Duluth nursing home cited by state inspectors

John Myers, Duluth News Tribune

Bayshore Health Center in Duluth has been cited by the Minnesota Department of Health for failing to report multiple patient altercations and problems — including a patient with frostbitten feet and another who used his power wheelchair to ram other patients.

The report, posted May 27, stems from a state inspection March 21 and 22 that found two serious violations of federal nursing home rules, including “a situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.”

John Stieger, a spokesman for the Minnesota Department of Health, said a May 20 reinspection by the state found Bayshore “corrected most of the deficiencies,” including the most serious.

The state has recommended a $4,050 one-time fine, and a $200 daily fine that is still accumulating, to the federal Center for Medicare and Medicaid Services, which has not yet rendered a decision, Stieger said.

In one Bayshore case in the report, a wheelchair-bound quadriplegic patient who was allowed to smoke but who couldn’t light his or her own cigarette was allowed to go outside without proper footwear and suffered frostbite on both feet. The incident was not reported.

In another case, several patients complained that a man in a power wheelchair would drive aggressively at high speeds and intentionally ram them. Again, the incidents were not properly reported, the state inspection found.

Another patient suffered blisters on his legs because hot packs placed by a staff member were too hot.

“The systematic failure to report and investigate incidents of potential abuse/ neglect had the potential to affect most residents of the facility,” the report noted.

Nursing homes across the state are inspected on a regular basis, and most if not all receive some sort of citations for deficiencies. Most are addressed quickly, as was the case with Bayshore, state officials said.

But the Bayshore report is considered serious because it “constituted both substandard quality of care and immediate jeopardy to a resident,” according to a letter from the state to the administrator of the health facility.

Douglas Aretz, executive director of Bayshore, said in written statements that the nursing home takes pride in its care and regrets the incidents reflected in the report.

“We’ve worked closely as a team and with the state on corrective action,” Aretz said. “Steps have included changes to our employee training, enhancements to internal communications and internal review audits of our corrective actions.”

In other cases at Bayshore, the state found that an incontinent patient was not cleaned properly and that a patient at high risk of pressure sores developed lesions because he or she was not placed correctly in bed.

The problems involved patients who suffered traumatic brain injury, dementia, Alzheimer’s and other physical and cognitive ailments.

State inspectors looked at facility records and conducted interviews of patients. According to the state report, the majority of patients surveyed had problems.

“This facility failed to ensure that all allegations of possible abuse or neglect were investigated for 15 of 17 residents interviewed,” Stieger said. “When MDH is onsite doing a survey, we interview a lot of residents and ask them if they feel they are being abused or mistreated. The residents’ replies in this survey lead to further investigation by MDH.”

According to the report, which used numbers rather than names of residents:

“Injuries of unknown origin were not reported for R91, R43 and R30; frostbite was not reported for R164; burns from hot packs were not reported for R76 and R26; rough treatment by staff and staff rudeness were not reported … for R36 and R10; and resident-to-resident altercations were not investigated or reported to the administrator or the state agency for R83, R64, R13, R175, R178, R180 and R22. R91, R164 and R76 sustained actual harm as a result of the incidents described.”

Bayshore, a 160-bed facility at 1601 St. Louis Ave. on Park Point, is operated by Ecumen, the state’s largest non-profit nursing home company. The center specializes in physical therapy and rehabilitation services, senior care, young adult care and serving people with memory loss, traumatic brain injuries or chronic illness who need 24-hour care.

The company says Bayshore is one of only four locations in Minnesota that has specialized young adult long-term care services, the only such location north of the Twin Cities.

“We have extremely high-care patients,” Aretz said. “But that’s why people turn to us. It’s our expertise. Our goal is to be the very best possible at that care.”

Ecumen also owns Lakeshore, a complex in Duluth that includes a nursing home and apartments for seniors.

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