A southern Minnesota nursing home is being blamed for one of its residents tumbling out of her inadequately equipped wheelchair and suffering fatal head and neck injuries.
The woman fell from her wheelchair at Koda Living Community in Owatonna last Aug. 2 and died five days later in a hospice care facility, according to details of a state Health Department investigation released Tuesday.
Her wheelchair lacked the foot rests that were added to her care plan a few days earlier, investigators determined. The foot rests were in the woman's room but out of sight behind her bed and were never installed, the report noted.
Nursing home staffers told investigators they were never told about the foot rests, nor was the need for them referenced on the resident's care paperwork.
With the foot rests not in place, the woman's right foot "got caught under her left heel, and [that] caused the wheelchair to stop suddenly" as a nursing assistant pushed the resident to the dining room, the report read. The resident fell forward and hit her forehead on the floor.
The woman suffered bleeding in the brain, a fractured vertebra in her neck, a dislocated and broken shoulder and other injuries, the report continued.
The nursing assistant told the nursing home's director of nursing that the foot rests "did not fit the wheelchair," according to the report. The nursing assistant also told another staff member that she forgot about the foot rests, the report added.
In response to the resident's fall, the nursing home's operators took several steps to prevent a similar incident: retrained staff about the use of foot rests, placed foot rests on wheelchairs as required and added foot rest storage bags to wheelchairs.
Koda administrator Mike Schultz said Wednesday that "there are questions that are in dispute" regarding the state's findings, "and we would like to resolve them."
Schultz declined to offer specifics about what the disagreements involved but added "our staff acted appropriately and responded as quickly as possible."
As is practice, the Health Department did not reveal the resident's name or age. Schultz did say the woman was living in the long-term section reserved for the elderly.
Koda Community Living opened in February 2013 as an 80-bed facility. It was funded by Steele County Communities for a Lifetime, a nonprofit organization, with equal representation by the county and Duluth-based Benedictine Health System, a nonprofit Catholic senior care provider with facilities in 40 communities in Minnesota, Illinois, Missouri, North Dakota and South Dakota.