South Carolina Nursing Home Blog : South Carolina Nursing Home Lawyer & Attorney : Poliakoff & Associates Law Firm : Elderly Care, Senior Care

As a follow up to the recent posts on the great work the Star-Tribune did on their series on falls in Minnesota nursing homes, here is another article from the Star-Tribune about the tragic death of a resident caused by neglect and improper training.  The incident, described in a state report, sent state Health Department investigators to 122-bed Crest View, and has added fresh scrutiny to a facility already under special review because of past care infractions.

The call from the nursing home came at 5:30 a.m. on July 31: Your husband, admitted last night for a short rehab stay, has been found not breathing. By 7 a.m. the woman and other family members had gathered at Crest View Lutheran Home in Columbia Heights when they heard the sirens. The fire department rescue squad entered her husband's room -- two hours after he died -- apparently called when the home's day-shift supervisor started work.

The Health Department report gives this account:  The man, who is not identified in the document, was still warm, but not breathing and without a pulse, when the rehab unit manager found him.  The LPN and her nurse supervisor did not know that the man had orders for resuscitation, so they didn't try to revive him. Even if they had known his "full code" status, the nurses did not know they were supposed to start CPR and call 911 even if no one witnessed his cardiac arrest -- a point of staff confusion affecting that resident and potentially 14 others with "full code" orders. In addition, neither nurse had current CPR certification, neither had been briefed on emergency procedures and neither knew where to find the resuscitation kit -- found during the inspection, but missing several pieces of equipment.

The home neglected the resident by not acting promptly to try to revive him, the department concluded, and was cited for three rule violations connected with the confusion, lack of action and lack of emergency training.

For the past nine months, the nonprofit Crest View has been one of four Minnesota nursing homes on a federal Special Focus Facilities list -- about 156 homes nationally with exceptionally troubling rule violations.  Crest View was placed on the list March 2. During three inspections since January 2008, the home was cited for 58 violations. (The state average is nine infractions per inspection). Complaint investigations added four more citations, including those from the incident in July.

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The L.A. Times reported that State officials have fined two nursing homes in Orange County for providing care so inadequate that it caused the deaths of two patients.

In one case, a woman died from dehydration.  This is clearly a preventable death.  The nursing home failed to give a resident sufficient fluids, causing her to suffer dehydration and acute kidney failure.   A doctor ordered that the patient's fluid intake and urine output be monitored during every shift.  A review of the patient's intake and output of fluids was blank or illegible.  The woman's condition had deteriorated so much that she was transferred to a hospital, where she was diagnosed with a urinary tract infection, dehydration and an "altered mental status."  

The patient died six days later, on Christmas Day.  Alamitos West Health Care Center in Los Alamitos was fined $100,000

 In the other, staff failed to provide CPR to a man suffering a heart attack because they mistakenly believed he was under orders not to be resuscitated.  A registered nurse supervisor did not call 911 as a patient was dying "because she thought the patient had orders" not to be resuscitated. In fact, the patient's medical record included an advance directive form from a family member on which was marked the option, "I DO WANT C.P.R." in an emergency situation.  A licensed vocational nurse called to inform a family member that the patient had died. The nurse told the family member that the patient was dead and that paramedics were not called because the facility had orders not to resuscitate the patient.  The family member told the nurse to hang up and call 911.  By the time paramedics arrived, they found the patient in bed with no heartbeat. He was covered with a sheet with no signs that CPR had been initiated.

State officials levied an $80,000 fine on the Huntington Valley Healthcare Center in Huntington Beach.

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