Resident Falls and Suffers Burns at Knute Nelson Alexandria
In a report from the Minnesota Department of Health, dated April 22, 2016, it was alleged that Knute Nelson Alexandria was neglected when s/he fell and was burned by the baseboard heater in the resident’s room.
Knute Nelson Alexandria – Baseboard Radiator Burn Injuries
Based on a preponderance of the evidence, neglect occurred when the facility failed to assess the risk for burns from a baseboard heater in the resident’s room. The resident rolled out of bed, came in contact with the heater, and sustained first, second, and third degree burns to the left hip and right foot including the heel and great toe.
The resident’s diagnoses included peripheral neuropathy or decreased feeling to the lower extremities. The resident was capable of making his/her needs known to staff but required the assistance from others for decision making. Due to declining health, the resident was provided with hospice care. At the time of the fall, the resident required extensive assistance from two staff and a walker for ambulation, two staff for repositioning, transfers, toilet use, and a wheelchair for mobility for longer distances. The resident had a history of falls at the facility and care plan interventions included keeping the call light and commonly used items within the resident’s reach, reminding the resident of safety precautions, providing proper footwear, and staying with the resident in the bathroom with toileting. At the time of the fall, the facility had implemented an alarm that alerted staff of the resident’s attempt at self-transfers.
Early one morning, staff entered the resident’s room responding to the silent alarm notification. The resident was lying between the bed and the baseboard heater his/her left hip and foot in contact with the heater. The left hip burn was not measured but determined to be first degree. The burn to the right foot measured 17 centimeters (cm) by 5 cm with weeping blisters present on the right heel and great toe. The burn was second degree. There was a third degree burn to a small area of the right great toe that measured .25 cm by 3 cm. The area was white with hard skin. The resident had an order for morphine sulfate for moderate to severe pain and staff provided the medication.
An interview with a staff member established when s/he found the resident on the floor touching the baseboard heater, s/he placed her/his leg between the heater and the resident to protect him/her from the heat. The staff said the baseboard heater was hot and it was difficult to keep her/his leg on the heater until help arrived.
At the time of the fall, the resident’s bed was positioned parallel to the electric baseboard heater with a nightstand between the bed and heater. There was approximately 19.5 inches between the resident’s bed and the heater. During an onsite visit, the surface of the baseboard heater taken with a laser infrared device was 130 degrees Fahrenheit. There was no prior assessment of the burn risk to the resident from the baseboard heater located in the resident’s room.
At the time of the incident, the facility had no policy or system in place to monitor the surface temperature of the baseboard heater. Of the five resident rooms with the same type of baseboard heater, none of the beds were positioned close to the heater.
The resident passed away two days after the incident.
The death certificate indicated the primary cause of death was pneumonia.
Substantiated Complaint Against Knute Nelson Alexandria – Medication Theft
In a report concluded on February 8, 2016, the Minnesota Department of Health cites the facility for exploitation – drug diversion.
It is alleged that a resident was financially exploited when a staff, alleged perpetrator (AP), took the resident’s medications for his/her own use. The AP confessed to facility management to taking the medications.
Based on a preponderance of the evidence financial exploitation did occur when the alleged perpetrator (AP) took two tablets of Percocet (a narcotic used to treat moderate to severe pain) that belongs to the resident for the AP’s own personal use.
Knute Nelson Alexandria Complaint Findings for Neglect – No CPR
In a report concluded on June 4, 2014, the Minnesota Department of Health cites Knute Nelson Alexandria for neglect of health care – failure to provide CPR.
It is alleged that neglect occurred when two licensed nurses did not initiate cardiopulmonary resuscitation (CPR) when a resident was found not breathing and pulseless. The resident’s advanced directives indicated that resident wanted CPR to be started.
Based on a preponderance of the evidence neglect occurred, when nursing staff failed to initiate cardiopulmonary resuscitation (CPR) as directed by the resident’s signed resuscitation guideline form.
When MDH interviewed the physician/medical director stated that staff should have initiated CPR, called transferred the resident to the hospital. The physician indicated that the facility policy directs staff to initiate CPR (unless designated as do not resuscitate/do not intubate) as the signs of death as difficult to gauge and are open to personal interpretation.
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 failure to provide CPR, burn injuries 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.