Neglect Led to Duluth Nursing Home Resident’s Fall

The Minnesota Department of Health has determined that a Benedictine Health Center employee neglected a resident, causing her to fall. The resident — who suffered from advanced Parkinson’s disease, dementia, a stroke and osteoarthritis — died nine days later. “There is nothing in the investigative records to indicate any relationship between the fall and the death,” Health Department spokesman John Stieger said. “Often in cases like this the resident has a number of health conditions.” Neither the resident nor the employee are identified in a Jan. 26 investigative report by the department’s Office of Health Facility Complaints. According to the report, the resident had left-side paralysis and required extensive assistance. Her care plan called for her to be transferred between wheelchair and toilet using a mechanical lift. The lift includes a vest, a buttock strap and straps for the lower legs. “The nursing assistant assignment sheet indicates that the EZ (mechanical lift) with the buttock strap is to be used for transfers to the bathroom,” the report said. On Aug. 27, the resident fell as the employee moved her between the bed and the bathroom. The employee admitted that she did not use the buttock strap during the transfer. The resident was diagnosed with head and left hip contusions. The woman “continued to have pain in her left hip, her ability to move declined, and her appetite decreased,” the report said. She was placed on hospice six days after the fall, and died three days after that. Mark Broman, executive director of the facility, said in an e-mail Thursday to the News Tribune that the incident was taken very seriously because they are committed to providing high-quality care and a high quality of life for all. “First, we wish to express our sincere condolences to the family,” Broman wrote. “This person was a treasured member of the Benedictine Health Center family.” He further stated, “We investigated the incident and determined that the employee did not follow the resident’s care plan or our policies. The employee was terminated and the incident reported to the Minnesota nursing assistant registry.” Broman said the lift was checked to ensure its safety and all staff members were retrained on the proper procedures in using it. According to the Health Department, the terminated employee has the right to appeal the report’s finding. If the findings stand, the report will be submitted to the nurse aide registry for possible inclusion on the abuse registry and the state Department of Human Services. The report found that Benedictine Health Center was in compliance with federal regulation and state rules. The report, however, will go on the center’s record. According to the Health Department website, there are seven substantiated complaints against Benedictine Health Center. Viewcrest Health Center, with eight substantiated complaints, is the only Duluth nursing home with more.