Waconia Good Samaritan Society Cited for Failure to Follow POLST
Based on a report dated, September 20, 2016, it was alleged that neglect occurred when the facility failed to ensure a resident’s wishes were carried out as facility staff failed to follow the resident’s Provider Order for Life Sustaining Treatment (POLST) from when he/she became unresponsive. Life saving measures were discontinued against the resident wishes and the resident passed away without being transferred to a hospital.
Based on a preponderance of the evidence, neglect occurred when staff did not provide emergency medical care to a resident, consistent with the resident’s advanced directive for life-sustaining treatment and cardiopulmonary resuscitation (CPR), and the resident died. CPR was started but discontinued when a staff misunderstood the Provider Order for Life Sustaining Treatment (POLST) form and directed staff to stop CPR.
The resident was admitted to the facility from a hospital after a short stay for respiratory issues, the resident was alert and oriented and made his/her own decisions about medical care. The facility had reviewed the POLST form on admission with the resident, and the form indicated the resident wanted cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. The form was signed by the resident, a nurse and the physician.
The resident had a change in condition, a decreased level on consciousness and difficulty breathing. A nurse was monitoring the resident’s vital signs and unresponsiveness, and performing a sternal rub. A second nurse assessed the resident, then left the room to check the electronic medical record to determine the CPR status and the emergency medical system (EMS) was activated. The resident’s condition declined and the nurse with the resident determined CPR was indicated, the Licensed Practical Nurse for the next shift care into the room and immediately started CPR. The nursing staff had not brought the emergency equipment of an automated external defibrillator and back board used to perform CPR to the resident’s room, and CPR was initially begun on the bed without a firm surface under the resident.
Good Samaritan Waconia Cited with Neglect after Fall From EZ Stand Lift
According to a report dated July 26, 2016, it is alleged that neglect occurred against Good Samaritan Waconia when the alleged perpetrator (AP) did not follow the care plan and the resident fell out of the EZ stand lift, sustained multiple fractures and died a few days later.
Based on a preponderance of the evidence, neglect occurred when the alleged perpetrator (AP) transferred the resident alone, used the wrong type of lift, and the resident fell out of the EZ stand lift, was lowered to the floor and sustained fractures of her left hip and left upper arm.
The resident was dependent on staff to assist with activities of daily living. The care plan interventions to be used when transferring the resident during toileting were: two staff to assist, using a total lift (hydraulic powered sling lift) and large sling. The AP worked with the resident prior to the fall. The AP did not review the resident’s care plan prior to transferring the resident. The AP used the EZ stand alone to transfer the resident from the wheelchair to a standing position. The resident suddenly lost strength in the left leg and wanted to sit down. The resident began to slip out the EZ stand. The AP lowered the resident to the floor. The on-call physician was contacted, and the resident was transferred to the hospital for further care. The resident sustained a left hip fracture and left upper arm fracture.
The resident’s death certificate was reviewed and indicated the resident expired at the hospital. The immediate cause of death was listed as complications of left femur fracture.
Good Samaritan Society Waconia Complaint Findings for Neglect – Failure to Administer Coumadin
In a report concluded on October 18, 2013, the Minnesota Department of Health cites Good Samaritan Society Waconia for neglect of health care – failure to administer Coumadin.
It is alleged that a resident was neglect when the facility failed to administer Coumadin for 10 days. The resident developed a clot in the left femoral artery.
Based on a preponderance of evidence, neglect is substantiated when a resident did not receive an anti-coagulant medication (Coumadin) for ten days as a result of a medication error (error in order transcription). Review of the incident did not provide evidence that confirmed that the medication error caused a clot to develop in the resident’s left femoral artery.
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 other form of elder abuse or neglect contact Elder Abuse and Neglect Attorney Kenneth LaBore at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.