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Deficient Respritory Care at Extendicare’s Nursing Homes

  • In July 2001, a Golden Valley resident was found with his feeding tube pulled halfway out and his oxygen tanks empty. In January 2003, Golden Valleyfailed to address a resident’s complaints of difficulty breathing. On January 30, 2003, the resident’s breathing became worse and the resident was sent to the emergency room.
  • In May 2003, a Golden Valley resident was transferred to the emergency room due to respiratory difficulty. Golden Valley staff had allowed her oxygen saturation level to plummet to 55%.
  • On February 16, 2005, a 57-year-old Golden Valley resident with a history of COPD and chronic hypoxia was short of breath, asking for oxygen, and requesting to go the hospital. Extendicare’s records reveal that GV staff failed to assess the resident’s condition and failed to provide oxygen or check her oxygen saturation levels between 3:30 pm Feb.16th and 2:00 pm Feb. 17th, despite a physician’s order to provide oxygen at 2-3 liters to keep her oxygen saturation level above 90%. The resident called 911 for herself at 3:15 pm on Feb. 16th, but Extendicare’s staff turned the paramedics away when they arrived at the facility. This resident repeatedly removed her oxygen canula and was short of breath throughout Feb. 17th. Her oxygen saturation was as low as 57%. Despite this significant change in condition and the resident’s repeated removal of her oxygen, Golden Valley staff did not notify her physician. GV staff did not call for an ambulance until 30 minutes after the resident’s oxygen level had dropped to 35%. The resident died before paramedics arrived.

In addition to the substandard respiratory care at Extendicare’s Golden Valley Rehabilitation and Care Center, Extendicare’s other Minnesota nursing home facilities have a long history of providing deficient respiratory care. Examples of such substandard care include:

  • In September 2003, a resident of Extendicare’s ROBBINSDALE REHAB & CARE CENTER was admitted to the hospital in a state of extreme neglect. He was dehydrated and malnourished. His tracheostomy tube had not been changed for a very long time, and could not be suctioned because it was so clogged. As a result of Extendicare’s neglect, the resident was left in a persistent vegetative state,
  • In February 2003, a comatose tracheostomy patient died at Extendicare’s ROBBINSDALE REHAB & CARE CENTER when she was left unattended with her alarm turned off. She was discovered not breathing.
  • In August 2004, a resident of Extendicare’s ROBBINSDALE REHAB & CARE CENTER was found with her tracheostomy tube uncared for and not suctioned.
  • In May 2004, the Minnesota Department of Health determined that the Director of Nurses at Extendicare’s ROSE OF SHARON MANOR had failed to assure that policies and procedures were available on how to administer CPR for residents with tracheostomies.
  • In April 2004, a resident at Extendicare’s TREVILLA OF NEW BRIGHTON (now known as HEALTH & REHABILITATION OF NEW BRIGHTON) facility was found to have an excoriated area around his tracheostomy site.
  • Extendicare’s TREVILLA OF NEW BRIGHTON facility failed to initiate contact precaution guidelines for residents with tracheostomies. These precautions are a necessary element of infection control at such facilities.
  • In April 2002, a resident of Extendicare’s RICHFIELD HEALTH CENTER was brought to the emergency room with “green ooze” coming from the stump of an amputated limb. This resident also had fluid in his lungs and was severely dehydrated. The hospital doctor said that the Extendicare’s facility had “really dropped the ball.”
  • In August 2004, the Minnesota Department of Health found that Extendicare’s RICHFIELD HEALTH CENTER had committed neglect of health care by failing to ensure that a resident was provided supplemental oxygen in accordance with physician’s orders.
  • On a July 2004 morning, a resident at Extendicare’s ROBBINSDALE REHAB & CARE CENTER was discovered to have an oxygen saturation level of only 80%. (An acceptable level of oxygen saturation is 90% or better.) Extendicare’s facility failed to follow up on the resident’s respiratory distress. By evening, paramedics had to be summoned for the resident. When the paramedics arrived the resident’s oxygen tank was empty. When the resident reached the hospital, his oxygen saturation had fallen to 70%. Hospital doctors found the resident to have a urinary tract infection, sepsis, and numerous bruises on his body.
  • In May 2004, Extendicare’s TREVILLA OF NEW BRIGHTON was found by the Minnesota Department of Health to have failed to ensure that residents who were identified with oxygen therapy received adequate assessment and monitoring for treatment and intervention.
  • In January 2004, Extendicare began accepting residents with tracheotomies to the ROSE OF SHARON MANOR skilled nursing facility. The staff, however, was not trained or qualified to provide the care necessary for tracheotomy patients. A 46-year-old male resident was admitted to Rose of Sharon Manor in March 2004. The facility did not have the supplies and equipment required for his respiratory care. On the evening of March 29th, the resident complained that he felt like his tracheotomy tube was plugged and asked that it be suctioned. No one attempted to suction his airway until the next day. The resident continued to complain of breathing difficulty. The airway was never cleared and a physician was never called. On April 1st, the resident complained of breathing difficulty to a staff aide. The aide was unfamiliar with the oxygen tank and went for help. The aide returned to the room and saw the resident sitting on the side of the bed. The resident turned blue, fell back and stopped breathing. He went into cardio-respiratory arrest. There was no one at Rose of Sharon with a valid CPR certification. CPR was not attempted. When the ambulance arrived the tracheotomy tube was promptly cleared. However, the resident could no longer be resuscitated and he died.