Neglect of Health Care, Fall and Fracture to Leg
Neglect of Health Care, Fall and Fracture to Leg, Pathstone Living Mankato Minnesota

Pathstone Living Mankato Complaint Findings for Neglect – Falls

In a report concluded on July 29, 2013, the Minnesota Department of Health cites Pathstone Living Mankato for neglect of health care – falls.

It is alleged that neglect occurred when staff, the alleged perpetrator (AP), was transferring a resident incorrectly causing a fall that resulted in a fracture.

Substantiated Complaint of Neglect Pathstone Living Mankato

Neglect occurred when the AP transferred the resident incorrectly causing a fall and fracture.  The resident’s care plan required 2 staff members for all patient transfers.  The AP had training from the facility to review resident nursing assistant care plans before providing resident care.  The AP transferred the resident alone and the resident fell.  The resident was sent to the emergency room and was found to have a fracture.

Interview and document review revealed that resident was admitted to the facility in early 2012 with diagnoses that included end stage renal disease.  The resident had a history of falls and the resident’s care plan included the assist of two for transfers.  The resident was being transferred by the AP alone and the resident’s legs buckled.  The resident fell.  The resident was immediately assessed by facility nursing staff, was found to have his/her right leg turned at an unnatural angle, and was immediately sent to the emergency room for evaluation.  The resident was found to have a right tibia fibula fracture.  The resident was admitted to the hospital for two days, and sent back to the facility on non-weight bearing status.

The AP was interviewed and stated that the resident was not on his/her group on the day of the incident, but the AP was assisting another staff member to weigh the resident.  The AP state the resident had a gait belt applied and s/he was weighing the resident alone when the resident fell.  The AP stated s/he had provided care for the resident before and thought the resident only needed the assist of one person to transfer.  The AP stated she had a care plan sheet for the residents at the time, and the care-plan sheet indicated that the resident required assist of two for transfers.  The AP stated she did not look at the care plan sheet before she assisted the resident to stand.  The AP stated was sufficient staff available at the time of the incident.

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 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


Pathstone Living Mankato Neglect Substantiated
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