Posts Tagged ‘Medication Theft’

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Vista Prairie at Windmill Pond Medication Diversion

Written By: Kenneth LaBore | Published On: 27th February 2017 | Category: Medication Drug Error | RSS Feed

Theft of Medication – Vista Prairie at Windmill Pond Financial Exploitation

Vista Prairie at Windmill Pond Financial Exploitation

According to a report dated January 23, 2017, the Minnesota Department of Health it was alleged that a client at Vista Prairie at Windmill Pond Alexandria was financially exploited when the alleged perpetrator (AP) took the client’s medication.

Vista Prairie at Windmill Pond Substantiated Allegation Medication Theft

Based on a preponderance of evidence, financial exploitation occurred when the alleged perpetrator (AP) took the client’s opioid medication.

The client received medication management from the home care provider according to the service agreement and service plan. The client had a physician’s order for oxycodone oral solution (five milligrams / five milliliters), to be taken every four hours as needed for pain.

Document review and observations made during the on-site investigation revealed a nurse drew up liquid oxycodone in syringes for the client, and placed them in a double-locked medication storage cabinet. Keys were only available to on-duty unlicensed staff. The keys were always kept in the immediate possession of staff.

Interviews were conducted with two nurses. One nurse was setting up oral medication oxycodone syringes for the client, and noticed syringes s/he had previously set-up appeared to lighter in color than the new syringes s/he just set up. The nurse examined the syringes s/he set up six days prior and noticed there were bubbles in the solution and the measurements were not as exact as his/her usual practice. The nurse said when s/he fills the syringes there are never any bubbles in the solution. They are precise measurements they are verified by a second nurse, and s/he re-checks them each three to four times right before placing the syringes in the medication storage cabinet. The nurse shared his/her concerns with the second nurse, who also observed that the syringes set-up six days prior were lighter in color than the new syringes. The nurse suspected the newly hired AP had diverted the medication. The nurses discovered the AP who was working as a newly hired AP had diverted the medication. The nurses discovered the AP, who was working as an unlicensed resident assistant, has a suspended nursing license, due to previous drug diversion in Minnesota and another state; the AP had failed to disclose the suspended license to the home care provider. The nurses notified the police.

A police report indicated police were called to the facility for a suspected drug diversion. The police interviewed the AP and s/he admitted to taking the medications from the client. Police forwarded this investigation to County Attorney for charging. The AP subsequently entered a plea of guilty for Felony Controlled Substance Crime in the 5th degree.

The AP was interviewed and admitted to taking medication from the client and diluting the solution in the syringes set up by the nurse. The AP stated s/he plead guilty to the Felony Controlled Substance charge.

Vista Prairie at Windmill Pond Alexandria Report Suspected 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 any 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

Nursing Home Medication Error Lawyer

Written By: Kenneth LaBore | Published On: 5th February 2017 | Category: Medication Administration Mistakes, Medication Drug Error, Nursing Home Abuse and Neglect, Wrongful Death | RSS Feed

Nursing Home Medication Error Lawyer

Minnesota Nursing Home Medication Error Lawyer

According to federal law nursing homes need to take several measures to protect residents from medication errors. Pursuant to federal regulation 42 CFR 483 45:

(d) Unnecessary drugs—General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used—

(1) In excessive dose (including duplicate drug therapy); or

(2) For excessive duration; or

(3) Without adequate monitoring; or

(4) Without adequate indications for its use; or

(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

(e) Psychotropic drugs. Based on a comprehensive assessment of a resident, the facility must ensure that—

(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident’s medical record and indicate the duration for the PRN order.

(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

(f) Medication errors. The facility must ensure that its—

(1) Medication error rates are not 5 percent or greater; and

(2) Residents are free of any significant medication errors.

Federal law mandates:

• Decrease medication errors and adverse drug events
• Assure proper medication selection
• Monitor drug interactions, overmedication, and undermedication
• Improve the documentation of medication administration

Information About Medication From Nursing Home Medication Error Lawyer

According to CMS, medications are an integral part of the care provided to nursing home residents. They are administered to achieve positive outcomes, such as curing an illness, diagnosing a disease or a condition, modifying a disease process, reducing or eliminating symptoms, or preventing a disease or symptom. However, any medication or combination of medications may result in adverse consequences. Therefore residents must only receive medications when there are clear clinical indications and when the potential benefits outweigh the risks.

The facility is expected to have a proactive, systematic and effective approach to monitoring, reporting, and acting upon the effects, risks, and adverse consequences of medications. The pharmacist may need to conduct the medication regimen review more frequently (for example weekly), depending on the resident’s condition and the risks for adverse consequences related to current medications. The requirement for the medication regimen review applies to all residents, including residents receiving respite care, residents at the end of life or who have elected the hospice benefit, residents with an anticipated stay of less than 30 days, or residents who have experienced a change in condition. Complex residents generally benefit from a pharmacist’s review during the transition from hospital to skilled nursing facility

Nursing Home Medication Error

There are several types of medication errors and mistakes in nursing homes and assisted living facilities including residents not being given medication, the wrong doses, wrong medication, theft and replacement of medications also call drug diversion. Medication errors often lead to hospitalizations for the nursing home resident.

Nursing Home Medication Error Reporting

Pursuant to Minn. Statute 144.7065, Subd. 5(1), events reportable under this subdivision include:

patient death or serious injury associated with a medication error, including, but not limited to, errors involving the wrong drug, the wrong dose, the wrong patient, the wrong time, the wrong rate, the wrong preparation, or the wrong route of administration, excluding reasonable differences in clinical judgment on drug selection and dose.

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

Nursing Home Medication Error Lawyer

If you have questions about medication errors in a assisted living facility or other elder provider or nursing home or other elder abuse and neglect issues contact Minnesota Nursing Medication Lawyer 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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Assisted Living Medication Error

Written By: Kenneth LaBore | Published On: 5th February 2017 | Category: Assisted Living Care Issues, Medication Administration Mistakes, Medication Drug Error, Wrongful Death | RSS Feed

Assisted Living Medication Error

Minnesota Assisted Living Medication Error

Despite the fact that many assisted living care providers charge more for a room and care than a nursing home there is a trade off you are getting a nicer room and usually newer more luxurious dining room and other areas but there very little training required to be a staff member in the facility.

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.

Assisted Living Medication Error

There are several types of medication errors and mistakes in assisted living facilities including residents not being given medication, the wrong doses, wrong time, improper preparation or administration, wrong medication, theft and replacement of medications also call drug diversion.

Assisted Living Medication Error Reporting

Pursuant to Minn. Statute 144.7065, Subd. 5(1), events reportable under this subdivision include:

patient death or serious injury associated with a medication error, including, but not limited to, errors involving the wrong drug, the wrong dose, the wrong patient, the wrong time, the wrong rate, the wrong preparation, or the wrong route of administration, excluding reasonable differences in clinical judgment on drug selection and dose.

In addition to the reporting requirements for the facility you should also report the medication error to the Minnesota Department of Health Office of Health Facility Complaints, OHFC. See the attached for more information about reporting elder abuse and neglect.

Assisted Living Medication Error Lawyer

If you have questions about medication errors 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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Sunrise Assisted Living Cited After Theft of Resident Medications

Written By: Kenneth LaBore | Published On: 16th January 2017 | Category: Financial Exploitation | RSS Feed

Drug Diversion Medication Theft at Sunrise Assisted Living of Roseville

Allegations of Medication Theft at Sunrise Assisted Living

In a report dated November 28, 2016, from the Minnesota Department of Health it is alleged that Sunrise Assisted Living in Roseville it is alleged that seven clients were financially exploited when staff, alleged perpetrator (AP), took the client’s medications.

Substantiated Neglect After Medications Being Taken from Residents at Sunrise Assisted Living

Based on a preponderance of evidence, financial exploitation is substantiated. The alleged perpetrator (AP) took pain medications belonging to seven different clients over the course of multiple incidents.

All seven clients received medication administration from the home care provider. Client #1 had a physician’s order for morphine 5 milligrams (mg). Client #2 had a physician’s order for tramadol 50 mg. Client #3 had a physician’s order for hydrocodone/APAP 5/325 mg. Client #4 had a physician’s order for oxycodone 2.5 mg (5 mg, half tablets). Client #5 had a physician’s order for oxycodone 5 mg. Client #6 had a physician’s order for hydrocodone/APAP 5/325 (half tablets). Client #7 had a physician’s order for hydrocodone/APAP 5 325 mg.

Interviews with staff were conducted. A nurse tried to refill the physician’s order for Client #7. The pharmacy called back later and told the nurse that it was too soon to refill the order. The nurse reviewed the facility medication administration records and the original physician’s order and determined Client #7 should have 30 tablets remaining. When checking the narcotic count sheet, the nurse noticed the AP had logged in the narcotic medications. This was unusual because the nurse received the medications from the pharmacy and always logged the medications in after receiving them from the pharmacy. The nurse notified the supervisor.

A review of the pharmacy delivery inventory sheets and the narcotic count book sheets revealed the following missing medications for each client: Client #1 had 30 tablets of morphine 5 mg missing; Client #2 had 30 tablets of tramadol 50 mg missing; Client #3 had 150 tablets of hydrocodone/APAP 5 325 missing; Client #4 had 120 half tablets of oxycodone 2.5 mg (5 mg half tablets) missing; Client #5 had 60 half tablets of oxycodone missing; Client #6 had 90 half tablets of hydrocodone/APAP 5 325 mg missing; and Client #7 had 90 tablets of hydrocodone/acetaminophen 5/325 mg missing.

The AP had falsified signatures, altered count documents, and falsified count inventory numbers and dates for all seven clients. Staff checked the document destruction bins and discovered empty bubble packs for Client #3, Client #4, and Client #5 along with what appeared to be practiced pages of staff signatures. The AP confessed s/he was responsible for all the missing medications to management.

A police report indicated police were notified by the home care provider that medications were missing. The home care provider provided police with documentation detailing the missing medications. The police interviewed the AP, and the AP admitted to taking medications from the clients.

The AP was interviewed and admitted to taking medications from clients.

If you have concerns about medication errors, theft of medication 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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Lyngblomsten Care Center Cited After Medication Theft

Written By: Kenneth LaBore | Published On: 16th January 2017 | Category: Financial Exploitation | RSS Feed

Lyngblomsten Care Center Cited After Medication Theft also Known as Drug Diversion

Medication Taken From Resident at Lyngblomsten Leads to MDH Complaint

In a report dated November 7, 2016, the Minnesota Department of Health alleged that Lyngblomsten Care Center in St. Paul, Minnesota it is alleged that a resident was financially exploited when the alleged perpetrator (AP) took resident’s pain medications.

Substantiated Medication Theft at Lyngblomsten Care Center

Based on a preponderance of the evidence, financial exploitation occurred when the alleged perpetrator (AP) took narcotic pain medications from multiple residents several times.

A physician ordered hydrocodone/acetaminophen (a opioid/narcotic pain medication) 5/323 milligrams (mg) every four hours as needed for the resident’s moderate to severe breakthrough pain. The facility staff administered for the resident’s medications.

At approximately 9:30 p.m., the resident requested prescribed pain medication and nurse went to retrieve the medication from an automated medication dispensing machine. The nurse entered his/her identification and password to retrieve the medication and the dispensing machine indicated it was “too early.” The nurse informed the supervisor, who contacted the pharmacy that services the medication dispensing machine. The pharmacy was able to tell the supervisor the AP had retrieved the pain medication for the resident at 7:12 p.m. The AP was working that evening on another unit and was not assigned to the resident. The supervisor spoke with the AP. The AP did not have a clear explanation.

The video surveillance in the medication room identified the AP entering the room, accessing the machine at 7:12 p.m., and placing the medication envelope in his/her right uniform pocket. A machine report verified the AP was the person who retrieved medication for the resident. The transaction report for the machine indicated the AP had retrieved the resident’s pain medication 73 times over a four month period. The AP had not documented any of the medications were given to the resident on the electronic medication administration record.

The resident was interviewed and stated s/he was having tooth pain that evening and requested the pain medication. The resident was given plain acetaminophen for pain relief.

Additional documentation review and staff interviews were conducted during the investigation. The AP retrieved narcotic pain medication from the medication dispensing machine for six residents from January 2016 to April 2016, retrieving a total of 350 opioid tablets. The AP did not document these tablets as administered to the six residents on the electronic medication administration record. S/he reported s/he had forgotten to document.

The police report indicated the AP admitted to taking one or two Oxycodone HCL (another opioid narcotic) 5 mg tablets from residents during five separate incidents over a four month period of time. In addition, the police searched the AP’s purse and found six opioid tablets that the AP admitted belonged to other residents in the facility. The case was forwarded to the county attorney for charges.

During an interview, the AP reported s/he had been taken one or two Oxycodone HCL 5 mg tablets from a resident during five separate incidents over a four month period. The AP stated s/he did not give medication to the resident on the evening of the incident. The AP indicated the tablets, found by the police in his/her purse, did not come from the facility.

After video surveillance confirmed the AP’s conduct, s/he was terminated from the facility.

If you have concerns about medication errors, drug version / medication theft 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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Home Care Services in Springfield Cited With Complaint After Medication Theft

Written By: Kenneth LaBore | Published On: 16th January 2017 | Category: Financial Exploitation | RSS Feed

Drug Diversion and Narcotic Medication Theft at Home Care Services

Substantiate Complaint After Narcotics Theft at Home Care Services

In a report dated September 19, 2016 from the Minnesota Department of Health, it is alleged that two clients from Home Care Services in Springfield Minnesota were financially exploited when the alleged perpetrator (AP) took the client’s narcotic medications.

Narcotic Medication Theft at Home Care Services

Based on a preponderance of the evidence, financial exploitation is substantiated. The alleged perpetrator (AP) took narcotic medications from two clients on several occasions.

Client #1 received services from the home care provider for daily wellness checks, oxygen tank service, assistance with compression stockings, and weekly blood pressure checks according to client’s service agreement. Client #1 had a physician’s order for several strengths of oxycodone (an opioid narcotic) to be taken as needed multiple times per day.

Client #2 received services from the home care provider for transfer assistance when bathing according to the client’s service agreement. Client #2 had a physician’s order for hydrocodone/APAP (an opioid narcotic).

Neither client received medication management service from the home care provider.

A family member reported they suspected a staff member was taking medications from both clients. The housing director sat in Client #1’s apartment while they were out of the apartment at supper. There was a medication bottle on a table in the living room with medication inside. S/he observed the AP knock on the door, enter the apartment, pour medications from Client #1’s medication bottle, and leave the apartment. The staff checked the pill bottle and said it was empty. S/he notified the police. Police came to the facility and the AP admitted s/he took pills from the clients a few times. Police searched the AP and discovered eight pills belonging to Client #1.

Interviews with clients revealed Client #2 was missing 14 hydrocodone/APAP tablets from the pill bottle that was stored in the medicine cabinet in the bathroom. Client #1 was missing over 20 tablets from the pill bottle that were stored on a table in the living room.

A police report was reviewed. Police searched the AP and interviewed him/her. Police discovered oxycodone tablets belonging to Client #1 in the AP’s pocket. The AP admitted to the police s/he took pills from both clients. Police forwarded their findings to the county attorney for possible criminal charges. Attempts to interview the AP were unsuccessful.

If you have concerns about medication errors, and drug diversion 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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Medications Stolen From Residents at Tealwood Management in Shakopee

Written By: Kenneth LaBore | Published On: 5th September 2016 | Category: Financial Exploitation | RSS Feed

Drug Diversion, Theft of Medications from Six Residents from Tealwood Management d/b/a All Saints Senior Living of Shakopee Minnesota

Tealwood Management After Medications Taken From Six Residents

In a report from the Minnesota Department of Health dated August 1, 2016, it is alleged that six clients were financially exploited when the alleged perpetrator (AP) took medications for his/her own use.

Drug Diversion and Medication Theft at Tealwood Management dba All Saints Senior Living in Shakopee

Based on a preponderance of the evidence, financial exploitation occurred when the alleged perpetrator (AP) stole medication from six clients.

Interview with the registered nurse revealed staff called her/him on March 23, 2016 shortly after 12:00 a.m. to report they found a bubble pack card of medications for were missing, medications had been replaced with other medications and packages had tape on them.

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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Medication Theft at Eaglecrest Senior Living

Written By: Kenneth LaBore | Published On: 7th August 2016 | Category: Medication Administration Mistakes, Medication Drug Error, Nursing Home Abuse and Neglect | RSS Feed

Medication Theft at Eaglecrest Senior Housing in Roseville

Eaglecrest Senior Living Cited After Medication Theft

In a report from the Minnesota Department of Health dated August 1, 2016, Eaglecrest Senior Housing in Ramsey was cited with drug diversion after medication taken from vulnerable resident.

Medication Taken From Resident at Eaglecrest Senior Living

Based on a preponderance of the evidence financial exploitation occurred when the alleged perpetrator (AP) took 30 Oxycodone tablets, and opioid pain medication, from the client for her/his own personal use.

The client received services from the provider for activities of daily living, housekeeping, laundry, meals and medication administration. The client had a physician’s order for Oxycodone 5/325 milligrams (MG) one tablet scheduled twice daily for pain. The medication was stored in the client’s locked kitchen cabinet, in a locked box, and the 39 tablets were packaged in bubble packs. The client had two bubble pack cards, one for the morning dose and one for the evening dose.

Interview with facility staff revealed the AP was in the public bathroom on the second floor when a staff heard a rustling sound of bubble pack. Later another staff went into the public bathroom on the second floor and discovered one Oxycodone 5.535 mg tablet on the floor. The staff notified the nurse. The nurse knew the client was the only one client on the second floor with a physician’s order for Oxycodone were missing from the client’s locked medication storage box. Staff searched the bathroom on the second floor and discovered both bubble packs from the client in the trash wrapped in paper towels and emptied of 39 tablets. Staff reported the AP was the only staff assigned to the client that shift. The nurse called the client administrator. The clinical administrator called the police.

A police report revealed police were contacted to come to the facility for theft of medication from a client. Police responded and interviewed staff and the AP. The AP admitted to the police s/he took the 39 tablets of Oxycodone from client, ingested five of them and hid the remaining tablets in his/her vehicle. Police searched to AP’s car, discovered the Oxycodone tablets belonging to the client, arrested the AP, and forwarded their investigation findings to the county attorney for formal charges.

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Cottage Grove White Pines II Cottage Grove – Pressure Sores Wound Injuries

Written By: Kenneth LaBore | Published On: 10th March 2015 | Category: Bed Sores and Pressure Ulcers, Financial Exploitation, Pressure Ulcers | RSS Feed

Pressure Sores Lead to Substantiated Complaint Against Cottage Grove White Pines II

Substantiated Complaint After Pressure Sores at Cottage Grove White Pines II

In a report dated December 20, 2016, the Minnesota Department of Health alleged that a client at Cottage Grove White Pines II was neglected when s/he developed a stage four pressure ulcer while at the facility.

Pressure Sore Ulcers at Cottage Grove White Pines II

Based on a preponderance of evidence, neglect occurred when staff failed to assess a client for a decline in condition and for skin concerns, which resulted in the client developing pressure ulcers. The client experienced a large sacral (upper buttock) pressure ulcer and a pressure ulcer on each of his/her heels after a significant weight loss.

The client had received services from the home care provider for three months. The client required assistance of one person with toileting every two hours, reassurance checks every two hours, shower with a skin check twice a week, dressing/grooming twice a day, and ambulation/escorts. During the client’s three month stay, the client experienced a decline in physical strength and was no longer able to ambulate. Approximately two months after admission, the client experienced a forty pound weight loss.

Ten days prior to discharge, an unlicensed staff member notified the registered nurse (RN) of the client’s skin concerns, observed during a bath, related to his/her sacrum and heels. The concerns were signed off by the RN, however, an assessment was not completed. Two days prior to discharge, the RN observed the areas of concerns due to a report of the sacrum having an open wound. The RN updated the client’s physician regarding a wound to his/her buttocks and right heel. Orders were received for wound care services from an outside agency. The following day the RN initiated heel protectors to be worn by the client. On the day of the client’s discharge, the RN completed a wound assessment with the agency wound care nurse. The wound care nurse determined the client required hospitalization due to possible infection. The client transferred to the hospital, required surgical debridement of large sacral ulcer and required a wound vacuum for treatment, as well as intravenous antibiotics for infection. The client also had a large ulcer on his/her right heel and a smaller ulcer on the left heel. The client continued to decline and died thirty-two days later. The cause of death was listed as Alzheimer’s.

During interviews, unlicensed staff stated the client had a redness of the sacral area for several weeks prior to the client’s hospitalization. Staff stated the nurses were updated, the client was repositioned every two hours, and cream was applied to area.

During an interview, the RN stated the client’s sacrum was for red three to four days prior to it opening. The day the RN observed the wound, s/he described the wound as about the size of an eraser. The RN also stated the client was repositioned every two hours and it was standard to reposition all clients at that frequency. The RN stated s/he usually assess skin concerns on the bath sheets, but did not recall doing a follow up or assessment of the initial skin concern. The RN also explained that the clients’ weights are reviewed by a nurse at the end of each month, however this client’s forty weight loss was missed. A nutritional supplement was started because the client’s appetite was poor. The RN stated a significant weight loss would warrant a change in condition assessment, but one was not completed.

During an interview, the hospital wound surgeon stated the sacral wound appeared chronic and there was no fast bacteria present that would cause rapid deterioration. The client was evaluated by the surgeon and underwent surgical debridement two days after hospital admission. The surgeon described the wound as large, ten centimeters (cm) by fifteen cm necrotic (black, dead) tissue and undermining. The wound was infected with multiple organisms. The surgeon stated the wound could not have been transitioned from a pinpoint opening to a large open wound in thirty-six to forty-eight hours.

During an interview with the client’s family, the family member stated s/he was not made aware of the pressure ulcer by the home care provider until the day of discharge. The family member explained the agency wound care nurse described the wound as severe and client required hospitalization. At the hospital, the family member was made aware by hospital staff that the client experienced a forty pound weight loss. After the surgery, the family member stated the surgeon described the wound as about the size of grapefruit with depth to the bone.

Medication Theft Drug Diversion from Client of Cottage Grove White Pines II

Cottage Grove White Pines II Cottage Grove Complaint Findings for Exploitation after Medication Theft

In a report concluded on March 17, 2014, the Minnesota Department of Health cites Cottage Grove White Pines II Cottage Grove for exploitation – staff.

It is alleged that financial exploitation occurred when a staff, alleged perpetrator (AP) took three tablets of a client’s narcotic medication without permission.

Substantiated Financial Exploitation Allegation Against Cottage Grove White Pines II Cottage Grove Minnesota

A preponderance of evidence established that financial exploitation did occur. The AP took three tablets of Oxycotin (a narcotic pain medication) that belonged to the client without the client’s permission. In addition, the AP took one tablet of Tramadol (an analgesic pain medication) that belonged to an additional client (client name unknown), without the client’s permission.

The police report indicated the AP stated s/he had a drug addiction and was addicted to pain killers. The AP stated the first theft took place right after being hired by the home care provider. The AP state that sometime in September of 2013 s/he took one Tramadol pill that belonged to another client. In addition, the AP admitted to the police that s/he took three Oxycotin pills that belonged to the client, that were noted to be missing when the narcotic medications were counted.

If you have concerns about medication mistakes, pressure sores or any other form of elder abuse or neglect contact 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 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

Signe Olivias Ogilvie Neglect Substantiated – Medication Theft – Physical Abuse

Written By: Kenneth LaBore | Published On: 10th March 2015 | Category: Elder Physical Abuse, Financial Exploitation, Medication Administration Mistakes | RSS Feed

Signe and Olivias Cited by MDH After Medication Theft from Three Clients

Medication Theft at Signe and Olivias in Olgilvie

In a report dated September 20, 2016, the Minnesota Department of Health, it was alleged that clients at Signe and Olivias in Ogilvie were financially exploited by staff. The alleged perpetrator (AP) took the clients’ medication for his/her personal use.

Based on a preponderance of the evidence, financially exploitation did occur when the alleged perpetrator (AP) withheld and disposed of medications that belonged to three clients. The AP admitted s/he willfully withheld and disposed of medications that belonged to the clients.

For the rest of MDH report click here

Elder Abuse, Physical Abuse by Staff, Neglect of Health Care

Elder Abuse, Physical Abuse by Staff, Signe Olivias Ogilvie Minnesota

Signe Olivias Ogilvie Complaint Findings for Physical Abuse

In a report concluded on February 17, 2011, the Minnesota Department of Health cites Signe Olivias Ogilvie for physical abuse by staff.

The allegation is abuse based on the following information: Client #1 was pinched by a staff person, alleged perpetrator (AP) resulting in a skin tear.

Substantiated Allegation of Physical Abuse by Staff at Signe Olivias Ogilvie

According to the Prevent Elder Abuse Physical Abuse and Neglect, indicators are signs or clues that abuse has occurred. Physical indicators may include injuries or bruises, while behavioral indicators are ways victims and abusers act or interact with each other. Many of the indicators listed below can be explained by other causes (e.g. a bruise may be the result of an accidental fall) and no single indicator can be taken as conclusive proof. Rather, one should look for patterns or clusters of indicators that suggest a problem.

If you have concerns about physical abuse, financial exploitation 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.

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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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