Death in northern Minnesota senior home linked to neglect, poor catheter care

A north-central Minnesota senior home has been cited for neglect in the case of an elderly man who died earlier this year from an infection caused by inadequate catheter care.

The state Department of Health determined that Minnesota Heritage House, an assisted living facility in Pequot Lakes, was negligent when its employees failed to flush a resident's catheter as needed and did not maintain proper hygiene while cleaning his catheter bags. As a result, the elderly man developed a severe urinary tract infection and died on Feb. 11, 2017, according to a recent state investigation report.

Investigators found that Heritage House failed to monitor its health aides and maintain proper infection control. They found a catheter bag hanging on a hand rail in the shower, with the tip of the catheter touching the bathroom floor. They also found a catheter drainage bag lying on the floor next to the resident, with a small amount of urine. The catheter bags were not properly labeled to indicate when they were last used, investigators found.

Constance Ford, of Park Rapids, daughter of the 86-year-old victim, Ralph Ford, said she raised concerns about her father's catheter care late last year after she discovered her father "in excruciating pain," complaining of an inability to urinate. Ford said she was shocked to discover, from a nurse's aide, that he had not urinated in 17 hours.

Ford said she also raised concerns about hygiene in summer 2016 when she noticed "puddles of urine" on the carpet in her father's bedroom. She said she suspected these spills were occurring as staff emptied his catheter bags, and she suggested to staff that they empty the bags in the bathroom rather than near his bed.

"It was a horrible way to treat a human being," she said. "His carpet was constantly wet with urine, and no one seemed to care."

Kathy Birchem, owner of Heritage House, declined to comment when reached on Monday.

Ford said she filed multiple complaints with the Minnesota Department of Health, which visited the facility early this year after her father was taken to the hospital with a urinary tract infection.

Reviewing the facility's records, investigators found the facility had ignored medical orders related to his catheter care. About five months before his death, a nurse practitioner ordered that his catheter be flushed two times a week to help prevent blockage. The flushes were not completed as ordered and Ford continued to have difficulty draining his urine, state investigators found. In addition, about seven weeks before his death, a medical specialist requested that his catheter be changed monthly. However, the facility's home care provider lacked any records showing the man received such care.

Ford was scheduled to have his catheter changed three weeks before his death. State investigators said this procedure was never documented as completed.

"The facility was not following their order transcription process, and failed to ensure that ordered and necessary cares were provided," the state ruled.

In interviews with state investigators, Heritage House staff said the sudden departure of the facility's director of nursing had made it difficult for nurses to keep track of procedures.

Chris Serres • 612-673-4308