Failure to Follow POLST at Walker Methodist Health Center
In a report from the Minnesota Department of Health, dated March 2, 2017, it is alleged that neglect occurred against Walker Methodist Health Center when cardiopulmonary resuscitation (CPR) was not performed on a resident who had a provider order for life sustaining treatment (POLST) form which indicated the resident requested resuscitation in the event that his/her heart stopped and s/he was not breathing.
Substantiated Neglect Due Failure to Provide CPR to Walker Methodist Health Center Resident
Based on a preponderance of the evidence, neglect occurred when nursing staff did not initiate cardiopulmonary resuscitation (CPR) on the resident when it was determined that the resident was not breathing and did not have a pulse.
The resident’s provider order for life sustaining treatment (POLST), signed by a physician, indicated the resident requested CPR be started if the resident had no pulse and was not breathing.
On the day of the resident’s death, the resident was in the dining room after lunch. The resident stood up from the wheelchair and sat on the floor. This was not uncommon for the resident. The nurse assigned to the resident and another staff member assisted the resident off the floor and sit back in the wheelchair.
Staff members took the resident to his/her room and put the resident into bed. The nurse went to get the blood pressure machine and attempted to take the resident’s blood pressure. The machine did not register a blood pressure on the resident. The nurse turned the machine off and on three times, attempting to get a blood pressure each time. The nurse said the resident was tired and looked sound asleep. S/he did not attempt to manually obtain an apical or radial pulse from the resident. The nurse left the resident alone to walk to the nurse’s station to look at the resident’s POLST. The nurse interpreted the POLST to read “comfort cares’ and did not start CPR. The nurse could not explain why the POLST was checked at that time.
The nurse then walked to an administrative nurse’s office where s/he also found the nursing supervisor. The nurse asked the nursing supervisor to come to the resident’s room to check the vitals machine. The nursing supervisor and the administrative nurse went to the resident’s room. The nurse assigned to the resident stated approximately ten minutes elapsed from the time the resident was brought back to his/her room from the dining room until the nursing supervisor and the administrative nurse entered the resident’s room.
The nursing supervisor entered the resident’s room and found the resident’s skin was blue in color, cool to the touch, and the resident was not breathing. The nursing supervisor took the resident’s apical pulse and determined the resident was deceased. The administrative nurse verified the resident did not have a pulse. The nurse assigned to the resident left the room to look at the resident’s medical record. The nursing supervisor and the administrative nurse also left the resident’s room for an undetermined amount of time. They reviewed the resident’s POLST and both read that the resident request CPR. The nursing supervisor and the administrative nurse did not start CPR, and no one at the facility called 911. The nursing supervisor said CPR was not started because the assigned nurse indicated the resident was expected to pass away and the family knew the resident was declining. The nursing supervisor began the facility notification procedure for the death of the resident.
The physician was interviewed and stated the POLST document indicated the resident requested CPR in the event the resident did not have a pulse and was not breathing.
The family of the resident was interviewed and stated they had considered a change to the resident’s POLST from CPR to do not resuscitate, but there was no change to the order at the time of the resident’s death.
The resident’s death certificate indicated the cause of death was due to multiple co-existing diseases.
Walker Methodist Health Center Cited With Neglect
In a report from the Minnesota Department of Health, dated August 1, 2016, it is alleged that a resident at Walker Methodist Health Center was neglected when the facility failed to provide supervision to him/her. The resident has not been located and been missing for multiple hours.
Based on a preponderance of the evidence neglect occurred when the resident left the facility unsupervised and sustained injuries from a fall. The facility staff had knowledge of a prior attempt by the resident to leave the facility . The facility failed to ensure elopement risk factors were evaluated and interventions in place for adequate supervision.
Walker Methodist Health Center Complaint Findings for Sexual Abuse
In a report concluded on January 13, 2015, the Minnesota Department of Health cites Walker Methodist Health Center for sexual abuse.
Based on a preponderance of the evidence, abuse is substantiated; the alleged perpetrator (AP) was observed sexually assaulting the resident. The facility acted immediately to ensure the resident’s safety and remove the AP from premises.
The resident had diagnoses that include Alzheimer’s disease, osteoporosis and generalized muscle weakness. The resident had cognitive deficits in all area and required assistance from staff for all cares and transfers. The resident was minimally verbal, giving occasional, one word responses to a direct question.
The night the resident was assaulted, the witness was on his/her way to the kitchen around 4:30 a.m. and stepped into the bathroom, located just inside the doorway of the resident’s room to wash his/her hands. The witness saw the AP’s back at the edge of the resident’s bed, the resident’s bare legs on both sides of the AP’s hips and the tape tabs, located on the sides of the resident’s incontinent product, open on the bed indicating that the resident’s brief was open. The witness did not release what the AP was doing until s/he saw the AP move in a back and forth, thrusting motion, about four times. When the witness realized that the AP was sexually assaulting the resident, s/he knocked on the door to alert the AP to his/her presence in the room. The AP turned around briefly and saw the witness. The AP then quickly moved back from the resident, placed the residents legs back on the bed and replaced the resident’s incontinent product. The witness immediately contacted the night supervisor who removed the AP from the floor. The police were called and the AP was taken to jail and charged with sexual assault. The resident was taken to the hospital for a sexual assault examination.
Walker Methodist Health Center Complaint Findings for Exploitation
In another report concluded on April 3, 2013, the Minnesota Department of Health cites Walker Methodist Health Center for exploitation by other.
Based on a preponderance of the evidence, financial exploitation is substantiated in connection with the theft of a resident’s credit card by the 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 sexual abuse or any other form of elder abuse or neglect contact Elder Abuse and Neglect Attorney Kenneth LaBore toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.