June 13, 2018 12:55 PM
A Minnesota Department of Health report has found a Brooklyn Park health care facility's negligence led to the death of a resident in October 2017 whose ventilator stopped overnight without staff knowing. The resident was found dead the next morning.
According to the report, Plateau Healthcare, LLC, "failed to follow the client's care plan, assess the client, or provide services that were essential to the client's health."
The man was identified in a police report as Taurus Grantham. According to family, Grantham had ALS and was nearly paralyzed.
On Tuesday, his father shared his frustrations about his son's death.
"That is inhumane," Andrew Grantham said. "Who does that to a person."
What remains unknown after a months-long investigation is how long Grantham was dead before he or she was found, and why the services were not completed during the ordered times.
The MDH report details the following:
The resident had a physician-ordered care plan that required continuous ventilator use. This required intake and output monitoring every four hours, oral suctioning every three to four hours and documenting the ventilator settings and readings every four hours.
Oxygen saturations should have been check twice per shift, and the ventilator should have been repositioned in the bed every two hours. The doctor also noted in the treatment plan all refusals should be documented.
The health department's investigation found the Grantham's chart had recorded the prescribed checks had occurred, but when interviewing the nurse practitioner on duty who was solely assigned to this one patient that evening, the story changed.
The nurse practitioner said in an interview, he or she did not do the prescribed checks other than the initial vitals taken at 8:41 p.m., according to the report. Additionally, the nurse practitioner said the patient didn't want to be woken up in the middle of the night, however, the practitioner did not answer when asked why the refusals were not documented.
The practitioner revealed he or she does not normally check if the client is breathing, rather just checking the machine is working, the report states.
What experts found from the ventilator log was that the machine had a low battery, which triggered alarms at 12:09 a.m. and 12:22 a.m., however, several staff members interviewed said they did not hear the alarm, the report reveals.
In a police report, the nurse practitioner said Grantham was last checked on at 11 p.m. before bed and was found unresponsive around 6 a.m., the MDH report states.
The report concludes the practitioner "failed to complete the ordered care for the client, falsely documented completing cares which were not done, and did not assess the client as indicated. The failures contributed directly to failing to notice that the ventilator was not plugged in when it needed to be and was not operating for most of the alleged perpetrator's shift."
Plateau Healthcare LLC released a statement Tuesday night, which read as follows:
It is important to note that the finding of neglect made by the Office of Health Facility Complaints was solely against the individual nurse. It was not against Plateau Healthcare. It should also be noted that the nurse against whom the neglect finding was made is no longer working with Plateau Healthcare.
Immediately following the incident, we conducted a detailed investigation into what happened and took action accordingly. In response to a correction order recently issued by the Minnesota Department of Health in connection with the OHFC investigation, we are again reviewing our processes and will make changes where needed. We are also evaluating our options with respect to an appeal of the order.
We strive to provide the highest quality care to our home care clients and are proud to serve them. We want our home care clients and their families to have peace of mind that they are receiving quality care in a compassionate and caring environment.
*Editor's Note: This initial report referred to a Brooklyn Center health care facility. The company's headquarters are in Brooklyn Center, which was the address listed on the report. The man died at a Brooklyn Park facility. The copy has been updated to reflect this change.
Theresa Malloy & Beth McDonough
Updated: June 13, 2018 12:55 PM
Created: June 12, 2018 12:18 PM
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