Minn. Care Center Blamed for Client Dying After 4th Fall in 3 Days

March 12--State investigators say operators of a Bloomington care center are responsible for the death of a client who arrived for a week of rehab and ended up dead following her fourth fall within three days.

The Martin Luther Care Center was negligent because its nursing staff failed to notify the client's doctor after repeated late-night falls, according to details of a state Health Department investigation released Wednesday.

The fourth fall in three days in early October inflicted a "catastrophic" brain injury, but staff did not contact the resident's doctor until six hours after finding the woman on the bathroom floor, the investigators found.

The doctor ordered a nurse to get the resident to an emergency room. Paramedics arrived to find the woman unresponsive. She was taken to the hospital and was dead two hours later with severe bleeding on the brain, the report continued.

Even though the facility had policies in place addressing falls, "Neglect occurred when facility staff failed to initiate adequate safety interventions in response to the resident's repeated falls."

Messages were left with the care center's director seeking reaction to the investigation, which also pointed out that "leadership staff failed to ensure that the policies were followed."

In response to the findings, the care center revised its policies, retrained staff and oversaw its employees' compliance under the revisions.

As is practice, the health department did not disclose the client's identity or approximate age.

According to the health department:

The visually impaired and often-confused client, who had a history of falling, entered the home for therapeutic rehabilitation after being hospitalized for a leg injury suffered in a fall at home. The plan called for her to return home in a week.

The falls at the care center all occurred at night. One involved the client being left unattended on the toilet and trying to get up and into a wheelchair.

Despite the nurses knowing the client's health history and injuries, no preventive actions were taken and her doctor was not notified.

The fourth and final fall occurred shortly after 10:30 p.m. on Oct. 4, and again she tumbled to the bathroom floor. Her blood pressure shot up and remained seriously high for three hours.

The resident was put to bed and 2 1/2 hours later was complaining of a headache. In response, staff gave the client Tylenol.

Thirty minutes later the resident vomited, and another blood pressure check found even higher levels. It was then that the doctor was contacted.

Paul Walsh -- 612-673-4482

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