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Thief River Care Center Neglect Substantiated after Amputation

Written By: Kenneth LaBore | Published On: 14th April 2018 | Category: Failure to Resond to Change in Condition, Pressure Ulcers | RSS Feed
Pressure Sores Leading to Amputation, Failure to Provide CPR at Thief River Care Center in Thief River Falls Minnesota

Pressure Sores Leading to Amputation, Failure to Provide CPR at Thief River Care Center in Thief River Falls Minnesota

Thief River Care Center Thief River Falls Complaint Findings for Neglect of Health Care

In a report concluded on January 10, 2018, the Minnesota Department of Health, cited Thief River Care Center for substantiated neglect of health care leading to an above the knee amputation.  It is alleged that a resident was neglected when the facility did not provide adequate assessment, monitoring and cares to prevent pressure ulcers.   The resident sustained a pressure ulcer that lead to an amputation of a limb.  The resident also sustained additional pressure ulcers on the buttocks and back of head.

Pressure Sores Lead to Above the Knee Amputation of Resident’s Leg

Based on a preponderance of evidence, neglect occurred when the resident developed an unstageable (full thickness ties loss in which the base of the ulcer is covered by a slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) left calf pressure ulcer.  The pressure ulcer was avoidable and the resident required an above the knee amputation.  In addition, the resident developed a pressure ulcer on his/her right calf, coccyx, buttocks, and back of head.  The facility failed to adequately assess the resident when s/he developed pressure ulcers and implement additional interventions to minimize the risk of additional pressure ulcer development.

The resident eventually passed away from medical conditions unrelated to the amputation.

Citation Against Thief River Care for a Failure to Perform CPR

In a report concluded on May 11, 2012, the Minnesota Department of Health cites Thief River Care Center Thief River Falls for neglect of health care.

The allegation is neglect based on the following: Staff did not initiate cardiopulmonary resuscitation (CPR) when Resident #1 was found with no pulse or respirations.  Resident #1’s record indicated that CPR should be performed.

What can the Office of Health Facility Complaints Investigate?

  • Complaints relating to quality of life and quality of care at health care facilities/agencies including resident rights concerns.
  • Minnesota licensed facilities: hospitals
  • nursing homes
  • boarding care homes
  • supervised living facilities
  • assisted living and home health agencies
  • Individuals or organizations exempted from licensure per MS 144A.46, Subd. 2.
  • Allegations of child maltreatment in non-licensed personal care provider organizations.
  • Only personal care assistance (PCAs) staff working in home care agencies.

The Minnesota Department of Health Facilities Complaint, OHFC Does Not Investigate:

  • Billing or insurance concerns.
  • Medical clinics.
  • PCAs who do not work for a home care agency.

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, amputations, failure to perform CPR 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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Federal Requirements for Long Term Care Facilities

Written By: Kenneth LaBore | Published On: 14th April 2018 | Category: Nursing Home Abuse and Neglect, Nursing Home Care Issues | RSS Feed
Federal Requirements for Nursing Homes and Long Term Care Facilities

Federal Requirements for Nursing Homes and Long Term Care Facilities

Federal Requirements for Long Term Care Facilities – 42 CFR 483

The federal requirements and regulations for long term care facilities also known as nursing homes are contained at 42 CFR 483.   Each regulation sets for the minimum standard of care which is then inspected by the Center for Medicaid Service and Minnesota Department of Health in surveys or complaint investigations.

Here is the Nursing Home Reform Act Federal Requirements for Long Term Care Facilities

These federal requirements for long term care facilities set the standard of care for the facility, staff and medical providers.

42 CFR 483

§483.1
Basis and scope.
§483.5
Definitions.
§483.10
Resident rights.
§483.12
Admission, transfer and discharge rights.
§483.13
Resident behavior and facility practices.
§483.15
Quality of life.
§483.20
Resident assessment.
§483.25
Quality of care.
§483.30
Nursing services.
§483.35
Dietary services.
§483.40
Physician services.
§483.45
Specialized rehabilitative services.
§483.55
Dental services.
§483.60
Pharmacy services.
§483.65
Infection control.
§483.70
Physical environment.
§483.75
Administration.

Many of the quality of care issues are addressed in 42 CFR 483.25, which has many subparts each on a specific type of care issue including:

42 CFR 483.25 Quality of care.

Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices, including but not limited to the following:

(a) Vision and hearing. To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident—

(1) In making appointments, and

(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

(b) Skin integrity.

(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that—

(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and

(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must—

(i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident’s medical condition(s) and

(ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments.

(c) Mobility.

(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident’s clinical condition demonstrates that a reduction in range of motion is unavoidable; and

(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

(d) Accidents. The facility must ensure that—

(1) The resident environment remains as free of accident hazards as is possible; and

(2) Each resident receives adequate supervision and assistance devices to prevent accidents.

(e) Incontinence.

(1) The facility must ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

(2) For a resident with urinary incontinence, based on the resident’s comprehensive assessment, the facility must ensure that—

(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident’s clinical condition demonstrates that catheterization was necessary;

(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident’s clinical condition demonstrates that catheterization is necessary, and

(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

(3) For a resident with fecal incontinence, based on the resident’s comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

(f) Colostomy, urostomy, or ileostomy care.  The facility must ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences.

(g) Assisted nutrition and hydration.  (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident’s comprehensive assessment, the facility must ensure that a resident—

(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident’s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

(2) Is offered sufficient fluid intake to maintain proper hydration and health; and

(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident’s clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

(h) Parenteral fluids.  Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident’s goals and preferences.

(i) Respiratory care, including tracheostomy care and tracheal suctioning.  The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents’ goals and preferences, and §483.65 of this subpart.

(j) Prostheses.  The facility must ensure that a resident who has a prosthesis is provided care and assistance, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences, to wear and be able to use the prosthetic device.

(k) Pain management.  The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences.

(l) Dialysis.  The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences.

(m) Trauma-informed care.  The facility must ensure that residents who are trauma survivors receive culturally-competent, trauma-informed care in accordance with professional standards of practice and accounting for residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

(n) Bed rails.  The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

(1) Assess the resident for risk of entrapment from bed rails prior to installation.

(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

(3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight.

(4) Follow the manufacturers’ recommendations and specifications for installing and maintaining bed rails.

Consumer Voice produced a chart of changes and new federal nursing home rules and regulations.

If you have any questions about injury or assault or care provided at a nursing home or other type provider such as assisted living or memory care, contact Nursing Home Neglect and Abuse Lawyer Kenneth LaBore, toll free at 1-888-452-6589 or 612-743-9058 or by email at KLaBore@MNnursinghomeneglect.com.

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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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Pine Ridge Residence Bagley Abuse to Client

Written By: Kenneth LaBore | Published On: 26th April 2017 | Category: Elder Physical Abuse, Patient Rights | RSS Feed
Pine Ridge Residence Bagley Abuse of Client by Staff Members Who Restrain Client in Bathroom

Pine Ridge Residence Bagley Abuse of Client by Staff Members Who Restrain Client in Bathroom

Pine Ridge Residence Bagley Abuse to Client

In a report from the Minnesota Department of Health, dated January 12, 2017, it was alleged that a client Pine Ridge Residence Bagley was abused when perpetrator #1, restrained the client in the bathrrom and propped a chair upder the dooe knob preventing the cleitn from getting out. It is also alleged, that a client was abused when alleged perpetrator #2, restrained the client in the bathroom by shutting the door and holding his/her foot against the door.

Pine Ridge Residence Bagley Substantiated Abuse

Based on the report, a preponderance of the evidence established that abuse occurred when the allged perpetrators (AP), AP #1 and AP #2, restricted the client from leaving the bathroom. The facility failed to assess and develop an individual plan for the client’s toileting needs resulting in staff confining the client to the bathroom for toileting.

The client had severe intellectual and developmental disabilities.  The client was ambulatory and non-verbal.  The client had a history of constipation issues and would go four to five days between bowel movements.

Staff members were interviewed.  When the client did not have a bowel movement, the staff would bring the client to the bathroom.  Staff instructed the client to stay seated on the toilet, but the client would continue to stand up or fling the bathroom door open with his/her hand.  Staff reported AP #1 placed a chair against the bathroom door on two occasions, while the client was supposed to be using the toilet.  On one occasion, AP #1 instructed another employee to place a chair against the bathroom door.  Over several months, AP #1 placed the chair outside the bathroom door multiple times when the client was inside the bathroom.  AP #2 would put a standing tray with some toys on it in front of the client when the client was seated on the toilet, close the bathroom door, then AP #2 would hold his/her foot against the door for about five to ten minutes.  This would restrict the client from leaving the bathroom.  The client’s comprehensive functional assessment did not address the client’s plan or needs for toileting.

AP #1 was interviewed and stated during morning cares s/he put the client in the bathroom and told the client to sit on the toilet.  The client did not want to sit, was getting up, and AP #1 instructed the client to sit back down on the toilet.  AP #1 stated the dining room chair was not propped up under the door knob, but was placed against the outside of the bathroom door.  AP #1 would sit on the chair with his/her back to the door.  The AP #1 stated that client was in the bathroom for five minutes and had voided on the toilet.  The AP stated there were other instances when s/he held her hand on the door knob or placed his/her body against the bathroom door hoping the client would have a bowel movement.  AP #1 stated this did prevent the client from leaving the bathroom.  The AP stated s/he never asked a staff person to place a dining room chair in front of the bathroom door with client inside.

AP #2 was interviewed and stated the client did not want to sit on the toilet to have a bowel movement.  AP #2 would place a standing tray with toys on it in front of the toilet in hopes the client would stay seated on the toilet.  AP #2 stated s/he put her foot against the door so the client would have privacy and would not leave the bathroom.  AP #2 stated the client gets upset if s/he stays in the bathroom with the client.  The AP stated the client was getting up off the toilet so s/he placed her foot against the door.

The client’s guardian stated it has been an ongoing issue with the client using the bathroom.  The guardian stated a chair in front of the bathroom door was not acceptable and did not want to the situation handled in that manner.

Pine Ridge Residence Bagley – 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 physical abuse, 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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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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