State investigators found neglect in the deaths of two residents who suffered falls at the same Northfield nursing home five months apart.
The first death at Three Links Care Center occurred in mid-May 2017 when a resident fell while being helped from the bathroom by a nurse’s aide who did not use a transfer belt, also known as a gait belt. State findings released last week concluded that the aide was to blame for the death.
Five months later, another resident fell, this time dropping out of a mechanical lift that was known to have a faulty part. In that case, the state found the care center responsible for the death.
The nursing home’s administrator, Mark Anderson, said Tuesday the facility is not appealing either determination. Anderson added that the facility stopped using the lift involved in the death in October, began daily inspections and turned to a safer model of lift.
As is practice, the Health Department did not disclose the names of either resident.
In the May death, the Health Department found:
Late in the afternoon, the resident used her walker as she made her way to the bathroom, but the nurse’s aide with her failed to attach the transfer belt to the resident.
After leaving the bathroom, the woman fell and hit her head on the wall. She died from bleeding on the brain a few days later.
The aide explained that she didn’t use the belt because she had failed to retrieve it from another resident’s room.
Three Links put the aide on leave for five days as her discipline. She and other staff also were retrained on the importance of using a gait belt as facility policy requires.
In the death in October, state investigators disclosed:
A resident was placed into a mechanical lift and fell to the floor when a rubber safety tab on the arm “popped off and caused the resident’s harness to disengage from the machine.”
The woman suffered a broken leg, inflicting pain that oxycodone couldn’t mask. She died days later from complications from her fall.
“The facility had not maintained the standing lift in accordance with the manufacturer’s instructions for safe operation,” the investigative report read.
Three Links had four lifts with the rubber safety tabs that “frequently loosened or cracked with wear and rendered the lift unsafe to use.”
Maintenance staff acknowledged having to consistently replace the rubber tabs, and the facility had no procedure to monitor the faulty part. Other lifts in Three Links had more secure steel tabs.
As part of its consequence for the death, Three Links was fined and placed under state monitoring.