MOORHEAD (KFGO) – A Moorhead assisted living facility has been fined and must make corrective actions after a resident fell multiple times and suffered severe bruising, including two brain bleeds.
Farmstead Care of Moorhead says it will appeal the findings by the Minnesota Department of Health.
According to a report from the Department of Health, inspectors began investigating the facility after a resident was admitted to an intensive care unit. Hospital staff reported the woman had bruises so severe, and in varying stages of healing, that they first suspected abuse. The inspectors found that the woman had fallen 14 times in the month leading up to the incident.
The report noted that the woman has Huntington’s disease, a condition leading to progressive degeneration of nerve cells, and affects movement and cognitive function.
About two weeks before being hospitalized, the resident requested the use of a wheelchair due to recent falls, but staff denied the request because they felt the woman, “should continue to be using their walker to keep their independence they have…”
The woman’s care plan included assistance with most activities, including dressing, toileting, showering, and meal setup. It also included safety checks six times a day.
During interviews with Farmstead Care staff, they acknowledged the woman’s recent falls. One nurse said the woman refused to add new services after each fall. Staff also said the woman quit working with her physical therapist.
Another nurse told investigators that many of the falls weren’t witnessed, and instead of pushing her call button, the woman would walk to the nurse’s station to tell staff she fell.
“The facility nurse stated that the resident struggled with remembering things and was impulsive so ‘we would tell her if you’re feeling weak, push your call light and we can help you, but that’s not something she would utilize,’” the report shows.
Investigators said Farmstead Care failed to assess the woman’s risk for falls and implement interventions to prevent falls or reduce the risk of serious injury after falling. The facility’s assisted living director told inspectors she was not sure why the resident’s assessments failed to identify the resident’s risk for falls, or why specific interventions weren’t in place.
On the day the woman was hospitalized, she reported feeling dizzy hours before tripping in her room. She hit a table and landed on the floor. The resident told first responders that she, “fell five or six times and had been calling for help, but nobody had heard her calls.”
When staff members found the woman, they contacted the on-call nurse who told them to call 911. First responders told state investigators they found blood all over the floor, walls, bed, and pillows. The woman was “completely saturated in blood from head to toe.”
The woman arrived at the hospital with cuts on her head and eyelid. She was hospitalized for 13 days.
The woman’s neurologist said she hadn’t seen her in over a year, and expected the Huntington’s disease to have worsened in that time. The woman’s primary doctor said Farmstead Care staff didn’t contact her about the falls, but if they had, she would have told the woman that she needs to use a wheelchair.
Farmstead Care received a $1000 fine and has been given a 90-day conditional license, meaning the facility must bring in an independent nurse consultant to help correct practices and develop a corrective action plan to address the violation. During those 90-days, it is not allowed to admit any new residents.
Farmstead Care issued the following statement:
Quality care is Farmstead Care of Moorhead’s top priority. We take all allegations regarding the level of care provided to our residents very seriously. Federal and state privacy laws prohibit Farmstead from sharing information about any particular resident. However, Farmstead disputes many of the factual assertions the Minnesota Department of Health’s findings appear to be based on. Accordingly, Farmstead has retained counsel and is appealing the Department’s findings.
The patient’s husband says the family does not agree with the state’s findings and fully supports Farmstead Living. He issued the following statement:
“The allegations are 100% false.”
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