Recent Substantiated Neglect at Golden Horizons after medication errors.
There is a substantiated claim for neglect after several falls and others including medication theft at Golden Horizons
Allegation of Neglect Against Golden Horizons After Resident Falls
In a report dated October 25, 2016, the Minnesota Department of Health allege that a client at Golden Horizon in Aitkin Minnesota was neglected when the client fell on multiple occasions and was injured.
Substantiated Citation Against Golden Horizon
According to the report: based on a preponderance of evidence, neglect is substantiated. A client experienced three falls with injuries in a month, and the home provider staff failed to provide adequate assessments, interventions or consult with the client’s physician.
The client received services from the home care provider for diagnoses that included Lewy Body dementia and chronic obstructive pulmonary disease. The client’s service plan indicated the client required assistance of one person for all activities of daily living, transfers, ambulation, repositioning every two hours, and toileting assistance every two hours.
The client experienced a fall early in the morning, during an overnight shift. The client was found laying on his/her floor with a laceration to his/her forehead. The home care provider staff updated the client’s family member, who transported the client to the urgent care. In the clinic, the client received four sutures. A home care provider’s post-fall investigation concluded that the client was in bed prior to the fall, but it was unknown how the client received the laceration.
Approximately three weeks later, the home care provider staff was ambulating with the client, while the client used a walker. The client lost his/her balance, fell onto his/her wheelchair, and received a skin tear to his/her right arm. The client did not have a gate belt on the client while ambulating. Staff updated the client’s family member, who transported the client to the emergency department (ED). At the ED, the skin tear was closed with dermabond. The registered nurse (RN) educated the staff member to use a gait belt at all times when walking with clients.
A week later, the client experienced a third fall. The client was sitting on the edge of his/her bed, when the staff member began to place a gait belt around the client’s waist. The client became frightened and fell off the bed onto his/her left side. The client received a hematoma to the back of the head, and staff suspected the client had hit his/her head on the bed. The home care provider staff updated the client’s family member. The following day, the client expressed having pelvic pain and the client’s family member brought the client to the ED. At the ED, an x-ray was completed, but could not exclude a pelvic fracture. The client was too confused to comply with further imaging. A troponin level (lab test to indicate a heart attack) was also elevated. The client was hospitalized for two days and discharged on comfort cares.
After each of the three falls, the client’s vitals signs were not taken and the client’s physician was not updated. There were no post-fall RN assessments completed after the first and second fall, therefore no new interventions were implemented or changes made to the service plan. A RN assessment was completed after the client returned from the hospital following third fall, but the only change in status documented was the client was no longer able to ambulate. No other changes were made to the service plan. Approximately two weeks later, the client passed. The death certificate indicated that the client did from natural causes.
Golden Horizons Substantiated Allegation of Neglect of Supervision – Resident to Resident
In a report dated October 31, 2014, the Minnesota Department of Health cited Golden Horizons it is alleged that neglect occurred when #1 was injured by client #2 who came into client #1’s room during the night. Client #1 indicated that he does not feel safe since this occurred.
Based on a preponderance of the evidence neglect is substantiated. The facility was aware of client #2’s aggressive behavior toward other clients but failed to provide adequate supervision to ensure the safety of clients in the facility. As a result, client #1 received a black eye after being hit by #2.
Golden Horizons Substantiated Allegation of Abuse – Physical Staff
In a report dated October 22, 2014, the Minnesota Department of Health cited Golden Horizons it is alleged that clients were abuse by staff, when alleged perpetrator (AP) forcefully pushed client #1’s (C1) hands down causing pain. In addition, the AP kicked client #2 (C2) in the ankle and forcefully pushed C2 into a chair.
Based on a preponderance of the evidence abuse is substantiated. The alleged perpetrator (AP) forcefully pushed client #1’s hands on the walker and bumper client #1’s hand into a dresser multiple times. In addition, the AP kicked client #2 on the right ankle forcefully pushed client #2 into a chair.
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 and fractures, lack of supervision or care, physical abuse or any other form of elder abuse or neglect contact Minnesota Elder Abuse Attorney Kenneth LaBore toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.