Minnesota Golden Living Center Roch/East Guilty of Neglect
The Minnesota Department of Health (MDH) made an unannounced visit to Golden Living Center Roch/East on June 12, 2008 and, after a thorough investigation, found the facility guilty of neglect.
In MDH's report, a resident suffering from lung cancer with metastasis to the bone was admitted to the facility on May 14, 2008 for pain management, hospice, and dependent care needs. Her physician ordered her pain to be assessed every shift. On the day after her admission, a hospice nurse was notified that the resident was suffering from pain and crying and moaning. The nurse checked medication records and found that she was receiving incorrect amounts of pain medication - Morphine every four hours instead of every hour.
In the ensuing days, the resident continued to suffer from severe pain. Hospice was contacted again on May 18, 2008 by a friend of the resident advising that the resident was not receiving the correct dosage of pain medication. In fact, it was noted on May 19, 2008 that the resident "screams out in severe pain when her body jerks or is moved ever slightly". She continued to suffer from severe pain until she was admitted to the hospital on May 23, 2008. Upon admission, she had an indwelling catheter and showed no urinary output since May 20, 2008. Her abdomen was distended. Hospital staff irrigated her catheter and her output was recorded as 2450 ml. (a full bladder is considered 500 ml). The resident died on May 24, 2008.
Two federal deficiencies were issued for Quality of Care and Urinary Incontinence. The facility was found to be neglectful in that the resident's pain was not managed, the facility failed to identify the location of her pain on multiple days, and her indwelling catheter was not monitored, even though she was having no urinary output.
