DULUTH - State investigators have found a Duluth nursing home responsible for failing in May to give a patient prescribed medication that may have led to her fatal stroke.
Lakeshore Inc.'s short-stay and rehabilitation facility at 4002 London Rd., deemed a nursing home by the state, faces no fine or penalties for the neglect.
"There's no repercussions other than the fact that this report is placed on a public website," said Sheila French, director of the Minnesota Department of Health's Office of Health Facility Complaints. "The public will be able to see they had a finding of maltreatment."
According to her unit's investigative report:
The woman, whose identity isn't being released, was a patient at Lakeshore Inc. from May 6 to May 25, following hospitalization for an infection. Her stay was to allow her to regain strength so she could return to assisted living.
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She had been taking Coumadin, a drug thinning medication, for 10 years after experiencing small strokes. The drug inhibits blood clots that can lead to strokes. But at Lakeshore, she was not given the medication, nor the required blood test on May 7 to monitor its effectiveness. As the result, she missed 18 doses.
On May 25, after regaining strength, she was discharged and returned to assisted living. Coumadin was not on her discharge medication list but should have been. Two days later she was admitted to a hospital and died on June 4, the result of a stroke due to a blood clot.
Lakeshore administrator Paul Libbon declined to discuss the case. But he said: "Our sympathies go out to this family on the loss of their loved one. We deeply regret this incident and will continue to work closely with our staff and regulators to assure that appropriate procedures and policies are in place to provide for the safety of out residents."
After a complaint was filed with the state following the woman's death, Lakeshore identified the problem and changed practices to prevent future lapses with Coumadin orders, according to the report. Such quick corrective action before an on-site investigation can ward off a neglect determination in the many maltreatment cases they see, French said.
But not this time.
That's because of the "egregious result," namely death, and because Lakeshore wasn't in compliance with federal regulations relating to the missed doses before the probe, French said.
The facility's latest state nursing home report card shows it generally meeting or exceeding state averages in a star rating system. The report card was based in part on a late 2009 inspection. The neglect case didn't figure into that report card, but it will affect Lakeshore's next report card, French said.
The late 2009 inspection found numerous deficiencies at the home, but only the most serious being fire code violations that did not present actual harm to residents.
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The prescription neglect was the first complaint filed against Lakeshore with the state department of health this year, and the third complaint that's been substantiated. The previous complaints found Lakeshore to be in violation of patient's rights, including a finding in 2008 that the facility illegally discharged patients who were still in need of care.
