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Written By: Kenneth LaBore | Published On: 26th March 2017 | Category: Uncategorized | RSS Feed
Click Here For Link To Report Abuse To Adult Protection

Click Here For Link To Report Abuse To Adult Protection

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.

If you have concerns about financial exploitation or any other form of elder abuse or neglect contact Minnesota Elder Abuse Attorney Kenneth LaBore toll free at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

Disclaimer

Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

 

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Narcotics Stolen from Residents at Capital View Transitional Care

Written By: Kenneth LaBore | Published On: 25th March 2017 | Category: Financial Exploitation | RSS Feed
Medication Theft - Stolen Pain Medications at Capital View Transitional Care in St Paul Minnesota

Medication Theft – Stolen Pain Medications at Capital View Transitional Care in St Paul Minnesota

Capital View Transitional Care Pain Medication Stolen From Clients

In a report dated March 2, 2017 from the Minnesota Department of Health, it was alleged that staff at Capital View Transitional Care

Capital View Transitional Care – Medication Theft

Based on a preponderance of the evidence, financial exploitation occurred when the alleged perpetrator (AP) took multiple narcotic medication from three resident’s over approximately two months.  There was no indication any of the residents suffered any pain as a result.

Resident #1 and #2 were at the facility for post operative care and were receiving narcotic medication for pain.  Resident #3 was receiving narcotics for leg pain.

During Resident #1’s discharge, the nurse reviewed the remaining narcotic medication with Resident #1.  Resident #1 stated s/he did not request or received the amount of pain medication doses that were recorded in the record as administered.  The nurse notified administration of the discrepancy.  Additional residents were interviewed and similar comments were obtained from Resident #2 and Resident #3.

Resident #1 was interviewed stating s/he did not take as many medications as documented by the facility.  The Resident only took one narcotic at any given time and the documentation indicated she received two tablets.

Resident #2 was interviewed and stated s/he did not like to take narcotics and denied taking all the narcotics documented in the medical record.

Resident #3 was not available for interview.

The AP was interviewed and admitted to taking narcotics from residents residing in the facility.  The AP stated she would sign out two medications, give one to the resident and keep the other.  In addition, the AP would sign out a narcotic medication when the resident didn’t ask for it and keep it for her/himself.  The AP was unable to identify which residents, how often, or how much narcotic medication was taken from the residents.

Based on a review of resident #1, #2, and #3’s medical records it is suspected that the AP took between 20-20 narcotics.

The facility reported the incident to the Board of Nursing and terminated the AP.

Report Suspected Abuse or Neglect at Capital View Transitional Care

Click Here For Link To Report Abuse To Adult Protection

Click Here For Link To Report Abuse To Adult Protection

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.

If you have concerns about medication theft / financial exploitation or any other form of elder abuse or neglect contact Minnesota Elder Abuse Attorney Kenneth LaBore toll free at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

Disclaimer

Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

 

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Resident at Cook County Northshore Falls from Lift and Fractures Arm

Written By: Kenneth LaBore | Published On: 21st March 2017 | Category: Fall Injuries, Patient Lift | RSS Feed
Fractures and Other Injuries - Cook County Northshore Resident Falls from Lift and Fractures Arm

Fractures and Other Injuries – Cook County Northshore Resident Falls from Lift and Fractures Arm

Preventable Neglect – Cook County Northshore Resident Falls from Lift and Fractures Arm

In a report dated February 28, 2017, from the Minnesota Department of Health a resident at Cook County Northshore Hospital and Care Center in Grand Marais was neglected with the alleged perpetrator (AP) transferred the resident with the use of a standing lift.  The resident sustained a fractured arm.

Cook County Northshore Substantiated Neglect after Fall with Fracture

Based on a  preponderance of the evidence, neglect occurred when the AP transferred the resident with a mechanical standing lift and did use the seated sling strap that was necessary for a safe transfer.  The resident was injured during the transfer and fractured and arm.

The resident had dementia.  The resident’s care card indicated the resident required one staff to use a standing lift for all transfers.  The resident’s care card instructed staff to use the seated sling strap and leg strap when using the mechanical standing lift with the resident.

After a shower, the AP attempted to transfer the resident from the shower chair to the resident’s wheelchair.  The AP used a standing lift for the transfer.  The AP applied the back strap and the leg strap, but did not secure the seated sling strap.  Before the resident was lowered into the wheelchair, the resident stepped backward off the standing lift platform.  The AP turned the resident’s call light on for help.  A couple minutes passed and no one responded to the call light.  The AP left the resident’s room with the resident on the standing lift.  A couple of minutes later the AP returned with another staff member.  The resident slipped further down in the standing lift.  The back strap caught the resident under the arms.  The resident hung in the lift by the arms.  The resident’s legs were twisted.  The nurse assessed the resident.  The resident had pain in the right arm and bruises.  The resident was transferred to the clinic.  An x-ray was obtained, and the resident had a fracture of the right proximal humerus.

The physician was interviewed and indicated the resident’s injuries were consistent with the events of the transfer.

The alleged perpetrator was interviewed and said s/he was not trained to use the seated sling strap and was not trained to look at the care card before providing care to the resident.  The AP stated the training she received to use the standing lift equipment was done by following another staff member.

Staff interviews and training documents confirmed the AP was not trained to use the resident’s care card, standing lift equipment, and seated sling strap.

Report Suspected Neglect or Quality of Care Issues – Cook County Northshore Hospital

Click Here For Link To Report Abuse To Adult Protection

Click Here For Link To Report Abuse To Adult Protection

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.

Kenneth LaBore has  a love of the Northshore and has a home in the Grand Marais area and is available to meet you in Grand Marais at your convenience.

If you have concerns about falls from Hoyer or other mechanical lifts or any other form of elder abuse or neglect contact Minnesota Elder Abuse Attorney Kenneth LaBore toll free at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

Disclaimer

Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

 

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Stage IV Pressure Sore Suffered by Resident at the Estates at Bloomington

Written By: Kenneth LaBore | Published On: 19th March 2017 | Category: Pressure Ulcers, Wound Care | RSS Feed
NPUAP Stage 4 Pressure Injury with Epibole - Neglect at Golden Living Center Bloomington AKA the Estates at Bloomington

NPUAP Stage 4 Pressure Injury with Epibole – Neglect at Golden Living Center Bloomington AKA the Estates at Bloomington

Substantiated Neglect After Serious Pressure Sores at the Estates at Bloomington

In a report dated August 25, 2017, the Minnesota Department of Health cited Golden LivingCenter in Bloomington now know as the Estates at Bloomington with neglect after a resident developed a stage IV pressure ulcer at the facility.

Pressure Ulcer Wounds Develop for Resident at the Estates at Bloomington

Based on a preponderance of the evidence, neglect occurred when the facility failed to adequately assess, monitor, and implement interventions to prevent and heal pressure ulcers.  The resident re-developed coccyx/buttocks pressure ulcers, which worsened.

The resident was admitted to the facility with a sacral pressure ulcer.  Staff implemented interventions to prevent the development of additional pressure ulcers.  Over the next several months, the sacral pressure ulcer healed, re-developed, and healed again.  New interventions were implemented; however, the resident’s care plan, and direct care staff aside sheet were not kept up to date with instructions for direct staff on how frequently to turn and reposition the resident.

Approximately two months after the last pressure ulcer healed, the resident developed two stage two pressure ulcers to her/his coccyx/buttocks.  Staff did not notify or obtain orders for treatment from the physician until 28 days later, when the ulcers had worsened and resident had four open areas to her/his buttocks.  One week later, the resident went to the hospital due to a decrease in responsiveness and a temperature of 101.6 degrees Fahrenheit.

According to the records, the hospital admitted the resident with a diagnosis of sepsis as well as a catheter associated urinary tract infection.  Upon admission into the hospital, the resident’s pressure ulcers had necrotic tissue with surrounding skin cellulitis.  The sacral bone was exposed.

When interviewed, the nurse practitioner stated s/he had never previously examined the resident’s pressure ulcers due to resident refusals.  The nurse practitioner was not informed of the pressure ulcers redevelopment until approximately one month after staff observed the new pressure ulcers.  The nurse practitioner indicated the facility’s lack of monitoring, and delay in treatment contributed to the worsening of the resident’s pressure ulcers.

The resident did not return to the facility.

Report Suspected Neglect Pressure Ulcers and Wounds – the Estates at Bloomington

Click Here For Link To Report Abuse To Adult Protection

Click Here For Link To Report Abuse To Adult Protection

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.

If you have concerns about pressure ulcers or any other form of elder abuse or neglect contact Minnesota Elder Abuse Attorney Kenneth LaBore toll free at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

Disclaimer

Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

 

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Theft of Funds from Client at Fair Oaks Lodge in Wadena Minnesota

Written By: Kenneth LaBore | Published On: 19th March 2017 | Category: Financial Exploitation | RSS Feed
Substantiated Financial Exploitation Complaint Against Fair Oaks Lodge

Substantiated Financial Exploitation Complaint Against Fair Oaks Lodge

Substantiated Financial Exploitation Complaint Against Fair Oaks Lodge

In a report from the Minnesota Department of Health, Dated March 1, 2017, it is alleged that a client at Fair Oaks Lodge in Wadena Minnesota was financially exploited when the Alleged Perpetrator (AP) took three checks from the resident’s checkbook.

Fair Oaks Lodge Cited After Theft From Client

Based on a preponderance of the evidence, financial exploitation occurred when the alleged perpetrator (AP) took three checks from the resident without the permission and used two of the checks to make purchases.

A resident told a facility staff member that a check appeared on the resident’s bank statement that the resident did not write.  The check was written at a store for $99.91   The administrator was notified of the fraudulent check and notified the police.

From the resident’s bank statement, the police were able to identify the store where the check was used and contacted the store.  The AP was identified on video surveillance in the store.  The police further identified that the resident had two additional checks taken.

The AP was interviewed and admitted to taking three checks from the resident.  The AP used two of the checks to make purchases.  One check was used for purchases in the amount of $99.91.  The second check was in the amount of $45.00.  The AP stated s/he did not use the third check and threw it away in the garbage.

The police forwarded the case to the prosecuting attorney to be reviewed for potential charges.  The facility terminated the AP.

Report Suspected Financial Exploitation – Fair Oaks Lodge

Click Here For Link To Report Abuse To Adult Protection

Click Here For Link To Report Abuse To Adult Protection

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.

If you have concerns about financial exploitation or any other form of elder abuse or neglect contact Minnesota Elder Abuse Attorney Kenneth LaBore toll free at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

Disclaimer

Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

 

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KSMS Our House Austin Neglect Substantiated

Written By: Kenneth LaBore | Published On: 18th March 2017 | Category: Bed Sores and Pressure Ulcers, Failure to Resond to Change in Condition, Pressure Ulcers, Wound Care | RSS Feed
Failure to Provide Proper Wound Care and Assessment - Pressure Sores - Ulcers - KSMS Our House in Austin Minnesota

Failure to Provide Proper Wound Care and Assessment – Pressure Sores – Ulcers – KSMS Our House in Austin Minnesota

KSMS Our House Austin Cited with Neglect After Serious Wounds

In a report from the Minnesota Department of Health dated, February 13, 2017, it is alleged that a client at KSMS Our House in Austin Minnesota was neglected when s/he presented to the hospital with an elevated temperature, a leg severely bruised with blisters, and a large ulcerated sore on his/her tailbone that was infected.

Negligence Supported Against KSMS Our House After Ulcerated Sore

Based on the report a preponderance of evidence, neglect occurred when the facility failed to provide proper care and treatment of the client’s coccyx, buttock, and heel wounds.  The client had recurrent problems with wound healing for over two years .  The facility Registered Nurse (RN) failed to provide adequate wound assessment and monitoring of the client’s wounds, and failed to provide direction and training to direct care staff who were to performing the delegated nursing task of wound care.

The client was cognitively impaired and was completely reliant on caregivers for all activities of daily living.  The client could not walk and was transferred by two staff with a mechanical lift. The client was incontinent of bowel and bladder and staff performed the client’s incontinence care.  The client had pressure sores on the coccyx and left heel for over two years.  Direct care staff performed the client’s daily wound treatments, without any written instructions or training by the RN.

The client’s only wound assessment by the facility RN was completed in 2014.  At that time, the client had a stage II pressure ulcer on the inside of the right buttock measuring 2 centimeters (cm) x 1.5 cm.  There was no evidence of further RN oversight of the client’s wound.  The client’s medical record was void of any wound assessments, pertaining to the client’s heel ulcer.

In March 2016, a hospital record indicated that the client still had the stage II pressure ulcer on the right buttock and had also developing stage II pressure ulcer on the sacrum.  Discharge orders to the facility including instructions for dressing changes and instructions to frequently change the client’s position.

In May 2016, direct care staff documented that the client had a “big open sore on her bottom” and the client’s family member took the client to the hospital for evaluation.  A culture of the wound drainage was taken.  Hospital discharge orders provided to the facility included instructions for dressing changes, including the application of antibiotic ointment for ten days.

In July 2016, a hospital record indicated that the client had multiple areas of dermis loss on the buttocks and inner groin, including a 4.5 cm x 0.7 cm open lesion on the left inner groin, a 3.5 x 2.0 cm open ulceration on the right lower buttock, a 4.5 cm x 2.0 cm open ulceration on the right buttock, a 0.3 cm x 5.0 cm open ulceration on the gluteal fold, and two open areas on the left buttock measuring 0.5. cm x 0.5 cm and 0.5 cm x 0.8 cm.  All areas were macerated.  Hospital discharge orders were provided to the facility including instructions for wound care, perineal care, and to document the client’s wound healing each day.

In August 2016, a hospital record indicated that the client had an unstageable ulcer on the left heel and the client was admitted for hospitalization due to osteomyelitis of the heel wound with culture results positive for MRSA and Strep.  The client underwent a surgical limb salvage procedure for the left heel.  The client’s buttock and groin wounds were also evaluated during hospitalization.  Hospital discharge orders provided to the facility included instructions for wound treatment and care of the surgical incision, which entailed application of an ace wrap to the client’s left leg.

In September 2016, a hospital record indicated that the client was emergently hospitalized due to a change in condition.  On hospital arrival, the client was unresponsive, had a fever of 101 degrees, oxygen saturations not above 87% on six liters of oxygen, bilateral blue feet, and a left lower leg that was red and swollen with fluid-filled blisters.  The client was admitted to the ICU with polymicrobial infections of the left leg, sacrum and urinary tract, along with pneumonia.  The client’s condition did not improve with volume resuscitation and broad-spectrum antibiotics.  Comfort measures were elected and the client was discharged to a skilled care facility on hospice care.

All of the client’s hospital visits from March 2016 to September 2016 were facilitated by the client’s family member, based on reports direct care staff gave the family member about the deteriorating condition of the client’s wounds.  During the same time period from March 2016 to September 2016, multiple direct care staff had informed the RN that the client’s wounds were worsening, looked infected, and had drainage that soaked through the dressings.  There was no evidence that the RN ever addressed the client’s wound, monitored the status of the client’s wounds for healing, or followed up on the culture results.  The client’s medical record was void of any wound assessments from March 2016 to September 2016 and void of any progress notes or evidence of follow-up about the client’s wound culture.  During the period March 2016 to September 2016, direct care staff performed the client’s wound dressings, without any evidence of training by the RN including the safe handling of contaminated materials.  The client’s care plan completed by the RN did not contain any information about the client’s wounds.

After the client had the left heel surgical procedure in August 2016, hospital discharge instructions included application of an ace wrap to the client’s left leg following incision care.  Only the RN applied the client’s ace wrap.  There was no evidence that the RN monitored the client’s left leg for circulation, motor ability, or sensation.  When the client was re-hospitalized in September 2016, the hospital record noted that the client’s left lower leg had an “an ace wrap that was bound too tightly” causing the appearance of “rug-burns”, in addition to an obvious cellulitis of the lower extremity which was red and swollen with fluid blisters.

When interviewed, the facility RN had no explanation regarding the inadequate nurse oversight of the client’s wounds.

__________________________

Tibia Fracture - Allegation of Neglect - Fractured Tibia - KSMS Our House in Austin

Tibia Fracture – Allegation of Neglect – Fractured Tibia – KSMS Our House in Austin

Tibia Fracture to Client Leads to MDH Complaint of Neglect Against KSMS Our House

In a report from the Minnesota Department of Health, dated February 13, 2017, it was alleged that a client at KSMS Our House in Austin Minnesota was neglected when s/he had a fall.  The client had progressively worse pain after the fall and it was discovered ten days later that the client had a tibia fracture.

Substantiated Neglect Complaint After Client Fractures Tibia in Fall

Based on the report a preponderance of evidence, neglect occurred when the facility failed to thoroughly assess the client after a fall, monitor the client’s change in condition, and intervene with proper nursing care that addressed the client’s acute needs.  Ten days after the fall, it was discovered that the client had a broken leg.

The client used a wheelchair propelled with his/her feet.  Due to unsteadiness when standing, balance problems, and history of falls, the client needed the assistance of one staff to stand and pivot for transfers.  The client needed the assistance of one staff for all activities of daily living.  The client could verbally express his/her needs and desires.  The client lived alone in an apartment and wore a pendant that s/he could push to alert staff when s/he needed help.

During a night in July 2016, the client paged staff at 3:45 a.m. because s/he had fallen in his/her apartment.  Direct care staff responded and found the client sitting on the floor.  The client told staff that his/her knees hurt.  After the client fell, the client was not thoroughly assessed by a nurse at any time for ten days, even though multiple direct care staff repeatedly reported to the RN the client’s symptoms of leg pain, leg swelling, bruising, difficulty with transfers, and inability to propel the wheelchair independently.  Ten days after the fall, the client’s family member took the client to the hospital due to the client’s complaints of ongoing severe leg pain.

The client’s hospital record indicated that the client had severe pain with movement and positive changes of the right leg and decreased range of motion in the right knee.  The client’s right and left anterior knees had diffuse bruising with greater bruising on the right lateral tibia, and right upper arm.  The client’s right calf was red, swollen, and warm to touch and was suspicious for cellulitis.  X-rays confirmed the client had a right tibial plateau fracture.  Conservative management of the fracture was elected.  The client was hospitalized to treat the cellulitis with intravenous antibiotics.  During hospitalization, the client declined with acute kidney injury and altered mental status.  After being hospitalized for seven days, the client was discharged to a skilled care facility.

The facility has a full-time Registered Nursing (RN) and nurses on-call at all times, when the facility’s RN is not onsite.  There was no evidence that a nurse thoroughly assessed the client’s status at any time during the ten days the client exhibited symptoms of fracture.  The facility’s RN made only two brief progress notes (a note two days after the fall and another note the day before the client went to the hospital) which did not include any detailed assessment information or address changes in the client’s condition that had been reported by direct care staff.  The facility’s medical record was void of any nursing progress notes prior to the client’s fall.

Statements by the facility’s RN concerning the client’s post-fall status were contradictory to multiple interviews of the direct care staff who provided care to the client after the client fell.

__________________________

 

Failure to Assess Change in Condition Fractured Leg

Failure to Assess Change in Condition Fractured Leg, KSMS Our House Austin

KSMS Our House Austin Complaint Findings for Neglect – Failure to Assess

In a report concluded on November 13, 2014, the Minnesota Department of Health cites KSMS Our House Austin for neglect of health care failure to assess change in condition.

It is alleged that neglect of health care occurred when the alleged perpetrator (AP) failed to assess a client #1’s pain.  The client had a broken leg.  In addition; the AP failed to send another client #2 to the hospital in a timely manner after a change in health status.

Substantiated Neglect Against KSMS Our House Austin

Based on preponderance of evidence neglect did occur when a client’s change in condition was not assessed by the AP to ensure timely medical intervention.

The client had diagnoses that included diabetes mellitus, chronic obstructive pulmonary disease (COPD), Coronary Artery Disease (CAD) and Asthma.  The client received assistance of one staff with activities of daily living (ADL) skills that included walking, medication administration, and daily accuceheck (blood sugar monitoring).  The client was independent with administration of his/her insulin injections.  The client’s medication regimen included pain control of Oxycodone (narcotic) 30 milligrams (mg) extended release tablets take one tablet by mouth every 12 hours. Oxycodone/APAP (narcotic) 5-325 mg tablet; take one or two tablets by mouth every 4 -6 hours as needed for pain.

On the morning of the client’s change in condition at 8:00 a.m., the staff identified, the client was “pretty out of it”.  The client had oxygen levels of 86% to 93%, required assistance to put medications in his/her mouth, and was unable to self-administer the insulin.  The staff notified the AP of the client’s change in condition.  The AP instructed staff to administer the client’s insulin, but did not assess the client’s condition in relation to the altered mental status and inability to self-administer medications.  The AP did not provide the staff with any parameters for monitoring the client or when to call the AP back.  In addition, the AP informed the staff not to call 911 unless the client was unconscious.  Later the same day, on the evening shift of work, the client was not able to stand up.  The staff notified the AP of the client’s inability to stand.  The AP instructed staff to use a mechanical lift for transfers without an assessment of the client’s status or provide the staff with any parameters for monitoring the client or when to call the AP back.  Eleven hours after the first reported change in condition had not improved and staff identified the client had an oxygen level of 86%, and a temperature of 101.5.  Staff did not call the AP for direction instead called 911 and the client was transported to the hospital and admitted to the hospital intensive care with a diagnosis of Toxic/metabolic Oxycodone, intermittent myoclonic jerks, acute delirium and pneumonia – likely from aspiration.  The client returned to the facility after a five-day hospital stay.

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.

If you have concerns about a failure to assess a change in condition, falls, fractures or any other form of elder abuse or neglect contact Elder Abuse and Neglect Attorney Kenneth LaBore at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

Disclaimer

Nursing Home Abuse and Neglect Lawyer Kenneth LaBore Offers Free Consultations and Serves Clients Throughout the State of Minnesota Call Toll Free at 1-888-452-6589

Nursing Home Abuse and Neglect Lawyer Kenneth LaBore Offers Free Consultations and Serves Clients Throughout the State of Minnesota Call Toll Free at 1-888-452-6589

 

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REM Hennepin Minnetonka Neglect After Medication Administration Errors

Written By: Kenneth LaBore | Published On: 1st March 2017 | Category: Medication Administration Mistakes, Medication Drug Error | RSS Feed
REM Hennepin Minnetonka Neglect Substantiated After Failure to Administer Seizure Medication for 13 Doses Over 3 Days

REM Hennepin Minnetonka Neglect Substantiated After Failure to Administer Seizure Medication for 13 Doses Over a Period of 3 Days

REM Hennepin Minnetonka Neglect After Failing to Provide Medication

In a report dated February 13, 2017, the Minnesota Department of Health, alleged that staff at REM Hennepin Minnetonka failed to administer thirteen doses of his seizure medication.  The client had a seizure, became unresponsive and was hospitalized.

REM Hennepin Minnetonka Failure to Provide Needed Seizure Medication

Based on a preponderance of the evidence, neglect occurred when the facility ran out of the client’s anti seizure medication, and the client missed thirteen doses of the medication.  As a result, the client had a seizure and required hospitalization.

The client has multiple diagnoses including epilepsy, personality disorder and impaired judgment, memory and reasoning.

Review of the facility’s report and the client’s medical record revealed that several staff were aware that the client’s anti-seizure medication was out of stock.  However, the staff continued to document the medication as being given over a three day period.  The client missed thirteen doses of the medication over those three days.  As a result, the client had a seizure and required hospitalization.  The client was admitted to the hospital and an intravenous medication was given to stop the seizure.  The client was successfully treated, medication changes were made, and s/he was discharged from the hospital the next day.

The client was not interviewed, as s/he no longer lived at the facility.

After the incident, new policies and procedures were put into place.  Through interviews, facility staff indicated they had been re-trained on the protocol for re-ordering medications prior to the site visit.

REM Hennepin Minnetonka – Report Suspected Abuse and Neglect

Click Here For Link To Report Abuse To Adult Protection

Click Here For Link To Report Abuse To Adult Protection

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.

If you have concerns about medication errors or  any form of elder abuse or neglect contact Minnesota Elder Abuse Attorney Kenneth LaBore toll free at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

Disclaimer

Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

 

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Red Wing Health Center Red Wing Neglect Substantiated

Written By: Kenneth LaBore | Published On: 1st March 2017 | Category: Fall Injuries, Financial Exploitation | RSS Feed
Substantiated Allegation of Neglect at Red Wing Health Center After Resident Suffers From Unstageable Pressure Ulcers Stage III/IV Pressure Sores While at the Facility

Substantiated Allegation of Neglect at Red Wing Health Center After Resident Suffers From Unstageable Pressure Ulcers Stage III/IV Pressure Sores While at the Facility

Red Wing Health Center Resident Suffers from Pressure Sores

In a report dated January 23, 2017 the Minnesota Department of Health alleged that a resident at Red Wing Health Center in Red Wing was neglected when s/he developed several unstageable pressure ulcers and Stage III/IV pressure ulcers while s/he was at the facility.

Red Wing Health Center Substantiated Neglect Due to Pressure Ulcers

Based on a preponderance of the evidence, neglect occurred when facility staff failed to implement a resident’s designated care plan interventions to heal pressure ulcers and prevent new ulcers from developing.  Although facility nurses were aware that the resident was resisting the care plan interventions, facility nurses failed to address any alternative approaches for effective wound management.  The resident developed nine new pressure ulcers in four months, including several that became infected and exhibited serious characteristics such as tunneling with depth, exposing muscle and bone.  The resident was hospitalized twice in four months with sepsis from wound infections.

The resident was admitted to the facility from another long-term care facility at the end of April 2016.  At the time of admission, the resident had two pressure ulcers, an unstageable pressure ulcer on the sacrum (2.7 cm x 1.5 cm x .4 cm) and a Stage II pressure ulcer on the right heel (1.8 cm x 1 cm).  The resident has complete paraplegia and multiple sclerosis.  The resident is unable to move his/her legs and has limited use of his/her arms.  The resident can use an electric wheelchair independently which the resident propels with a joy stick.  The resident is alert and oriented.

The resident had an alternating air mattress on his/her bed and a pressure redistributing cushion in the electric wheelchair.  Staff were supposed to turn and re-position the resident every two hours and offload the resident hourly per the resident’s care plan, but these interventions were not carried out.  There was no planned turning or re-positioning schedule for pressure redistribution and staff did not offer to turn or reposition the resident unless the resident requested it.  The resident was expected to offload him/herself by reclining the backrest of the wheelchair, but the frequency of offloading was not monitored by staff.  The nursing assistant care guides regarding the resident’s daily care tasks were void of any interventions aimed at wound management, including turning, re-positioning, or offloading the resident.  Nurses did not provide adequate oversight of the resident’s daily care by nursing assistants or the resident’s daily needs to heal wounds and prevent new wounds from developing.

Although staff stated that the resident consistently refused wound management interventions, there was no evidence that staff evaluated the inadequacy of interventions of assessed the resident’s individualized needs for alternative interventions.  At the end of June 2016, the resident was hospitalized with sepsis due to a sacral wound infection.  The sacral pressure ulcer had deteriorated to Stage IV with exposed muscle and Stage II pressure ulcer on the right hip (10 cm in diameter), a Stage II pressure ulcer on the left hip (6 cm in diameter), a Stage II pressure ulcer on the left ischium (2 cm x 2 cm), and a Stage II pressure ulcer on the right ischium (2 cm x 2 cm).

After the resident returned to the facility from the hospital, there was no evidence that staff re-evaluated the resident’s care plan interventions to determine modifications necessary for wound management and skin integrity.  There was no evidence that staff initiated structured care interventions, including possible behavioral strategies, to promote wound healing and prevent new skin breakdown.

In mid-September 2016, the resident was hospitalized again with sepsis due to wound infections.  On hospital admission, the resident had eleven pressure ulcers.  Four of eleven pressure ulcers had grossly deteriorated.  The sacral pressure ulcer (12 cm x 10 cm) was unstageable with purulent foul drainage and macerated edges.  The left hip pressure ulcer was unstageable (9 cm x 7 cm) with purulent foul drainage.  The right hip pressure ulcer had deteriorated to Stage IV (12 cm x 12 cm 1.5 cm) with bone felt at the bottom of the wound bed.  The right ischium pressure ulcer had deteriorated to Stage IV (6 cm 5 cm 6 cm) with muscle exposed.  The resident also had seven additional pressure ulcers, including Stage III pressure ulcer on the left lateral ankle (3.5 cm x 2.0 cm), five pressure ulcers classified as unstageable on the right posterior shoulder (5.0 cm x 4.0 cm), the right heel (2.0 cm x 2.0 cm x 2.5 cm), the left heel (2.2 cm x 1.2 cm), the left lateral foot (1.0 cm x 1.5 cm), the right medical ankle (1.3 cm 0.7 cm), and a Stage I pressure ulcer on the right lateral ankle.  The resident was hospitalized for eight days due to the seriousness of the wounds.

After the resident returned to the facility from the hospital, there was no evidence that staff re-evaluated the resident’s care approaches or made any changes in the resident’s daily care routine.  At the time of the onsite investigation, staff were not turning, repositioning, or offloading the resident and the Nurse Manager of the resident’s until did not know how many wounds the resident had, what the condition of the resident’s wounds were, or what the care plan interventions were to heal the resident’s wounds and prevent new wounds from developing.

Red Wing Health Center – Report Abuse and Neglect

Click Here For Link To Report Abuse To Adult Protection

Click Here For Link To Report Abuse To Adult Protection

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.

Hold Negligent Providers Like Red Wing Health Center Accountable

Attorney Kenneth LaBore has handled many preventable serious and fatal burn injuries, many due to the failure to follow safety policies and procedures related to oxygen use and smoking.    Burns can also happen from scalding water, heaters and electric pads and blankets and other ways.

If you have concerns about pressure sore injuries or any other form of elder abuse or neglect contact Minnesota Elder Abuse Attorney Kenneth LaBore toll free at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

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Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

 

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Physical Abuse by Staff

Physical Abuse by Staff Heritage House of Milaca Minnesota

Heritage House of Milaca Complaint Findings for Exploitation

In a report concluded on January 31, 2011, the Minnesota Department of Health cites Heritage House of Milaca for exploitation by staff.

The allegation is abused based on the following:  Employee (A), alleged perpetrator (AP) grabbed Client #1’s wrist causing bruising on Client #1’s hand and wrist.

Substantiated Complaint Against Heritage House of Milaca

According to the National Center on Elder Abuse, elder abuse is a growing problem. While we don’t know all of the details about why abuse occurs or how to stop its spread, we do know that help is available for victims. Concerned people, like you, can spot the warning signs of a possible problem, and make a call for help if an elder is in need of assistance.

•Physical Abuse
•Sexual Abuse
•Emotional or Psychological Abuse
•Neglect
•Abandonment
•Financial or Material Exploitation
•Self-neglect

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.

If you have concerns about financial exploitation or any other form of elder abuse or neglect contact Minnesota Elder Abuse Attorney Kenneth LaBore at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

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Wheelchair Injury Fall

Wheelchair Injury Fall Red Wing Health Center Red Wing Minnesota

Red Wing Health Center Cited for Abuse – Exploitation – Drug Diversion

In a report dated February 4, 2016, the Minnesota Department of Health cited Red Wing Health Center alleged that a resident was financially exploited when a staff, alleged perpetrator (AP) took a resident’s pain medication for his/her own personal use.

Based on a preponderance of the evidence financial exploitation did occur when the alleged perpetrator (AP) took 39 oxycodone (a narcotic) tablets from the resident for his/her own personal use over a period of approximately a month.

Red Wing Health Center Red Wing Complaint Findings for Neglect – Falls

In a report concluded on April 26, 2012, the Minnesota Department of Health cites Red Wing Health Center Red Wing for neglect of health care -falls.

The allegation is neglect based on the following: Resident #1 had a fall, with serious injuries, when Employee (J)/Alleged Perpetrator (AP) placed Resident #1 in the wrong wheelchair, which did not have a pressure alarm or self-release seat belt.

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.

If you have concerns about falls, fractures, financial exploitation or any other form of elder abuse or neglect contact Elder Abuse and Neglect Attorney Kenneth LaBore toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

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Lake Owasso Residence Shoreview Neglect of Supervision

Written By: Kenneth LaBore | Published On: 1st March 2017 | Category: Sexual Abuse | RSS Feed
Lake Owasso Residence Shoreview Cited with Substantiated Neglect by MDH after Failure to Supervise Clients Leads to Forced Sexual Activity

Lake Owasso Residence Shoreview Cited with Substantiated Neglect by MDH after Failure to Supervise Clients Leads to Forced Sexual Activity

Lake Owasso Residence Shoreview Neglect Failure to Supervise Clients

In a report dated February 3, 2017, the Minnesota Department of Health, it was alleged that Lake Owasso Residence Shoreview staff failed to provide adequate supervision and two client engaged in sexual activity with each other.

Lake Owasso Residence Shoreview Substantiated Neglect by Staff

According to the MDH report of substantiated neglect: based on a preponderance of the evidence, neglect occurred when the facility failed to provide adequate supervision of two clients resulting in Client #1 forcing sexual activity.

Client #1 was diagnosed with mild intellectual disability.  Client #2 was diagnosed with moderate intellectual disability.

The two clients lived in adjacent areas on the same hallway.  Client #1 resided at the facility for five days when staff notified the supervisor that there were concerns about the interactions between the two clients that put Client #2 at risk.  Client #1 would follow Client #2 around and site very close to Client #2.  The supervisor told the staff member to keep eye contact on Client #1 and maintain separation between the two clients.  The information was not shared with all staff members.  No plan was implemented to provide additional supervision or other strategies to maintain the safety of all clients.

Two days later, Client #2 told staff that Client #1 knocked on Client #2′ door and asked for sex.  Staff immediately reported this information to a supervisor.  No additional supervision was implemented.  Three days later, Client #1 was not in the common area and a staff person called out Client #1’s name.  Client #1 responded from Client #2’s bedroom.  Client #1 came out of the bedroom adjusting her/his pants.  The same day, Client #2 told staff the two clients had intercourse.  The supervisor was notified, but no additional supervision or interventions were implemented.  The following day, Client #2 told another staff member that Client #1 raped Client #2.  The supervisor notified the director who initiated an investigation Client #2 was sent to the hospital for an evaluation and Client #1 was sent to the hospital because he was a danger to other clients.

Client #1 was interviewed and said Client #1 and Client #2 had sexual intercourse.

Client #2 was interviewed and said on three occasions, including the incident when Client #1 was in Client #2’s room, Client #1 had forced Client #2 to have sexual intercourse.  Client #2 said s/he was to scared to tell anyone.

Client #2’s hospital record was reviewed and the sexual assault exam indicated there was evidence of vaginal penetration and the client had genital tear/laceration.  During an interview, the sexual assault nurse examiner stated that Client #2’s injury was consistent with penetration.

Lake Owasso Residence Shoreview – Report Suspected Abuse and Neglect

Click Here For Link To Report Abuse To Adult Protection

Click Here For Link To Report Abuse To Adult Protection

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.

Kenneth LaBore has handled many cases of elder sexual abuse and is well versed in the arguments and experts needed to get accountability for such personal violations to vulnerable people often unable to defend themselves or call out for help.

If you have concerns about sexual abuse or any other form of elder abuse or neglect contact Minnesota Elder Abuse Attorney Kenneth LaBore toll free at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

Disclaimer

Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

 

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Accurate Home Care Ostego Neglect Leads to Fall With Injuries

Written By: Kenneth LaBore | Published On: 28th February 2017 | Category: Fall Injuries, Hoyer Lift, Inadequate Staffing/Training, Patient Lift | RSS Feed
Accurate Home Care Ostego - Resident Suffers Serious Injuries Fall From Improper Transfer From Mechanical Lift

Accurate Home Care Ostego – Resident Suffers Serious Injuries Fall From Improper Transfer From Mechanical Lift

Accurate Home Care Ostego Neglect After Resident Suffers Injuries From Fall

In a report dated February 2, 2017, the Minnesota Department of Health alleged that a patient at Accurate Home Care Ostego when a staff, alleged perpetrator unsafely transferred a patient, dumping water on his/her face. Emergency response was called, CPR was initiated and the patient was admitted to hospital pneumonia.

Accurate Home Care Ostego Fall Leads to Series of Events Ending With Pneumonia

Based on a preponderance of the evidence, neglect occurred when the alleged perpetrator (AP) did not follow the patient’s care plan and did not initiate cardiopulmonary resuscitation (CPR) when the client experienced respiratory distress.

The patient had quadriplegia and was ventilator dependent.  The patient’s plan of care indicated the patient was a full code and had an emergency protocol in place.  The care plan had an emergency airway clearance protocol including using a manual resuscitation bag (a pump device to assist ventilation) with 100% oxygen, irrigating with saline, and suctioning.  If there was no result with those actions, staff were to call 911.  Staff were to continue to use the bag until help arrived or the situation resolved.

On the evening of the incident, the AP transferred the patient to bed with a mechanical lift.  The patient requested the  AP hook-up the humidification to the tracheostomy prior to removing the lift sling.  Because the sling was still under the patient, the AP turned the patient from side to side.  The humidifier on the bedside table tipped over causing water to back up into the humidifier tubing.  The AP attempted to shake the water out of the tubing and elevated the head of the bed, but the patient was not getting enough air.  The patient requested with AP ventilate with the bag.  The AP did not comply, but instead went upstairs to get the family member.  When the AP and the family member returned to downstairs, the patient was unresponsive and did not have a pulse.  The family member suctioned the patient, used the bag, and did chest compressions.  The AP did not assist with CPR.  A second family member came to assist.  The second family member provided the backup ventilator and suctioned the patient.  The first family member called 911, and then the AP took over CPR.  During this time, the AP unable to find a pulse.  The patient went to the hospital and was admitted for one day with a diagnosis of aspiration pneumonia.

The family member interview indicated the patient was not to have the humidification tubing hooked up until the sling was out from underneath him/her.  The family member stated when they came downstairs the ventilator was off.

The alleged perpetrator (AP) participated in an interview.  The AP state s/he had received training specific to this patient’s care plan.  The AP indicated s/he did not start providing ventilation with the manual resuscitation bag, because the patient had a pulse.  However, resuscitation can be provided regardless of the status of the patient’s pulse.

Accurate Home Care Ostego – Report Abuse and Neglect

Click Here For Link To Report Abuse To Adult Protection

Click Here For Link To Report Abuse To Adult Protection

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.

If you have concerns about financial exploitation or any other form of elder abuse or neglect contact Minnesota Elder Abuse Attorney Kenneth LaBore toll free at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

Disclaimer

Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

 

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