Posts Tagged ‘Falls’

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Resident at Cook County Northshore Falls from Lift and Fractures Arm

Written By: Kenneth LaBore | Published On: 21st March 2017 | Category: Fall Injuries, Patient Lift | RSS Feed
Fractures and Other Injuries - Cook County Northshore Resident Falls from Lift and Fractures Arm

Fractures and Other Injuries – Cook County Northshore Resident Falls from Lift and Fractures Arm

Preventable Neglect – Cook County Northshore Resident Falls from Lift and Fractures Arm

In a report dated February 28, 2017, from the Minnesota Department of Health a resident at Cook County Northshore Hospital and Care Center in Grand Marais was neglected with the alleged perpetrator (AP) transferred the resident with the use of a standing lift.  The resident sustained a fractured arm.

Cook County Northshore Substantiated Neglect after Fall with Fracture

Based on a  preponderance of the evidence, neglect occurred when the AP transferred the resident with a mechanical standing lift and did use the seated sling strap that was necessary for a safe transfer.  The resident was injured during the transfer and fractured and arm.

The resident had dementia.  The resident’s care card indicated the resident required one staff to use a standing lift for all transfers.  The resident’s care card instructed staff to use the seated sling strap and leg strap when using the mechanical standing lift with the resident.

After a shower, the AP attempted to transfer the resident from the shower chair to the resident’s wheelchair.  The AP used a standing lift for the transfer.  The AP applied the back strap and the leg strap, but did not secure the seated sling strap.  Before the resident was lowered into the wheelchair, the resident stepped backward off the standing lift platform.  The AP turned the resident’s call light on for help.  A couple minutes passed and no one responded to the call light.  The AP left the resident’s room with the resident on the standing lift.  A couple of minutes later the AP returned with another staff member.  The resident slipped further down in the standing lift.  The back strap caught the resident under the arms.  The resident hung in the lift by the arms.  The resident’s legs were twisted.  The nurse assessed the resident.  The resident had pain in the right arm and bruises.  The resident was transferred to the clinic.  An x-ray was obtained, and the resident had a fracture of the right proximal humerus.

The physician was interviewed and indicated the resident’s injuries were consistent with the events of the transfer.

The alleged perpetrator was interviewed and said s/he was not trained to use the seated sling strap and was not trained to look at the care card before providing care to the resident.  The AP stated the training she received to use the standing lift equipment was done by following another staff member.

Staff interviews and training documents confirmed the AP was not trained to use the resident’s care card, standing lift equipment, and seated sling strap.

Report Suspected Neglect or Quality of Care Issues – Cook County Northshore Hospital

Click Here For Link To Report Abuse To Adult Protection

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.

Kenneth LaBore has  a love of the Northshore and has a home in the Grand Marais area and is available to meet you in Grand Marais at your convenience.

If you have concerns about falls from Hoyer or other mechanical lifts 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

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

 

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KSMS Our House Austin Neglect Substantiated

Written By: Kenneth LaBore | Published On: 18th March 2017 | Category: Bed Sores and Pressure Ulcers, Failure to Resond to Change in Condition, Pressure Ulcers, Wound Care | RSS Feed
Failure to Provide Proper Wound Care and Assessment - Pressure Sores - Ulcers - KSMS Our House in Austin Minnesota

Failure to Provide Proper Wound Care and Assessment – Pressure Sores – Ulcers – KSMS Our House in Austin Minnesota

KSMS Our House Austin Cited with Neglect After Serious Wounds

In a report from the Minnesota Department of Health dated, February 13, 2017, it is alleged that a client at KSMS Our House in Austin Minnesota was neglected when s/he presented to the hospital with an elevated temperature, a leg severely bruised with blisters, and a large ulcerated sore on his/her tailbone that was infected.

Negligence Supported Against KSMS Our House After Ulcerated Sore

Based on the report a preponderance of evidence, neglect occurred when the facility failed to provide proper care and treatment of the client’s coccyx, buttock, and heel wounds.  The client had recurrent problems with wound healing for over two years .  The facility Registered Nurse (RN) failed to provide adequate wound assessment and monitoring of the client’s wounds, and failed to provide direction and training to direct care staff who were to performing the delegated nursing task of wound care.

The client was cognitively impaired and was completely reliant on caregivers for all activities of daily living.  The client could not walk and was transferred by two staff with a mechanical lift. The client was incontinent of bowel and bladder and staff performed the client’s incontinence care.  The client had pressure sores on the coccyx and left heel for over two years.  Direct care staff performed the client’s daily wound treatments, without any written instructions or training by the RN.

The client’s only wound assessment by the facility RN was completed in 2014.  At that time, the client had a stage II pressure ulcer on the inside of the right buttock measuring 2 centimeters (cm) x 1.5 cm.  There was no evidence of further RN oversight of the client’s wound.  The client’s medical record was void of any wound assessments, pertaining to the client’s heel ulcer.

In March 2016, a hospital record indicated that the client still had the stage II pressure ulcer on the right buttock and had also developing stage II pressure ulcer on the sacrum.  Discharge orders to the facility including instructions for dressing changes and instructions to frequently change the client’s position.

In May 2016, direct care staff documented that the client had a “big open sore on her bottom” and the client’s family member took the client to the hospital for evaluation.  A culture of the wound drainage was taken.  Hospital discharge orders provided to the facility included instructions for dressing changes, including the application of antibiotic ointment for ten days.

In July 2016, a hospital record indicated that the client had multiple areas of dermis loss on the buttocks and inner groin, including a 4.5 cm x 0.7 cm open lesion on the left inner groin, a 3.5 x 2.0 cm open ulceration on the right lower buttock, a 4.5 cm x 2.0 cm open ulceration on the right buttock, a 0.3 cm x 5.0 cm open ulceration on the gluteal fold, and two open areas on the left buttock measuring 0.5. cm x 0.5 cm and 0.5 cm x 0.8 cm.  All areas were macerated.  Hospital discharge orders were provided to the facility including instructions for wound care, perineal care, and to document the client’s wound healing each day.

In August 2016, a hospital record indicated that the client had an unstageable ulcer on the left heel and the client was admitted for hospitalization due to osteomyelitis of the heel wound with culture results positive for MRSA and Strep.  The client underwent a surgical limb salvage procedure for the left heel.  The client’s buttock and groin wounds were also evaluated during hospitalization.  Hospital discharge orders provided to the facility included instructions for wound treatment and care of the surgical incision, which entailed application of an ace wrap to the client’s left leg.

In September 2016, a hospital record indicated that the client was emergently hospitalized due to a change in condition.  On hospital arrival, the client was unresponsive, had a fever of 101 degrees, oxygen saturations not above 87% on six liters of oxygen, bilateral blue feet, and a left lower leg that was red and swollen with fluid-filled blisters.  The client was admitted to the ICU with polymicrobial infections of the left leg, sacrum and urinary tract, along with pneumonia.  The client’s condition did not improve with volume resuscitation and broad-spectrum antibiotics.  Comfort measures were elected and the client was discharged to a skilled care facility on hospice care.

All of the client’s hospital visits from March 2016 to September 2016 were facilitated by the client’s family member, based on reports direct care staff gave the family member about the deteriorating condition of the client’s wounds.  During the same time period from March 2016 to September 2016, multiple direct care staff had informed the RN that the client’s wounds were worsening, looked infected, and had drainage that soaked through the dressings.  There was no evidence that the RN ever addressed the client’s wound, monitored the status of the client’s wounds for healing, or followed up on the culture results.  The client’s medical record was void of any wound assessments from March 2016 to September 2016 and void of any progress notes or evidence of follow-up about the client’s wound culture.  During the period March 2016 to September 2016, direct care staff performed the client’s wound dressings, without any evidence of training by the RN including the safe handling of contaminated materials.  The client’s care plan completed by the RN did not contain any information about the client’s wounds.

After the client had the left heel surgical procedure in August 2016, hospital discharge instructions included application of an ace wrap to the client’s left leg following incision care.  Only the RN applied the client’s ace wrap.  There was no evidence that the RN monitored the client’s left leg for circulation, motor ability, or sensation.  When the client was re-hospitalized in September 2016, the hospital record noted that the client’s left lower leg had an “an ace wrap that was bound too tightly” causing the appearance of “rug-burns”, in addition to an obvious cellulitis of the lower extremity which was red and swollen with fluid blisters.

When interviewed, the facility RN had no explanation regarding the inadequate nurse oversight of the client’s wounds.

__________________________

Tibia Fracture - Allegation of Neglect - Fractured Tibia - KSMS Our House in Austin

Tibia Fracture – Allegation of Neglect – Fractured Tibia – KSMS Our House in Austin

Tibia Fracture to Client Leads to MDH Complaint of Neglect Against KSMS Our House

In a report from the Minnesota Department of Health, dated February 13, 2017, it was alleged that a client at KSMS Our House in Austin Minnesota was neglected when s/he had a fall.  The client had progressively worse pain after the fall and it was discovered ten days later that the client had a tibia fracture.

Substantiated Neglect Complaint After Client Fractures Tibia in Fall

Based on the report a preponderance of evidence, neglect occurred when the facility failed to thoroughly assess the client after a fall, monitor the client’s change in condition, and intervene with proper nursing care that addressed the client’s acute needs.  Ten days after the fall, it was discovered that the client had a broken leg.

The client used a wheelchair propelled with his/her feet.  Due to unsteadiness when standing, balance problems, and history of falls, the client needed the assistance of one staff to stand and pivot for transfers.  The client needed the assistance of one staff for all activities of daily living.  The client could verbally express his/her needs and desires.  The client lived alone in an apartment and wore a pendant that s/he could push to alert staff when s/he needed help.

During a night in July 2016, the client paged staff at 3:45 a.m. because s/he had fallen in his/her apartment.  Direct care staff responded and found the client sitting on the floor.  The client told staff that his/her knees hurt.  After the client fell, the client was not thoroughly assessed by a nurse at any time for ten days, even though multiple direct care staff repeatedly reported to the RN the client’s symptoms of leg pain, leg swelling, bruising, difficulty with transfers, and inability to propel the wheelchair independently.  Ten days after the fall, the client’s family member took the client to the hospital due to the client’s complaints of ongoing severe leg pain.

The client’s hospital record indicated that the client had severe pain with movement and positive changes of the right leg and decreased range of motion in the right knee.  The client’s right and left anterior knees had diffuse bruising with greater bruising on the right lateral tibia, and right upper arm.  The client’s right calf was red, swollen, and warm to touch and was suspicious for cellulitis.  X-rays confirmed the client had a right tibial plateau fracture.  Conservative management of the fracture was elected.  The client was hospitalized to treat the cellulitis with intravenous antibiotics.  During hospitalization, the client declined with acute kidney injury and altered mental status.  After being hospitalized for seven days, the client was discharged to a skilled care facility.

The facility has a full-time Registered Nursing (RN) and nurses on-call at all times, when the facility’s RN is not onsite.  There was no evidence that a nurse thoroughly assessed the client’s status at any time during the ten days the client exhibited symptoms of fracture.  The facility’s RN made only two brief progress notes (a note two days after the fall and another note the day before the client went to the hospital) which did not include any detailed assessment information or address changes in the client’s condition that had been reported by direct care staff.  The facility’s medical record was void of any nursing progress notes prior to the client’s fall.

Statements by the facility’s RN concerning the client’s post-fall status were contradictory to multiple interviews of the direct care staff who provided care to the client after the client fell.

__________________________

 

Failure to Assess Change in Condition Fractured Leg

Failure to Assess Change in Condition Fractured Leg, KSMS Our House Austin

KSMS Our House Austin Complaint Findings for Neglect – Failure to Assess

In a report concluded on November 13, 2014, the Minnesota Department of Health cites KSMS Our House Austin for neglect of health care failure to assess change in condition.

It is alleged that neglect of health care occurred when the alleged perpetrator (AP) failed to assess a client #1’s pain.  The client had a broken leg.  In addition; the AP failed to send another client #2 to the hospital in a timely manner after a change in health status.

Substantiated Neglect Against KSMS Our House Austin

Based on preponderance of evidence neglect did occur when a client’s change in condition was not assessed by the AP to ensure timely medical intervention.

The client had diagnoses that included diabetes mellitus, chronic obstructive pulmonary disease (COPD), Coronary Artery Disease (CAD) and Asthma.  The client received assistance of one staff with activities of daily living (ADL) skills that included walking, medication administration, and daily accuceheck (blood sugar monitoring).  The client was independent with administration of his/her insulin injections.  The client’s medication regimen included pain control of Oxycodone (narcotic) 30 milligrams (mg) extended release tablets take one tablet by mouth every 12 hours. Oxycodone/APAP (narcotic) 5-325 mg tablet; take one or two tablets by mouth every 4 -6 hours as needed for pain.

On the morning of the client’s change in condition at 8:00 a.m., the staff identified, the client was “pretty out of it”.  The client had oxygen levels of 86% to 93%, required assistance to put medications in his/her mouth, and was unable to self-administer the insulin.  The staff notified the AP of the client’s change in condition.  The AP instructed staff to administer the client’s insulin, but did not assess the client’s condition in relation to the altered mental status and inability to self-administer medications.  The AP did not provide the staff with any parameters for monitoring the client or when to call the AP back.  In addition, the AP informed the staff not to call 911 unless the client was unconscious.  Later the same day, on the evening shift of work, the client was not able to stand up.  The staff notified the AP of the client’s inability to stand.  The AP instructed staff to use a mechanical lift for transfers without an assessment of the client’s status or provide the staff with any parameters for monitoring the client or when to call the AP back.  Eleven hours after the first reported change in condition had not improved and staff identified the client had an oxygen level of 86%, and a temperature of 101.5.  Staff did not call the AP for direction instead called 911 and the client was transported to the hospital and admitted to the hospital intensive care with a diagnosis of Toxic/metabolic Oxycodone, intermittent myoclonic jerks, acute delirium and pneumonia – likely from aspiration.  The client returned to the facility after a five-day hospital stay.

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 a failure to assess a change in condition, 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 KLaBore@MNnursinghomeneglect.com.

Disclaimer

Nursing Home Abuse and Neglect Lawyer Kenneth LaBore Offers Free Consultations and Serves Clients Throughout the State of Minnesota Call Toll Free at 1-888-452-6589

Nursing Home Abuse and Neglect Lawyer Kenneth LaBore Offers Free Consultations and Serves Clients Throughout the State of Minnesota Call Toll Free at 1-888-452-6589

 

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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 – 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

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.

Disclaimer

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

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

 

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Augustana HCC of Apple Valley Allegations of Neglect After Resident Fall From Lift

Written By: Kenneth LaBore | Published On: 7th February 2017 | Category: Fall Injuries, Financial Exploitation, Hoyer Lift, Patient Lift | RSS Feed

 

Fall from Patient Lift Leads to Femur Fracture at Augustana Healthcare Center of Apple Valley

Fall from Patient Lift Leads to Femur Fracture at Augustana Healthcare Center of Apple Valley

Resident at Augustana HCC Apple Valley Suffers Fractured Femur After Fall From Lift

According to a report from the Minnesota Department of Health, dated January 17, 2017, it is alleged that a client at Augustana HCC of Apple Valley was neglected when the facility staff failed to safely transfer a resident using a lift.  The resident had a fall and was hospitalized with a right femur fracture.

Substantiated Neglect Against Augustana HCC Apple Valley After Fall

Based on the preponderance of evidence, neglect occurred when the alleged perpetrator (AP) incorrectly transferred the resident using a standing lift.  The resident fell, sustained a right femur fracture and required surgery.

The resident was cognitively intact and able to direct his/her own cares.  The resident’s care plan directed staff to transfer the resident with a standing lift and the assistance of one staff.  Manufacturer’s instruction for the standing lift indicated leg straps were to be used for resident safety with the standing lift.

Approximately two months prior to the fall, a physical therapist evaluated the resident, because the resident was refusing the use the abdominal harness of the standing lift due to difficulty breathing.  The physical therapist educated the resident that all the buckles, abdominal and leg, were to be strapped when using the standing lift and the resident agreed.  During the interviews, three staff members indicated the resident refused the leg straps and told staff s/he could stand better without using the leg straps.  However, if staff members were firm and told the resident leg straps were required during the transfer, the resident would comply.  The facility policy on the standing lift equipment indicated to keep the residents feet on the footplate and secure the shin straps around the resident’s leg and calf area.

The AP was interviewed.  On the morning of the fall, the resident put on the call light to use the toilet.  The AP entered the resident’s room and placed the resident on the standing lift.  The resident refused the leg straps.  The AP told the resident the leg straps needed to be applied for safety, but the resident still refused the leg straps.  The AP requested assistance from a nurse.

After five minutes, the resident’s need to use the toilet was urgent and there was no response to the call for assistance.  The AP transferred the resident to the toilet.  After toileting, during the transfer from the standing lift to the wheelchair, the resident’s foot slipped off the platform.  The resident slipped down in the lift approximately one foot off the floor and was lowered to the floor.

The resident had pain in his/her right hip and requested an X-ray revealed an incomplete fracture of the mid-right femur.  The resident has hospitalized and had hip surgery, which was complicated by acute respiratory failure related to his/her chronic respiratory difficulties.  The resident returned to the facility thirteen days later, but was readmitted to the hospital that same day for respiratory distress.  The resident returned to the facility four days later on hospice care and died the next day.

The resident’s primary physician was interviewed and explained that the anesthesia from the surgery worsened the resident’s already chronic respiratory conditions.

The death certificate indicated the resident died eighteen days after the fall.  The immediate cause of death was listed as complications related to immobility due to the right hip fracture from the fall.

If you have questions about falls from patient lifts or other types of elder abuse call Kenneth LaBore for a free consultation at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

 

Augustana HCC of Apple Valley Financial Exploitation

Augustana HCC of Apple Valley Financial Exploitation By Staff Member

Investigation of Financial Exploitation at Augustana HCC of Apple Valley

According to a report dated November 20, 2015, Augustana HCC of Apple Valley had an allegation that a resident was financially exploited when a staff, alleged perpetrator (AP) made multiple unauthorized charges to resident’s credit card.

Substantiated  Exploitation by Staff at Augustana HCC of Apple Valley

Based on a preponderance of evidence financial exploitation occurred, when the alleged perpetrator (AP) took the resident’s credit card, used it to make purchases for his/her own personal use and without the resident’s permission or knowledge.

The resident was admitted to the facility for short term rehabilitation after hospitalization.  Review of the resident’s record indicated that the resident was moderately impaired in her/her cognition but was able to make his/her daily decisions and needs known.

Document review and interviews revealed that a police officer reported to the facility staff that the resident had unauthorized charges that were made on her/his credit card while the resident  at the facility.  Through their investigation the police were able to determine that the unauthorized charges were made over a three day period between the hours of 7:00 a.m. and 9:00 a.m. in Walmart, Cub Foods, and a Shell gas station, all stores located in the Apple Valley area.  The video surveillance footage provided by Walmart store showed an individual wearing scrubs using the resident’s credit card to make purchases on one of three different occasions that the resident’s credit card was used in Walmart.  The police showed the facility staff the video and facility staff positively identified the individual in the video as AP.

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 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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Nursing Home Injuries

Written By: Kenneth LaBore | Published On: 5th February 2017 | Category: Bed Sores and Pressure Ulcers, Failure to Resond to Change in Condition, Fall Injuries, Hoyer Lift, Medication Drug Error, Nursing Home Abuse and Neglect, Patient Lift, Sexual Abuse, Wrongful Death | RSS Feed
Minnesota Abuse and Neglect Nursing Home Injuries

Minnesota Abuse and Neglect Nursing Home Injuries

Minnesota Nursing Home Injuries

There are many ways that residents suffer nursing home injuries, many are falls, being dropped from lifts or injured in transfer, falls from the toilet or in the shower, fall from bed or out of a wheelchair.  Since the way that many injuries happen is foreseeable the facility has an obligation to analysis and assess the risks to each resident and take reasonable measures and interventions to protect them from preventable accident situations.

Pursuant to federal and state regulations nursing homes have an obligation to keep their residents safe.  They are considered vulnerable adults by legal definition since they are staying in a nursing home facility.

According to 42 CFR 483.25, nursing homes must take efforts to prevent accidents which would include falls, medication errors, or any other way you could be injured such as through the use of oxygen, smoking, scalding burns, urinary tract infections, pressure wounds and others set out in the statute.

Common Types of Nursing Home Injuries

Here are some summaries on various topics related to nursing home falls and fractures, pressure sores and other nursing home injuries:

Head Injuries

Subdural Hematoma

Hip Fractures

Femur Fractures

Patient Lift Injuries

Wrongful Death from Falls

Fractures from Falls

Falls from Wheelchairs

Falls in Bathroom

Falls in Shower

Falls from Bed

Nursing Home Neglect Fractures

Bedsore Stages

Pressure Injury Stages

Pressure Sore Injury

Pressure Injuries

Nursing Home Fall Injuries Lawyer

If you or someone you love is in a skilled nursing facility or nursing home and the victim of abuse or neglect injuries contact Attorney Kenneth LaBore for a free consultation to discuss the fall or injuries and he does not charge a fee unless there is a verdict or settlement offer with the wrongdoer.  Call Kenneth LaBore at 612-743-9048 or toll free at 1-888-452-6589 or send an email to KLaBore@MNnursinghomeneglect.com.

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Assisted Living Falls

Written By: Kenneth LaBore | Published On: 5th February 2017 | Category: Assisted Living Care Issues, Fall Injuries, Hoyer Lift, Patient Lift, Wrongful Death | RSS Feed
Residents Need Proper Assistance and Supervision to Avoid Assisted Living Falls

Residents Need Proper Assistance and Supervision to Avoid Assisted Living FallsAssisted Living Falls

Minnesota Assisted Living Falls

Injuries due to falls in nursing home and assisted living falls are common some due to obvious neglect other the cause is not as clear.   The underlying cause of many accidents is a delay in response from the time the resident needed some assistance and a response.   Or a failure to do toileting or wellness checks or some other necessary service as providing medications.

Information on Assisted Living Falls

Assisted living facilities are defined by statute and are in summary apartments for seniors where additional minimum services are available for purchase by contract.  Each resident has a different contract based on their individual needs.

According to Minnesota Statute 144G.03, Subd. 2, assisted living shall be provided or made available only to individuals residing in a registered housing with services establishment. Except as expressly stated in this chapter, a person or entity offering assisted living may define the available services and may offer assisted living to all or some of the residents of a housing with services establishment. The services that comprise assisted living may be provided or made available directly by a housing with services establishment or by persons or entities with which the housing with services establishment has made arrangements.

(b) A person or entity entitled to use the phrase “assisted living,” according to section 144G.02, subdivision 1, shall do so only with respect to a housing with services establishment, or a service, service package, or program available within a housing with services establishment that, at a minimum:

(1) provides or makes available health-related services under a home care license. At a minimum, health-related services must include:

(i) assistance with self-administration of medication, medication management, or medication administration as defined in section 144A.43; and

(ii) assistance with at least three of the following seven activities of daily living: bathing, dressing, grooming, eating, transferring, continence care, and toileting.

All health-related services shall be provided in a manner that complies with applicable home care licensure requirements in chapter 144A and sections 148.171 to 148.285;

(2) provides necessary assessments of the physical and cognitive needs of assisted living clients by a registered nurse, as required by applicable home care licensure requirements in chapter 144A and sections 148.171 to 148.285;

(3) has and maintains a system for delegation of health care activities to unlicensed personnel by a registered nurse, including supervision and evaluation of the delegated activities as required by applicable home care licensure requirements in chapter 144A and sections 148.171 to 148.285;

(4) provides staff access to an on-call registered nurse 24 hours per day, seven days per week;

(5) has and maintains a system to check on each assisted living client at least daily;

(6) provides a means for assisted living clients to request assistance for health and safety needs 24 hours per day, seven days per week, from the establishment or a person or entity with which the establishment has made arrangements;

(7) has a person or persons available 24 hours per day, seven days per week, who is responsible for responding to the requests of assisted living clients for assistance with health or safety needs, who shall be:

(i) awake;

(ii) located in the same building, in an attached building, or on a contiguous campus with the housing with services establishment in order to respond within a reasonable amount of time;

(iii) capable of communicating with assisted living clients;

(iv) capable of recognizing the need for assistance;

(v) capable of providing either the assistance required or summoning the appropriate assistance; and

(vi) capable of following directions;

(8) offers to provide or make available at least the following supportive services to assisted living clients:

(i) two meals per day;

(ii) weekly housekeeping;

(iii) weekly laundry service;

(iv) upon the request of the client, reasonable assistance with arranging for transportation to medical and social services appointments, and the name of or other identifying information about the person or persons responsible for providing this assistance;

(v) upon the request of the client, reasonable assistance with accessing community resources and social services available in the community, and the name of or other identifying information about the person or persons responsible for providing this assistance; and

(vi) periodic opportunities for socialization; and

(9) makes available to all prospective and current assisted living clients information consistent with the uniform format and the required components adopted by the commissioner under section 144G.06. This information must be made available beginning no later than six months after the commissioner makes the uniform format and required components available to providers according to section 144G.06.

See the State of Minnesota Assisted Living Guide

Types of Assisted Living Falls

There are many types of falls which occur in assisted living facilities including, falls in the bathroom due to loss of balance or slipping on wet surfaces such as in the shower, falls during transfers from wheelchairs or from patient lifts, falls  from bed, when using a walker or cane and others.  The injuries related to these often preventable falls include head injuries, subdural hematomas, fractured hips, pelvis, and femurs to name of few.  The injuries can be very serious and the combination of the injuries and the disabilities which result can lead to untimely death.

Assisted Living Falls Reporting

The facility is mandated to report serious falls to the Minnesota Commissioner of Health under Minnesota Statute 144.7065, Subd 5.(7) patient death or serious injury associated with a fall while being cared for in a facility.

In addition to the reporting requirements for the facility you should also report any falls with injury to the Minnesota Department of Health Office of Health Facility Complaint, OHFC.  See the attached for more information about reporting elder abuse and neglect.

Assisted Living Falls Neglect Attorney

If you have questions about fall injuries in a assisted living facility or other elder provider or nursing home or other elder abuse and neglect issues 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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Memory Care Falls

Written By: Kenneth LaBore | Published On: 3rd February 2017 | Category: Assisted Living Care Issues, Caregivers Resources, Fall Injuries, Hoyer Lift, Patient Lift, Wrongful Death | RSS Feed
Alzheimer's Dementia Memory Care Falls

Alzheimer’s Dementia Memory Care Falls

Memory Care Falls Result in Part Due to Lack of Training

Falls in memory care and other elder care facilities are common occurrences.  The resident’s usually have Alzheimer’s or dementia and are prone to confusion and many are able to ambulate which leads to a higher risk of falls.  Due to osteoporosis and other age related issues falls lead to very serious many leading to death.  The irony is that despite the lack of regulation and training many memory care providers charge premium prices and often exceed the expense for rehabilitative care and skilled nursing in a traditional nursing home.

You may think that many memory care providers are providing cares similar to a nursing home.  This assumption is reasonable when you seen literature talking about “nursing services in a home like environment”.  What this means is that you are renting an apartment or room and that you are subcontracting for home care services to be provided at that location.  The staff at the memory care provider needs no special credentials as they are not considered nursing aides.  They need only limited training and the limited disclosures to tenant families.  According to Minnesota Statute 325F.72. Written disclosure shall include, but is not limited to the following:

(1) a statement of the overall philosophy and how it reflects the special needs of residents with Alzheimer’s disease or other dementias;
(2) the criteria for determining who may reside in the special care unit;
(3) the process used for assessment and establishment of the service plan or agreement, including how the plan is responsive to changes in the resident’s condition;
(4) staffing credentials, job descriptions, and staff duties and availability, including any training specific to dementia;
(5) physical environment as well as design and security features that specifically address the needs of residents with Alzheimer’s disease or other dementias;
(6) frequency and type of programs and activities for residents of the special care unit;
(7) involvement of families in resident care and availability of family support programs;
(8) fee schedules for additional services to the residents of the special care unit; and
(9) a statement that residents will be given a written notice 30 days prior to changes in the fee schedule.

According to Minnesota Statute 144D.065 (a)(2), direct-care employees must have completed at least eight hours of initial training on topics specified under paragraph (b) within 160 working hours of the employment start date.  The specialized training under paragraph (b) includes:

(b) Areas of required training include:

(1) an explanation of Alzheimer’s disease and related disorders;
(2) assistance with activities of daily living;
(3) problem solving with challenging behaviors; and
(4) communication skills.

As you can see the training for specialized memory care staff is very limited and does not include any medical training what-so-ever.  The lack of training with many resident which have limited mobility and other medical and physical issues leads to many forms of preventable injuries including falls.

Memory Care Falls

There are many types of falls which occur in memory care facilities.  The residents need to be supervised to assure they do not wander or elope from the facility, fall down stairwells, slip out of chairs or wheelchairs, fall from beds or in the bathroom off the toilet or in the shower.

Common injuries from falls in memory care facilities include, head injuries, including subdural hematomas, pelvic and hip fractures, fractured femur and other limbs.

Reporting Memory Care Falls

Pursuant to Minnesota Statute 144.7065, Subd. 1., each facility shall report to the commissioner the occurrence of any of the adverse health care events described in subdivisions 2 to 7 as soon as is reasonably and practically possible, but no later than 15 working days after discovery of the event. The report shall be filed in a format specified by the commissioner and shall identify the facility but shall not include any identifying information for any of the health care professionals, facility employees, or patients involved. The commissioner may consult with experts and organizations familiar with patient safety when developing the format for reporting and in further defining events in order to be consistent with industry standards.

The statute goes on in Subd. 5, to state that it is required for the facility to report patient death or serious injury associated with a fall while being cared for in a facility.

Attorney for Memory Care Falls

If you have questions about fall injuries or other forms 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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Cornerstone Villa Resident Death Leads to Substantiated Neglect Complaint

Written By: Kenneth LaBore | Published On: 31st January 2017 | Category: Fall Injuries | RSS Feed
Resident of Cornerstone Villa in Buhl Cited with Neglect After Resident Death From Facial Fractures After Fall

Resident of Cornerstone Villa in Buhl Cited with Neglect After Resident Death From Facial Fractures After Fall

Facial Fractures Lead to Resident Death at Cornerstone Villa

In a report from the Minnesota Department of Health, dated December 21, 2016, concerning Cornerstone Villa in Buhl Minnesota it was alleged that a resident was neglected when facility staff failed to follow the resident’s care plan, and s/he had a fall resulting in facial fractures.  The resident passed away two days later.

Cornerstone Villa Cited with Substantiated Neglect After Resident Death

Based on a preponderance of the evidence, neglect occurred when the facility failed to provide assistance with ambulation when the resident’s assessment and care plan indicated the resident required assistance when ambulating and the resident fell and sustained facial fractures.

The resident’s diagnoses included Alzheimer’s, sensory difficulty, and generalized weakness.  The resident and determined the resident was weak and was not safe to ambulate independently.  The care plan indicated ambulation only with assistance from staff.  The physical therapist evaluated the resident the next day and determined the resident was unsteady when ambulating and needed contact guard assist which means a staff person must have a hand on resident at all times to prevent falls.  The care plan indicated the need to assist the resident when transferring and ambulating.  Later that evening, five staff observed the resident ambulating independently with the walker on his/her unit and another adjoining unit, but staff did not intervene.  Staff heard the after hours front door alarm, went to the door, and found the resident outside lying on the cement in the doorway.  Staff who found the resident called for a nurse.  The nurse provided the resident with medical care to control the bleeding and another nurse called for an ambulance.

The resident’s condition was so severe that a local hospital had to transfer the resident to a trauma center.  The resident had sustained multiple facial fractures, requiring intubation to maintain a patent airway.  After evaluation and considering the extent of the resident’s facial fractures, conservative care was chosen for the resident and the resident died at the hospital two days later.

The resident’s death certificate indicated the cause of death was complications from facial fractures after a fall.

Cornerstone Villa Buhl – Report Suspected Abuse and Neglect

Click Here For Link To Report Abuse To Adult Protection

Click Here For Link To Report Abuse To Adult Protection

As an attorney who has seen hundreds of elder abuse and neglect cases many of which were falls, this case is very sad as it was so preventable had the staff been paying attention.  It was clear that the resident had Alzheimer’s and sensory difficulty, and was at great risk for falling, the staff had a chance to intervene and redirect the resident to a safe area but they failed to act to protect the vulnerable adult under their care.

For more information about how to get accountability for preventable fall injuries or 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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Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589

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

 

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Minnesota Assisted Living Falls Lawyer

Written By: Kenneth LaBore | Published On: 31st January 2017 | Category: Assisted Living Care Issues, Fall Injuries, Hoyer Lift, Patient Lift, Wrongful Death | RSS Feed
Assisted Living Falls Lawyer and Fracture Injuries

Assisted Living Falls Lawyer and Fracture Injuries

Minnesota Assisted Living Falls Lawyer

There are many types of fall injuries I have seen as a nursing home and assisted living falls lawyer.  Falls can happen when the resident is not given care they need with transfer and toileting or when they are dropped or fall from patient lifts, fall in their wheelchairs, or in the bathroom. Many of these falls would be preventable with proper assessment of the resident’s needs and risks and then adequate care and supervision to prevent accidents.

Falls in assisted living and other elder care situations can lead to fractures such as femur, pelvis and hip, head injuries with complications, such as subdural hematomas, and other injuries some leading to death.

Information About Assisted Living Falls

According to Minnesota Statute 144.7065, Subdivision 1., reports of adverse health care events are required.  Each facility shall report to the commissioner the occurrence of any of the adverse health care events described in subdivisions 2 to 7 as soon as is reasonably and practically possible, but no later than 15 working days after discovery of the event. The report shall be filed in a format specified by the commissioner and shall identify the facility but shall not include any identifying information for any of the health care professionals, facility employees, or patients involved. The commissioner may consult with experts and organizations familiar with patient safety when developing the format for reporting and in further defining events in order to be consistent with industry standards.

Subd. 5. Care management events.  Events reportable under this subdivision are:

(7) patient death or serious injury associated with a fall while being cared for in a facility;

Assisted Living Falls Lawyer

If you need information about assisted living falls or other forms of elder abuse and neglect or other call Kenneth LaBore for a free consultation with no fee unless a verdict or settlement offer by the wrongdoer.  Call Mr. LaBore directly at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.

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Falls From Bed in Nursing Homes

Written By: Kenneth LaBore | Published On: 30th January 2017 | Category: Bed Rail Strangulation and Asphyxiation, Fall Injuries, Hoyer Lift, Nursing Home Abuse and Neglect, Patient Lift, Wrongful Death | RSS Feed
Nursing Home Injuries Falls From Bed

Nursing Home Injuries Falls From Bed

Falls From Bed

There are many injuries which happen in areas you would think you are safe such as in bed. It is not uncommon for vulnerable adults such as nursing home residents to have falls from bed from rolling out of bed, or losing their balance exiting or entering bed. Serious injuries can occur from falling from the bed and hitting the bed, floor or nightstand or other obstacle near the bed such as a table or oxygen tank. Residents can suffer femur and hip fractures, and other life threatening injuries such as head injuries with hematomas.  Many accident also happen when residents are transferred from wheelchairs to bed or from mechanical patient lifts to and from beds and lose balance or fall from the lift.

Approximately 1.8 million emergency room visits and over 400 thousand hospital admission occur to those over the age of 65 resulted from falling out of bed according to the Center for Disease Control.

Falls From Bed Can Be Prevented

Pursuant 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.

(n) Bed rails.  The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

(1) Assess the resident for risk of entrapment from bed rails prior to installation.

(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

(3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight.

(4) Follow the manufacturers’ recommendations and specifications for installing and maintaining bed rails.

Pursuant to Minnesota Statute 144.7056, Subdivision 1., each facility shall report to the commissioner the occurrence of any of the adverse health care events described in subdivisions 2 to 7 as soon as is reasonably and practically possible, but no later than 15 working days after discovery of the event. The report shall be filed in a format specified by the commissioner and shall identify the facility but shall not include any identifying information for any of the health care professionals, facility employees, or patients involved. The commissioner may consult with experts and organizations familiar with patient safety when developing the format for reporting and in further defining events in order to be consistent with industry standards.

Minnesota Statute 144,7065, Subd. 5., mandates reporting under care management events. Events reportable under this subdivision (7) patient death or serious injury associated with a fall while being cared for in a facility

Attorney For Falls From Bed

I 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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