Photo: KSTP/Matt Belanger
Photo: KSTP/Matt Belanger
June 28, 2018 12:59 PM
A Minnesota Department of Health investigation has found neglect occurred at a Northfield health care facility where a resident in January fell and died.
That patient had fallen two weeks prior to the fatal fall, and the investigation revealed both times the woman was improperly transferred by an overnight staff member who was unlicensed and lacked knowledge of the patient’s care plan, the report states.
The woman died on Jan. 28 at a home on the Laura Baker Service Association’s campus located at 211 Oak Street.
MDH concludes in its report published Tuesday, “The facility failed to re-assess the client’s transfer needs after the first fall, failed to investigate the circumstances of both falls, and failed to evaluate the care giver’s competence to perform client care.”
However, the facility’s internal investigation concluded, “neglect was not suspected in the incident,” and it failed to address discrepancies in accounts of the falls, MDH found.
The campus is comprised of several homes, and each house was staffed with one unlicensed caregiver who worked overnight.
The first fall happened on Jan. 14, and the report states the resident counselor was not using a transfer belt. The report also notes the woman was reluctant to transfer with the resident counselor twice that night.
“The client was weak and tired from standing at the grab bar so long; the counselor was also tired from trying to support the client at the grab bar,” the report reads.
Then, the client slid to the floor leaving the counselor unable to get her up without assistance. The counselor called the caregivers in the other homes for assistance, but they could not leave because they were the only people in those homes, the report states.
The resident called 911, and the woman was not injured from the fall.
MDH did not find evidence the registered nurse investigated what happened in the Jan. 14 fall regarding the failure to use a transfer belt, did not re-educate the counselor or re-assess the woman’s needs.
Exactly two weeks later, the woman fell again on the bathroom on Jan. 21, and this fall was deadly.
The MDH report says the woman was standing up and using the grab bar, when she “fell forward and landed sideways on top of her left arm. The client’s face was down.”
The woman “expelled a large volume of secretions. The client’s respirators were gurgly,” the report continues.
She was not speaking and appeared distressed, the report details, and the counselor left her in the bathroom to call first the caregivers at other homes who could not come to assist because they were the only ones there. At 1:30 a.m., 15 minutes after the fall, the 911 call was placed.
Law enforcement arrived first and noted the counselor had the woman’s head in his or her lap. (The report does not specify the gender of the employee involved, which is standard in these investigations.)
MDH investigators learned the woman was not breathing when first responders came, and “The resident counselor was not assisting the client in any way.”
The counselor was not familiar with the woman’s care directive or where to find it and went to search, investigators learned.
Authorities moved the woman and started CPR, however, it was stopped due to the client’s do not resuscitate directive, MDH reports.
More specifically though, CPR was not to be administered if the woman was breathing, though her care directive specifically says if she was aspirating and not in cardiac arrest, staff “should provide comfort interventions, defined as the use of ‘medications, oxygen, oral suction, and manual clearing of airways as needed for immediate comfort; avoid calling 911, call hospice instead,’” according to the report.
The health department found staff did not provide the necessary interventions.
The facility’s log read the woman was “face-down and she was aspirating” when the counselor called emergency personnel, “and they did what they could but she passed away,” according to the MDH report.
The report notes she did not have a transfer belt on in the second fall. Emergency responders told investigators they advised the counselor to use the transfer belt after the first fall.
“All emergency personnel, who responded to the client’s falls in mid-January and late-January 2018, expressed concerns regarding the resident counselor abilities as a care giver. On both occasions, the resident counselor appeared frustrated with the client, did not know what to do next, and did not appear competent to provide client care,” the report stated.
“The resident counselor’s knowledge of the client’s care was insufficient to meet the client’s needs. The resident counselor appeared under-trained,” it continues.
Looking back at medical records, investigators learned the staff notes in early December 2017 indicated the woman “had further declined in weakness,” and she required two or three caregivers to safely transfer her and relied more on a wheelchair, according to the report.
However, MDH found no evidence the registered nurse modified the care plan or educated staff to accommodate the woman’s change in her mobility status.
The report also states, “There was no evidence that the RN followed up to re-assess the client’s needs for safe transfers.”
When the client died, the care plan called for the client to transfer by standing, shuffling and pivoting.
MDH issued correction orders relating to the facility, which have since been corrected.
Laura Baker Services Association Executive Director Sandi Gerdes issued the following statement to KSTP:
In January, a long-time resident at LBSA died. The person was on hospice and had DNR/DNI orders in place, so her death was not unexpected. We miss her and are mourning her loss. We care deeply for all of the people we support.
When the Health Department investigated her death after they received our required notification, they determined that we as an agency were neglectful.
We received, responded to, and implemented corrective actions addressing their findings. They have accepted our response and we have cleared all of the citations. We could appeal the finding; we are still making a final determination if we will do so.
The client’s family is very supportive of our work with their sister. They are surprised by the finding, and would move their sister back to LBSA were she alive to do so. In fact, the person and her family asked that she be allowed to receive hospice care at her home at 211 Oak Street.
We believe that we always have room to improve and grow. Beyond mourning the loss of a client, we take this opportunity to continue to improve.
We stand behind our mission to support the life choices and dreams of people with intellectual and developmental disabilities and help them reach their goals.
Updated: June 28, 2018 12:59 PM
Created: June 27, 2018 08:41 PM
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