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Martin Luther Care Center Resident Dies After Four Falls in Three Nights

The Minnesota Department of Health has completed its investigation of neglect concerns at Martin Luther Care Center, a nursing home in Bloomington, Minnesota.

A complaint was filed with the MDH alleging that a resident was neglected when the resident had numerous falls and staff failed to provide adequate medical care after a fall, which resulted in a fatal cerebral hemorrhage.

The MDH investigated the matter and found that a preponderance of evidence established neglect occurred when facility staff failed to initiate adequate safety interventions in response to the resident’s repeated falls. The resident sustained a non-survivable brain injury after falling four times in three days.

The resident was admitted to the facility’s TCU for rehabilitative therapies after being hospitalized due to a fall at home. The resident was weak, had difficulty with weight-bearing, and was unable to pivot properly. The resident’s anticipated length of stay was one week before s/he could return home.

The resident had a history of falls and balance problems. The resident was confused and visually impaired. The resident was assessed to be at high risk for falls. The resident’s care plan did not address the resident’s confusion, failure to use the call light appropriately, mobility needs, toileting needs, or how often staff were to check on the resident, who was known to self-transfer without calling for staff assistance.

The resident resided in the TCU for six days, demonstrating unsafe behavior during the first three nights. Over the final three nights, s/he fell four times, with all falls occurring between 10:35 p.m. and 4:10 a.m. During three of the falls, the resident got out of bed because s/he needed to use the toilet. During the other fall, staff left the resident unattended on the resident’s bathroom toilet and the resident tried to self-transfer from the toilet to the wheelchair. The resident struck his/her head on all four falls, sustaining two hematomas on the back of the head during the first three falls.

Nurses did not evaluate the root cause of the resident’s falls, implement appropriate preventative measures to meet the resident’s safety needs, or contact the physician regarding the resident’s clinical status. After falling a fourth time, the resident’s blood pressure increased significantly. The physician was not called. The resident’s blood pressure remained elevated for three hours. The physician was still not called. At that point, the resident was placed in bed and not checked on for two-and-a-half hours, at which time he/she complained of a headache. His/her blood pressure was not rechecked, and the physician was not called. Half an hour later, the resident vomited. Blood pressure was checked, and was higher than previously marked. The physician was finally contacted six hours after the fall, and directed staff to take the resident to the hospital. By the time the paramedics arrived, the resident was unresponsive.

The MDH determined that Martin Luther Care Center is responsible for neglect of its resident. The MDH found that the facility had policies in place that addressed falls management and reduction of falls, care plan development and implementation, and physician notification regarding resident change in condition or clinical status. Multiple unit staff failed to adhere to the policies and leadership staff failed to ensure that the policies were followed. [Case no. H5272055]

This is not the first investigation of Martin Luther Care Center by the MDH. In April of this year, the MDH determined that the facility is responsible for financial exploitation of its resident. The MDH found that the alleged perpetrator was a trusted employee in a management level position. The individual employee was in a position that enforced policies and procedures, provided education to the employees about the policies and procedures, and he/she even interpreted polices and procedures. [Case no. H5272053]

Medicare rates nursing homes, including this 137-bed nursing home. Martin Luther Care Center was assigned a rating of below average based on the government’s health inspections of the facility. Deficiencies cited by Medicare include the facility’s inability to provide necessary care and services to maintain the highest well-being of each resident, failure to immediately tell the resident, the resident’s doctor and a family member of situations (injury/decline/room, etc.) that affect the resident, and failure to store, cook, and serve food in a safe and clean way.

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 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.