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).”
3720 23rd Avenue South
Minneapolis, Minnesota 55407
A “Not for Profit” 190-certified bed Medicaid/Medicare-participating facility
Overall Rating – 3 out of 5 possible stars
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
A “For-Profit” 60-certified bed Medicaid/Medicare-participating facility
Overall Rating – 3 out of 5 possible stars
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
A “For-Profit” 64-certified bed Medicaid/Medicare-participating facility
Overall Rating – 3 out of 5 possible stars
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
A “Not for Profit” -127 certified bed Medicaid/Medicare-participating facility
Overall Rating – 3 out of 5 possible stars
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
A “not for profit” 179-certified bed Medicaid/Medicare-participating facility
Overall Rating – 3 out of 5 possible stars
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 Rosenfeld Injury Lawyers 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 (888) 424-5757 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.
If you are looking for information on a specific facility or an attorney, please see links below to respective locality pages.