Family says nursing home fatally poisoned woman with juice, cleaner mix-up

Residents at a Northern California nursing home expected cranberry juice in late August when staff served cups with a red liquid inside. Instead, 93-year-old Trudy Maxwell and two others swallowed an industrial cleaner – one that severely blistered Maxwell’s mouth, throat and esophagus, according to a lawsuit filed Thursday.

“The toxic chemical essentially melted the lining of Trudy’s digestive tract,” the suit alleges.

Maxwell was taken to the hospital but died two “excruciating days after being poisoned,” it states.

Now, her relatives are suing the nursing home, accusing Atria Park of San Mateo of dependent-adult abuse, negligence and wrongful death. The lawyer representing Maxwell’s family said her death was avoidable – calling it “a tragic part of the epidemic of neglect of seniors” – and demanded accountability from the company, which was being paid thousands of dollars a month to take care of her.

“Their job is to keep senior citizens safe, and they did the opposite of that. They snuffed out a life,” attorney Niall McCarthy told the Washington Post.

Maxwell was one of three Atria Park residents hospitalized Aug. 27 after drinking the industrial cleaner, the suit alleges. Like Maxwell, 93-year-old Peter Schroder Jr. died after spending nearly two weeks in the hospital, KNTV reported, and his family has also filed a lawsuit against Atria. McCarthy said he doesn’t know the fate of the third resident.

In a statement to the Post, Atria Senior Living described what happened as an “isolated” incident in which an employee unintentionally poisoned three residents while violating the company’s policies, although it didn’t specify which ones. Atria said residents are its top priority, which is why “staff are thoroughly trained and able to meet our residents’ needs at all times.”

“We take this incident very seriously,” Atria said in the statement. “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.”

The San Mateo County district attorney is reviewing the police investigation into the poisonings at Atria. Stephen Wagstaffe told KGO that his office’s consumer fraud unit is also investigating Atria generally to see whether the company has been “conducting themselves in appropriate, businesslike fashion.”

Maxwell, a lifelong Bay Area resident who was diagnosed with dementia in 2018, started living at Atria Park in October 2020, according to the lawsuit. Her family paid nearly $6,000 a month for her one-bedroom unit. Because of her dementia, Maxwell needed help to change clothes, feed herself and move about the facility.

Around 7:30 a.m. Aug. 27, an employee at the nursing home escorted Maxwell from her room in the memory-care unit to the cafeteria for breakfast, according to the lawsuit. Around that time, an Atria staff member was violating protocol by filling a pitcher with liquid dishwashing detergent that had “a nearly identical consistency and color to cranberry juice,” and planned to put it into a commercial dishwashing machine, the company said in its statement.

Instead, another staff member picked up the pitcher and, mistaking it for juice, served it to three residents, Atria added in the statement.

Maxwell drank it, and her reaction was immediate, according to the lawsuit filed by her family. The liquid burned and blistered her mouth, throat and esophagus, according to the lawsuit. “Trudy was in extreme pain, distress, and agony,” it states.

Atria staff, nevertheless, did not call 911 immediately, instead waiting “over 30 excruciating minutes,” the Maxwell family alleges in its lawsuit. Once they did and Maxwell was taken to a hospital, “doctors noted that she likely would not survive, due to the extent of the injuries immediately noticeable to her mouth and throat,” according to the lawsuit.

Maxwell’s family also alleges that Atria “did nothing” to train staff properly, even though there had been a similar incident at another Atria facility in the Bay Area four days earlier when a dementia patient fell ill after drinking an unknown liquid, the lawsuit claims. The man died eight days later.

Atria said the two incidents are “isolated and unrelated.”

Between the two, Atria should have alerted other facilities and bolstered staff to appropriate levels, measures that might have saved Maxwell, according to the lawsuit. Instead, the “red flag warning” was ignored and Atria did nothing, the lawsuit claims.

The incident with the industrial cleaner was not the first time that Atria failed Maxwell, the lawsuit states. Shortly after moving her into Atria in the fall of 2020, family members said they felt that the facility’s care fell short of their expectations. On multiple occasions, they noticed that Maxwell was wearing bandages and hadn’t had her adult diaper changed, according to the lawsuit.

Atria endangered Maxwell and other residents by putting profits over care, the lawsuit alleges. In an effort to cut costs, the company failed to properly vet and train employees, the Maxwell family asserts. To staff its facilities, Atria allegedly employed few permanent workers, instead tapping “a rotating cast” of temps who didn’t have an appropriate amount of safety training and knew little about residents like Maxwell, the lawsuit states.

Those practices made Atria Park “a magnet” for violations of the state’s health and safety codes, the lawsuit alleges, including 12 complaints over the past five years.

McCarthy told the Post that Maxwell’s relatives hope their lawsuit forces Atria to change how it does business by providing better care to its residents.

“She was totally dependent on them, and the staff served her a poisoned cocktail,” McCarthy said, adding that “they want to make sure this same fate doesn’t befall another family.”