Neglect Resident Fall Resulted in Neck Fracture
Neglect Resident Fall Resulted in Neck Fracture, Maple Manor Healthcare Rochester

Maple Manor Healthcare Rochester Complaint Findings for Neglect – Falls

In a report concluded on April 15, 2014, the Minnesota Department of Health cites Maple Manor Healthcare Rochester for neglect of health care – falls.

It is alleged that neglect occurred when a resident fell and broke her neck and died.

Substantiated Complaint Maple Manor Healthcare Rochester After Falls

Based on a preponderance of evidence established that neglect occurred when a resident fell three to four feet from an EZ lift, struck his/her head on the floor, and sustained bilateral lamina fractures of the C2 which could not be repaired.  The rubber safety catch on the mechanical lift failed to secure the harness in place and the resident fell out of the harness sideways during mid-transfer.

The resident was non-ambulatory and completely reliant on staff to meet all mobility needs.  The resident’s mode of transfer was staff-assisted via EZ lift mechanical device.  During a routine transfer by staff, one side of the transfer harness slipped off the main transfer arm after staff had already raised the resident up to a standing position.  The safety catch, a black rubber grommet which secures the transfer harness in place on the lift, was missing.  The resident fell approximately four feet to the floor, lost consciousness for about one minute, the resident’s advanced dementia and surgical risk, non-surgical management was elected.  The resident died three days later.

The facility had experienced problems with the safety catch popping off EZ lifts, six to nine months prior to the resident’s fall.  Although the facility replaced the safety catches when they dislodged from the lifts, the facility did not implement and day-to-day safety precautions to ensure the physical security of residents who used EZ lifts.  Facility staff stated that routine monthly maintenance was performed on all EZ lifts and consisted on an inspection of 41 items, including the safety catches.  The facility had no written records of any of the EZ lift inspections, monthly maintenance that was performed, or dates when safety catches were replaced.

Neglect was determined because the facility failed to implement a system to reduce avoidable accidents with EZ lift mechanical devices.  The facility ongoing problems with the safety catches popping off the EZ lifts for six to nine months prior to the resident’s fall.  The facility continued to use the EZ lift without implementing any safety precautions which addressed checking the safety catches for proper placement prior to transferring residents with the mechanical lift.

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 injuries from mechanical lifts, falls or any other form of elder abuse or neglect or wrongful death contact Elder Abuse and Neglect Attorney Kenneth LaBore at 612-743-9048 or toll free at 1-888-452-6589 or by email at


Maple Manor Healthcare Rochester Neglect Substantiated
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