Cecil Gary, a 60-year-old resident of the McCracken Nursing and Rehabilitation Center, had a history of stroke and was also an amputee. Although he had limitations in caring for himself, he was aware of his surroundings and generally enjoyed his life.
As a resident of this nursing home, he experienced eight different episodes of dehydration and later developed nausea and severe pain. In this particular incident, the nursing home staff left him in bed, in distress, for about 27 hours before calling paramedics to transfer him to a local hospital. When he was transferred, he was diagnosed as being severely dehydrated and in hypovolemic shock and acute kidney failure.
At the hospital, he received 27 liters of fluid before sending him back to the nursing home. Once he was back at McCracken Nursing and Rehabilitation, he fell, breaking his hip in three places. Gary was not a candidate for hip surgery given his medical condition.