Recent MDH Substantiated Neglect Findings against Mala Strana Care & Rehab after emotional abuse by staff.

Fall from Mechanical Lift at Mala Strana Care and Rehab Center
Fall from Mechanical Lift at Mala Strana Care and Rehab Center

Allegation of Neglect After Resident Fall at Mala Strana Care & Rehab

In a report dated August 30, 2016, the Minnesota Department of Health alleged that a resident at Mala Strana Care & Rehab in New Prague was neglected when an employee, the Alleged Perpetrator (AP), did not follow the resident’s care plan and the resident fell, resulting in multiple facial injuries.

Substantiated Neglect After Fall from Mechanical Lift at Mala Strana

Based on a preponderance of the evidence, neglect did occur when the AP did not adhere to the resident’s fall risk care plan interventions to maintain the resident’s safety.  The AP transferred the resident to bed with a mechanical lift and not obtain the assistance of a second staff person to safeguard the resident.  The AP then left the resident’s room but did not move the mechanical lift away from the resident’s bedside, did not lower the bed from the high position, and did not place the fall mattress on the floor next to the resident’s bed.  While unattended, the resident rolled out of the bed, struck his/her head on the mechanical lift, and sustained a hematoma to the forehead and lacerations to the inner cheek and inner lip.

The resident was admitted to the facility with a terminal diagnosis.  The resident was declining rapidly, receiving hospice care, and had stopped eating.  The resident had severe cognitive impairment and was legally blind.  The resident was completely reliant on staff to meet all his/her care needs.  The resident had intense abdominal pain related to the end-stage disease, resulting in continued restlessness and agitation, despite the administration of comfort medications.  The resident slept only short intervals of one or two hours.  The resident constantly tried to get out of bed or out of the Broda chair.  For all these reasons, the resident was at high risk for falls.  The resident’s care plan indicated that staff were to maintain the resident’s safety by transferring the resident with a mechanical lift (full body lift) and the assistance of two staff, positioning the resident in bed with pillows, and keeping the bed in the low position with a fall mattress on the floor next to the bed.  Staff were to check on the resident every hour when s/he was in bed.  When the resident was awake, the resident was transferred to a Broda chair which was placed at the nurse’s station or within eyesight of staff 1:1 monitoring, due to the resident’s level of restlessness and high risk for falls.

For more information about this fall from a mechanical lift at Mala Strana click here

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, improper use of medical equipment, falls or any other form of elder abuse or neglect contact Minnesota Elder Abuse Attorney Kenneth LaBore at 612-743-9048 or toll free at 1-888-452-6589 or by email at


Fall from Lift at Mala Strana Care & Rehab Center
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