, told the KSAT 12 Defenders following the hearing that she still does not believe justice was served.

"I'm going to appeal it and go to another court," said Smith, who had asked for $9,500 in damages plus court costs, which included fees to subpoena a San Antonio police detective assigned to investigate the incident last August.

"It tells me: 'Watch out for putting your loved ones in a damn rest home or a memory care facility,'" Smith said.

The hearing inside a courtroom at Bexar County's Justice of the Peace Precinct 1 did little to clear up the mystery of what happened to Smith's mother, Mary, during her four-day stay last August at Autumn Leaves of Westover Hills, a memory care facility in the 10100 block of West Military Drive.

After being picked up, Mary was found with large bruises on her arms and backside, as well as large, infected gashes on her arm and leg that had been treated with butterfly stitches.

Mary's physician was forced to lance the gash on Mary's leg, drain the infection from it and prescribe antibiotics.

When Smith reached out to an administrator from Autumn Leaves in August, she says she was given several versions of what happened, including an accusation that Smith had brought in her mother already injured.

View a slideshow of Mary's injuries below.

Autumn Leaves' alternating narrative continued in court, where cameras were not permitted.

Margaret Rodriguez, executive director of the facility, said Mary had a documented history of erratic behavior and past behavior disturbance. 

Rodriguez then said that Mary had bruising on her right hand and calves when she arrived at the facility.

Rodriguez then produced for the court two incidents reports, one which showed that Autumn Leaves staff members noticed a gash on Mary's leg while trying to bathe her on Aug. 9.

The second incident report showed that Mary's arm was bleeding while she was being escorted by a medical technician. 

The wound was later treated by staff members.

The report states the injury may have been from an encounter with another resident at the facility.

Rodriguez then used a laptop to show surveillance footage recorded inside the facility that appears to show Mary swing at another resident in a hallway.

Rodriguez, who spoke briefly to Smith after the judge ruled against Autumn Leaves, declined to answer questions from the Defenders as she left court, stating only that she was not the executive director when the incident happened and that she was satisfied with the judgment.

A criminal case related to the incident has been closed pending further investigation because investigators were unable to determine if a crime occurred or if Mary injured herself.

Officials with the Texas Health and Human Services Commission released more than 250 pages of documents to the Defenders related to complaints against Autumn Leaves of Westover Hills, including Mary's case.

The allegation that Mary was abused inside the facility was unsubstantiated, but an allegation related to Mary's rights as a patient was substantiated.

Records show the violation came from the facility not notifying Mary's hospice care about the incidents.

Smith pointed out earlier this year that neither her family nor the state was contacted after staff noticed Mary's injuries.

Substantiated, Not Cited

Including Mary's case, on four occasions since September 2016, the commission's Regulatory Services Division found that complaints against Autumn Leaves of Westover Hills were substantiated.

State records show that on all four occasions, investigators declined to cite the facility, and instead checked off a box that reads "Substantiated, Not cited."

In May 2018, a patient wandered off from the facility and was found two hours later at a Walmart 5 miles away.

Last November, a state investigation determined that a hospice patient was not provided adequate pain medication.

"On one occasion the client was observed to be in a great deal of pain and cried out in pain," the report states.

In September 2016, an Autumn Leaves employee witnessed a caregiver slap a resident.

The caregiver admitted to the slap, was placed on leave and was later terminated.

The family declined to press criminal charges in that case, records show.

Despite the list of substantiated complaints, state records show Autumn Leaves currently has no deficiencies.

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