Bloomington Nursing Home Abuse Attorney
It is a sad reality that many elderly Americans suffer needlessly while residing in nursing facilities where their physical, mental and emotional harm have been caused by those in charge of providing care. The Bloomington nursing home neglect attorneys at Rosenfeld Injury Lawyers LLC have handled many Minnesota cases involving abusive mistreatment, neglect and abuse.
Every day, family members face the truth that they are no longer able to find the resources or offer the time and skills necessary to provide a level of care their elderly loved one requires. Usually, the only option is to place a disabled, infirmed or aging spouse, parent or grandparent in a nursing facility. Sadly, many of these residents are betrayed and hurt by the nursing staff and management due to a substandard level of care or by other residents due to a lack of much-needed supervision.
Even though there are less than 87,000 residents living within the Bloomington city limits, almost one out of every five, or nearly 16,000 are senior citizens. This high ratio of retirees in the small community has placed a significant burden on the number of nursing home beds available for individuals requiring a high level of skilled care. Unfortunately, with more and more baby boomers entering their retirement years, the demand is likely to increase substantially in the years ahead.Bloomington Nursing Home Resident Health Concerns
Our Hennepin County elder abuse lawyers recognize that many nursing home victims of abuse and neglect are afraid to speak out or unable due to a physical, mental or emotional impairment. Many victims of mistreatment conceal their harm and never report the incident to anyone.
To assist family members, our Bloomington nursing home abuse lawyers continuously review, examine and evaluate opened investigations, filed complaints, safety concerns and health violations found in publicly available information including Medicare.gov. Many families use this valuable information as an effective decision-making tool for deciding where to place a loved one who requires a high level of skilled health care and hygiene assistance.Comparing Bloomington Area Nursing Facilities
Our Minnesota elder abuse attorneys have compiled the list below detailing specific Bloomington area nursing facilities that currently maintain substandard ratings compared other facilities throughout the United States. In addition, our team of attorneys has published our primary concerns outlining specific cases that have caused residents at these facilities direct or indirect harm, injury or death.
GOLDEN LIVINGCENTER – BLOOMINGTON
9200 Nicollet Avenue South
Bloomington, Minnesota 55420
A “For-Profit” 76-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
Failure to Immediately Notify the Resident’s Doctor, Family Member and Resident of Any Change in the Resident’s Condition Including a Decline in Health
In a summary statement of deficiencies dated 11/06/2015, a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “ensure the primary physician was notified when pressure ulcers developed and worsened for [1 resident the facility] reviewed for pressure ulcers.”
The deficient practice was noted by the state investigator who noted that even though the resident’s Progress Note revealed that the resident was admitted to the facility and had existing pressure ulcers on his feet, a 08/27/2015 Admission MDS (Minimum Data Set) assessment documented five days later revealed that the resident “had no stage one or greater pressure ulcers.”
It is also noted that the resident “subsequently developed at least two pressure ulcers while residing in the facility with various descriptions, but frequently referred to as buttocks wounds. Evidence was lacking in [the resident’s] medical record to show his primary physician and or Nurse Practitioner have been notified of the significant change in condition including the [worsening of the pressure ulcers].”
The state investigator notes that “the first indication of the presence of any sacral/coccyx wound was in the Nurse’s Notes dated 09/11/2015. A significant change in condition was not identified, despite the development of new pressure ulcers.”
The documentation “lacks specific information such as measurements, a physical description of the wounds, the stages of each one, and a follow-up plan.” The surveyor noted that the facility Visit Records from palliative care and hospice indicated the resident “was seen and the note referred only to existing foot wounds. Hospice orders also dated 09/11/2015, however, included zinc oxide barrier cream for buttocks and sacral wounds.”
A notation was made in the 09/14/2015 Hospice Nursing Note indicating that the resident’s wounds on buttocks are larger (not deeper) due to sitting in a wheelchair all day.” Another notation from 10/11/2015 describes the resident’s right buttock and inner thigh wound: open area near coccyx is 8.0 centimeters by 4.0 centimeters, wound bed dark tissue, inferior regions measuring 3.0 centimeters by 2.0 centimeters open area without slough (soft non-living tissue), inner thigh open area measures 4.0 centimeters by 1.8 centimeters.”
By 10/25/2015, documentation in the Nurse’s Notes indicates that the bottom wound is now “black in color and has a foul odor.” However, the state investigator notes the description “were minimal, but represented an extreme change to the wound when compared to descriptions in past notes and the physician was not notified.”
Five days later on 10/30/2015, the Nurse’s Notes by hospice indicate that the resident’s “coccyx wound had obviously increased in size measuring 12.0 centimeters by 5.0 centimeters by 3.0 centimeters […and] the right lower buttocks measured 3.0 centimeters 2.0 centimeters [and the] coccyx wound edge borders were non-blanchable and crusted. One bed necrotic (dead tissue). 30% – 40% loose necrotic tissue noted. Serosanguinous (blood-tinged clear) drainage observed in large amounts.”
The state investigator interviewed the facility’s Wound Nurse, Director of Nursing and Assistant Director of Nursing and 9:20 AM on 11/04/2015 where the Assistant Director of Nursing “reported that the physician was notified of [the resident’s] wounds, but was unsure whether the physician or Nurse Practitioner had visualized the wounds, as 60 days are not up (between required physician visits.” The state investigator also noted that “documentation did not reflect the physician had been notified of [the resident’s] wounds until notes reflected [that the Nurse Practitioner] saw the resident on 11/01/2015 […and] the physician on 11/05/2015.”
The hospice nurse indicated in a 9:49 AM 11/04/2015 interview that “the physician was notified of wound healing at hospice interdisciplinary (IDT) rounds, but had not visualized the ulcer adding, ‘our doctors rarely come out to view wounds’.” The Director of Nurses indicated at 12:17 PM on 11/04/2015 that “he would have expected documentation including measurements and physician notification.”
Our Bloomington nursing home neglect attorneys recognize failing to notify resident’s physician of a change in their condition could diminish the quality of their life. The deficient practice by the nursing staff at Golden Living Center – Bloomington might be considered mistreatment or negligence because their actions failed to follow the facility’s policy title: Guideline Statement Policy that reads in part:
“Ensure that proper notifications are made when a resident has a change in health status. The definition of immediate is as soon as possible no longer than 24 hours.”
“The center will consult the resident’s physician, nurse practitioner or physician assistants, and if known, notify the resident’s legal representative or an interested family member when there was a significant change in the resident’s physical status, such as a deterioration of health or clinical complications.”
MARTIN LUTHER CARE CENTER
1401 East 100th Street
Bloomington, Minnesota 55425
A “For-Profit” 137-certified bed Medicaid/Medicare-participating facility
Overall Rating – 3 out of 5 possible stars
Primary Concerns –
Failure to Provide Care and Services to Every Resident to Ensure Their Highest Well-Being Is Maintained
In a summary statement of deficiencies dated 01/20/2016, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “ensure services were provided to minimize the risk of infection and clotting.” The deficient practice by the nursing staff at Martin Luther Care Center affected one resident at the facility.
The deficient practice was noted by state surveyor upon observation of a resident on 01/27/2016 at approximately 8:30 AM in the resident’s room. At times, the resident had no dressing to a wound “observed on the resident’s left upper arm.” At that time, Licensed Practical Nurse indicated that the resident received medical treatments three times a week on Monday, Wednesday and Friday and stated “she did not manage [the resident’s medical treatment] or dressing and was unaware of what was actually related to [the resident’s] dressing at 3:00 PM as she was off duty.”
An additional observation was made of the resident 8:37 AM the following day on 01/20/2016 when the resident “was again lying in bed. No dressing was observed on his upper left extremity access site. When asked who had removed the dressing he stated he had because it was itching. He further explained he always removed the dressing and denied nurses in the facility had ever managed the site or remove the dressing.”
The state investigator reviewed the resident’s 08/16/2015 Care Plan that directed staff to check bruit and thrill daily [bruit is a rushing roaring sound heard through a stethoscope and thrill is the sensation or strong pulse of blood flowing through blood vessels, to ensure proper function of the fistula (surgical passage)]. In addition, the resident’s Care Plan also directs the nursing staff to take vital signs daily and as needed, observe [the resident’s medical treatment] every shift and report negative findings/changes to the physician.”
The medical staff is directed to apply pressure if bleeding occurs at the access site until the bleeding stopped “and to notify the physician, remove the dressing from the access site six hours after the medical treatment is completed and “wash access site daily with cares – do not scrub vigorously.” Much of the same information was documented in the resident’s TAR (Treatment Administration Record) including the need to notify the doctor if there is an absence of sound while listening for bruit and thrill with a stethoscope. The order date in the TAR was 01/28/2016.
However, the TAR (Treatment Administration Record) from November 2015, December 2015 through the end of January 2016 “lack directed to monitor document condition of the resident. However, the TAR from this time did direct staff to remove bandages every night on Monday, Wednesday and Friday because [the resident] had some skin breakdown from the tape.”
At 11:02 AM on 01/20/2016, Licensed Practical Nurse providing the resident care stated that the resident’s “dressing was always removed by morning and therefore, [the Licensed Practical Nurse] did not document monitoring of bruit and thrill or clotting [at the resident’s access site].”
The state investigator conducted a 1:39 PM 01/28/2016 interview with the facility’s Director of Nursing who revealed: “that when [the resident] returned from the hospital, his orders were not transcribed into the MAR (Medication Administration Record).” The Director of Nursing stated that “the problem is that the unit does not get a lot of [residents who require the specific medical treatment] and it was missed.” The Director also stated that the resident “has lots of orders.”
Our Bloomington nursing home neglect lawyers recognize a failing to follow procedures and protocols to ensure that every resident receives adequate care to maintain their highest well-being the place their health in jeopardy. The deficient practice by the nursing staff to provide adequate services to the resident could be considered mistreatment or negligence because their actions failed to follow the facility’s policies and guidelines and state:
“Check dressing site daily. Monitor, document and report PRN [as needed] of infection to access the site: redness, swelling, warmth your drainage.”
EDINA CARE and rehabilitation CENTER
6200 Xerxes Avenue South
Richfield, Minnesota 55423
A “Not for Profit” 118-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Ensure That All Residents Requiring Range of Motion Treatment Receive Range of Motion Treatment to Optimize Their Health and Well-Being
In a summary statement of deficiencies dated 06/25/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “provide range of motion (ROM) services to [a resident at the facility].”
The deficient practice was noted the state investigator after a 3:18 PM 06/23/2015 observation and interview noting that the resident “was lying in bed with her left hand curled into a fist and all of her fingers bent toward the palm of her hand.” The state investigator asked the resident “if she could open up her left hand.” However, the resident “was able to lift all of her fingers a few inches with the exception of the third finger on her left hand.”
The investigator also noted that the resident reported that doing so was “not painful, just stiff. When asked if she would like to have had our ROM [Range of Motion] exercises, she replied, ‘Yes’.”
The following day at 9:26 AM on 06/24/2015, the state investigator observed the resident “receiving morning care from two nursing assistant [… when the resident’s] left can remain in a fist throughout the cares.” One nursing assistant providing the resident care stated that the resident’s “left hand did not open all the way, and the nursing staff had been putting a rolled up washcloth in [the resident’s] on left hand a while ago, but [the resident] refused and fought anyone who tried to do it.”
The investigator reviewed the resident’s 04/24/2015 Care Plan indicating that “the resident had a memory deficit with impaired judgment and decision-making, as well as reliance on staff for self-care related to dementia, requiring two staff to assist her with personal hygiene.” In addition, the resident’s Care Plan lacked direction for staff to provide [range of motion] services or any intention to minimize the risk for further decline in ROM in [the resident’s] hand.”
A review of the resident’s 05/20/2015 Nursing Note revealed that “hospice provided a hand splint for the resident’s left hand. Unfortunately, the resident was unable to tolerate due to pain and a wash cloth placement has been unsuccessful in the past.” The notation indicates that there will be a follow up therapy for other suggestions. However, a review of the April 2015 through June 2015 Nursing Notes “lacked any notation that a trial of washcloths or splints had been tried or the resident’s refusal for a hand device.”
The stated investigator conducted 06/23/2015 interview with the Registered Nurse providing the resident care who stated that that the resident “had been on hospice from 03/20/2014 to 05/26/2015 […and that] Hospice staff had ordered splints for [the resident’s] left hand, but she refused to wear the splint, therefore, was discontinued.” The Registered Nurse then stated that staff members “did not provide any ROM services for [the resident, explaining] that nursing had attempted to place a rolled up washcloth into the palm of her hand but it was too painful for the resident.”
However, during a follow-up next day interview conducted 11:01 AM on 06/24/2015, the same Registered Nurse stated that the resident “was unable to open her fingers on her left hand due to pain and not rigidity” and the refusal to utilize a washcloth or splint was “only brought up that morning in nursing meetings via word-of-mouth and not been directly brought to the attention of therapy staff for suggestions regarding [range of motion].”
The investigator conducted a 9:01 AM 06/24/2015 interview with the facility’s Director of Rehabilitation who reported that the resident “had never been assessed by a therapist regarding her left hand contracture, nor had therapy staff been asked to assess the resident.” In a subsequent interview occurring less than an hour later at 10:02 AM, the Registered Nurse providing the resident care explained that when the resident “was admitted to the facility, she was able to play the piano, but now was unable to open her fingers on her left hand.”
The surveyor and Registered Nurse observed the resident’s hand approximately one hour later at 11:15 AM when the resident “attempted to reach for [the resident’s] hand to open her fingers, the resident pulled away. However, when [the Register Nurse asked the resident] if she could open her fingers by herself, she was able to perform the same movement as observed by the surveyor on 06/23/2015.” The surveyor noted that “no verbal or physical signs and pain were observed […and that the resident] stated again it was not painful.”
When the Registered Nurse attempted “to move her ring finger on her left hand upwards, [the resident] pulled away and stated, ‘That hurts’.” In response, the Registered Nurse stated, “we should have been asking her daily for her to move her fingers by herself and document any refusals.
Our Richfield nursing home neglect attorneys recognize it failing to provide residents necessary care for a range of motion could be detrimental to their overall health and well-being. The deficient practice by the nursing staff at Edina Care and Rehabilitation Center might be considered mistreatment or negligence because their actions could have led to the unnecessary increase of contracture of the resident’s hand.
PARK HEALTH AND REHABILITATION CENTER
4415 West 36 1/2 Street
Saint Louis Park, Minnesota 55416
A “For-Profit” 81-certified bed Medicaid/Medicare-participating facility
Overall Rating – 3 out of 5 possible stars
Primary Concerns –
Failure to Provide Every Resident an Environment Free of Accident Hazards and Provide Adequate Supervision to Prevent Avoidable Accidents from Occurring
In a summary statement of deficiencies dated 05/14/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “implement interventions to minimize the risk of falls.” The deficient practice by the nursing staff at Park Health and Rehabilitation Center involved one resident at the facility.
The deficient practice was noted by a state investigator who observed a resident of 3:41 PM on 05/12/2015 “lying in her bed. The bed was elevated to a high position (higher than waist height). When asked why the bed was at this high height, [the resident] stated, ‘sometimes it’s up, sometimes down. They do what they want’.”
Later that afternoon at 4:04 PM, the resident “was observed with the remote control to adjust the height of the bed. She was elevating and lowering the bed independently.” The following day at 12:02 PM on 05/13/2015, the resident “was again observed with her bed in a highly elevated position. The mat was placed on the floor to her right side near the window.” At 1:35 PM, the state investigator observed the resident “in her bed. The bed was at waist level.”
Later in the afternoon at 4:30 PM, a Registered Nurse provided the state investigator a Nursing Assistant Care Guide and verified the guide directed the [Nursing Assistants] to put [the resident’s] bed in the low position.” Again at 5:13 PM the same day, an observation was made of the resident with “the bed again noted to be at waist level” with the resident occupying the bed.
The investigator then reviewed the 04/10/2015 Fall Injury Assessment: Prevention and Management Care Plan that identify that the resident is at risk for falls. Instruction in the Care Plan “directed staff to put [the resident’s] bed in the low position.” However, “the Care Plan lacked evidence that the resident was able to raise or lower the bed via the remote that was attached to the bed. In addition, the Care Plan lacked evidence of how the facility was going to ensure [the resident’ is] bed was in the low position.”
A review of the resident’s 04/10/2015 MDS (Minimum Data Set) identified the resident “is being operatively intact.” However, the subsequent MDS (Minimum Data Set) “indicated the facility was going to complete a cognitive assessment, but it was blank.”
The investigator also reviewed the resident’s 04/13/2015 report and a Nursing Note that revealed that “the resident rolled out of bed on 04/12/2015 at 11:45 PM. At that time, [the resident] complained of pain to her upper left and lower left extremities, but no injury is found upon x-ray. It was noted [that the resident] had impaired cognition and did not remember the incident stating, ‘I must have been dreaming’.”
A 2:16 PM 05/13/2015 interview was conducted with the Nurse Manager/Registered Nurse who verify that the resident’s [bed] “that was not in the low position and stated she expected the bed to be at the low position as the Care Plan directed.” The Registered Nurse also explained that the resident “was confused upon admission, therefore, her bed was placed in the low position with mat on the floor […and that] the resident was no longer confused about the bed was now in the mid-position and she has not had a more incidences of falling out of the bed.”
Our St. Louis Park nursing home neglect attorneys recognize it failing to follow procedures and protocols to provide every resident an environment free of accident hazards and adequate supervision to prevent avoidable accidents from occurring could place the health and well-being of the resident in jeopardy. The deficient practice by the nursing staff at Park Health and Rehabilitation Center could be considered negligence or mistreatment because their actions failed to follow the facility’s Care Plan.
GOLDEN LIVINGCENTER – HOPKINS
725 Second Avenue South
Hopkins, Minnesota 55343
A “For-Profit” 138-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
Failure to Ensure That Residents Remain Safe from Serious Medical Errors That Result in Actual Harm and Death of the Resident
In a summary statement of deficiencies dated 01/27/2016, a complaint investigation was opened against the facility for its failure to “ensure the residents were free from significant medication errors.” The deficient practice by the nursing staff involved one resident at the facility who “did not receive a blood thinning medication for eight days as ordered by their physician.” As a result, “the resident developed blood clots, had a serious stroke and died.”
The complaint investigation included a full review of the resident’s records that revealed the resident “relied on the nursing staff to administer medications, and received [daily medications as per the physician’s orders].” While at the facility, the resident was prescribed anticoagulant medication “given to prevent blood clots, and the blood is closely monitored for clotting with laboratory tests… to determine the correct dosage.”
However, the state investigator noted that the resident’s MAR (Medication Administration Record) included in order to check the resident’s blood clotting factors. However, during the same timeframe, the resident’s MAR (Medication Administration Record) did not indicate a new order for an anticoagulant medication and there was no record that the medication dose was administered to the resident.
The facility’s Medication Error Form indicated that the resident “received an order to continue [the anticoagulant medication and the order was] “transcribed onto another patient’s electronic MAR by mistake.” As a result, the resident “did not receive their medication” on specific dates and times.
The state investigator noted that the resident’s Progress Note indicated that the resident “presented with stroke-like symptoms [that include] slurred speech and impaired vision.” As a result, the resident “was sent to the hospital emergency room.” During the event, the nurse noted that there was a “medication omission error at that time.”
The hospital Admission Emergency Department Note indicated that the resident’s clotting value test results score was 1.0 on admission, which was below therapeutic value. This was verified with the nursing home and the nursing home notified the hospital that [the resident] had not received [their medications at various times on various dates] when it was discontinued by error. The hospital death report documented that [the resident’s] cause of death was a large acute ischemic stroke.”
The state investigator interviewed a facility’s Licensed Practical Nurse who “stated that he had transcribed the order for [the resident…], But had made an error and put the order on the MAR (Medication Administration Record) of [another resident]. He stated it was a busy shift with [multiple] orders for three different residents, and the Health Unit Coordinator was not on duty. He stated the duplicated orders for [the other resident] was noticed [at a later date and that resident] had not been given extra doses.” The LPN stated that even though “the order was removed from [the other resident’s] MAR (Medication Administration Record)” he did not realize that that the deceased resident had not been administered their medication for the Care Plan and physician’s orders.
The state investigator interviewed the facility’s Director Nursing who stated “the two nurses equally share the error, and that technically the policy was followed. She stated the facility had changed the policy to include checking the MAR (Medication Administration Record) and then audited.”
Our Hopkins nursing home neglect attorneys recognize the failing to follow protocols to ensure that residents remain safe from serious medical errors likely caused the death of the resident. The deficient practice by the nursing staff could be considered mistreatment or negligence because their actions failed to follow the facility’s policy title: Anticoagulant Therapy Guideline that reads in part:
“Enter the correct order for the anticoagulant (blood thinner) drug on the [resident’s] MAR (Medication Administration Record).”