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State investigators cite neglect in two Northfield nursing home deaths

Northfield News - 2/21/2018

The deaths of two patients at Three Links Care Center in Northfield were due to neglect, according to reports by the Minnesota Department of Health.

Both investigations concluded at the end of December and released this month. According to reports from the department, the first incident took place in May 2017 when resident fell while being transferred and hit his/her head. They later died from brain injuries. The second took place in October 2017. A resident reportedly fell from a standing lift, fracturing their leg and dying of complications from the fall.

Three Links was fined for the complaints, and the state will monitor the facility going forward. The facility has the option to appeal the state's findings, but will not do so.

"We extend our condolences to the families involved," Three Links CEO Mark Anderson said Tuesday. "I think the community has always known that we're dedicated to providing quality care and ensuring the health and safety of those who reside here.

"When we learned of the incidents, we suspended the staff involved, reported the incidents to the state, contacted the families and conducted our own investigation.

"At the time of the incidents, we evaluated our policies and procedures to make sure they are best practice. We retrained all staff on safety procedures. We certainly want to protect our residents and reduce the risk for potential harm."

May incident

According to the MDH report, a resident was neglected in May when an employee failed to follow the resident's care plan and transferred the resident without a gait/transfer belt. The resident had a history of decreased balance and impaired coordination. His/her care plan indicated a staff member was to assist the resident with ambulation and provide hands-on assist with the gait belt.

On the afternoon of the incident, the resident reportedly walked to the bathroom with his/her walker, with a nurse's aid following behind with a wheelchair. The two then headed back to the resident's room where the resident stood and waited, as the aid changed his/her oxygen tubing.

While standing, the resident lost balance and fell and hit his/her head against the wall, sustaining a massive brain bleed. The resident died from his/her injuries, according to the report.

In the investigation, the nurse's aid said he/she did not use a transfer belt at any time during the sequence of events and admitted one should have been used. The aid stated that the facility provided ongoing training on the need to utilize transfer belts.

The facility reportedly placed the aid on five days leave after the fall and provided additional training to him/her and other nursing staff. State investigators determined the individual worker was at fault.

October incident

According to the second report, a resident was neglected when he/she fell from a stand lift, due to a malfunction of the lift. Three Links reportedly had not maintained the standing life in accordance with the manufacturer's instruction.

The resident, who was non-ambulatory, required extensive staff assistance with all activities of daily living, due to advanced age, weakness and right-side physical deficits, the report found.

On the morning of the incident, the resident was reportedly being lifted by a single nurse's aid, who checked to ensure the harness was attached to the resident and the lift. The rubber safety tab on the right side of the lift arm reportedly popped off and the resident's harness detached from the arm. The resident fell and fractured his/her leg.

The resident was transferred to the hospital but was not eligible for surgery due to advanced age. He/she was discharged back to the facility, where his/her health progressively declined and he/she died three days later.

State investigators determined the facility was at fault for neglect as it didn't have procedures in place to ensure the proper operation of the lift. The facility ordered new lift arms with metal clips to replace the arms with rubber safety tabs.

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