Dorothy Mae Lyles was admitted to Sanatoga Center after a hospitalization. At the time of her admission to the nursing home facility, she was noted to have pressure sores. She was also noted to be a high risk for developing additional pressure sores due to her need for assistance with mobility. Nevertheless, there was no repositioning program in place when she was admitted.
Two months later, she was transferred to a hospital and received treatment for pressure ulcers at a wound healing center. She continued to develop pressure ulcers.
Lyles, 88, subsequently developed septic shock and died from an infected sacral pressure ulcer. She was survived by her daughter.