June 28, 2018 06:25 PM
A Northfield police report reveals more details about the death of a female resident at a facility in the city following a fall in January.
The police report confirms Karen Marie Johnson was 63 when she died at the Laura Baker Services Association campus at 211 Oak Street on Jan. 28.
When police arrived on the scene she was unconscious, the report states. A Minnesota Department of Health investigation said the man who helped transfer her during the fall waited to call 911 and did not know her medical directive.
Health department investigators said law enforcement arrived first and noted the counselor had the woman’s head in his lap.
“The resident counselor was not assisting the client in any way,” MDH reported.
The police report states EMTs arrived on scene and located her do not resuscitate and do not intubate directives. They hooked her up to heart monitors at 1:49 p.m. and confirmed the time of death.
These details are some of the reasons the health department found the facility neglected Johnson.
The report published Tuesday found “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 facility issued a statement from its executive director Sandi Gerdes to KSTP on Wednesday, but declined to go on camera:
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.
According to the police report, 46-year-old David Wayne Vetter was the resident counselor who helped transfer Johnson on Jan. 14 and Jan. 28 when she fell.
KSTP is working to learn if Vetter, of St. Paul, is still employed with Laura Baker Services and efforts to reach him Thursday were unsuccessful.
Both times Vetter did not transfer Johnson properly, and he did not immediately call 911, MDH found.
Vetter called the other homes on the campus first in both situations and asked if another caregiver could assist, but MDH said each residence had one overnight worker attending to five to 10 patients and could not leave them alone to help.
The second fall was fatal and similar to the first one with that counselor two weeks prior. The health department said Vetter failed to use a transfer belt in both.
“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 MDH 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.
First responders 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 cardio 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 MDH report said Johnson 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” on Jan. 28.
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.
Looking back at medical records, medical 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 mobility status.
According to Johnson’s obituary posted on Bierman Funeral Hoe’s website, she moved into the Laura Baker Services in 1985 and lived there until 1994. She moved back in 1999 and lived there until she died.
KSTP reached out to family but has not yet heard back.
Updated: June 28, 2018 06:25 PM
Created: June 28, 2018 04:51 PM
Copyright 2018 - KSTP-TV, LLC A Hubbard Broadcasting Company