Failures

In the aftermath of this incident, we quickly realized Commonwealth Senior Living was offering unregulated services to a vulnerable group of people with virtually no legal protection. Faced with many versions of what happened or didn’t happen in this incident, we sought legal help.

In various filings, Commonwealth Senior Living listed many reasons as to why the Daily Check-in Program failed for 4 consecutive days:

Reason 1

" ... this case represents a perfect storm of unforeseen events and an unfortunate series of human errors ... " [ source ]

Reason 2

Staff took a call from another resident and marked Diane’s box on the Daily Check-in Log when it wasn’t actually her; other staff believed Diane was accounted for. [ source ]

Reason 3

Staff saw someone and marked him/her on the wrong line; which made it look like Mom was seen. [ source ]

Reason 4

Commonwealth Senior Living staff misread the Program Log. [ source ]

Reason 5

Receptionist responsible for Program Log on 12/13 reported that “Ms. Franklin was out of the building until that afternoon.” [ source ]

Reason 6

Commonwealth Senior Living " ... was not on notice that its belt-and-suspenders Daily Check-in system might be subject to multiple human errors resulting in terrible consequences ... " [ source ]

Reason 7

The Residents were independent and many of them regularly left Commonwealth Senior Living making it difficult or inconvenient for the Staff to perform the Program. [ source ]