Benedictine Health Center cited for neglect

A Duluth nursing home has been cited by the Minnesota Department of Health for neglect of a resident that nearly resulted in his death, according to a report made public today.

The Benedictine Health Center was found to have improperly set and monitored a resident’s feeding tube on July 20, 2008. Consequently, he received liquid feeding solution at a rate more than six times faster than prescribed. The identity of this man, who is classified as a vulnerable adult, remains protected.

The following morning, the resident, who is cognitively impaired and unable to speak, began to experience breathing difficulties and was transferred to a hospital, where he was diagnosed with aspiration pneumonia. This is a type of pneumonia caused by the inhalation of foreign matter into the lungs. This often happens when stomach contents enter the lungs, following a bout of vomiting, according to Mayo Clinic staff.

The man could easily have died, according to the Minnesota Department of Health.

“The resident was not expected to live but is in stable condition and was discharged back to the facility,” the investigative report said.

To its credit, the report said Benedictine had taken corrective action by Aug. 5, 2008. This action includes training staff on the proper use of feeding tubes and stressing the necessity of monitoring their flow.

“The quality care we provide to residents is our highest and first priority,” said Mark Broman, administrator of the 120-bed nursing home.

Broman explained that a nurse hired from a temporary service made an error in adjusting the resident’s feeding tube pump. The error was discovered by staff, and the resident was quickly transferred to the hospital for care.

The event prompted Benedictine to launch its own internal investigation, and Broman said: “Our investigation identified the error and the individual responsible. We subsequently asked the temporary agency we were using not to allow that person to return to our facility.”

Broman said Benedictine also has stepped up training and testing of staff to ensure such a mistake doesn’t occur in the future.

In the last four years, Benedictine has been cited for three substantiated violations by the Minnesota Department of Health. The only other nursing home in Duluth with more substantiated violations during the same time span was Viewcrest Health Center, which had four. Chris Jensen Health & Rehabilitation Center, also of Duluth, has been cited three times during the same period, as well.

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