Duluth’s Bayshore Nursing Home Fatally Neglects its Resident

The Minnesota Department of Health (MDH) has completed its investigation of resident neglect at the Bayshore Residence and Rehabilitation Center, a nursing home in Duluth, Minnesota. A complaint was filed with the MDH alleging that Bayshore’s staff did not do a proper assessment of the resident’s fall risk and did not update its care plan for the resident.

The MDH investigated the matter and found neglect occurred when Bayshore’s staff failed to properly assess a resident who was at a high risk for falls, and failed to reassess the risks after each of several falls, and failed to develop effective interventions to reduce the risk of falls and injury. The resident required one staff person to assist with transfers and two staff to assist with walking short distances.

The resident had seven falls out of the wheelchair during the evening shift in the four months before his death. The MDH determined that Bayshore failed to identify the pattern of falls to develop interventions to reduce the risk of falls. On the day of the last, and fatal, fall, the resident fell out of the wheelchair striking his head and sustained a head injury. Three hours later, the resident was pale, drowsy, and less responsive. The resident was transferred to a hospital, where he was diagnosed with several areas of bleeding in the brain. The resident died as a result of these injuries a few days later.

The MDH found that Bayshore failed to ensure that its staff addressed the resident’s pattern of falling and failed to address the root cause of the falls. Bayshore failed to implement additional or different interventions in response the resident’s recurring falls.

The MDH determined that the Bayshore Residence and Rehabilitation Center was responsible for neglect of the facility’s resident.  [Case no. H5227052]

This is not the first investigation of the Bayshore Residence and Rehabilitation Center by the MDH.  In January 2014, the MDH found that Bayshore’s staff neglected  five different residents, one of whom required hospitalization. The MDH found that Bayshore’s staff failed to transcribe or implement physician’s orders in a timely manner for five residents. [Case no. H5227045]

Medicare rates nursing homes, including this 139-bed for-profit nursing home facility.  Medicare has assigned an overall rating to Bayshore Residence and Rehabilitation Center as a “much below average” facility.  In addition, Medicare has assigned an overall rating to Bayshore as a “much below average” facility based on the government’s health inspections of the facility.

According to Medicare’s most recent annual inspection, Bayshore Residence and Rehabilitation Center was cited by the government for 16 separate health deficiencies (significantly higher than the state average of 6.6 deficiencies for Minnesota nursing homes). Medicare has issued deficiency citations to Bayshore for this nursing home’s:

• Failure to provide care by qualified persons according to each resident’s written plan of care.
• Failure to give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
• Failure to give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills.
• Failure to make sure that each resident gets a nutritional and well balanced diet.
• Failure to properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
• Failure to develop policies and procedures for influenza and pneumococcal immunizations.
• Failure to develop a complete care plan that meets all of a resident’s needs, with timetables and actions that can be measured.
• Failure to allow the resident the right to participate in the planning or revision of the resident’s care plan.
• Failure to have a program that investigates, controls and keeps infection from spreading.

Bayshore’s 2013 annual inspection was equally troublesome. Bayshore Residence and Rehabilitation Center was cited by the government for 15 separate health deficiencies (significantly higher than the state average of 6.2 deficiencies for Minnesota nursing homes). Medicare issued deficiency citations to Bayshore for this nursing home’s:

• Failure to provide care by qualified persons according to each resident’s written plan of care (for which Bayshore was cited again in 2014).
• Failure to provide necessary care and services to maintain the highest well being of each resident.
• Failure to assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene.
• Failure to give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
• Failure to make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function.
• Failure to make sure that each resident gets a nutritional and well balanced diet (for which Bayshore was cited again in 2014).
• Failure to immediately tell the resident, the resident’s doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident.
• Failure to make sure that residents are safe from serious medication errors.
• Failure to make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents.
• Failure to have a program that investigates, controls and keeps infection from spreading (for which Bayshore was cited again in 2014).

Bayshore’s 2012 annual inspection was troublesome. Medicare issued deficiency citations to Bayshore for this nursing home’s:

• Failure to 1) hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
• Failure to develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property.
• Failure to provide care by qualified persons according to each resident’s written plan of care.
• Failure to provide necessary care and services to maintain the highest well being of each resident.
• Failure to assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene.
• Failure to have a program that investigates, controls and keeps infection from spreading (for which Bayshore was cited again in 2013 and 2014).

The Kosieradzki • Smith Law Firm represents clients in cases involving catastrophic injury caused by nursing homes like Bayshore Residence and Rehabilitation Center  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 or other care facility, 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.