Bloomington Nursing Home Abuse Attorney - Part 2

PROVIDENCE PLACE
3720 23rd Avenue South
Minneapolis, Minnesota 55407
(612) 238-2566

A “Not for Profit” 190-certified bed Medicaid/Medicare-participating facility

Overall Rating – 3 out of 5 possible stars

3 stars rating

Primary Concerns –

Failure to Provide Adequate Supervision to Minimize the Potential of the Resident from Eloping/Wandering Away from the Facility Undetected

In a summary statement of deficiencies dated 12/15/2015, a complaint investigation was opened against the facility for its failure to “ensure adequate assessments, appropriate interventions and supervision were in place to minimize the risk of elopement [for a resident who wandered away from the facility without supervision].”

The investigation into the filed complaint involved a review of a resident’s records reveal that the resident “had been admitted to the facility for wound care” and that the Admission Nursing Assessment indicated that “the resident had no risks for elopement, and had no cognitive deficits.” The documentation also revealed that the resident “was a paraplegic and was not able to walk. At the time of admission, the assessment indicated the resident had a wheelchair. The initial Care Plan dated 11/04/2015 [revealed that there were] no safety concerns listed and no supervision level indicated.”

A review of the 10:00 PM 11/06/2015 Progress Notes indicated that the evening Registered Nurse knows the resident “was missing at 3:00 PM, and documented other staff had told her [the resident] had been in the front of the building asking for cigarettes from staff and residents.”

An interview was conducted at 3:30 PM on 11/12/2015 with the Registered Nurse in charge of providing the resident care who stated “she had noted the resident was missing at 3:30 PM on 11/06/2015 and had searched the facility and called the police to file a missing person report. She was notified that [the resident] was at the hospital in intensive care for hypothermia and had been admitted at 7:00 PM.”

11:00 AM on 12/14/2015, the day shift Registered Nurse stated during an interview that the resident “had gotten into an electric wheelchair at 9:00 AM on 11/06/2015, and left to attend an outpatient appointment. The nurse saw him again at the nurse’s station between 1:00 PM and 1:30 PM and had administered medications to him. She had not heard from other staff that [the resident] had been at the front entrance of the building asking for cigarettes.”

During a 1:20 PM 11/12/2015 interview with the facility’s Clinical Manager, it was revealed “that two days after admission, [the resident] was up in his motorized wheelchair for the first time to attend an outpatient appointment […and] he was not sure if the nurses had assessed if the elopement risk was increased when [the resident] had access to the motorized wheelchair.”

During the interview, the nurse also stated the resident “return the facility after the appointment and was seen going in and out of the building and asking for cigarettes. At approximately 2:15 PM, the afternoon nurse asked where [the resident] was, and a search was started.” The Registered Nurse also stated that the resident “was found about a mile and a half away by police and taken to the hospital for hypothermia and assessment for injuries from falling out of the wheelchair.” Registered Nurse also stated that “new admits are not oriented to the community or told of the leave policy unless they ask to leave.”

An interview was conducted at 10:30 AM on 11/12/2015 with the resident who stated “he left the facility on his own without notifying the staff and try to find a store to buy cigarettes […and] he got lost and was not able to find his way back to the facility […and] tipped over in the wheelchair and fell, and then the ambulance took him to the hospital.”

Our Minneapolis nursing home neglect attorneys recognize that failing to provide adequate supervision to minimize the potential risk of a resident wandering away from the facility can place their health and well-being in jeopardy. The deficient practice by the nursing staff that Providence Place could be considered mistreatment or negligence because their actions failed to follow the facility’s 12/10/2011 policy title: Missing Resident that reads in part:

“All residents will be accounted for by conducting around the beginning of each shift. The resident is missing, searches to be conducted and the police notified.”

BIRCHWOOD CARE HOME
715 West 31st Street
Minneapolis, Minnesota 55408
(612) 823-7286

A “For-Profit” 60-certified bed Medicaid/Medicare-participating facility

Overall Rating – 3 out of 5 possible stars

3 stars rating

Primary Concerns –

Failure to Follow Procedures and Protocols to Report and Investigate Any Act or Alleged Act of Abuse, Neglect or Mistreatment of Residents

In a summary statement of deficiencies dated 01/08/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “operationalize their Abuse Prevention Policy for promptly reporting to the State Agency (SA).” The deficient practice by the nursing staff and administration at Birchwood Care Home involve five residents “that were identified for alleged sexual abuse, resident to resident altercation and misappropriation of property.”

It was also noted by the state investigator that the “facility’s policy was unclear as to when the facility staff was to report alleged incidences to the State Agency. This had the potential to affect 47 of the 58 residents who reside in the facility.”

The deficient practice was noted by a state investigator who interviewed the resident at 10:25 AM on 01/05/2015 [over an] allegedly reported sexual abuse [incident].” During the interview, the resident “indicated for men came into her room, force themselves on her and sexually abused her. The alleged abuse was immediately reported to the Director of Nursing after the interview. The facility did not immediately report the incident to the State Agency.”

The state investigator also reviewed the resident’s MDS (Minimum Data Set) noting that the resident “had hallucinations and delusions.” This investigator also noted that 11:45 AM on January 2015, the licensed Social Worker was interviewed and stated that the facility did not call in the resident’s incident to the Office of Health Facility Complaints or State Agency because the resident “is delusional and it happens all the time.” A subsequent interview on the same day at 12 o’clock noon with the facility’s Director of Nursing revealed that “the incident was not reported as [the resident] had delusions.”

However, a review of the resident’s 03/02/2014 Vulnerable Adult Internal Investigation Reporting Form revealed that the resident “was hospitalized after a resident to resident altercation” where another resident hit the resident “on the head on 03/01/2014.”

That report noted that the resident had “reported the incident to a Chart Nurse immediately [stating that another resident] verbally threatened [the resident] by stating you are done and you are dead after [the threatening resident] found out [the resident] was overheard by facility staff while on the phone talking about the incident.” A third resident reported to the facility staff that [the threatening resident had hit the resident] on the head.” At that point, the threatening resident “came to the nurses’ station and started yelling at the [reporting resident].”

After that altercation, the facility did notify the state agency the following day on 03/02/2014. It was on that Admission Record dated 03/04/2015 that revealed that the resident “had a problem with anger as he kicked the door.”

An interview was conducted 11:05 AM on January 2015 With a facility’s Registered Nurse who stated that “she would report any abuse or incidences right away and replied, (common entry point) myself’.”

The investigator noted that “the charge nurse on duty at the time the staff became aware of a reportable incident, or the Director of Resident Services, Director of Nursing or the Administrator is responsible for submitting an incident report to the State Agency as soon as possible (within 24 hours from the time of initial knowledge that the incident occurred).” The investigator also notes that “the facility did not report timely to the State Agency and in addition, they could not be determined at what point the staff should call the State Agency due to the inconsistent time frames listed in the policy.”

Upon review of the facility’s policy titled Vulnerable Adult Policy it indicates that all “staff members at Birchwood care home were mandated reporters […and] staff were to report assault, prostitution, criminal sexual conduct, mistreatment of confined persons, mistreatment of residents and or drugs, use of drugs to injure or facilitate crime.” However, the policy in the first section reads that notification should be made by the Charge Nurse or the Director of Resident Services, Director of Nursing or the Administrator if they are in the building. That person would then make an initial report to the State Agency and the CEP.”

Our Minneapolis nursing home neglect attorneys recognize that failing to report and investigate any action or allegation of abuse, neglect or mistreatment could place the health and well-being of the resident immediate jeopardy. The deficient practice by the nursing staff an administrator at Birchwood Care Home might be considered negligence or mistreatment because their actions failed to follow established procedures and protocols enforced by state and federal nursing home regulators.

HIGHLAND CHATEAU HEALTH CARE CENTER
2319 West Seventh Street
Saint Paul, Minnesota 55116
(651) 698-0793

A “For-Profit” 64-certified bed Medicaid/Medicare-participating facility

Overall Rating – 3 out of 5 possible stars

3 stars rating

Primary Concerns –

Failure to Provide Care to Ensure That Every Resident Builds or Maintains Their Dignity and Respect of Individuality

In a summary statement of deficiencies dated 01/28/2016, a notation was made by a state surveyor during an annual licensure and certification survey involving the facility’s failure to “provide services in a manner that promoted dignity for [two residents at the facility].”

The deficient practice was noted by state surveyor who reviewed a resident’s Admission MDS (Minimum Data Set) indicating that the resident “was cognitively intact.” In addition, the resident’s Current Care Plan indicated that the resident “was a fall risk, was continent of bowel and bladder, and use the front wheeled walker to ambulate with moderate independence in the room.”

The state investigator interviewed the resident in the resident’s room at 9:27 AM on 01/26/2016. During the observation, it was noted that “a facility commode was placed against the outside wall of the resident’s room.” At that time, the resident “reported having to wait up to an hour in the past for the call light to be answered and reported having had incontinent accidents while waiting […and] explained that approximately 1.5 weeks ago, after putting the call light on to get assistance to get up to use the commode, the staff person came and instructed her to go in the brief she was wearing.”

The resident also indicated that “the staff person replied not being able to assist her […and] further added that it seemed once you were in bed in the evening, the staff did not want to get you up again; they act like they don’t care.” The resident also “indicated trying to do more for herself and stated it is really hard when told to do something like that, it was just wrong.”

The state investigator conducted an interview at 10:30 AM on 01/28/2016 with the facility’s Director of Nursing who indicated that “this was not the expectation of the facility to wait that long for call light and to void in one’s incontinent product rather than being assisted out of bed to use the commode.

Our St. Paul nursing home neglect attorneys recognize it failing to ensure that every resident builds or maintains their dignity and respect of individuality could cause emotional harm or trauma to the resident. The deficient practice by the nursing staff at Highland Château Health Care Center might be considered negligence or mistreatment because their actions failed to follow established standards of care as required by state and federal nursing home regulations.

EBENEZER CARE CENTER
2545 Portland Avenue South
Minneapolis, Minnesota 55404
(612) 879-2262

A “Not for Profit” -127 certified bed Medicaid/Medicare-participating facility

Overall Rating – 3 out of 5 possible stars

3 stars rating

Primary Concerns –

Failure to Develop, Implement and Enforce a Complete Care Plan That Meets Every Need of the Resident, Including Actions and Timetables That Can Be Measured

In a summary statement of deficiencies dated 12/30/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “develop a comprehensive care plan [for a resident at the facility] reviewed for behaviors.”

The deficient practice was noted by state investigator who reviewed a resident’s Quarterly MDS (Minimum Data Set) that revealed that the resident “was cognitively intact” and “displayed physical behavioral symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing, and abusing others sexually) 1 to 3 times in the last seven days.”

During a 3:09 PM 12/29/2015 interview, a registered nurse and MDS Coordinator verified that the MDS (Minimum Data Set) indicated the resident “had behaviors directed toward others.” The Registered Nurse also stated, “it was a known behavior for [that resident to joke] around and push people.” The Registered Nurse also verified that the resident “did not have a behavioral section in [their] care plan […and] these behaviors should have been on Care Plan.”

The state investigator conducted a 12:12 PM 12/30/2015 interview with the facility’s licensed Social Worker who said “if that was a baseline behavior for [the resident], the facility’s practice would be to have interventions in place on the Care Plan and ensure that the staff has the tools in place to carry out the interventions.”

Our Minneapolis elder abuse attorneys recognize that failing to develop, implement and enforce a complete Care Plan that meets the needs of every resident to place the health and well-being of all residents in jeopardy. The deficient practice by the nursing staff that Ebenezer Care Center might be considered negligence or mistreatment because their actions failed to follow the facility’s December 2013 policy title: Admission Care Plan that reads in part:

“Each resident admitted to the facility will have a Care Plan begun on admission to ensure that each resident’s needs are assessed in all care needs are met.”

SHOLOM HOME WEST
3620 Phillips Parkway South
Saint Louis Park, Minnesota 55426
(952) 935-6311

A “not for profit” 179-certified bed Medicaid/Medicare-participating facility

Overall Rating – 3 out of 5 possible stars

3 stars rating

Primary Concerns –

Failure to Ensure That Working Call Light Systems Are Available for Every Resident’s Room, Bathing Area or Bathroom

In a summary statement of deficiencies dated 06/12/2015, a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “ensure [a resident’s] call light was functioning properly for a resident who was capable of using the call light.”

The deficient practice was noted by state surveyor after a review of a resident’ as medical records that noted that it 4:03 PM on 06/09/2015, “the call light was observed lying on [the resident’s] the floor when the surveyor pushed the button to activate it; the call I did not activate outside the room even after several attempts. The red button was noted to be very tight and was not pushing inward evenly.”

The following morning at 9:10 AM, the call light was observed lying on [the resident’s] bed next to the pillow and [the resident] was lying in his bed time. When [the call light was] activated it was still not working.” Subsequently, on the following morning 06/11/2015 at 6:50 AM through 12:20 PM, “the call light was observed hanging on top of the headboard, still not activating when pushed.”

Twenty minutes later at 12:40 PM, during environmental tour with the Campus Director of the Physical Plant and the Administrator, the call light was observed hanging on top of the headboard.” At that time, the resident “was observed lying in bed. When the Campus Director the Physical Plant activated the call light it did not activate, he indicated it was not working even after pushing the cord and the entire unit on the wall inward, it still did not work. The Administrator then left the room and stated she was going to report to the nurse manager in the unit to get the call light fixed immediately.”

The Licensed Practical Nurse (LPN) providing the resident care was asked at 12:44 PM if the resident uses the call light. At the LPN responded that the resident seldom uses it but does use it at times. Two hours later 20 7 PM, the Director of Nursing “acknowledged the call light need to be in proper function for residents who are capable of using it.”

In a subsequent interview at 11:44 PM on 06/12/2015, when asked at the facility had a system of ensuring call lights were proper functioning manner, the Campus Director for the Physical Plant stated audits were done quarterly and the last time it had been done was on 04/15/2015.”

The state investigator brought up the policy “the call lights were to be checked daily he indicated he was not sure would ask the Administrator who was responsible for ensuring the call light project daily. The Campus Director of the Physical Plant indicated he thought he would add to the housekeeping checklist for the staff to check it daily as they clean the rooms daily.”

Approximately 17 minutes later, the Campus Director of the Physical Plant approached surveyor and stated he talked to both the Administrator and the Director of Nursing and both were not aware of the policy indicated call lights were to be checked daily, which was the opposite of what was being done quarterly. He stated this way to be reviewed.”

Our St. Louis Park nursing home neglect lawyers recognize that failing to provide working call light systems place the health and well-being of the resident in jeopardy and degrade the quality of their daily living. The deficient practice by the nursing staff, Administrator and Maintenance Director might be considered negligence or mistreatment because their actions failed to follow the facility’s 2008 policy title: Call Light, Use of Policy that reads in part:

“Check all call lights daily and report any defective call lights to the nurse immediately.”

The Ugly Truth

Many families are unaware of the reality of nursing home abuse and neglect until the harm and damages already done. The ugly truth of the nursing home industry involves the reality that many administrators and corporations place generating profits well ahead of the level of quality care each resident is afforded.

Whether the nursing home resident suffered serious injuries caused by an intentional action, or an employee at the nursing home failed to perform their responsibilities and duties, the end result is usually catastrophic for the victims.

Litigation laws involving nursing home and abuse and neglect are in place and enforced in an effort to protect residents and provide well-deserved compensation. However, protecting elderly citizens from abuse, mistreatment and neglect requires extensive collaboration with nursing home attorneys, lawmakers, family members and advocates.

Many cases of nursing home neglect often go undetected by family members who are unaware of what constitutes an act of negligence. While abuse often leads to emotional and physical scars, negligence is often harder to detect. However, the most common types of negligence cases filed by victims will involve:

  • Facility acquired bedsores (pressure ulcers; decubitus ulcer; pressure sores) that could have been prevented
  • Dehydration and malnutrition when a resident is deprived access to fluids and nutritional food
  • Unexplained injuries such as bruising, broken bones, lacerations, cuts and burns
  • Sexual assault by caregivers, employees, residents or visitors
  • Falling accidents causing injury or death as a result of a lack of competent supervision or no supervision at all
  • Medication errors where the victims suffer serious injury or death after receiving another resident’s drug, the wrong dosage or no medication at all
  • Wrongful death

The least conspicuous forms of negligence in a nursing facility come from negligent hiring practices where the facility fails to perform proper and adequate background checks and hire employees with histories of neglect or abuse on the elderly.

Families are often unaware that any and all forms of negligence in a nursing facility is actionable, especially if it can be found that the staff, medical team, administrator and/or nursing facility breached their duty of care and did not follow acceptable medical practices in regard to providing the resident care. Because of that, many family members will often hire a reputable nursing home abuse attorney to handle their case for compensation and to seek justice on behalf of the victim.

Hiring Legal Representation

Monetary compensation is often available in any abusive or negligent action of a nursing facility, employees, staff members or other residents. The victim and family members are often afforded an opportunity to seek financial compensation for past and future medical/injury treatment, mental anguish, emotional distress pain, suffering and other damages.

The Bloomington nursing home abuse attorneys at Nursing Home Law Center LLC can take immediate action against the facility and all responsible parties to prevent the destruction of valuable evidence or the loss of memory from all witnesses of the event/incident/accident. We encourage you to contact our law offices today at (800) 926-7565 to schedule an initial, free fall case consultation. We accept all nursing home neglect cases on contingency. This means the family members and victim are provided immediate legal representation without an upfront payment.

For additional information on Minnesota laws and information on nursing homes look here.

Nursing Home Abuse & Neglect Resources

If you are looking for information on a specific facility or an attorney, please see links below to respective locality pages.

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