Bayshore Residence Cited for Neglect After Resident Dies

Written By: Kenneth LaBore | Published On: 1st September 2015
Fall Injuries, Fall Accident from Wheelchair Bayshore Residence and Rehabilitation Center Duluth

Fall Injuries, Fall Accident from Wheelchair Bayshore Residence and Rehabilitation Center Duluth

Bayshore Residence Cited for Neglect After Fall from Wheelchair and Death from Subdural Hematoma

In a report concluded on May 4, 2015, the Minnesota Department of Health cites Bayshore Residence & Rehab Ctr with Neglect of Health Care.  It is alleged that a resident was neglected when staff did not do proper assessment for fall risk and did not update the care plan.  The resident fell out of his/her wheelchair, sustained a cerebral hemorrhage head injury and subsequently died.

Based on the preponderance of the evidence MDH determined that neglect occurred when the staff failed to comprehensively assess a resident at high risk for falls, and reassess the risks after each fall to develop effective interventions to reduce the risk of falls and injury.  The resident sustained a head injury in the fall from the wheelchair and later died.  The resident had several falls out of the wheelchair and the staff failed to assess and implement fall interventions to minimize the risk of falls.

On the day of the final fall, the resident was in the activity room and fell out of the wheelchair striking his/her head and sustained a head injury.  When staff found the resident, s/he was lying on his/her back a few feet from the wheelchair.  Staff were not present and had not seen the resident fall.  The resident had a swollen bump on the back of the head, and neurological checks were initiated.  Three hours later, the resident was observed to be pale, drowsy, and less responsive.  The resident was sent to the hospital and diagnosed with several areas of bleeding in the brain.  The resident died as a result of these injuries a few days later.

Bayshore Residence Cited for Neglect of Health Care – Medication

In a reported concluded in January 19, 2016, the Minnesota Department of Health cites with alleged negligence after a resident was neglected when s/he not receive nine doses of medication, and was hospitalized.  Based a preponderance of the evidence neglect did occur when the resident did not receive anti-seizure medications as ordered.  The resident had an increase in seizures, confusion and falls and was hospitalized.

Bayshore Cited for Neglect of Medications

In a report concluded on January 19, 2016, the Minnesota Department of Health cites facility after resident was neglect and staff had a significant transcription error for the resident’s Coumadin orders and s/he did not receive medications according to physician’s orders.  Based on a preponderance of the evidence neglect occurred when the resident did not receive anticoagulant medication as ordered.   The resident required emergency medical evaluation and adjustment of anti-coagulant medications.

The Nurse manager stated in an interview that the orders for warfarin (Coumadin) were not entered  into the computer correctly for transcription.  She stated that some of the orders were misplaced by the health unit coordinator’s desk and were not entered timely.  She acknowledged that this was not the expected process and that the nurse was re-educated.

The primary physician for the resident state in an interview that omission of warfarin (Coumadin) put the resident at a higher risk for developing additional clots, and it was physically uncomfortable to have additional injectable medication.

For more information from the Minnesota Department of Health, Office of Health Facility Complaints concerning nursing homes, assisted living and other elder care providers view resolved complaints at the MDH website.

Substantiated Complaint Against Bayshore Residence and Rehabilitation Center After Medication Error

In a report dated, January 19, 2016, The MDH cited Bayshore Residence after it alleged that a resident was neglected when s/he did not receive nine doses of medication, and was hospitalized.

Based on a preponderance of the evidence neglect did occur when the resident did not receive anti-seizure medications as ordered.  The resident had an increase in seizures, confusion and falls; and was hospitalized.

If you have concerns about fall injuries, medication errors or any other form of elder abuse or neglect contact Minnesota Elder Abuse Attorney Kenneth LaBore toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

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