Minnesota Nursing Home Neglect and Abuse

Kosieradzki • Smith
Law Firm, LLC

877 552 2873
Call Us Today

Anoka Rehab and Living Center Neglects Resident

Category Archives:
Medication Errors

Medication Errors

Anoka Rehab and Living Center Neglects Resident

By Kosieradzki Smith Law Firm

August 6, 2013

The Minnesota Department of Health (MDH) has completed its investigation of neglect concerns at the Anoka Rehab and Living Center in Anoka, Minnesota.  A complaint was filed with the Department alleging that neglect occurred when a resident was not provided an ordered medication for approximately three weeks resulting in adverse effects. [Case no. H5205031]

The Department investigated the matter and found that the resident did not receive Coumadin, as ordered by a physician for 17 days. The resident developed discoloration in the left leg and confusion. The resident required hospitalization, was diagnosed with a clot in the left leg, and required three surgeries to increase circulation to the left leg. The MDH determined that the Anoka Rehab and Living Center is responsible for neglect of the facility’s resident.

The resident was admitted to the facility, from the hospital and had orders for the medication Coumadin. The order directed to staff was to hold the Coumadin dose on the day of discharge from the hospital, then give Coumadin 2.5 mg for two days, and then complete an INR lab draw. The order directed staff to update the physician with the lab results for further Coumadin orders. Staff did not ensure that the lab was drawn, or that the results were obtained or called to the physician. Therefore, the resident did not receive a dose of Coumadin for 17 days.

The Kosieradzki • Smith Law Firm represents clients in cases involving catastrophic injury caused by nursing homes and other care facilities that fail to provide proper care. If you believe your loved one has been harmed due neglect or abuse in a nursing home, take action and contact the Kosieradzki • Smith Law Firm online or call us toll-free at (877) 552-2873 to set up a no-cost, no-obligation consultation.

Yet Another Finding of Neglect at the Red Wing Health Center

By Kosieradzki Smith Law Firm

July 19, 2013

On January 3, 2011 the Minnesota Department of Health revised an investigative report on a substantiated claim of neglect on the part of Red Wing Health Center.  [Report no H5223045]

The neglect occurred when the facility failed to respond to one of its resident’s decline in health.  From the middle of June 2010 to the time the resident was hospitalized on July 10th, the Red Wing Health Center staff collected and documented information pertaining to the resident’s decline in health. This information included data on “Food and Fluid Records”, “24 Hour Nursing/Change of Condition” reports, and in facility “Progress Notes.”

All of the information revealed an on going significant decreased nutritious intake and severe decline in the resident’s physical health. However, the facility failed to respond and address the change in the resident’s health. Red Wing Health Center did not attempt any sort of intervention to decrease the resident’s decline in health. Additionally, neither the resident’s physician nor the clinical dietician was notified of the resident’s change in health.

As a result of the facility’s inaction, the resident’s opportunity for nutritional and medical evaluation and treatment were delayed.  On July 10, 2010, the resident was admitted to the hospital and diagnosed with Wegner’s granulomatosis (an uncommon disorder which causes inflammation of the blood vessels, which in turn restricts blood flow to various organs).

The MDH found that the Red Wing Health Center’s staff were aware of the resident’s on-going decline and failed to respond or address the patient’s decline in condition, failed to offer on-going interventions to decrease the resident’s risk of further decline, and failed to notify the dietician and the physician of the on-going decline.

This is not the first investigation of the Red Wing Health Center by the MDH.  Here are three other investigations in which the MDH substantiated a finding of neglect:

  • In April 2012, the MDH found that the facility’s resident was neglected when he sustained a fall after being placed in a wheelchair that did not have a pressure alarm or a self-release seat belt. The resident had dementia and required total assistance from the Red Wing Health Center staff.  The MDH found that the facility failed to have a system in place to mark or identify resident specific wheelchairs. [Case no. H5223057]
  • In March 2012, the MDH investigated an allegation that a resident with pneumonia did not receive her antibiodics prescribed by her physician because the nursing home’s staff failed to transcribe the medication order properly. The resident died.  The Medical Examiner determined that the cause of her death bronchopneumonia and COPD.  The MDH found that Red Wing Health Center’s policies and procedures did not provide an effective system related to transcribing orders into the computer with stop dates, notifying appropriate persons when a medication is not available, reviewing new orders for compliance/implementation and completing audits of all antibiodic orders/stop dates and that the antibiodics are being ordered. [Case no. H5223060]
  • In September 2011, the MDH investigated an allegation that the facility’s resident fell and suffered a traumatic femur fracture when being transferred from her wheelchair into bed by the care staff.  The care staff, however, failed to use the mechanical lift that was required by the resident’s care plan. [Case no. H5223052]

The Kosieradzki • Smith Law Firm represents clients in cases involving catastrophic injury caused by nursing homes that fail to provide proper care. If you believe that you or your loved one has suffered serious harm because the nursing home failed to do its job, take action and contact the Kosieradzki • Smith Law Firm online or call us toll-free at (877) 552-2873 to set up a no-cost, no-obligation consultation.

 

 

Fairview Nursing Home Resident Neglected

By Kosieradzki Smith Law Firm

July 12, 2013

Fairview University Transitional Services is a nursing home in Minneapolis.  The Minnesota Department of Health (MDH) just released a report, no. H5170018, finding that the nursing home failed to ensure that anticoagulant medication was administered to its resident.  This medication is used to protect patients from blood clots.  The resident subsequently went into cardiac arrest in mid-January and died from blood clots in his lungs, according to the state’s investigation report.

The state concluded that “[b]ased on a preponderance of the evidence, neglect is substantiated when a resident did not receive heparin during the fourteen days that he was at the facility.”  The investigation found that the “nursing staff at the nursing home failed to review the medical information pertaining to the resident.”  The MDH found that “the facility’s policies and procedures did not provide an effective system of reviewing all medical information pertaining to treatment of the resident.”

The MDH investigation revealed that the resident had a cardiopulmonary arrest while at the nursing home and the resident was transferred to the hospital for further care; the resident died at the hospital; a chest CT revealed that the resident had large bilateral pulmonary embody (blood clots); and the resident’s death certificate declared that the immediate cause of death was massive pulmonary emboli.

According to the Star Tribune, the  Fairview nursing home disputes the state investigation findings: “Officials from the home called the incident an ‘isolated event’ that does not support a finding of neglect, according to the report. They also argued that ‘it is unlikely’ that the lapse led to the blood clots.

The Kosieradzki • Smith Law Firm represents clients in cases involving catastrophic injury caused by nursing homes and other care facilities that fail to provide proper care.  Nursing homes commonly deny any wrongdoing when confronted.  For the experienced personal injury lawyer representing a neglected nursing home resident, a thorough understanding of a nursing home’s medication policies and procedures—and a meticulous level of inquiry to determine whether they were followed—is the resident and his or her family’s best tools in evaluating and proving medication mismanagement.

To learn more, please check out our recent series of blogs discussing medication errors in nursing homes:

Mismanaged Medications in Nursing Homes: An Overview (Part 1 of 6)

Mismanaged Medications in Nursing Homes: Proper Medication Management (Part 2 of 6)

Mismanaged Medications in Nursing Homes: A Resident’s Medical Records and Medication History (Part 3 of 6)

Mismanaged Medications in Nursing Homes: Maintaining Adequate Staffing and Staffing Procedures (Part 4 of 6)

Mismanaged Medications in Nursing Homes: A Nursing Home and Its Pharmaceutical and Laboratory Services (Part 5 of 6)

Mismanaged Medications in Nursing Homes: Conclusion (Part 6 of 6)

If you believe you or your loved one has suffered medication errors because the nursing home failed to do its job, take action and contact the Kosieradzki • Smith Law Firm online or call us toll-free at (877) 552-2873 to set up a no-cost, no-obligation consultation.

Mismanaged Medications in Nursing Homes: Conclusion (Part 6 of 6)

By Kosieradzki Smith Law Firm

July 1, 2013

Transitions between caregivers, changes in condition, and complex medication regimes increase the risk of harm to a nursing home resident. If residents are to be afforded the quality of care that federal nursing home regulations mandate—and more important, the dignity all residents deserve—nursing homes must diligently assess and manage all of these factors.

This means the nursing home must maintain effective clinical oversight, competent nursing, efficient pharmacy resources, quality laboratory services, and a standard level of attention given to all its residents.

For the other parts in this series, click on the following:

Mismanaged Medications in Nursing Homes: An Overview (Part 1 of 6)

Mismanaged Medications in Nursing Homes: Proper Medication Management (Part 2 of 6)

Mismanaged Medications in Nursing Homes: A Resident’s Medical Records and Medication History (Part 3 of 6)

Mismanaged Medications in Nursing Homes: Maintaining Adequate Staffing and Staffing Procedures (Part 4 of 6)

Mismanaged Medications in Nursing Homes: A Nursing Home and Its Pharmaceutical and Laboratory Services (Part 5 of 6)

For the experienced personal injury lawyer representing a neglected nursing home resident, a thorough understanding of a nursing home’s medication policies and procedures—and a meticulous level of inquiry to determine whether they were followed—is the resident and his or her family’s best tools in evaluating and proving medication mismanagement.

The Kosieradzki • Smith Law Firm represents clients in cases involving catastrophic injury caused by nursing homes and other care facilities that fail to provide proper care. If you believe you or your loved one has suffered medication errors because the nursing home failed to do its job, take action and contact the Kosieradzki • Smith Law Firm online or call us toll-free at (877) 552-2873 to set up a no-cost, no-obligation consultation.

TOPICS:   Medication Errors

Mismanaged Medications in Nursing Homes: A Nursing Home and Its Pharmaceutical and Laboratory Services (Part 5 of 6)

By Kosieradzki Smith Law Firm

June 28, 2013

Nursing homes are required to provide and coordinate pharmaceutical services to meet each resident’s needs, and this includes a duty to provide accurate information to the pharmacy furnishing pharmaceutical services.

When transmitting orders to the pharmacy, nursing homes have a dual responsibility to review the medications, as well as to communicate accurate information. If there are any administrative or clerical errors on either end of the facility’s responsibility, then there is a significant chance of mismanaged medication administration.

An experienced lawyer will compare the medications supplied by the pharmacy against the prescribing doctor’s orders.

For any medication order that must be administered promptly, such as an insulin prescription for a diabetic, the facility must administer the medication at the prescribed time. This means at night, on weekends, or on holidays. If the facility’s chosen pharmacy has already made its daily delivery, the nursing home must still find a way to administer the medication at the prescribed time.

To ensure that residents receive their medications safely and in accordance with a physician’s orders, professional standards of care require a licensed pharmacist to review each resident’s drug regimen regularly. This review must occur at least monthly, and any irregularities need to be reported to the physician and the facility’s director of nursing—they have a duty to act on any such reports.

It is important to note that because the pharmacist must use his or her expert understanding of medications and medication interactions, this responsibility cannot be offloaded to subordinate staff members.

The drug regimen review process includes reviewing the nursing home resident’s record for emerging or existing adverse medication consequences, and the potential for adverse drug reactions and medication errors.

Additionally, nursing homes must provide laboratory services to meet their resident’s needs. Lab studies ordered by the physician or pharmacist are essential to evaluating the patient’s response to the medication. The nursing home is responsible for the quality and timeliness of such services, even if the facility does not provide laboratory services on-site.

An experienced lawyer should obtain the contract between the nursing home and the laboratory, as well as the facility’s policies and procedures on laboratory services. Any communications between the facility and the laboratory should be examined as well.

For the other parts in this series, click on the following:

Mismanaged Medications in Nursing Homes: An Overview (Part 1 of 6)

Mismanaged Medications in Nursing Homes: Proper Medication Management (Part 2 of 6)

Mismanaged Medications in Nursing Homes: A Resident’s Medical Records and Medication History (Part 3 of 6)

Mismanaged Medications in Nursing Homes: Maintaining Adequate Staffing and Staffing Procedures (Part 4 of 6)

Mismanaged Medications in Nursing Homes: Conclusion (Part 6 of 6)

The Kosieradzki • Smith Law Firm represents clients in cases involving catastrophic injury caused by nursing homes and other care facilities that fail to provide proper care. If you believe you or your loved one has suffered medication errors because the nursing home failed to do its job, take action and contact the Kosieradzki • Smith Law Firm online or call us toll-free at (877) 552-2873 to set up a no-cost, no-obligation consultation.

Mismanaged Medications in Nursing Homes: Maintaining Adequate Staffing and Staffing Procedures (Part 4 of 6)

By Kosieradzki Smith Law Firm

June 27, 2013

In implementing its policies and procedures, a nursing home facility must hire, retain, and supervise its employees in a manner that minimizes the risk of maltreatment to residents, including having qualified staff administer any medication.

For medications administered on an “as needed basis,” such as anti-anxiety medications like alprazolam (brand name Xanax), diazepam (Valium), or clonazepam (Klonipin), the decision to give the drug must be based on a nurse’s assessment of the resident’s condition and an assessment of whether previously administered doses of the medication or effective. The nurse must document the basis for each instance of medicine administered on an as-needed basis.

The nursing home staff must document all medication orders. This means documenting medication administration on both the physician’s “order sheet” and the resident’s medication administration record. The nursing home must transcribe physician orders accurately, frequently, with start and stop dates, as well as clarify any unclear orders with the physician.

It is the job of a skilled personal injury layer to accurately evaluate whether the nursing home’s practice complied with the expectations set forth in the facility’s policies, procedures, and training records.

To give an example, let’s say that a nursing home’s policies and procedures require two nurses to complete the transcription process—one to transcribe the orders into a resident’s medication administration record, a second to check that the transcript is accurate.  If the facility is following federal regulations, two signatures should indicate a thorough review and transcription of a resident’s medicine records; there should be no discrepancies. However, two signatures on a form that has evident discrepancies means that, in practice, the facility is failing to ensure responsible medication management. This carelessness can have disastrous results.

Mismanaged Medications in Nursing Homes: An Overview (Part 1 of 6)

Mismanaged Medications in Nursing Homes: Proper Medication Management (Part 2 of 6)

Mismanaged Medications in Nursing Homes: A Resident’s Medical Records and Medication History (Part 3 of 6)

Mismanaged Medications in Nursing Homes: A Nursing Home and Its Pharmaceutical and Laboratory Services (Part 5 of 6)

Mismanaged Medications in Nursing Homes: Conclusion (Part 6 of 6)

The Kosieradzki • Smith Law Firm represents clients in cases involving catastrophic injury caused by nursing homes and other care facilities that fail to provide proper care. If you believe you or your loved one has suffered medication errors because the nursing home failed to do its job, take action and contact the Kosieradzki • Smith Law Firm online or call us toll-free at (877) 552-2873 to set up a no-cost, no-obligation consultation.

Details about the Community Memorial Nursing Home in Osakis, Minnesota

By Kosieradzki Smith Law Firm

June 26, 2013

This 52-bed nursing home was cited with 5 health deficiencies, according to Medicare’s 2012 annual report. These include the Community Memorial Home’s:

  • Failure to provide care by qualified persons according to each resident’s written plan of care;
  • Failure to allow residents the right to participate in the planning or revision of care and treatment;
  • Failure to ensure that residents are fully informed and understand their health status, care and treatments; and
  • Failure to ensure that the nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

Medicare has also identified 2 complaints and facility-reported incidents associated with Community Memorial Hospital.

In addition, the Minnesota Department of Health has substantiated one report of a significant medication error resulting in medication administration not in line with the facility’s resident’s care plan.  During the course of the investigation, it was determined that six residents were involved in medication errors due to the medications arriving from the pharmacy to the facility with the wrong administration directions. The facility did not have a policy or procedure to check medications against the original physician’s order when it was delivered to the facility. The facility did not identify this system failure at the time of MDH’s visit. [Report no. H5045008]

When your loved one has suffered neglect or abuse by those entrusted to care for them because the nursing home or other care facility failed to do its job, take action and contact the Kosieradzki • Smith Law Firm online or call us toll-free at (877) 552-2873 to set up a no-cost, no-obligation consultation.

Mismanaged Medications in Nursing Homes: A Resident’s Medical Records and Medication History (Part 3 of 6)

By Kosieradzki Smith Law Firm

June 26, 2013

Reviewing a resident’s medical records should be the first thing any plaintiff lawyer investigates.  Medical records should include, among other things, documentation of all communications with the attending physician’s chart to assess his or her evaluation of the resident’s condition in relation to the prescribed medications. An experienced plaintiff lawyer should pay particularly close attention to the attending physician’s chart to assess his or her evaluation of the resident’s condition in relation to the prescribed medications. Additionally, billing records can be checked against any pharmacy records for discrepancies.

It is important to evaluate whether the prescribed medications were necessary. A resident’s medication regime should promote the highest practicable health, and should include only medications that are clinically indicated to treat a resident’s assessed conditions.

Federal nursing home regulations define unnecessary drugs as any medication used in excessive doses, for an excessive duration, without adequate monitoring, without adequate indications for use, or in the presence of adverse consequences indicating the dose should be lowered or stopped altogether.

Federal nursing home regulations also mandate that residents who have not used anti-psychotic drugs should not be given these drugs unless anti-psychotic drug therapy is necessary to treat a specific condition, as diagnosed and documented in the resident’s clinical record. For residents who do require anti-psychotic drugs, the facility must ensure that the resident receives gradual dose reductions and behavioral interventions in an effort to discontinue such drugs, unless to do so would decrease the standard of care for a resident.

On May 30, 2012, the Centers for Medicare and Medicaid Services (CMS) announced an initiative to reduce the use of anti-psychotic drug administration in nursing homes. A 2010 report by CMS indicated that more than 17 percent of nursing home patients had daily doses of anti-psychotic medications exceeding recommended levels. Further, CMS found that almost 40 percent of patients with dementia were receiving anti-psychotic drugs at some point in 2010, even though there was no diagnosis of psychosis.

By obtaining and reviewing all records and documents related to a resident’s care plan, a personal injury lawyer will be able to identify the resident’s needs, and how the facility met those needs.  These records include the resident’s pre-admission assessment, the discharge and transfer records from the hospital, physician orders for medications and laboratory procedures, and any communications between the nursing home staff and the physician that verifies or clarifies the medication orders.

For the other parts in this series, click on the following:

Mismanaged Medications in Nursing Homes: An Overview (Part 1 of 6)

Mismanaged Medications in Nursing Homes: Proper Medication Management (Part 2 of 6)

Mismanaged Medications in Nursing Homes: Maintaing Adequate Staffing and Staffing Procedures (Part 4 of 6)

Mismanaged Medications in Nursing Homes: A Nursing Home and Its Pharmaceutical and Laboratory Services (Part 5 of 6)

Mismanaged Medications in Nursing Homes: Conclusion (Part 6 of 6)

The Kosieradzki • Smith Law Firm represents clients in cases involving catastrophic injury caused by nursing homes and other care facilities that fail to provide proper care. If you believe you or your loved one has suffered medication errors because the nursing home failed to do its job, take action and contact the Kosieradzki • Smith Law Firm online or call us toll-free at (877) 552-2873 to set up a no-cost, no-obligation consultation.

Mismanaged Medications in Nursing Homes: Proper Medication Management (Part 2 of 6)

By Kosieradzki Smith Law Firm

June 5, 2013

Proper management of nursing residents’ medication needs and safety does not happen on its own.  It requires a commitment to safety and diligence by the nursing home’s administration and nursing staff.  To ensure that a nursing home accurately manage the complexities and challenges of its residents medications:

  • The nursing home administration must ensure that each resident’s medication is managed and reviewed by a physician, and that each resident has access to his or her own personal physician;
  • The physician is responsible for providing and reviewing the medication orders and the total program of care at the time of a resident’s admission and at each subsequent examination of the resident;
  • The nursing home administration must ensure that the physician approves the resident’s admission, reviews the resident’s care plan (especially medical services and medication management), participates in the resident’s assessment and care planning, monitors changes in the resident’s medical status, and is available to consult or treat when called upon by the facility; and
  • If a physician is unavailable or does not respond to any call for service, the nursing home must have another physician available to supervise the patient’s medical care.

Whether the particular nursing home has a proper system place is a critical issue when a resident has been harmed as a result of a nursing home’s failure to provide the right medication, in the right amount, at the right time.  The following blogs in this series will outline how we investigate cases of mismanaged medication.

For the other parts in this series, click on the following:

Mismanaged Medications in Nursing Homes: An Overview (Part 1 of 6)

Mismanaged Medications in Nursing Homes: A Resident’s Medical Records and Medication History (Part 3 of 6)

Mismanaged Medications in Nursing Homes: Maintaing Adequate Staffing and Staffing Procedures (Part 4 of 6)

Mismanaged Medications in Nursing Homes: A Nursing Home and Its Pharmaceutical and Laboratory Services (Part 5 of 6)

Mismanaged Medications in Nursing Homes: Conclusion (Part 6 of 6)

The Kosieradzki • Smith Law Firm represents clients in cases involving catastrophic injury caused by nursing homes and other care facilities that fail to provide proper care. If you believe you or your loved one has suffered medication errors because the nursing home failed to do its job, take action and contact the Kosieradzki • Smith Law Firm online or call us toll-free at (877) 552-2873 to set up a no-cost, no-obligation consultation.

TOPICS:   Medication Errors

North Ridge Care Center Employee Stole Narcotic Medication from Nursing Home Residents

By Kosieradzki Smith Law Firm

June 4, 2013

A Minnesota Department of Health investigation has found that an employee of the North Ridge Care Center was stealing a resident’s prescription painkillers. The employee was also found to have been stealing prescription medication from at least 12 other residents of the New Hope, Minnesota nursing home, although the number of residents impacted may have been as high as 24, according to the MDH report.  [Report no. H5183093]

According to the MDH report:

  • After the suspected employee left the facility, another nurse spotted a discrepancy in the medication charting for one of the residents;
  • When confronted by administrative staff, the suspected employee admitted to taking  prescription Oxycodone tablets from the resident for the employee’s own personal use;
  • The employee also admitted to taking narcotic medication from several other residents over a four-month period;
  • The suspected employee was terminated from employment at the facility; and
  • The case was forwarded to the county attorney’s office for possible prosecution.

Click here for more details about the North Ridge Care Center.

The Kosieradzki • Smith Law Firm represents clients in cases involving catastrophic injury caused by nursing homes and other care facilities that fail to provide proper care. If you believe your or your loved one has suffered medication errors because the nursing home failed to do its job, take action and contact the Kosieradzki • Smith Law Firm online or call us toll-free at (877) 552-2873 to set up a no-cost, no-obligation consultation.