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 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.
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.