Head Injury After Client Falls in Shower at Gondola Group in Rosemount

Substantiated Complaint of Neglect Against Gondola Group

In a report from the Minnesota Department of Health dated October 18, 2016, it was alleged that a client of Gondola Group in Rosemount was neglected when s/he had a fall in shower and sustained several vertebrae fractures.

Fall in Shower Leads to MDH Complaint

Based upon a preponderance of the evidence, neglect is substantiated.  The home care provider staff left a client unattended in the shower, and the client fell and experienced cervical fractures.

The client was admitted to the home care provider with diagnoses that included dementia, syncope with collapse, and cerebral ischemia (lack of oxygen to the brain).  The client had a known history of fainting related to heart problems.  The client’s nursing assessment indicated the client required assistance of one person for transfers, ambulation, and showering.

The facility policy required staff members providing showers to remain in the bathroom during the shower, if the client was a full assist.  The staff were required to review each client’s service plan.  The service plans were accessible to staff.

The day of the incident, the client was sitting on a shower chair in a bath tub with a raised edge.  The client requested to wash his/her own body and hair.  The staff member handed the client a wash cloth, then left the client unattended in the shower.  The staff member stated s/he left to go into the client’s room, which was located across the hallway from the bathroom, to gather clothes.  The client got out of the shower unassisted, began to dry her/himself, and fell.  When the staff member heard a loud noise and entered the bathroom, s/he saw the client lying on the floor bleeding from the back of the head.  The staff member pressed a towel to the head wound, called 911, and send the client to the hospital.  The staff member notified the registered nursing and the client’s family.

At the hospital, the client was found to have neck fractures and was treated with surgery, and required pins for stability and neck brace.  The client returned to the home care provider after his/her hospitalization.  The client required daily pin care, and the brace restricted head and upper body movement.  Three months later, the pins were removed and client remained in a neck brace.

During an interview, the client stated s/he was often left alone during showers.  S/he stated staff usually helped him/her onto the shower chair, turned on the water, and then would leave to gather his/her things.  On the day of the incident, the client stated s/he remembers falling head first, but then could not remember anything else until s/he was at the hospital.

During staff interviews, a nurse stated s/he told staff not to leave clients alone in the shower and to only provide showers when two staff members were in the facility, but s/he also said a/he was aware that some staff were providing showers  to clients when there was only one staff member on duty.

During an interview, the client’s family member stated the injuries from the fall had been difficult on the client.  The family member explained that while the client was in the neck brace with pins, s/he had to lay in one position and was uncomfortable for three months.  Since the client was unable to get up unassisted, the family member stated s/he provided the client with a bell to alert staff of his/her needs.  The client has had to be in a hard neck brace for another three months and a soft neck brace for an additional three months.

During an interview, the alleged perpetrator (AP) stated the client liked doing tasks independently and often asked to wash his/her own hair and body.  S/he  stated usually the client would wait until the shower until staff could assist the client out.  The AP state s/he knew s/he was supposed to stay with the client, but was not aware , at the time of the incident, of the client’s fall risk and history of fainting.

For more information from the Minnesota Department of Health, Office of Health Facility Complaints concerning nursing homes, assisted living, home care 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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