Star-Tribune Series Part 2
The second part of the Star-Tribune's investigation into fatal falls at nursing homes concentrate on the lack of sanctions. Seventeen days after Agnes Johnson died, state investigators drove out to the White Community Hospital and Nursing Home to interview the staff. An aide told them she had turned away momentarily while using a mechanical lift to maneuver Johnson from her bed to a wheelchair, and Johnson slipped from the device's sling to the floor, breaking her shoulder and thigh. The OHFC concluded that she died from neglect. It concluded that the aide violated the home's guidelines requiring two people to perform lifts, according to a report. It also determined the nursing home had not properly trained the aide to use the lift. Despite the mistakes and Johnson's death, the OHFC did not cite the nursing home for violating state and federal regulations. The state found neglect in 17 cases statewide since 2004 where residents were seriously injured or died after falling out of lifts. It has issued citations for errors in only three cases.
When a Minnesota investigation finds that a nursing home was at fault, regulators require nothing more of the nursing home if it fired the worker involved or developed a corrective plan before investigators arrived. Minnesota rarely issues fines against nursing homes. That is why some health care advocates question the OHFC's effectiveness in holding nursing homes accountable for abuse and neglect -- including falls. They question a regulatory approach in which more than 1,000 Minnesota deaths were attributed to falls in nursing homes from 2002 through 2008, but the OHFC fully investigated only about 75 of those.
Federal officials audit the OHFC's process for evaluating reports of all types of incidents -- including falls -- and triaging them for possible investigation. In the past two years, the OHFC has not met federal standards in how it selects cases to investigate. Last year, federal auditors said that in a sample of complaints, OHFC triaged only 60 percent correctly.
In one of the sampled cases, the OHFC declined to do an on-site investigation into whether a nursing home was using mechanical lifts correctly and if the facility was following physician orders for medical checkups after injury. The auditors said the case should have been given the highest possible priority because other residents who were being moved with lifts were at risk.
But Minnesota's practice of not routinely issuing citations has a drawback, she acknowledged. To help consumers shop for nursing homes, the federal government developed a five-star quality rating that uses the number of citations issued against each home as part of the rating. That means that some substantiated cases of neglect are not reflected in the ratings for Minnesota homes.
In 2005, two nurses aides at Viewcrest Health Center were using a mechanical lift to move a resident from a wheelchair to bed. Without warning, the sling tore and the elderly woman fell to the floor. The fall left her in great pain and her overall condition deteriorated. Six days later, she died. OHFC investigators discovered that Viewcrest was using a sling that had been patched to fix a broken strap, despite the manufacturer's recommendation to discard and not repair damaged slings. Despite the harm to the resident, the OHFC did not cite Viewcrest for violating government rules.
Viewcrest was found at fault in 2006, when the OHFC ruled that the nursing home didn't properly care for a resident, a known falls risk, who fell and broke her neck. The OHFC did issue citations in that case. Two years later, in 2008, the OHFC again cited Viewcrest because it didn't develop a care plan to help a resident who had fallen 11 times. But in the same year, the OHFC determined Viewcrest was at fault when a resident rolled off a bed and broke her leg while being cared for by a nurses aide. The state regulators said the facility did a poor job training the aide to care for the resident. No citations were issued. Then, in 2009, there was another fall-related incident at Viewcrest. The staff left a resident, who was at risk for falls, alone in his wheelchair and did not activate an alarm that would have sounded as he fell and cut his head. For a third time in four years, the OHFC declined to issue citations for mistakes the home made that resulted in falls.
Helen Fellerman, 93, had a rare disease that made her particularly prone to bleeding. She was also unsteady, forgetful and had a history of falls. So alarms were attached to her bed and wheelchair at Stillwater Good Samaritan Center so staff members would know when she was on the move. But when Fellerman tumbled from her wheelchair on the night of Aug. 31, 2005, the alarm did not go off, an OHFC report noted. She had been left alone for about 30 minutes. She died three days later. The fall had caused bleeding inside her skull, made worse by her medical condition.
