Minneapolis Nursing Home Abuse Attorney

Minneapolis Elder 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
(612) 377-4723

A “For-Profit” 120-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

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.

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BETHANY RESIDENCE AND REHABILITATION CENTER
2309 Hayes Street Northeast
Minneapolis, Minnesota 55418
(612) 781-2691

A “For-Profit” 66-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 star rating

Primary Concerns –

Failure to

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.

REDEEMER RESIDENCE
625 West 31st Street
Minneapolis, Minnesota 55408
(612) 827-2555

A “For-Profit” 129-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 star rating

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.”

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BYWOOD EAST HEALTH Care Center
3427 Central Avenue Northeast
Minneapolis, Minnesota 55418
(612) 788-9757

A “For-Profit” 98-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

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
(612) 827-5931

A “Not for Profit” 330-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 star rating

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.

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ROBBINSDALE REHABILITATION AND CARE CENTER
3130 Grimes Avenue North
Robbinsdale, Minnesota 55422
(763) 588-0771

A “For-Profit” 75-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 star rating

Primary Concerns –

Failure to Provide Adequate Care and Services to Prevent the Development of a New Pressure Sore or Allow an Existing Bedsore to Heal

In a summary statement of deficiencies dated 12/17/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “ensure [a resident at the facility] who had been identified at risk for pressure ulcers received assistance with repositioning.”

The deficient practice was noted by state investigator reviewed a resident’s MDS (Minimum Data Set) indicating that the resident “was at high-risk pressure ulcers due to impaired bed mobility and impaired transfer.” In addition, the MDS (Minimum Data Set) further noted that the resident “had an unstageable stage IV pressure ulcer (full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (e.g.) tendon, joint capsule. Undermining and sinus tracts also may be associated with Stage IV pressure ulcers).” The MDS (Minimum Data Set) also noted that the resident “required two person assist for transfers and bed mobility and had no behaviors of refusing care.”

A notation was made on 11/25/2015 of the resident’s unstageable ulcer [which is an ulcer with full tissue thickness loss in which the base of the ulcer was covered by slough and eschar and therefore the true depth of the damage cannot be estimated until these are removed].” The resident’s wound measured 2.8 centimeters by 1.4 centimeters by 0.4 centimeters and healing well with no slough noted.”

Seven days later on 12/02/2015, the resident’s unstageable ulcer remained the same in size as the previous week. The following week, the unstageable pressure had decreased in size to a measurement of 2.4 centimeters by 0.6 centimeters by 0.4 centimeters and “was healing well no slough noted.” The following two weeks, the measurement stayed the same except a notation that the wound was now “pink in color.”

However, on 12/16/2015, an observation was made of the resident concerning repositioning. The state investigator noted that “at 1:32 PM [the resident] was placed in her bed [and remain there] for three hours and 45 minutes without being repositioned.”

The investigator reviewed the resident’s Skin Integrity Assessment: Prevention and Treatment Care Plan that instruct the staff “implement an individualized turning schedule in applicable (every) two hours, to lay [the resident] on the left side while in bed but not at all times, in turn [the resident] with two pillows slightly high on side. Wheelchair positioning per Medical Doctor order.”

Our Robbinsdale nursing home neglect attorneys recognize the failing to provide adequate care and services according to physician’s orders when allowing a resident’s bedsore to heal could place their health and well-being in jeopardy. The deficient practice by the nursing staff at Robbinsdale Rehabilitation and Care Center might be considered negligence or mistreatment because their actions failed to follow established procedures and protocols for providing acceptable standards of care.

CENTENNIAL GARDENS FOR NURSING and REHABILITATION
3245 Vera Cruz Avenue North
Crystal, Minnesota 55422
(763) 535-6260

A “For-Profit” 130-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Ensure That All Services Provided by the Nursing Facility Meet the Highest Level of Professional Standards of Quality

In a summary statement of deficiencies dated 02/05/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “develop an initial care plan to include smoking safety for [a resident at the facility] who is newly admitted and was observed smoking since admission to the facility.”

The deficient practice was noted by state investigator who conducted a 12:13 PM 02/05/2016 observation of a resident “propelling himself in front of the entrance of the facility […and skidding] to a stop on the sidewalk and dropped a pack of cigarettes on the ground at which time an unidentified individual walking up the sidewalk was noted to assist [the resident] to pick up a cigarette and assist him with a lighter.”

The investigator also reviewed the resident’s 02/02/2015 Admission History and Physical documentation that indicates “he suffered from weakness as well as poor coordination and control of right arm and leg.” The resident’s History and Physical (H & P) further indicated that the resident had a long “history of smoking reported he had been smoking cigarettes. A facility assessment labeled NUR (nurse) Q Shift Post Admit Charting dated 02/05/2015 indicated [the resident] required extensive assist for transfers, was alert to a person only and was at risk for falls.”

The investigator also reviewed the 02/03/2015 Progress Notes that reveal that the resident “was noted by staff walking and wanting to leave the facility. The note further indicated [the resident] was found on the floor inside the front entrance of the facility the same evening while attempting to go outside and smoke a cigarette.”

While the facility’s Progress Notes indicated staff was aware of the resident’s [desire to smoke, and that [the resident] has fallen in the facility, attempting to go outside and smoke, there was no evidence the facility developed and implemented interventions to decrease the risk of falls for [the resident] related to smoking.”

A review of the resident’s 02/04/2016 Care Plan identify the resident “At riskfor falls but did not identify smoking as a causative factor even though [the resident] had fallen while attempting to exit the facility to smoke a cigarette nor do they implement interventions to reduce the risk of falls.

The state investigator conducted a 12:30 PM 02/05/2016 interview with the facility’s ED (Executive Director) stated that the resident “should have a Wanderguard to alert staff if he is attempting to leave the facility to smoke […and stated that the resident] was not in any way, shape or form able to be outside by himself.”

An interview was conducted at 1:10 PM on the same day 02/05/2015 with the facility’s Director of Social Services (DSS) who stated that “the facility was a non-smoking facility and if a resident was identified to be smoking, staff was to take the resident’s cigarettes away and call family. He further stated that if a resident wishes to smoke, they had moved to another facility.” The Director of Social Services also stated: “there were no residents currently in the facility that were deemed unsafe to smoke so safety interventions had not been addressed in regard to the accident prevention related to smoking.”

Our Crystal nursing home neglect attorneys recognize the failing to follow procedures and protocols that meet the highest level of professional standards could place the health and well-being of one or more residents an immediate jeopardy. The deficient practice by the nursing staff at Centennial Gardens for Nursing and Rehabilitation might be considered negligence or mistreatment because their actions failed to follow the facility’s June 2015 policy title: Care Plan Policy and Procedure that reads in part:

“It is the policy of Crystal Care and Rehabilitation Center to provide a temporary Care Plan within 24 hours of admission. The Care Plan would ensure the appropriate care required to maintain or attain the resident the highest level of practical function possible.”

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CAMDEN CARE CENTER
512 49th Avenue North
Minneapolis, Minnesota 55430
(612) 529-7747

A “For-Profit” 87-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Make Sure That Every Resident Is Provided the Highest Level of Care to Ensure They Maintain Their Highest Well-Being

In a summary statement of deficiencies dated 06/20/2016, a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “provide appropriate care and services including assessment, care plan development and implementation of interventions.” The deficient practice by the nursing staff at Camden Care Center involved one resident “who had non-pressure related skin issues.”

The deficient practice was noted after state investigator observed a resident between 7:05 AM until 8:42 AM on 01/27/2015 of a Certified Nursing Assistant providing morning care to a resident at the facility. After removing the resident’s incontinence brief, the Nursing Assistant washed under the resident’s abdominal fold when the resident replied that it hurt. The Nursing Assistant told the resident “it was a tear under the left abdominal fold, and verified there was no gauze dressing between [the resident] abdominal fold and groin. At 8:09 AM, [a Registered Nurse providing the resident care] arrived to perform wound care.”

The Wound Care Nurse measured wounds on the resident’s left breast, cleansed the wound and applied a dressing. In addition, the Wound Nurse also performed care to the resident’s abdominal slits and noted a 9.2 centimeter long slit in the resident’s left groin.

The state investigator reviewed the resident’s 06/03/2015 Care Plan that revealed that the resident “was at risk for impaired skin integrity.” Notations were also made that interventions “instructed staff to assist [the resident] with repositioning as needed with each check and change […and encourage the resident] to make frequent position changes when [the resident] was able when in a chair or in bed, report skin issues to the physician as they arise and skin checks per facility protocol with bath and as needed.

A review of the resident’s Pressure Ulcer Care Area Assessment indicated that the resident “was a risk for skin breakdown related to incontinence, immobility, decreased sensation related to past stroke and reliance upon staff for repositioning.” The 11/10/2015 Nursing Assistant Assignment Sheet instructed the staff that the resident “required the total assistance of two to check and change before breakfast after lunch in during the night on rounds or as needed and encourage repositioning.”

The investigator also reviewed the resident’s January 2016 TAR (Treatment Administration Record) instructing the staff “to wash and dry abdominal folds and groin, apply 4 x 4 to skinfolds (started 01/20/2015). The treatment was set up for every shift. The information was not on the Care Plan or the Nursing Assistant Assignment Sheet.”

A 9:00 AM 01/27/2015 interview was conducted by the state investigator with the Registered Nurse providing the resident care who stated, “I was not aware of the slits on her abdomen. There are no wound sheets because the wounds developed in December while I was on vacation. The nurse who found the wound should have called the Medical Doctor. I am not a Wound Nurse; the Director is a Wound Nurse. I don’t know if the information is on the weekly sheets. It should be, the nurse should have updated the Care Plan.”

Two hours later at 11:00 AM, second Registered Nurse “was interviewed and stated, ‘I don’t [do] Care Plan turning a repositioning schedules because it is a compliance issue, you cannot get the staff to follow the schedule.”

That same day at 2:31 PM, on 01/27/2015, the Director of Nurses was interviewed and stated that the Nursing Assistant “told me about the slit on [the resident’s] right groin this morning. No one told me about the other wounds or that there was not a treatment for [the medical condition]. The nurse needs to chart on it and tell the Wound Nurse about it. The nurses need to put the appropriate interventions for the open area in place and document. The nurse needs to update the Care Plan. The nurse needs to get a treatment immediately from the doctor.”

In addition, the facility’s Director of Nurses also revealed that “the nurse would follow up weekly and as needed until resolved. I would expect a comprehensive skin assessment to be completed. There should be a tissue tolerance. There should be weekly skin checks for all residents.”

The Director of Nurses also stated that “to determine how often the residents need to be repositioned, we look at the tissue tolerance and comorbidities. Residents need to be turned at baseline, every two hours minimum. If there is a wound, every one hour. If the wound is nasty, the resident should only be up for meals. The individualized turning/repositioning schedule should be on the assignment sheets and Care Plans.

Our Minneapolis nursing home neglect attorneys recognized failing to follow procedures and protocols when providing a level of care to residents could place their health and well-being in jeopardy. The deficient practice by the nursing staff at Camden Care Center might be considered negligence or mistreatment because their actions failed to follow the facility’s 06/20/2005 Policy Title: Skin Care Protocol that reads in part:

“Skin assessments will be completed on a weekly basis.”

ANTHONY HEALTH CENTER
3700 Foss Road Northeast
St Anthony, Minnesota 55421
(612) 788-9673

A “For-Profit” 150-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 star rating

Primary Concerns –

Failure to Follow Procedures and Protocols When Investigating and Reporting Any Actual Report of Neglect, Abuse or Mistreatment of Residents

In a summary statement of deficiencies dated 10/29/2015, a notation was made by a state surveyor during an annual licensure and certification survey involving the facility’s failure to “Ensure bruises of an unknown origin were immediately reported to the Administrator and State Agency.” The failure by the nursing staff at Saint Anthony Health Center affected one resident at the facility.

The deficient practice was noted by state investigator reviewed a resident’s MDS (Minimum Data Set) indicating that the resident “had severe cognitive impairment required the extensive assistance of two staff for bed mobility, dressing, locomotion and toileting.”

The investigation involved a 04/20/2015 Incident Report “indicating during evening cares, nursing assistant alerted [a licensed practical nurse on duty] about a bruise to [the resident’s] left in her gluteal area on 04/18/2015.”

At that time, the Licensed Practical Nurse “noted the cause was unknown.” The Registered Nurse on duty “assess the bruise with [another Registered Nurse] on 04/20/2015. The bruise was noted to be 11.0 centimeters by 6.0 centimeters, dark purple in color and located on the inner aspect of the left buttock covering an area near the coccyx and anus.” It was noted that the resident “was unaware of how the bruise occurred.”

The investigation was initiated on 04/20/2015 when the facility’s Executive Director and Director of Nursing were notified of the incident. However, during a 1:28 PM 10/29/2015 interview with the state investigator, the Director of Nursing stated that “she was not sure why they were notified two days later, ‘we report injuries of unknown origin’.”

Our Saint Anthony nursing home abuse attorneys recognized failing to follow procedures and protocols to investigate and report any incident involving an injury of unknown origin could place the health and well-being of the resident in jeopardy. The deficient practice by the nursing staff, administrators and management at Saint Anthony Health Center might be considered negligence or mistreatment because their actions failed to follow the facility’s October 2006 policy title: Vulnerable Adult Abuse Prohibition Policy that reads in part:

“Mandated reporters will immediately report to the Administrator/Executive Director and that the facility shall report immediately to the Common Entry Point.”

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GOLDEN VALLEY REHABILITATION AND CARE CENTER
7505 Country Club Drive
Golden Valley, Minnesota 55427
(763) 450-6900

A “For-Profit” 164-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

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

In a summary statement of deficiencies dated 01/30/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “ensure dignified care was provided for [a resident at the facility] who complain staff did not respond to a call light in a timely manner.”

The deficient practice was noted by state surveyor who conducted a review of a resident’s Admission MDS (Minimum Data Set) that identify the resident “had no cognitive impairment, was frequently incontinent of bowel and required extensive assistance from staff from bed mobility, toileting and personal hygiene.”

In addition, the state surveyor reviewed the resident’s 01/13/2015 Care Plan indicating that “the resident had a pressure ulcer, instruct the staff to keep [the resident’s] skin clean, dry and free of body wastes, perspiration and wound drainage, and also to protect the skin from fecal and or urinary incontinence.”

A 6:28 PM 01/26/2015 interview was conducted with the resident and a family member who stated: “several weeks ago an incident happened that upset [the resident].” During the interview, the resident “stated he had and having difficulty with an upset stomach, has some loose stools and couldn’t walk, so the facility suggested wearing an incontinent brief.” The resident also stated that “he had an incontinent bowel movement so he put the call light on to request assistance with changing the soiled brief.”

At that point in the interview, the family member stated that the resident “had been complaining about past long call wait times, so she made a point of watching the clock when [the resident] turn the call light on to see how long it would take for the staff to assist [the resident] with cares.”

The family member stated that “after 50 minutes, no one had come in to help [the resident] so the family member went and raised the concern with [the] Referral Manager [stating that the Referral Manager] took notes and said the situation of [the resident] waiting over 50 minutes for assistance was unacceptable.” The family member also stated that the resident “had a pressure ulcer on his butt, so she was very upset the staff let him lay in stool for so long.” The resident also stated “he couldn’t believe the staff had left him like that and felt, ‘Hopeless’.”

The investigator reviewed the resident’s 01/16/2015 Resident Care Concern Form documenting the event that indicated that the resident “had put the call light on at 2:02PM for assistance with personal hygiene related to an incontinent bowel movement. The nurse entered the room to complete a blood sugar check and a Nursing Assistant entered the room to answer the call light. While both staff or in the room, [the resident] stated he needed assistance and the [Nursing Assistant] stated she would be back after helping another resident.”

However, the Nursing Assistant “never returned to provide [the resident] assistance. The form indicated after the investigation, [the Nursing Assistant] had forgotten to come back to assist [the resident].” The same investigator also noted that “the Administrator reviewed the form and sign the form three days later on 01/19/2015.”

The state investigator conducted an interview at 8:52 AM on 01/29/2015 with the facility’s Corporate Nurse Consultant and Director of Nursing who stated that the resident “sitting in stool for an hour could be a concern of not respecting the resident’s dignity.” In an interview conducted at 10:23 AM the same day on 01/29/2015 with the facility Administrator, the Administrator stated that “the incident involving [the resident] was ‘poor customer service’ and verified a resident should not sit in stool for almost an hour before receiving staff assistance.”

Our Golden Valley nursing home neglect attorneys recognized failing to follow procedures and protocols and a level of care that builds and maintains the dignity and respect of individuality could cause emotional harm to the resident. The deficient practice by the nursing staff at Golden Valley Rehabilitation and Care Center might be considered negligence or mistreatment because the damaging effects of their actions caused by allowing a resident to sit in their own bowel movement for almost an hour without assistance from the nursing staff.

The Consequences of a Poorly Managed Facility

Every day throughout Minneapolis, families entrust the care of an elderly loved one to nursing facilities that pledge to do everything possible to ensure their health and well-being. Unfortunately, residents are often betrayed at the most vulnerable point in their life by the institution in charge of providing them care.

Many nursing facilities are poorly managed or inadequately staffed with poorly trained or unqualified Registered Nurses, Licensed Practical Nurses, Certified Nursing Aides and others employees on the medical team. Without proper oversight, many residents become the victim of abuse, mistreatment or neglect in a variety of ways including:

  • Bedsores (decubitus ulcer; pressure ulcers; pressure sores)
  • Sepsis (blood infection) and osteomyelitis (bone infection) due to untreated or undetected open wounds
  • Dehydration and malnutrition
  • Medical mistakes including giving the resident medication belonging to another resident, overmedication, under medication or missed dosages
  • Head injuries, fractures and broken bones caused by falling
  • Physical, mental and emotional injuries caused by unnecessary or an unauthorized chemical/physical restraint
  • Elopement and wandering away from the facility undetected
  • Choking
  • Unsanitary conditions
  • Physical assault by other residents or caregivers
  • Sexual abuse
  • Emotional trauma including humiliation, abandonment, shaming and retaliation
  • Wrongful death

If you have found signs and symptoms that your loved one has suffered neglect or abuse in a nursing facility, you are probably outraged and heartbroken. In all likelihood, you are left wondering what you can do. Many families will hire an attorney to investigate any and all actions causing your loved one harm and take necessary action to hold the facility and nursing staff accountable for their negligence, abuse or mistreatment.

Hiring a Lawyer

The Minneapolis nursing home abuse attorneys at Rosenfeld Injury Lawyers LLC have immediate access to all resources necessary to determine whether or not your loved one has received the highest level of care they deserve. Our team of Minnesota elder abuse attorneys will address your concerns and document all pertinent evidence and facts needed to build a case for compensation. Through our actions, we can restore your loved one’s peace, safety and dignity and ensure that they are receiving the highest level of medical care to maximize their well-being at one of the most vulnerable times of their life.

Working as your loved one’s advocate, we take every legal step to ensure others at the facility do not have to experience the same harm in the future. Successful nursing home neglect and abuse cases require careful examination and investigation to determine every cause of harm and injury and the level of responsibility the nursing home and staff had in providing care to your loved one.

We encourage you to contact our Hennepin County elder abuse law offices today at (888) 424-5757 to schedule your free, no obligation full case review. All information you share with our law offices and attorneys remains confidential. We accept all wrongful death lawsuits, personal injury claims and nursing home neglect cases through contingency fee arrangements. This means we provide immediate legal representation, counsel and advice without an upfront fee.

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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.

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