Minneapolis Nursing Home Abuse Attorney
After families spend weeks researching and locating the best nursing facility, they have every right to expect that the nursing professionals will treat their loved one under their care skillfully and faithfully. Unfortunately, many facilities place profits before patient care. In fact, the Minneapolis nursing home neglect attorneys at Rosenfeld Injury Lawyers LLC understand the terrible reality that many corporations in the nursing industry provide only a minimal standard of care to every resident.
Federal and Minnesota state laws require that all nursing facilities and nursing staff report every incident of abuse, neglect or mistreatment. Despite these laws, the vast majority of incidences of abuse, neglect and mistreatment often go unreported. This is often because the victim is vulnerable and either lacks the capacity to vocalize their concerns or are too afraid of retaliation from caregivers and residents causing them harm.
The alarming increasing rate of cases involving mistreatment and abuse are likely to continue in the future. This is because many more senior citizens reside in the Minneapolis area than ever before. Out of the nearly 400,000 residents residing within the Minneapolis city limits, approximately 50,000 are 65 years and older. This number more than doubles when counting all the senior citizens residing in Hennepin County.Minneapolis Nursing Home Resident Health Concerns
Our Minneapolis elder abuse attorneys have long responded to the increasing problems involving negligence and abuse and nursing facilities. Our experience, skilled negligence practice group serves as a legal advocate for every nursing facility resident throughout the state.
In an effort to help, we continuously review, assess and evaluate publicly available national databases including Medicare.gov outlining specific cases of abuse and neglect in nursing facilities nationwide. We publish our findings on opened investigations, filed complaints, safety violations and health concerns involving nursing homes throughout Hennepin County.Comparing Minneapolis Area Nursing Facilities
Our Minnesota nursing home neglect attorneys have compiled and published the list below detailing specific Minneapolis area nursing facilities that currently maintain below average ratings compared with other nursing homes nationwide. In addition, we have added our primary concerns by highlighting detailed cases that have resulted in the direct harm or injury of residents at the facility.
THE VILLA AT BRYN MAWR
275 Penn Avenue North
Minneapolis, Minnesota 55405
A “For-Profit” 120-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
Failure to Provide Medical Treatment and Care to Ensure the Resident Maintain Their Highest Level of Well-Being
In a summary statement of deficiencies dated 05/07/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “coordinate services to ensure [the resident’s medical treatment] was managed to minimize the risk of infection and clotting.”
The deficient practice was noted by state investigator observed a resident “in her room waiting for transportation [to an appointment for medical treatment]. The resident stated she was dialyzed three times each week on Tuesdays, Thursdays and Saturdays […and] explained her access site dressing was changed at the facility and she removed the dressing when she returned to the facility.” The resident under observation “directed attention to her personal garbage receptacle where a discarded dressing was observed. She denied staff had access and removed the dressing.”
However, the following morning at 7:10 AM on 05/06/2015, the resident “was sitting in her wheelchair in her room […and] reported she had already removed the dressing (applied at the facility) herself and had again discarded the dressing. The soiled dressing was observed in the garbage receptacle in her room.”
The state investigator conducted at 2:18 PM 05/06/2015 interview with the facility’s Licensed Practical Nurse (LPN) who stated he was the resident’s primary nurse.” During the interview, the LPN reviewed the resident’s TAR (Treatment Administration Record) and physician’s order and “verified that the TAR (Treatment Administration Record) lacked information to direct staff in the management of the dressing access site, assessment of potential clotting, infection and presence of bruit and thrill [bruit is a rushing roaring sound heard through a stethoscope and thrill is a buzzing sensation or strong pulse as blood flows through blood vessels].” The LPN indicated that the only thing the TAR (Treatment Administration Record) notes is for the LPN for the resident’s antibacterial ointment on the resident’s access site.
The state investigator conducted a telephone interview with the resident’s primary care nurse at 2:45 PM on 05/06/2016 which revealed that the facility “generally did not give directions or orders to manage the access site and [that] was left up to the discretion of the facility or resident.” The resident’s primary care nurse asked the Nurse Practitioner at the location where the treatment was given for further clarification and reported that “she expected the facility staff would have monitored bruit and thrill at least daily and to manage the access site.”
The resident’s primary care nurse at the treatment facility indicated that the facility “does not give orders regarding site management, but could see why it would be problematic. The nurse stated we don’t know what they are doing and they don’t know what we are doing. We have to come up with a better plan.”
State investigator conducted a 10:36 AM 05/07/2015 interview with the Director of Nursing at the Villa at Bryn Mawr who checked the resident’s records. Upon review, the Director of Nursing noted that “monitoring of bruit and thrill was on the TAR (Treatment Administration Record) through March 2015, but no direction regarding dressing care was found with the exception to apply [the resident’s antibacterial ointment] to the site.”
The Director of Nursing also stated during that interview, “I believe it fell off (no longer appeared on the consecutive TAR (Treatment Administration Record)) and was not added to the April TAR.” The Director also noted, “we all make mistakes. We have no specific orders from [the treatment facility] to manage the site.”
The investigator reviewed the undated guidelines from the treatment clue that directed the staff “check dressing site daily. Monitor, document and report PRN [as needed] any signs and symptoms of infection to access site [including] redness, swelling, warmth or drainage.”
Even though state investigator requested that the facility provide the surveyors their policy on handling the problem, it was not provided.
Our Minneapolis nursing home neglect attorneys recognized failing to follow protocols when providing care and treatment to a resident could place their health and well-being in jeopardy. The deficient practice by the nursing staff at the Villa at Bryn Mawr could be considered negligence or mistreatment because it fails to follow established procedures and protocols enforced by state and federal nursing home regulators.
BETHANY RESIDENCE AND REHABILITATION CENTER
2309 Hayes Street Northeast
Minneapolis, Minnesota 55418
A “For-Profit” 66-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
In a summary statement of deficiencies dated 09/14/2015, a complaint investigation was opened against the facility for its failure to “maintain a dressing on the [resident’s] catheter.” The deficient practice by the nursing staff at Bethany Residence Rehabilitation Center resulted in harming a resident “when the leg wound became infected and painful and required hospitalization.”
The complaint investigation involved a review of a resident’s 02/19/2013 Plan of Care that show the resident received specific medical treatments three times every week “had a central venous catheter (CVC) in the upper chest which was to be covered with a dry dressing. The Care Plan directed staff to observe for signs of infection and bleeding at the catheter site.” The resident’s 02/20/2013 Care Plan also noted that the resident “needed the assist of one staff or transfers, dressing, bathing and grooming.”
The state investigator also reviewed the resident’s 08/03/2015 Physician’s Note that documents the resident “heaviness wound on the right middle leg that had been open for 141 days, eschar (colored or clear) drainage and no pain. The wound measured 3.6 centimeters by 2.6 centimeters with a depth of 0.2 centimeters.”
The physician’s orders of 08/03/2015 noted that an enzymatic Santyl ointment that works by breaking down dead skin was to be applied “daily to the wound and covered with adhesive foam.”
10 days later on 08/13/2015, a nurse at the facility noted on the Resident’s Weekly Skin Checklist “that the wound bed was dark red with inflamed tissue surrounding and a foul odor.” That Registered Nurse was interviewed at 1:40 PM on 09/03/2015 and indicated “the dressing removed on 08/13/2015 had a date of 08/09/2015 written on it and was the same dressing she applied on Sunday, 08/09/2015.”
That Registered Nurse “reported the air to the [facility process] Director of Nursing [… stating that] the dressing was changed on 08/14/2015, and when the dressing was removed there were several white crawling bugs in the wound under the scabbed area on the side of the wound […and] stated she covered the wound and sent [the resident] to the hospital.”
The state investigator noted that the 08/20/2015 Hospital Discharge Summary noted that the resident “was admitted to the hospital from 08/14/2015 to a 22,015 for treatment” and that the “once cleansed and visible maggots removed and [the resident] received intravenous antibiotics.”
The state investigator interviewed the facility’s Licensed Practical Nurse on 08/28/2015 at 3:00 PM to verify that the dressings on the resident were not completed between 08/10/2015 and 08/12/2015 “because he misread the order and just checked that the dressing was in place and did not change the dressing.”
A review of the facility’s 08/14/2015 Progress Note documented that the Social Worker providing off-site treatment “had called the state [noting that the resident] had arrived with a foul body odor. The Social Worker also expressed concern that [the resident] did not have a dressing covering the catheter site on the chest several times when [the resident] arrived for medical treatment.”
The state investigator noted that the resident’s 02/13/2015 treatment record included in order “to check the dressing every shift and to keep the catheter covered with a gauze dressing.”
Our Minneapolis nursing home neglect lawyers recognized failing to follow protocols when providing care to a resident requiring special services could place the health and well-being of the resident in immediate jeopardy. The deficient practice by the nursing staff at Bethany Residence and Rehabilitation Center might be considered negligence or mistreatment because their substandard actions or inaction led to the growth of maggots in the resident’s open wound.
625 West 31st Street
Minneapolis, Minnesota 55408
A “For-Profit” 129-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Follow Procedures and Protocols to Immediately Notify the Resident’s Doctor and Family Member of Any Change in the Resident’s Situation (Injury/Decline/Room)
In a summary statement of deficiencies dated 10/15/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “notify responsible party of a fall shortly after [the resident’s] admission.” The deficient practice by the nursing staff at Redeemer Residence was brought to the attention of a family member who “reported the lack of notification.”
The deficient practice was noted by a state investigator who interviewed a family member of a resident at Redeemer Residence at 1:40 PM on 10/12/2015. The family member reported that the resident “had experienced a fall on Friday, however, she had only learned of the information when she came to visit today (Monday) […and] confirmed she was the responsible party for [the resident].”
The state investigator reviewed the resident’s Nurse’s Notes that revealed: “the resident had been admitted to the facility looking frail and cachectic [in ill health, and] was instructed to use the call light if she needed help, and the bed was in the lowest position.”
The state investigator conducted a review of the resident’s 7:38 PM 10/09/2015 Fall Report that revealed that the resident “was found prone (face down) on the floor at around 6:45 PM.” The notes also reveal that the resident stated, “I don’t know what happened. I fell.” Other notations indicate that the “resident showed some confusion and no agitation. No injuries, bleeding, contusion, abrasion or hematoma (bruising, scrapes or swelling filled with blood) noted on the head.” At that point after the fall, the nursing staff assisted the resident to bed noting “will be monitored throughout the night.”
A 3:26 PM 10/14/2015 interview was conducted with the Registered Nurse who provided the resident care at the time of the fall. Notations were made that the Registered Nurse “was on duty had notified the family of [the resident] fall on 10/09/2015 at 8:20 PM.” In addition, “a safety form dated 10/09/2015 indicated [that the Registered Nurse] notified [the resident’s] family at 8:30 PM.”
However, 10:23 AM on 10/15/2015, a follow-up telephone call was placed by the family member who “reported she arrived the facility to visit [the resident three days earlier] on 10/12/2015, at approximately 10:30 AM. During her visit [the resident] told her she had experienced a fall.” At that time, the family member “inquired with the nurse who was working that day, who verified her mother indeed had fallen [3 days prior] on 10/09/2015.” When the family member was told that the fall “was documented that a nurse had called her the day of the fall, she emphatically reported, ‘that’s a lie’ and said no message had been left on either her home or cell phone.”
The state investigator conducted a follow-up interview with the Registered Nurse who stated “he had contacted [the other Registered Nurse who documented] family for notification of the fall. The nurse verified he had not actually contacted [the resident’s family, but] thought the nurse probably intended to contact [the resident’s] family, but then forgot.” At the time of the fall, that Registered Nurse was the night manager of the unit and “stated he expected the family to be called regarding all falls.”
Our Minneapolis elder abuse attorneys recognized failing to follow procedures and protocols to immediately notify responsible parties, family members, and the resident’s doctor violates state and federal regulations. The deficient practice by the nursing staff at Redeemer Residence might be considered negligence or mistreatment because their actions failed to follow the facility’s September 2011 policy title: Fall Management Policy – Protocol for Investigation of a Fall that reads in part:
“Licensed nurses to contact family member/designated person.”
BYWOOD EAST HEALTH Care Center
3427 Central Avenue Northeast
Minneapolis, Minnesota 55418
A “For-Profit” 98-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
Failure to Follow Procedures and Protocols to Maintain the Resident Safety from Serious Medication Errors
In a summary statement of deficiencies dated 04/30/2015, a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “ensure [a resident] was free of a significant medication error. The facility’s process for double checking insulin medication sheets prior to the new month start failed to identify and order change, and failed to prevent incorrect insulin sliding-scale doses from being given for four days in April 2015.”
The deficient practice was noted by state investigator reviewed a resident’s medical records for 10/16/2014 Insulin orders indicating that the resident was to receive 16 units of insulin medication “under the skin three times a day before meals (also has a sliding scale) in addition to [other medications].”
The state investigator also reviewed the resident’s CCA (Care Area Assessment) indicating that the resident “had diabetes, was obese, received a therapeutic diet for diabetes and [other medical condition].” The resident was hospitalized “for lung disease and acute worsening, diabetes uncontrolled and worsening heart failure. During the illness [the resident] received [a drug that treats allergic disorders and acute lung illness] that can cause a rise in blood sugar levels.”
Upon return to the facility from the hospital on 03/12/2015, a notation was made that the resident’s “SS insulin coverage was increased. A handwritten order was implemented” noting that specific units of insulin were to be given on a sliding scale based on the resident’s blood glucose levels and that the doctor needed to be called.”
10 days later on 03/22/2015, the April 2015 Order Set that had the aggressive SS insulin orders verified by the first check nurse correctly.” Three days later on 03/25/2015, “the prior aggressive SS insulin order was discontinued and [the resident] resumed her usual schedule insulin dosing and a new SS insulin order was written.” This order provided details on blood glucose sliding-scale increments of how many units of insulin would be given to the resident along with orders to call the doctor. The order was also to be implemented that day.
Five days later on 03/30/2015 “the second check nurse did not identify that in order change for the SS coverage had occurred. The computer printed aggressive SS insulin coverage [the one that had been discontinued] was approved by the second check nurse incorrectly. The printed medication record [noting the wrong SS insulin coverage for the resident was instead] implemented on 04/01/2015.”
The state investigator reviewed the resident’s MDS (Minimum Data Set) indicating that the resident “was cognitively intact, minimally depressed and experienced hallucinations and delusions.”
The same day on 04/01/2015 the resident received the first incorrect dosage of insulin SS coverage at 6:00 AM when the resident’s blood glucose level measured 150. Instead of the resident receiving two units of insulin administered according to doctor’s orders, the resident received instead six units of SS coverage.
Five hours later at 11:00 AM, the resident’s blood glucose level was not recorded. “However it was documented that six units of SS insulin was given instead of two units that should have been administered.” Again 5 ½ hours later at 4:30 PM, the resident’s blood glucose levels registered 76 and no SS coverage was given. Again at 9:00 PM, the resident’s blood glucose levels measured 99 and again no SS coverage was given.
The following morning on 04/02/2015 6:00 AM, the resident’s blood glucose levels were measured. The Treatment Nurse should have administered two units of insulin but instead administered six units of SS coverage.” 11:00 AM, the nursing staff did not record the resident’s blood glucose levels. However, five units of insulin were administered to the resident even though it was unclear “how many units should have been given since five units was not an option on the SS insulin coverage [chart].”
The following morning at 6:00 AM on 04/03/2015, the resident’s blood glucose level measured 184. Instead of being administered two units of insulin according to the physician’s orders, the medication nurse administered six units of SS coverage.” The resident again received an additional six units of SS coverage at 11:00 AM when their blood glucose level measured 173 instead of the two units in accordance with physician’s orders.
The last incorrect dosage of insulin was given to the resident at 6:00 AM on 04/04/2015 when the resident’s blood glucose level measured 174. At that time, the medication nurse administered six units of SS coverage instead of two units per physician’s orders.”
During an interview with the Registered Nurse administering the insulin medication to the resident noted that “she gave the wrong dose on Friday.” In addition, that Registered Nurse “noted that the second check was done after the order change on 03/25/2015, and [the mistake] should have been caught.”
The state investigator conducted a 2:45 PM 04/30/2015 interview with the facility’s Assistant Director of Nursing who stated “she had reviewed the errors with [the Registered Nurse administering insulin to the resident] and was aware errors in administration and transcription had occurred for the first four days of April, after the SS insulin coverage orders have been changed on 03/25/2015.”
In addition, the Assistant Director of Nursing stated that “the insulin order should have been caught on the second check review that was completed on 04/30/2015.”
Our Minneapolis elder abuse lawyers recognize a failing to follow procedures and protocols when administering medication could place the health and well-being of the resident in immediate jeopardy. The deficient practice by the nursing staff at Bywood East Health Care Center might be considered mistreatment or negligence because the Director of Nursing, Administrator and facility failed to establish or adopt a double check procedure for reviewing insulin administration records against the physician’s orders to revise their 2009 policy titled: Policy and Procedure for Administration of Insulin.
WALKER METHODIST HEALTH CENTER
3737 Bryant Avenue South
Minneapolis, Minnesota 55409
A “Not for Profit” 330-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
Primary Concerns –
Failure to Ensure That Every Resident Is Provided an Environment Free of Accident Hazards and Provided Adequate Supervision to Prevent an Avoidable Accident from Occurring
In a summary statement of deficiencies dated 02/08/2016, a complaint investigation against the facility was opened for its failure to “ensure elopement risk factors were evaluated and interventions implemented for adequate supervision for [one resident at the facility] with a history of elopement.” The deficient practice by the nursing staff at Walker Methodist Health Center resulted in actual harm of a resident who “wandered from the facility and had a fall with injuries that included a laceration and hematoma to the upper corner of the left eye, bruises to bilateral arms and a swollen right knee.”
The complaint investigation involved a review of the resident’s medical records and Nursing Home Admission Notes that identified the resident “was admitted to the facility’s short-term rehabilitation memory care unit located on the third floor on 08/18/2015, following the hospital admission for acute confusion when found by EMS [Emergency Medical Services] wandering and dropping winter coats on the street.”
The state investigator noted that the resident’s 08/18/2015 hospital Discharge Summary “identify the resident’s family had noticed cognitive impairments over the past year, and long-term memory care placement was being considered.”
However, a review of the resident’s 11/12/2015 Care Plan “identify the resident was a vulnerable adult due to cognitive impairments with the goal that the resident will be safe in his/her environment. The only intervention directed staff to assist in emergencies.”
The investigator also reviewed the resident’s 09/24/2015 Nursing Notes, it revealed the resident “exited the secured short-term rehab memory care unit on 09/21/2015, by the stairway.” The facility’s Nursing Notes also “indicate the resident initially insisted that [they] want to go to the post office and that the resident was difficult to redirect back to the unit.”
The following day on 09/22/2015, the facility’s Nursing Notes “identified the resident had a Wanderguard (bracelet type device that triggers an alarm on all exit doors located on the first floor of the) due to seeking to exit from the unit and refusing to return to the unit.”
9 days later on 10/01/2015, the facility’s Nursing Notes identified that “the resident cut off the wander guard and that staff pinned the wander guard to the back of the resident sweater, and the 30-minute checks were completed. The resident’s record lacked evidence of documentation that a reassessment of the Safety Risk Assessment was done. The record also lacked documentation that further interventions were implemented to ensure the resident safety other than the placement of a Wanderguard in which the resident had the ability to remove.”
That same day 10/21/2015, “resident transferred from the secured short-term memory rehab unit to the fourth floor long-term unsecured unit.” The state investigator reviewed the facility’s 11/10/2015 Resident Records that reveal “at approximately 10:15 AM [the resident] left the facility and traveled to Northeast Minneapolis.” In addition, the 11/10/2015 Nursing Notes “identify the resident was returned to the facility by a passerby six hours after [they] left the facility.”
Upon return to the facility by a passerby, the resident was noted to have “a laceration and hematoma to the upper corner of the left eye, abrasions to bilateral arms, and a swollen right knee. At that point, “the resident was sent and admitted to the hospital for evaluation of the injuries [before being readmitted to the facility].”
The state investigator conducted a 9:30 AM 11/12/2015 interview with the facility’s Registered Nurse providing the resident care who “voiced awareness of the resident’s attempt to elope prior to being transferred to the fourth floor […and] stated the facility had a bed management team that discussed admissions and placement of residents.” The Registered Nurse also said that the resident “was fearful of elevators and would not go on one, therefore was suspected the resident had the ability to watch staff exit to the stairwell by pressing the button to release the door […and] stated the resident was not due for [their] Quarterly Minimum Data Set when asked if a reassessment for safety risk factors was completed.”
A 12:25 PM 11/12/2015 interview was conducted by the state investigator with the facility’s Director of Nursing who verify that the resident “had a history of [elopement].” In addition, the Director of Nursing stated: “an evaluation was completed by the Interdisciplinary Team (IDT) prior to the resident being transferred to the unsecured long-term care unit and that the IDT deemed this was an appropriate placement for the resident.” However, the Director of Nursing stated: “there was no documentation of the evaluation or what factors were considered when this decision was made.”
The state investigator observed the resident’s room on the fourth floor which revealed “the room was located on the back side and out of view from the nursing station and in the same hallway as the stairwell door. The elevator doors were located directly across from the nursing station.”
Our Minneapolis elder abuse lawyers recognize the failing to follow procedures and protocols to ensure that every resident is provided an environment free of accident hazards and provided adequate supervision to minimize the potential of elopement could place the health and well-being of the resident in immediate jeopardy. The deficient practice by the nursing staff at Walker Methodist Health Center might be considered negligence or mistreatment because their actions failed to follow the established procedures and protocols enforced by federal and state nursing home regulators.