Fall From Broda Chair Leads to Death of Resident at MN Veterans Home in Minneapolis
In a report from the Minnesota Department of Health dated August 25, 2016, it is alleged that a resident at the MN Veterans Home in Minneapolis neglected when s/he had a fall out of a full body lift causing a cervical fracture. The resident passed away 11 days later, cause of death was determined to be cardiorespiratory complications of immobility, blunt force neck, and a fall. In addition, the facility failed to provide proper lift sheet and equipment for lift being used.
MN Veterans Home Cited with Neglect After Resident Falls
Based on a preponderance of the evidence neglect is substantiated. The resident fell out of a sling during a mechanical lift transfer.
The resident had left sided weakness and received staff assistance for repositioning and transfers. The resident’s care plan directed two staff to use a mechanical full body lift and medium sling for all transfers. The resident used a Broda (specialized positioning wheelchair) for mobility. The resident had cognitive impairment.
Interviews and document review revealed prior to the fall, the resident was in bed. Two staff placed a medium lift sling under the resident and attached the four loops on the sling to the corresponding four hooks on the lift. Three staff were present during the lift/transfer process. One staff used the controller to lift the resident’s feet to help guide the resident into the chair. Staff indicated that prior to lifting the resident; all four of the sling loops were securely on the lift hooks. After lifting the resident, staff began to move the lift to align with the resident’s Broda chair per protocol. Staff indicated the sling support bar suddenly tilted vertically, the left shoulder loop became unattached from the lift, and the resident slipped out of the sling onto the floor. Staff immediately notified the centimeter laceration on the top of her/his head. The nurse arranged for emergency transportation to the hospital. Staff removed the lift and sling from service.
After the fall, a manufacturer representative of the lift came out to the facility and examined the lift and the sling. The representative stated the lift was in good working order and the sling was not in good condition. The representative stated the lifts had no history of the hanger bars tilting as described. The sling used was not the same manufacturer of the lift; however, used the same loop system and was compatible with the lift. The manufacture’s operation manual did not indicate the manufacturer’s sling was required to use the lift. The manual did indicate the manufacturer’s slings could be used with other lifts that used a four-point hanger bar loop system. However, the manufacturer later submitted a Manufacturer and User-facility Device Experience (MAUDE) report which stated the root cause of the incident was “caregiver inattention and technique”.
The resident returned to the facility 8 days later on hospice care due to her/his injuries, which included a cervical neck fracture. The resident passed away 3 days later. The certificate of death indicated the cause of death as cardiorespiratory complication of immobility, due to blunt force neck injury from a fall.
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 KLaBore@MNnursinghomeneglect.com.