One nursing home resident died after becoming trapped between a mattress and the bed’s grab bar. A resident of a different nursing home died after a staff member failed to follow the physician’s orders for care.
In both cases last year, allegations of neglect by the east metro nursing homes were substantiated, according to reports released by the Minnesota Department of Health last week.
Both nursing homes, in Roseville and Stillwater, respectively, are appealing the decisions. The identities of the residents were not released in either case.
LANGTON PLACE, ROSEVILLE
The resident at Langton Place in Roseville had grab bars attached to both sides of the bed to help with getting into or out of bed.
On May 31, 2017, a nurse reported checking on the resident and noting no problems. An hour and a half later, nursing staff checked on the resident again and found the resident face-down on the bed, according to a report by the Health Department. The resident’s head was wedged between the mattress and grab bar. A nurse called for help, moved the resident and began resuscitation efforts.
Another nurse called emergency services, but it was too late. By the time medics arrived, the resident was not breathing and died at the facility, the report said.
“The facility had no policy, procedure, or system to ensure the proper sizing of mattresses, the fit of the grab bars, and the space between the mattresses and the grab bar device to reduce the risk for entrapment,” the report said.
The medical examiner added that the resident’s airway had been compromised, which led to death, the report said. The facility denied blame.
“We deeply regret the death of this resident and extend our sympathy to the family. We continue to examine such unexpected incidents fully so we can better learn how to identify, eliminate, and avoid any similar risks,” said a statement from Presbyterian Homes & Services Management, which operates Langton Place.
“However, we do not agree with the state’s findings and believe their responses have not taken into account all of the facts,” the company added.
THE ESTATES AT GREELEY, STILLWATER
The resident at the Estates at Greeley in Stillwater had a history of neck cancer and relied on a tracheostomy to breathe. He required staff assistance for “all activities of daily living” according to a separate state report.
The resident also used a speaking valve, which allowed him to breathe in, but not to let air back out.
On June 12, 2017, a staff member performed tracheostomy care on the resident and left. When the speech therapist arrived a while later, she noticed the resident was pale, unresponsive and didn’t seem to be breathing, the state report said.
She and the staff member called emergency services and began resuscitation efforts. An ambulance took the resident to the hospital, where he later died.
The family of the resident told the Health Department that the staff member had previously forgotten to remove the speaking valve from the resident, preventing him from breathing, the report said. Three witnesses told authorities they overheard the staff member mention forgetting to remove the speaking valve.
The staff member told investigators that they had not received thorough training on the placement of the speaking valve, but said that he or she had done it several times. The director of nursing could not provide documentation that staff had appropriate training for placement of a speaking valve.
“We want to provide the best care possible to our residents and we feel so bad that this occurred. It was a mistake and we are so sorry for the loss of this resident and for his family,” said Jay Wobig, administrator at the Estates at Greeley.
“In light of this one-time incident, we have reviewed our policies, procedures, and staff training to ensure something like this does not happen again,” Wobig said.
