Archive for the ‘Inadequate Staffing/Training’ Category

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Accurate Home Care Ostego Neglect Leads to Fall With Injuries

Written By: Kenneth LaBore | Published On: 28th February 2017 | Category: Fall Injuries, Hoyer Lift, Inadequate Staffing/Training, Patient Lift | RSS Feed

Accurate Home Care Ostego – Resident Suffers Serious Injuries Fall From Improper Transfer From Mechanical Lift

Accurate Home Care Ostego Neglect After Resident Suffers Injuries From Fall

In a report dated February 2, 2017, the Minnesota Department of Health alleged that a patient at Accurate Home Care Ostego when a staff, alleged perpetrator unsafely transferred a patient, dumping water on his/her face. Emergency response was called, CPR was initiated and the patient was admitted to hospital pneumonia.

Accurate Home Care Ostego Fall Leads to Series of Events Ending With Pneumonia

Based on a preponderance of the evidence, neglect occurred when the alleged perpetrator (AP) did not follow the patient’s care plan and did not initiate cardiopulmonary resuscitation (CPR) when the client experienced respiratory distress.

The patient had quadriplegia and was ventilator dependent. The patient’s plan of care indicated the patient was a full code and had an emergency protocol in place. The care plan had an emergency airway clearance protocol including using a manual resuscitation bag (a pump device to assist ventilation) with 100% oxygen, irrigating with saline, and suctioning. If there was no result with those actions, staff were to call 911. Staff were to continue to use the bag until help arrived or the situation resolved.

On the evening of the incident, the AP transferred the patient to bed with a mechanical lift. The patient requested the AP hook-up the humidification to the tracheostomy prior to removing the lift sling. Because the sling was still under the patient, the AP turned the patient from side to side. The humidifier on the bedside table tipped over causing water to back up into the humidifier tubing. The AP attempted to shake the water out of the tubing and elevated the head of the bed, but the patient was not getting enough air. The patient requested with AP ventilate with the bag. The AP did not comply, but instead went upstairs to get the family member. When the AP and the family member returned to downstairs, the patient was unresponsive and did not have a pulse. The family member suctioned the patient, used the bag, and did chest compressions. The AP did not assist with CPR. A second family member came to assist. The second family member provided the backup ventilator and suctioned the patient. The first family member called 911, and then the AP took over CPR. During this time, the AP unable to find a pulse. The patient went to the hospital and was admitted for one day with a diagnosis of aspiration pneumonia.

The family member interview indicated the patient was not to have the humidification tubing hooked up until the sling was out from underneath him/her. The family member stated when they came downstairs the ventilator was off.

The alleged perpetrator (AP) participated in an interview. The AP state s/he had received training specific to this patient’s care plan. The AP indicated s/he did not start providing ventilation with the manual resuscitation bag, because the patient had a pulse. However, resuscitation can be provided regardless of the status of the patient’s pulse.

Accurate Home Care Ostego – Report Abuse and Neglect

Click Here For Link To Report Abuse To Adult Protection

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 financial exploitation or any other form of elder abuse or neglect contact Minnesota Elder Abuse Attorney Kenneth LaBore toll free at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

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Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

Aging Joyfully Eden Prairie

Written By: Kenneth LaBore | Published On: 21st February 2017 | Category: Inadequate Staffing/Training, Uncategorized, Wrongful Death | RSS Feed

Death After Failure to Monitor Heart Pump at Aging Joyfully Eden Prairie

Aging Joyfully Eden Prairie Allegation of Neglect After Failure to Plug in Heart Pump

In a report from the Minnesota Department of Health, dated January 4, 2017, it is alleged that a client at Aging Joyfully Eden Prairie was neglected when staff failed to plug in and monitor the client’s heart pump. The client passed away.

Aging Joyfully Eden Prairie Substantiated Neglect After Resident Death

Based on a preponderance of the evidence, neglect is substantiated. Staff failed to plug a “heart pump” device into wall/outlet power. The client was dependent on the device and when the device batteries depleted, the client died.

The client was admitted to the home care provider with diagnoses that included heart failure with a left ventricle assist device (LVAD) and dementia. The client required assistance with activities of daily living, meals, and LVAD management. The client had 10 percent heart function. The home care provider staff were required to test the LVAD daily and record the device readings, and the client’s vital signs and weight. At bedtime, the staff were required to change the LVAD from battery power to wall/outlet power.

The University of Minnesota LVAD training protocol defines a LVAD as a mechanical circulatory device or “heart pump” that assists a failing heart by increasing blood flow to the rest of the body. The device is used to increase quality of life and survival for people living with end stage heart failure. The LVAD controller runs off battery power. The requirement for sleep procedures were to change the controller from battery power to wall/outlet power by disconnecting the batteries, connecting the controller to the power module, ensuring the power module is connected to wall power, and placing the batteries on the charger for the next day’s use. The LVAD controller had a system alarm that sounds for various reasons including a low battery.

Aging Joyfully Eden Prairie – Report Suspected Abuse and Neglect

Click Here For Link To Report Abuse To Adult Protection

If you have concerns about any other form of elder abuse or neglect contact Minnesota Elder Abuse Attorney Kenneth LaBore toll free at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

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Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

Substantiated Complaint Against Augustana Emerald Crest After Death of Client

Written By: Kenneth LaBore | Published On: 1st February 2017 | Category: Housing With Services Care Issues, Inadequate Staffing/Training, Wrongful Death | RSS Feed

Allegations of Neglect of Supervision at Augustana Emerald Crest in Shakopee

Augustana Emerald Crest Allegations of Neglect

In a report dated, January 3, 2017 by the Minnesota Department of Health alleging that Augustana Emerald Crest in Shakopee, it is alleged that a client was neglected when staff failed to provide adequate supervision and s/he ingested dishwasher detergent. The client was hospitalized.

There is another report with similar facts also dated January 3, 2017.

Augustana Emerald Crest Substantiated Neglect Allegation

Based on a preponderance of the evidence, neglect of supervision occurred when a staff member left a corrosive chemical detergent unattended and within the client’s reach. The client drank some of the chemical and sustained burns to the throat, requiring hospitalization. The client subsequently died from complications of ingestion.

The client had a history of dementia and was noted to have deficits in cognition, with poor judgment and decision-making. S/he also had the tendency to take food and drinks from the kitchen. The client’s cognitive assessment noted that cupboards needed to be locked due to this behavior.

Staff interviews and documentation review indicated that, on the day of the incident, the client was in the dining area next to the kitchen waiting for breakfast. A facility staff member was changing and replacing an almost empty dishwasher container of UltraKlene in the kitchen. The staff member left the detergent out on the counter. The client grabbed the cleaning solution, poured a glass and proceeded to take a sip as witnessed by another client. The client spit out the liquid, but then proceeded to drink a quarter cup of coffee. Approximately three hours later, the client began complaining of a sore throat and had continued to spit out phlegm, which contained blood. S/he was noted to have a swollen upper lip with a raspy voice. The registered nurse assessed the client and it was noted that the client’s throat felt swollen. Emergency services was called. Staff reported they were not aware of the ingestion until this point.

The client was hospitalized for 13 days, was diagnosed with aspiration pneumonia and severe dysphagia (difficulty swallowing). The client was not able to eat or drink to sustain life, and died. The death certificate indicated the client died from complications of sodium hydroxide detergent ingestion.

According to information from the manufacturer, the detergent UltraKlene contains sodium hydroxide and is corrosive in nature, causes respiratory tract irritation, and is harmful if swallowed. If ingested, it causes burns to the mouth, throat and stomach.

For more information about how to get accountability for elder abuse and neglect related injuries call Kenneth LaBore for a free consultation at his direct number at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com. There is no fee unless a there is a verdict or settlement offer from the wrongdoer.

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Nursing Home Bedsore Lawyer

Written By: Kenneth LaBore | Published On: 31st January 2017 | Category: Inadequate Staffing/Training, Nursing Home Abuse and Neglect, Pressure Ulcers, Wound Care | RSS Feed

Minnesota Nursing Home Bedsore Lawyer

Elder care nursing home bedsore lawyer cases usually involve a pressure sore or ulcer also known as bedsore which started or worsened due to a lack of care. Disabled residents require assistance with many activities of daily living including in many situations turning and repositioning themselves in bed. Many pressure sores can be prevented or diminished if there is pressure relief from areas likely to develop wounds such as the back, rear-end/coccyx, and heels.

Often times pressure sores and ulcers occur due to a lack of well trained staff, particularly nursing aides. According to federal regulations, the facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e).

(a) Sufficient staff. (1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans.

Federal and State Regulations Summary From Nursing Home Bedsore Lawyer

Federal regulations mandate that based on the comprehensive assessment of a resident, the facility must ensure that—

(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and

(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Minnesota regulation in Statute 144.7065,requires reporting [by the facility to the Commissioner of the Department of Health] of Stage 3 or 4 or Unstageable ulcers acquired after admission to a facility, excluding progression from Stage 2 to Stage 3 if Stage 2 was recognized upon admission.

Nursing Home Bedsore Lawyer Kenneth LaBore

If you have questions about nursing home abuse and neglect and want accountability for preventable bed sores contact Kenneth LaBore for a free consultation. There is no fee unless there is a verdict or settlement offer from the wrongdoer. Mr. LaBore can be reached directly at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

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Nursing Home Scalding Injury

Written By: Kenneth LaBore | Published On: 30th January 2017 | Category: Burn Injuries, Inadequate Staffing/Training | RSS Feed

Shower and Bath Scalding Injury Burns

Scalding Injury

There are many ways that nursing home residents suffer injury in a bathroom and shower, few are as preventable as scalding injuries due to hot water in the shower or bath. Nursing homes are mandated to assess resident risks and to provide adequate care and supervision to prevent accidents. Facilities need to check the water temperature on the water heaters and then again assure that the water is not dangerously hot for residents. Like children, elder residents with thin skin and age related issues can burn even quicker than a younger person. Anyone can suffer 3rd degree burn injuries in just seconds or a few minutes depending the temperature.

Hot Water Scalding Injury Burn Chart

According to 42 CFR § 483.25, quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices, including but not limited to the following:

(d) Accidents. The facility must ensure that—

(1) The resident environment remains as free of accident hazards as is possible; and

(2) Each resident receives adequate supervision and assistance devices to prevent accidents.

Scalding Injury Burns

Information About Burns from Hot Water Scalding Injury from the CDC, scalds, which are burns attributed to hot liquids or steam, account for 33%–58% of all patients hospitalized for burns in the United States. Adults aged ≥65 years have a worse prognosis than younger patients after scald burns because of age-related factors and comorbid medical conditions, and they are subject to more extensive medical treatment than younger adults. To estimate the number of emergency department (ED) visits for nonfatal scald burns among U.S. adults aged ≥65 years and describe their characteristics, CDC analyzed ED visit data from the National Electronic Injury Surveillance System All Injury Program (NEISS-AIP) for 2001–2006. This report summarizes the results, which indicated that adults aged ≥65 years made an estimated 51,700 initial visits to EDs for nonfatal scald burns during 2001–2006, for an average of 8,620 visits per year and an estimated average annual rate of 23.8 visits per 100,000 population. Two thirds of visits were made by women. Most (76%) of the nonfatal scald injuries occurred at home; 42% were associated with hot food and 30% with hot water or steam. The findings in this report highlight the need for effective scald-prevention programs targeted to older persons.

Scalding Injury Burn Attorney

If you have questions about elder burn injuries or any form nursing home abuse and neglect contact Kenneth LaBore for a free consultation. There is no fee unless there is a verdict or settlement offer from the wrongdoer. Mr. LaBore can be reached directly at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

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Fractures from Falls in Minnesota Elder Care Facilities

Written By: Kenneth LaBore | Published On: 29th January 2017 | Category: Fall Injuries, Hoyer Lift, Inadequate Staffing/Training, Nursing Home Abuse and Neglect, Patient Lift, Wrongful Death | RSS Feed

Head Injury, Arm Fracture, Hip Fracture, Femur Fracture, Subdural Hematoma, Hip Fractures from Falls

Fractures From Falls in Nursing Homes

Many of the fractures from falls in nursing homes and other care settings are preventable had the resident received proper supervision or had their been adequate numbers of well trained staff to perform tasks such as transfers from wheelchairs and chairs, toileting, and assessment related to falls from the bed. Fractures can be very serious and due to complications can often lead to permanent injuries and disabilities or death.

Fractures From Falls From Patient Lift

Fractures From Falls From Hoyer Type Mechanical Patient Lift

One of the higher risk situations for residents of nursing homes or other elder care facilities is patient transfer from bed to wheelchair, wheelchair to bed or toilet and other transfers. The use of a mechanical patient lift can assist with these transfer when done safely but can lead to serious injuries when not performed correctly. Many times accident are due to the lifts not being used or set up as directed by the manufacturer. Another reason is the failure to use the right size or proper type of sling for the patient lift. Many falls occur when the sling is not attached to the lift clips per directions.

Nursing Home and Elder Injuries and Fractures as a Result of Wheelchairs

Fractures From Falls From Wheelchairs and Chairs

Injuries from wheelchair and even reclining chairs are common in senior care environments. The injuries usually occur due to a wheelchair tips over on ramps or curbs, falls down stairs, allows the resident to slip out of the chair, the resident’s feet are allowed to drag causing leg and feet injuries and others. Residents must receive the supervision and care necessary to avoid injuries including wheelchair falls and injuries.

Nursing Home Injuries Due to Falls in Bathrooms

Fractures From Falls In Bathroom

The bathroom is an area where many types of injuries occur. Fall injuries related to a loss of balance when setting down or getting up from the toilet. Injuries from lifts on the toilet or in the shower. Injuries from slipping in the shower or entering bath or shower. Injuries also occur when dressing and undressing for baths and showering. Most injuries in the bathroom are preventable if the resident receives the patient assistance and supervision necessary to provide for their toileting and hygiene needs.

Nursing Home Falls from Bed Can Lead to Serious Injury Fractures and Death

Fractures From Falls From Bed

Although it may seem like someone is safe in their bed, vulnerable nursing home residents suffer serious fractures, head injuries and others when they fall from their bed onto the floor or hit their head or body on items near the bed such as oxygen tanks and night stands. Many of the injuries as result of falling from bed are preventable, however, nursing homes often refuse or negligently fail to provide bed rails, lower the bed height, provide safety mats or other safety interventions to protect residents at risk of falls.

Fractures From Falls are Often Medical Malpractice Cases

If you suffer an fractures from falls when a resident in a nursing home, assisted living, memory care, hospital or other medical or senior care environment the provide may be responsible in part or whole for a lack of supervision or improper use of medical equipment and other reasons. You need expert medical opinions in Minnesota to bring a lawsuit for medical malpractice and for many issues related to wrongful death claims.

If you have questions about nursing home abuse and neglect and fractures or other fall related injuries contact Kenneth LaBore for a free consultation. There is no fee unless there is a verdict or settlement offer from the wrongdoer. Mr. LaBore can be reached directly at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

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Head Injuries From Nursing Home Falls

Written By: Kenneth LaBore | Published On: 27th January 2017 | Category: Fall Injuries, Hoyer Lift, Inadequate Staffing/Training, Nursing Home Abuse and Neglect, Patient Lift, Wrongful Death | RSS Feed

Elder Abuse Falls Subdural Hematoma Head Injuries

Head Injuries Commonly Occur From Nursing Home Falls

Most head injuries are preventable by definition. They occurs as a result of a failure to provider adequate supervision or timely response to vulnerable adults often when trying to get out of bed, after a call light goes without being answered or getting up from a toilet when left alone, or from improperly performed transfers from patient lifts such as hoyer lifts.

Head Injuries Include Subdural Hematomas

It does not take a fall from a high place or extremely hard trauma to cause permanent injury to the head. Many subdural hematomas occur when someone falls from the height of their bed to the floor. The nightstand or other obstacles such as oxygen tanks are also a risk for head injury if there is a fall. The sharp corners and hard material can cause a localized injury or cut which can lead to swelling, bleeding and sometimes death if not addressed immediately.

Information about Head Injuries and Traumatic Brain Injury

According to the Alzheimer’s Association, traumatic brain injury is a threat to cognitive health in two ways:

A traumatic brain injury’s direct effects, which may be long-lasting or even permanent, can include unconsciousness, inability to recall the traumatic event, confusion, difficulty learning and remembering new information, trouble speaking coherently, unsteadiness, lack of coordination and problems with vision or hearing.
Certain types of traumatic brain injury may increase the risk of developing Alzheimer’s or another form of dementia years after the injury takes place.

The Center for Disease Control, CDC states: in general, total combined rates for traumatic brain injury (TBI)-related emergency department (ED) visits, hospitalizations and deaths have increased over the past decade. Total combined rates of TBI-related hospitalizations, ED visits, and deaths climbed slowly from a rate of 521.0 per 100,000 in 2001 to 615.7 per 100,000 in 2005. The rates then dipped to 595.1 per 100,000 in 2006 and 566.7 per 100,000 in 2007. The rates then spiked sharply in 2008 and continued to climb through 2010 to a rate of 823.7 per 100,000.

Total combined rates of TBI-related hospitalizations, ED visits, and deaths are driven in large part by the relatively high number of TBI-related ED visits. In comparison to ED visits, the overall rates of TBI-related hospitalizations remained relatively stable changing from 82.7 per 100,000 in 2001 to 91.7 per 100,000 in 2010. TBI-related deaths also decreased slightly over time from 18.5 per 100,000 in 2001 to 17.1 per 100,000 in 2010. Note that the axis scale for TBI-related deaths appears to the right of the chart and differs from TBI-related hospitalizations and ED visits.

Minnesota Elder Abuse and Neglect and Head Injury Attorney

Attorney Kenneth LaBore has handled hundreds of elder abuse and neglect cases involving serious injury or death and many due to falls and often resulting in head trauma with some form of permanent brain injury. Many of these cases and injuries have been prevented with proper care and supervision by the provider.

For a free consultation with Kenneth LaBore concerning injuries from falls, including TBI and head injury or other types of elder abuse call 612-743-9048 or 1-888-452-6589 or by email KLaBore@MNnursinghomeneglect.com.

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Nursing Home Fall Injury Lawyer

Written By: Kenneth LaBore | Published On: 25th January 2017 | Category: Bed Rail Strangulation and Asphyxiation, Fall Injuries, Grab Bars, Guards, Hoyer Lift, Inadequate Staffing/Training, Medical Device Product Liability, Nursing Home Abuse and Neglect, Patient Lift, Wrongful Death | RSS Feed

Head Injury, Arm Fracture, Hip Fracture, Femur Fracture, Subdural Hematoma, Hip Fracture, and Reasons to Call Nursing Home Fall Injury Lawyer Kenneth LaBore

Minnesota Nursing Home Fall Injury Lawyer

A personal injury attorney who is the area of practice as a nursing home fall injury lawyer is handling a case that is a combination of many types of cases in Minnesota. There is a breach of a duty, which is a negligence claim, but since most cases involve a care or service obligation of a professional nature an expert affidavit is needed to support the elements of the case unless admitted by the defendant facility, such as duty, breach, causation (breach of duty caused alleged injury) and damages as prescribed by Minnesota Jury Instructions.

Many of the cases I see are falls or falls in combination of some other form of related neglect such as medication error, dehydration etc. I assembled a summary of information for nursing home fall injuries.

Legal Obstacles for Nursing Home Fall Injury Lawyer

The minimum standards of care for nursing homes is set for in state and federal regulations and there are several which apply to the issue of falls and fall prevention in nursing homes. In general a resident entering a nursing home or skilled nursing facility needs to have a comprehensive assessment performed by qualitied professionals such as a doctor or nurse practitioner, physical therapist, occupational or speech therapist, dietary, and others depending on the care needs of the resident at that time. The facility is obligated to perform subsequent assessments when there is a change in the condition of the nursing home resident with the intent to get intervention to assist or get out side care if needed.

Here is More Information about Nursing Home Fall Injury

The American Academy of Orthopedic Surgeons publishes a fall prevention brochure for seniors.

The Centers for Disease Control and Prevention and the National Center for Injury Prevention and Control offer various sheets and education materials on fall prevention strategies and statistics.

The Centers for Disease Control and Prevention and the National Center for Injury Prevention and Control produces: Falls – Older Adults.

The Centers for Disease Control and Prevention and the National Center for Injury Prevention and Control also produces: What Outcomes are Linked to Falls? and Hip Fractures Among Older Adults.

The Minnesota Department of Health and the Center for Medicare and Medicaid Services CMS has a power point on Who is at Risk? and How Can Older Adults Prevent Falls?

Nursing Home Fall Injury Lawyer Kenneth LaBore

Kenneth LaBore is an attorney who has handled thousands of injury cases and hundreds of elder abuse neglect and wrongful death claims for clients throughout the state of Minnesota. Many of the cases include falls, medication errors, failure to respond to a change in condition, assaults and other forms of abuse and neglect. There is a common theme of short staffing leading to a environment where vulnerable adults usually senior citizens some with dementia or Alzheimer’s are put at risk.

For a free consultation with Nursing Home Injury Lawyer Kenneth LaBore call him directly at 612-743-9048 or toll free at 1-888-452-6589. Mr. LaBore can also be reached by email at KLaBore@MNnursinghomeneglect.com. There is no fee unless there is a verdict or settlement with wrongdoer.

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Chris Jensen Health and Rehab Center on CMS Special Focus Facility List Due to High Number of Deficiencies in Quality of Care

Written By: Kenneth LaBore | Published On: 7th January 2017 | Category: Facilities - Nursing Homes, Inadequate Staffing/Training, Pressure Ulcers | RSS Feed

Chris Jensen Health and Rehabilitation Center is Placed on Medicare Special Focus Facility Initiative List

Information About Chris Jensen Health and Rehabilitation Center

Name: CHRIS JENSEN HLTH & REHAB CTR
Address: 2501 RICE LAKE ROAD
DULUTH, MN 55811
Phone: 218-625-6400 Fax: 218-625-6452
Administrator: MS. AMY PORTER
Minnesota Licensed Bed Capacity: (Nursing Home Beds = 170)
Federally Certified Beds: (Dual Medicare/Medicaid Skilled Nursing and Nursing Facility Beds = 170)

Chris Jensen Health and Rehab Center Survey Results

Results from a survey dated May 12, 2016, indicated that Chris Jensen Health and Rehabilitation Center in Duluth Minnesota had deficiencies which were severe enough to place them on dubious list of special focus facility list of nursing homes with high numbers of serious deficiencies.

On April 7, 2016, the Minnesota Department of Health completed a Post Certification Revisit (PCR) and on April 5, 2016, the Minnesota Department of Public Safety completed a PCR to verify that the facility had achieved and maintained compliance with federal certification deficiencies issued pursuant to an extended survey, completed on February 10, 2016. The MDH presumed, based on their plan of correction, that the facility had corrected these deficiencies as of March 29, 2016. Based the visit, it was determined that your Chris Jensen Health and Rehabilitation Center has not obtained substantial compliance with the deficiencies issued pursuant to our extended survey, completed on February 10, 2016. The deficiencies not corrected are as follows:

FTag 282, F 282, 42 CFR 483.20(k)(3)(ii) Services By Qualified Persons/per Care Plan

FTag 314, F 314 , 42 CFR 483.25(c) Treatment/Services To Prevent/heal Pressure Sores

The most serious deficiencies in the facility were found to be isolated deficiencies that constituted actual harm that was not immediate jeopardy (Level G), as evidenced by the attached CMS-2567, whereby corrections were required.

As a result of the revisit findings, the Category 1 remedy of state monitoring remained in effect.

In addition, this Department recommended to the CMS Region V Office the following actions related to the imposed remedies in their letter of March 7, 2016:

Discretionary denial of payment for all Medicare and Medicaid admissions effective April 10, 2016, remain in effect.

Click here for the rest of the May 12, 2016 survey.

For more information from the Minnesota Department of Health, inspection surveys and reports, website, which usually has the most recent survey and the one taken before that.

To speak with an Attorney Kenneth LaBore concerning elder abuse or neglect or related injuries call his direct number 612-743-9048 or by email to KLaBore@MNnursinghomeneglect.com.

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MN Veterans Home Resident Suffers Head Injury After Fall

Written By: Kenneth LaBore | Published On: 8th December 2016 | Category: Fall Injuries, Hoyer Lift, Inadequate Staffing/Training | RSS Feed

Resident at MN Veterans Home Suffered Fractured Neck Resulting in Death after Fall from Lift

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.

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.

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