Substantiated Complaint After Pressure Sores at Cottage Grove White Pines II
In a report dated December 20, 2016, the Minnesota Department of Health alleged that a client at Cottage Grove White Pines II was neglected when s/he developed a stage four pressure ulcer while at the facility.
Pressure Sore Ulcers at Cottage Grove White Pines II
Based on a preponderance of evidence, neglect occurred when staff failed to assess a client for a decline in condition and for skin concerns, which resulted in the client developing pressure ulcers. The client experienced a large sacral (upper buttock) pressure ulcer and a pressure ulcer on each of his/her heels after a significant weight loss.
The client had received services from the home care provider for three months. The client required assistance of one person with toileting every two hours, reassurance checks every two hours, shower with a skin check twice a week, dressing/grooming twice a day, and ambulation/escorts. During the client’s three month stay, the client experienced a decline in physical strength and was no longer able to ambulate. Approximately two months after admission, the client experienced a forty pound weight loss.
Ten days prior to discharge, an unlicensed staff member notified the registered nurse (RN) of the client’s skin concerns, observed during a bath, related to his/her sacrum and heels. The concerns were signed off by the RN, however, an assessment was not completed. Two days prior to discharge, the RN observed the areas of concerns due to a report of the sacrum having an open wound. The RN updated the client’s physician regarding a wound to his/her buttocks and right heel. Orders were received for wound care services from an outside agency. The following day the RN initiated heel protectors to be worn by the client. On the day of the client’s discharge, the RN completed a wound assessment with the agency wound care nurse. The wound care nurse determined the client required hospitalization due to possible infection. The client transferred to the hospital, required surgical debridement of large sacral ulcer and required a wound vacuum for treatment, as well as intravenous antibiotics for infection. The client also had a large ulcer on his/her right heel and a smaller ulcer on the left heel. The client continued to decline and died thirty-two days later. The cause of death was listed as Alzheimer’s.
During interviews, unlicensed staff stated the client had a redness of the sacral area for several weeks prior to the client’s hospitalization. Staff stated the nurses were updated, the client was repositioned every two hours, and cream was applied to area.
During an interview, the RN stated the client’s sacrum was for red three to four days prior to it opening. The day the RN observed the wound, s/he described the wound as about the size of an eraser. The RN also stated the client was repositioned every two hours and it was standard to reposition all clients at that frequency. The RN stated s/he usually assess skin concerns on the bath sheets, but did not recall doing a follow up or assessment of the initial skin concern. The RN also explained that the clients’ weights are reviewed by a nurse at the end of each month, however this client’s forty weight loss was missed. A nutritional supplement was started because the client’s appetite was poor. The RN stated a significant weight loss would warrant a change in condition assessment, but one was not completed.
During an interview, the hospital wound surgeon stated the sacral wound appeared chronic and there was no fast bacteria present that would cause rapid deterioration. The client was evaluated by the surgeon and underwent surgical debridement two days after hospital admission. The surgeon described the wound as large, ten centimeters (cm) by fifteen cm necrotic (black, dead) tissue and undermining. The wound was infected with multiple organisms. The surgeon stated the wound could not have been transitioned from a pinpoint opening to a large open wound in thirty-six to forty-eight hours.
During an interview with the client’s family, the family member stated s/he was not made aware of the pressure ulcer by the home care provider until the day of discharge. The family member explained the agency wound care nurse described the wound as severe and client required hospitalization. At the hospital, the family member was made aware by hospital staff that the client experienced a forty pound weight loss. After the surgery, the family member stated the surgeon described the wound as about the size of grapefruit with depth to the bone.
Cottage Grove White Pines II Cottage Grove Complaint Findings for Exploitation after Medication Theft
In a report concluded on March 17, 2014, the Minnesota Department of Health cites Cottage Grove White Pines II Cottage Grove for exploitation – staff.
It is alleged that financial exploitation occurred when a staff, alleged perpetrator (AP) took three tablets of a client’s narcotic medication without permission.
Substantiated Financial Exploitation Allegation Against Cottage Grove White Pines II Cottage Grove Minnesota
A preponderance of evidence established that financial exploitation did occur. The AP took three tablets of Oxycotin (a narcotic pain medication) that belonged to the client without the client’s permission. In addition, the AP took one tablet of Tramadol (an analgesic pain medication) that belonged to an additional client (client name unknown), without the client’s permission.
The police report indicated the AP stated s/he had a drug addiction and was addicted to pain killers. The AP stated the first theft took place right after being hired by the home care provider. The AP state that sometime in September of 2013 s/he took one Tramadol pill that belonged to another client. In addition, the AP admitted to the police that s/he took three Oxycotin pills that belonged to the client, that were noted to be missing when the narcotic medications were counted.
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 mistakes, pressure sores or any other form of elder abuse or neglect contact Elder Abuse Attorney Kenneth LaBore at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com