Editor's note: This updated story contains new information via a statement from the Minnesota Nurses Association.
A patient at St. Luke’s hospital was discovered one morning with a bedpan underneath her, and a wound on her buttocks in the shape of the bedpan.
It happened a second time to the same patient, special investigator Michele Strahan said in a report for the Minnesota Department of Health’s Office of Health Facility Complaints. The report led to a finding of maltreatment by neglect against the hospital. It cited inadequate staffing of the night shift as a factor.
But St. Luke’s denies that staffing was the problem.
“St. Luke’s deeply regrets that this incident happened,” Chief Medical Officer Dr. Gary Peterson said in a statement. “We believe it was the result of a lack of communication, not staffing. As the report details, we have taken several measures to improve communication among our staff, to ensure our patients receive the best possible care.”
But the co-chairpersons of the Minnesota Nurses Association at St. Luke's say staffing was correctly identified as a problem.
"We agree with the (Office of Health Facility Complaints) that inadequate staffing was a major factor in this incident and hope that St. Luke's management will agree to sit down and discuss this and other short-staffing issues with front-line nurses," Pete Boyechko and Amanda Gunter said, in part, in a statement. "We believe that more conversations around short staffing along with language in our new contract will prevent situations like this in the future."
Boyechko and Gunter said that concerns about short staffing led St. Luke's nurses to authorize a strike in the fall. The strike was averted when nurses ratified a new contract on Sept. 25.
The report doesn’t name the patient and doesn’t say when the incidents occurred. The investigation was concluded on Aug. 23 and posted on the health department’s website on Tuesday.
According to Strahan’s report, the patient was admitted to St. Luke’s after suffering a hip fracture in a fall. She was in an advanced state of dementia, was confused and unable to make her needs known and was unable to use her call light.
She needed help from two staff members and a mechanical lift to get out of bed and two staff members to reposition her in bed. She was supposed to be repositioned every two hours, which is standard procedure for avoiding bed sores.
About three days following the surgery, the night nurse didn’t have anyone to help her reposition the patient, so she did so alone and was able to make slight adjustments to the patient’s position. About 5 a.m., the night nurse found another staffer to help her adjust the patient. When they did, they found a bedpan under the patient “and the patient had a red outline of the bedpan on her buttocks.”
Virtually the same scenario occurred “on another night” and was discovered around 8 the next morning, according to the report. Again, the bedpan left bruises and a mark in the shape of a bedpan, and the patient “had a red peeling abrasion in the shape of the bedpan on her entire buttock.”
The day nurse interviewed all of the staff on the day shift, but none admitted placing the bedpan, the report added.
Strahan reported she interviewed staffers, who said nursing assistants were sometimes unavailable because they were assigned to sit with patients who needed close observation.
As a result of an internal investigation, St. Luke’s created a plan to use whiteboards in patient rooms to document when patients were placed on bedpans and when they needed to be checked again, according to the report. It also informed staff of the plan through in-house articles and blog posts and a leadership meeting, and researched what other facilities were doing to decrease the risk of such an incident occurring.
The report noted that St. Luke’s has the right to appeal the maltreatment finding. But a St. Luke’s spokeswoman said the hospital doesn’t plan to do so.