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Mahnomen nursing home’s narcotic overdose kills resident

By April 6, 2016

The Minnesota Department of Health (MDH) has completed its investigation of neglect concerns at the Mahnomen Health Center nursing home in Mahnomen, Minnesota. A complaint was filed with the Department alleging that a resident was neglected when a staff member administered a dose of morphine that was ten times what was ordered. The resident died less than two hours later.

The Department investigated the matter and found that the facility had failed to transcribe narcotic medications accurately and the resident was administered 10 times more of narcotic than the doctor had ordered. Prior to administration of the medication, the nurse who administered the medication questioned the dose, but could not find the original physicians order. A second nurse at the nursing home verified that what was drawn up in the syringe matched the order in the nursing home’s medication administration record. Approximately 15 minutes after administering the medication the nurses contacted the nurse who had transcribed the order and determined they had administered an incorrect dose of the narcotic medication.

The MDH found that Mahnomen Health Center failed to have adequate policies in place to ensure that its staff accurately transcribed and administered medications. The MDH determined that the Mahnomen Health Center is responsible for neglect of the facility’s resident. [Case no. H5238014]

For more information, today’s Star Tribune has also reported on this fatal neglect. Click here to read today’s article, “Morphine error leads to patient’s death; northwest Minnesota nursing home faulted”.

The Star Tribune also reports: “The state also found that Mahnomen Health Center failed to immediately report an injury of another patient, who suffered two hand lacerations that required seven stitches. A nursing assistant last August found a patient in her room with bleeding from her fingers. The patient was sent to the hospital’s emergency department but the incident was not immediately reported to the state, according to the Department of Health.”

This is not the first investigation of Mahnomen Health Center by the MDH.  In July 2014, the MDH found that Mahnomen Health Center’s staff stole narcotic pain medications from at least eight residents of the facility.  Click here to learn more. [Case no. H5238012]

In August 2011, the MDH found that Mahnomen Health Center neglected its resident, who choked to death, by failing to develop a proper care plan directing the staff on the pureed consistency food requirement and the resident’s history of rapid eating and choking. “The facility provided less or no supervision during snacks for residents at risk for choking.” [Case no. H5238010]   The Kosieradzki Smith Law Firm successfully handled a lawsuit against Mahnomen Care Center for the wrongful death of this resident.

Medicare rates nursing homes, including this nursing home facility.  Medicare rates Mahnomen Health Center as a “below average” facility.  In addition, Medicare rates Mahnomen Health Center as a “much below average” facility based on the government’s health inspections of the facility. Deficiencies cited by Medicare include Mahnomen Health Center’s:

  • failure to hire only people with no legal history of abusing, neglecting or mistreating residents;
  • failure to 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;
  • repeated failures to make sure that each resident’s drug regimen is free from unnecessary drugs;
  • repeated failures to make sure that each resident’s entire drug/medication is managed and monitored to achieve highest well being;
  • failure to make sure that residents are safe from serious medication errors;
  • repeated failures to have a licensed pharmacist review each resident’s medication(s) at least once a month,  and report any irregularities to the attending doctor;
  • failure to maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards;
  • repeated failures to have a program that investigates, controls and keeps infection from spreading;
  • failure to make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public;
  • failure to provide care by qualified persons according to each resident’s written plan of care;
  • failure to make sure that residents receive treatment/services to not only continue, but improve the ability to care for themselves;
  • repeated failures to assist 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 residents with reduced range of motion get propertreatment and services to increase range of motion;
  • repeated failures 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 provide medically-related social services to help each resident achieve the highest possible quality of life;
  • failure to provide care by qualified persons according to each resident’s written plan of care;
  • failure to make sure that each resident gets a nutritional and well balanced diet; and
  • failure to provide or obtain dental services for each resident.

As the Star Tribune reports in today’s paper, “The medication error death comes amid a sharp increase in cases of abuse and neglect at state-licensed nursing homes. The number of maltreatment complaints from nursing home patients and their families has doubled over the past five years, from 588 complaints in 2011 to 1,177 in the 2015 fiscal year, according to the Health Department.”

The Kosieradzki • Smith Law Firm represents clients in cases involving catastrophic injury caused by nursing homes like the Mahnomen Care 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, 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.

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