"Terminal decline," the doctor called it a condition in which a brain destroyed by Alzheimer's disease takes the rest of the body down with it. It's an irreversible "freight train," he said, headed for the terminal of death.
"This is what we see," Dr. John Hampton Fullerton told a Sacramento Superior Court jury in the wrongful death and elder abuse trial targeting the nation's largest assisted living company. "It's not pretty. You die from the inside out, you die from the outside in."
Fullerton testified that there was nothing Emeritus at Emerald Hills in Auburn could have done to stop the erosion of Joan Boice's body, that no amount of "repositioning" could have saved her from pressure sores he said erupted "spontaneously" in the skin of the 82-year-old woman.
Under cross-examination Monday, Fullerton sought to ward off the lawyer for Boice's family, who peppered him with questions about the Emeritus Corp.'s failure to assess the woman's condition according to state regulations before taking her in.
The medical director of an assisted living facility called Aegis of Corte Madera, Fullerton grudgingly admitted his high-end residential care site in Marin County did all the things plaintiff's lawyer Lesley Ann Clement suggested Emerald Hills did not do when it accepted Boice.
Reading from documents and facing the jury in Judge Judy Holzer Hersher's courtroom, Clement rattled off in her questioning to Fullerton all of Emeritus' purported shortcomings. It failed to obtain a medical doctor's assessment of Boice within the 30 days before she moved in. Its staff did not conduct a pre-placement assessment, or a functional assessment to determine the extent of her dementia and whether she was capable of performing the activities of daily living. It didn't make sure it had enough staff to care for her.
"I didn't see the evidence they had actually met Mrs. Boice," Fullerton testified. In the next breath, he said it wasn't that big a deal, that the woman had recently just been assessed by a doctor in her previous assisted living facility. "You feel the patient has already been vetted," he said, in spite of state Department of Social Services regulations that require the more timely assessments.
Attorneys for Emeritus are expected to conclude their case today. Clement will likely follow with brief rebuttal evidence, and then closing arguments will likely get under way later in the week. The case should make it to the jury no later than Friday.
When jurors retreat into deliberations, their decision likely will play Fullerton's two days of testimony Thursday and Monday against that of the plaintiffs' key medical expert, Dr. Kathryn Locatell. She testified earlier in the trial that Boice, who died in February 2009, was in only a mild stage of Alzheimer's when she moved into Emerald Hills in September 2008.
Locatell has testified as an expert in elder abuse cases for 16 years. She also has worked as a consultant to state and federal agencies in their investigations into allegations of elder abuse in residential and nursing facilities. She told jurors that Emeritus failed to meet the "standard of care" for assisted living facilities, according to her assessment of the records in the Boice case.
In November 2008, Boice's last full month in Emerald Hills, the facility had only one staff person on duty during the swing shift to take care of as many as 17 residents in the memory care unit, the records showed. On the graveyard shift, there were times when the staffing level fell to zero.
Locatell testified that medical technicians who dispensed drugs to the residents were not adequately trained, that the executive director at Emerald Hills quit a month after Boice was admitted and that nobody was assigned to replace her.
"Chaos and dysfunction is how I would characterize what I saw," Locatell testified.
Locatell saw the the progression of Boice's Alzheimer's much differently than Fullerton viewed it. She said the Alzheimer's contributed to her passing but "did not cause her death."
In his testimony, Fullerton, a volunteer faculty member on numerous university hospital staffs and a geriatrics specialist with an estimated 100 patients, related to the jury his theories on "terminal decline." By the time Boice's family brought her to Emeritus in September 2008, there was nothing officials at Emerald Hills could do to stop it, he said.
Looking at Boice's records, Fullerton testified she lost 17 pounds in the three months before she moved in. She experienced multiple falls in her previous residential care facility. She could barely swallow. She became incontinent. Her Alzheimer's had advanced to somewhere between moderately severe and "end stage" by the time she got to Emerald Hills, the doctor testified.
Fullerton surmised Boice also had suffered a series of small strokes, although there was no definitive evidence in her medical records to support the diagnosis. Still, Fullerton said, Boice's brain and body were so far gone that Emerald Hills was powerless to prevent the pressure sores that broke out on both of her heels, her right foot, her right rear hip, her right elbow and elsewhere.
"The brain could go no further," Fullerton testified, under questioning from defense attorney Bryan Reid. "Other parts of the body start dying, too, and the skin, just being another organ, started to die."
Fullerton agreed under questioning from Clement that most of Boice's pressure sores cleared up and no more spontaneously developed when she left the Emeritus Corp. facility for the nearby Foothill Oaks Care Center in Auburn.
"They beat the odds," Fullerton said of Foothill, adding later, "and the patient still died."