The Minnesota Department of Health has completed its investigation of neglect concerns at Lighthouse, an assisted-living facility in Columbia Heights, Minnesota.
A complaint was filed with the MDH alleging that a client was neglected when staff failed to provide adequate medical care when the resident had a change in condition.
The MDH investigated the matter and found that neglect did occur when the facility failed to provide timely medical response to a resident’s change in condition. The resident developed vomiting, diarrhea, abdominal pain, and abdominal distention and staff did not seek a timely medical evaluation. The resident died, with cause of death being a bowel infarction (restricted blood supply to the bowel) due to an incarcerated hernia.
The resident, who had a diagnosis of dementia and a history of inguinal hernia, required assistance with activities of daily living.
The resident was diagnosed with a right inguinal hernia nine months prior to the resident’s death and received medical care twice for increased swelling and pain in the area of the hernia. Both times, the physician was able to reduce the hernia and gave instructions to return if unable to reduce the hernia and/or the client had unrelenting pain and swelling. In addition, the physician instructed staff to check for tenderness/pain in the resident’s inguinal hernia area when assisting the resident to change incontinent pads. This instruction was listed on the facility’s electronic medication administration record, although staff was not aware of this intervention and indicated they would not know it was listed there unless they were administering medications and looking to administer an as needed medication or treatment for the resident.
The following morning, staff observed the following: The resident complained of stomach pain when getting up for the day. At approximately 7:15-7:30 a.m., the resident was screaming “help me, help me” and pointed to his/her stomach. The residentdid not eat breakfast, and vomited at least once. The client had several explosive bowel movements, and complained of abdominal pain when staff barely touched his/her abdomen. Staff noted that these symptoms and more were reported to the nurse throughout the morning.
A family member noticed the resident could not speak due to pain, the resident’s abdomen was distended and skin color was white. After calling 911, an ambulance arrived. Hospital records indicated the resident was in shock and respiratory failure, and was placed on a mechanical ventilator to assist with breathing. Tests were conducted and the resident was found to have a large strangulated right inguinal hernia with obstruction and necrosis (death of tissue) of the entire small bowel. An emergency surgical consult was conducted and it was determined that the resident’s disease was too extensive to conduct surgery. Comfort care was provided. The resident was removed from the mechanical ventilator and died at 9:13 p.m. that evening.
The MDH determined that Lighthouse of Columbia Heights is responsible for neglect. The MDH found that staff were not aware of the duty to check the resident’s inguinal hernia for swelling/tenderness during each incontinence pad change. In addition, several unlicensed staff indicated they reported changes in the resident’s condition to a licensed nurse the day the resident died, although the nurse indicated staff did not report the abdominal pain. The evening before the resident died, the staff did not report symptoms of stomach pain and vomiting, despite having a duty to do so. The MDH found that the cumulative effect of these omissions represents a system failure. [Case no. HL26853007]
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