EFMH Sues Healthcare Providers Who Neglected Vulnerable Woman to Death

Regina Suazo, 61, was blind and intellectually disabled. But she loved celebrating holidays, going out to lunch and trips to the thrift store.

For 40 years, she had a very active and full life at a supportive living home in Albuquerque, said her brother Silas Suazo. Then one day she fell out of a chair in her living quarters — a chair that had no arms to use for support. Two weeks later, in June 2022, she fell out of the same chair, which wasn’t replaced despite staff knowing it had been a danger and that she had a high risk of falling, he said.

“From that point forward, things really changed for her dramatically,” Suazo told the Journal, recounting how she went downhill after trying to recover at an Albuquerque rehabilitation center and then another supportive living facility.

Within seven months, Regina Suazo was dead, the victim of sepsis caused by “institutional neglect,” according to the May 2023 finding of the state Office of the Medical Investigator. The OMI ruled the manner of death as “homicide.”

A wrongful death lawsuit filed Friday in 1st Judicial District Court in Santa Fe includes as defendants ARCA, Genesis ElderCare, Genesis Healthcare and Onyx Supportive Living in Albuquerque. Onyx was the last place Suazo resided. On Nov. 28, 2022, staff there called EMS, reporting that she had failed to eat or drink for several days, vomited and had a dangerously low blood oxygenation level of 88%.

As Albuquerque Fire Rescue paramedics arrived to rush her to the hospital, they first had to find light bulbs “because there was no light source” in her room, states a Department of Health report. The DOH also substantiated neglect by a nurse at the Onyx supportive living home related to Regina Suazo’s care.

The lawsuit contends all the defendants failed Regina Suazo. It alleges violations of the standard of care, failure to train and supervise staff and failing to protect patient safety despite notice of problems.

“Defendants’ negligence successively and collectively caused Ms. Suazo’s death, an indivisible injury,” the lawsuit alleges.

Administrators at Genesis and Onyx didn’t return Journal phone calls seeking comment Friday.

Michele Cody, ARCA’s chief development officer, told the Journal she couldn’t discuss any specific individual’s cases, but addressing general allegations of neglect, she said, “At ARCA the well-being of the people we serve is always our number one priority.”

Last year, after learning of the death of one developmental disabilities (DD) waiver client at an unidentified facility in New Mexico, the state conducted in-person wellness checks on thousands of other DD waiver clients to ensure they were well cared for. The subsequent inquiry found at least five incidents of serious neglect and abuse. Investigators determined that three clients had died.

Regina Suazo was one of them, said Brian Egolf, a Santa Fe attorney who filed the lawsuit.

“The complaint sets forth what we think is a deep-seated and widespread decay in these organizations,” Egolf said. “That you could have multiple layers of staff committing what we allege are intentional acts that caused the death of Regina Suazo is shocking and would take deliberate, focused and intensive effort to root out of these corporations. There was obviously tolerance for the way Regina was treated at every level of these corporations.”

‘Seven months of sadness’

Silas V. Suazo was the oldest of three children, his sister Regina, the youngest.

Despite being blind since the age of 6, she made gifts for the family, and loved to celebrate family birthdays and getting her hair and nails done. In sifting through her belongings after her death, Silas Suazo found a container full of Christmas photos of her at the mall.

“She took a picture with Santa Claus every year. She was 55 and she was taking pictures with Santa Claus. These things in life to her were joyous events that she loved, even though she couldn’t see the pictures. She kept them. Her room was full of pictures. She couldn’t see them, but she knew they were there,” he said.

Their mother, a hairdresser who is now deceased, was able to place Regina into the DD waiver program in the early 1980s, and she lived at an ARCA supported living apartment or group home since then, the lawsuit states.

At ARCA, “she had a job per se putting together utensils for senior homes,” Silas Suazo said. “She was doing tasks like this for 40 years.” Her personalized health care plan notes her risk for falls, and between 2017 and 2021, she suffered at least 15 falls, one in 2018 left her with a broken pelvis.

“I can remember maybe 15 to 20 years ago, the staff was pretty constant in the supportive living houses themselves,” Silas Suazo said. But then, he said, there seemed to be a lot of turnover.

“That affected Regina dramatically, because, first of all, you add the fact that intellectually she struggles, but also the fact that she doesn’t know who’s in the house. All of a sudden, one day, there’s somebody named Mary or somebody named Bill, it’s hard for someone like that who can’t see who it is,” he added.

Her second fall in June 2022 left her with two fractures on her lower spine, but Silas Suazo and his brother, as her guardians, were informed by a case manager on contract with the DOH that ARCA had failed to report them, as required by law, the lawsuit alleges. They then learned the home where she had long lived had abruptly been closed without warning.

Regina was transferred to Genesis Rio Rancho Center for rehabilitation, but the lawsuit alleges she was neglected to the point of developing pressure sores. When her brothers would visit, the lawsuit states, Genesis “sought to hide her deteriorating condition.”

“More than once, family members found her sitting completely naked at the Genesis facility. On several instances, they found Ms. Suazo soaking wet from a beverage she had spilled hours before,” it states.

The lawsuit alleges she was supposed to be returned by Genesis staff to bed after lunch, but family members would return hours later and find her still sitting in her wheelchair. Staff there continued giving her oxycontin despite repeated and insistent warnings from her family and physician that she tended to suffer severe adverse reactions to the drug. Finally, Genesis workers did attend to her recovery, and she was ready to be transferred out.

But then the family learned that she would still need daily physical therapy to recover from her spinal fractures, and ARCA said it could no longer accommodate her needs.

A care coordinator hired through the state DD waiver program found a place where Regina Suazo could get a higher level of care, or so the family was told, Silas Suazo said.

But at Onyx, the lawsuit states, her condition worsened after she failed to get the required medical treatment for pressure sores, and became malnourished and dehydrated. She came down with COVID, while her isolation and disorientation grew and contributed to her death for the next two months, the lawsuit states.

“You cannot use the fact that there’s a positive diagnosis for COVID as an excuse to ignore someone to death,” Egolf said.

When Silas Suazo’s wife visited after work, Regina would tell her, “I want to go home.”

“What she really meant is that she wanted to go back to her home that she knew at ARCA. That was the difficult part,” Silas Suazo said. “These last seven months were what I call the seven months of sadness.”

When Onyx staff transported Regina to his family’s house for Thanksgiving, “we knew something was terribly wrong.”

She couldn’t drink water or eat, Silas recalled. Her wounds were covered. Her clothes were dirty, her slippers torn, she was delirious and it appeared she had not bathed for many days, the lawsuit stated.

Silas and his brother, as their sister’s guardians, “were relying on all the folks who were in a position of telling them this is the best place for Regina, and they trusted everybody, and that’s an additional layer of tragedy of the situation. The biggest failing obviously was for Regina but the system failed the guardians too because they weren’t getting timely information, accurate information about what was happening,” Egolf said.

When she finally got medical attention, it was too late, the lawsuit states.

Despite multiple treatment attempts at Presbyterian Rust Medical Center, the lawsuit states, her injuries, including malnutrition, dehydration, sepsis from multiple festering pressure sores, and her resulting organ failure, were beyond the point where her life could be saved by medical treatment. She died on Dec. 2, 2022.

“We thought she was getting the care that she needed. And in all likelihood, it was not anywhere close to what she needed to recover and live,” said Silas Suazo.

The lawsuit blames ARCA for breaches in the “standard of care.” But for ARCA’s negligence, it alleges, “Ms. Suazo would not have needed to receive care at Defendant Genesis Healthcare — where she developed additional and foreseeable injuries that would progressively worsen over the remainder of Ms. Suazo’s life — and would not have needed transfer to Onyx, where her injuries further and foreseeably worsened, resulting in her eventual death.”

Silas Suazo believes better training for those who work with the developmentally disabled and vulnerable population in New Mexico is crucial. If only staff had paid attention to a blind woman in a room with a chair that was unsafe, he believes his sister would be alive today.

“This didn’t need to happen.”