Failures of care at ND nursing homes: One resident denied visitors while dying; others found outside in the cold

Illustration by Troy Becker / Forum News Service
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FARGO — A wheelchair-bound resident of Trinity Homes in Minot rolled herself outside to have a smoke on a bitter-cold day in February 2017.

The woman hadn’t checked out, so staff didn’t know she’d ventured outside in subzero cold. The woman wore a hat and an unfastened coat — inadequate protection against the 6 below temperature.

To make matters worse, the woman’s wheelchair got stuck in a snowdrift. With the 10 mph wind, she could have gotten frostbite in 10 to 30 minutes, state health inspectors determined later.

Fortunately, a member of the maintenance staff saw the woman and wheeled her back into the nursing home.

Inspectors determined the woman had been placed in “immediate jeopardy,” a serious deficiency and one of the reasons Trinity Homes in Minot was designated a “special focus facility,” which means it consistently failed to meet resident care and protection standards.


Trinity Homes was the only nursing home in North Dakota with that designation , which applies to 88 of the more than 15,700 long-term care facilities in the nation. Because it corrected the deficiencies, state regulators notified Trinity Health that it no longer was a special focus facility in a letter dated June 28, after The Forum inquired about the matter.

Another five nursing homes in North Dakota — noted below — are classified as special focus facility candidates, of which there are 435 around the country, meaning that they also have consistently performed poorly and could be downgraded to a special focus facility.

Trinity Homes, which was inspected in February 2017, also was cited for placing residents in “immediate jeopardy” for leaving a cart with toxic cleaning solutions unattended for 17 minutes in a hallway on a unit with a wandering patient, according to the inspection report.

When an inspector was observing, a resident exited a room, walked over to the cleaning cart and stared at items in the cart before entering another room, the report said.

In a follow-up inspection, in October 2018, inspectors received several complaints about inadequate staffing at Trinity Homes. Inspectors cited the home for failing to ensure sufficient nursing staff to meet the needs of four of 36 sampled residents.

“At nights there is not enough staff,” one resident said, according to the inspection report. “I’ve had to wait for long periods of time at night (after 10 p.m.) to get help getting up to use the bathroom and back into bed.

“Someone (staff) even told me, ‘I have a bad back. I can’t help you.’”

Another resident said staff had failed to answer a call light for 45 minutes, according to the report.


"We've since changed our smoking rules," said Randy Schwan, a Trinity Health vice president. "We're now a no-smoking facility. We appreciate the work the state health department does to keep hospitals and nursing homes safe and glad we were able to remedy their concerns in a way that's consistent with their rules."

Resident in handcuffs

Western Horizons Care Center in Hettinger was found deficient in allowing several residents to fall or “elope” from the facility — leave without notice or authorization, according to an inspection in June 2017.

In one case, a resident was getting up to use the toilet without a walker and fell, striking her head, with a small amount of blood visible at the back of her head.

“My head hurts,” the resident said, according to the inspection report. Although the resident denied dizziness, one pupil was dilated with no evident reaction to light. A doctor was notified by memo, but a managerial nurse said later, “I would have sent her down to the hospital right away,” according to the report.

Another fell outside, resulting in small wounds to both hands and a large abrasion on an elbow and knee as well as shoulder pain. It was not known how the resident left the building without an alarm sounding.

The male resident left again at least twice.

“Failure to notify the physician and/or the resident’s wife regarding his two subsequent elopements limited their ability to make informed decisions regarding his safety,” inspectors wrote.

Western Horizons Care Center also was cited for deficiencies in an incident in which a resident took a golf club from an administrator’s office and used it to threaten another resident, according to the inspection report.


A sheriff's deputy took the disruptive resident in handcuffs to a hospital emergency room — a step inspectors said was premature, since restraints are supposed to be used only as a last resort to ensure resident safety.

When spoken to by staff, the resident became more agitated and aggressive, using the golf club and wheelchair to “push staff and make unruly demands.” The agitated resident also tried to take the deputy’s gun, according to the report.

The unruly resident suffered a small cut on one wrist, apparently from the handcuffs.

Inspectors also cited Western Horizons for poor housekeeping and sanitation, including a wastebasket with briefs saturated with urine, a toilet that hadn’t been flushed, strong odor of urine and debris on a dining room floor, according to the inspection report.

Staff failed to provide services to treat urinary tract infections for a patient with a history of such infections and failed to immediately contact the patient’s doctor after the patient tested positive for an infection.

Also, in what inspectors said was a repeat deficiency, Western Horizons failed to prevent a wandering resident from leaving the building several times. On one occasion, the resident was brought to the emergency room after having been on the ground in the cold for at least 30 minutes.

The nursing home was cited for a lack of competent nursing staff, with widespread noncompliance with regulations involving the use of physical restraints, urinary incontinence, accidents, supervision and protecting residents’ dignity.

Western Horizons, which was subject to fines of $193,772, has new management and has addressed the deficiencies cited in the 2017 inspection, said Dawn Bunn, who took over as administrator in January.

"There's a whole new management staff now," she said. "We're already turning it around and heading in the right direction."

nursing home walker.jpg
Getty Images / Special to Forum News Service
Getty Images / Special to Forum News Service

'Haunted by the fact'

Inspectors cited Knife River Care Center in Beulah for “actual harm” resulting from refusing to respect a resident’s right to have visitors.

One resident was refused family visits despite repeated requests because the home didn’t want visitors during a flu outbreak. Visitation requests were made over a period of five days to see the resident, who was ill, according to an inspection report in April 2018.

The patient died without getting to see relatives, despite multiple requests for a visit.

One relative, who complained about the visitation refusal, offered to wear a mask, gloves and gown and still was denied access.

“The complainant indicated he/she is heartbroken and can’t get over the fact all (Resident #7) wanted was one last visit,” the inspection report said.

A second relative also complained. “The second complainant indicated family members continue to be haunted by the fact Resident #7 expired without family present,” the person said, according to the report.

A third complainant said he was turned away at the door and refused access, but was given no prior notice that the home was on lockdown. Inspectors found that the patient had repeatedly asked for family visits, and family members contacted administrative staff to try to arrange visits, but their requests were denied.

“I don’t want any visitors,” the medical director had said, according to a nursing supervisor interviewed by inspectors.

The home was on lockdown for four days, according to the inspection report, but was opened on the day the patient died.

Rosanne Schmidt, interim administrator at Knife River Care Center since August 2018, said corrective steps have been taken and visitation policies have changed.

“The leadership here at Knife River Care Center has completely changed over,” she said. “Completely. It’s a completely different environment today. A lot has changed, and it’s for the better.”

The board has changed the visitation policy, so visitors no longer are banned during flu outbreaks, Schmidt said. “It was a bad policy.”
A correction plan to resolve deficiencies was signed off on “months ago,” she said. The home had been subject to a $7,543 fine.

Unruly, intoxicated residents

Dunseith Community Nursing Home in Dunseith failed to investigate five of eight elopements by a resident, and failed to complete a thorough investigation of four residents’ unauthorized departures, according to an inspection report from June 2018 .

A group of several residents repeatedly left the facility without giving notice or being given permission as a result of insufficient supervision or monitoring. Inspectors said the staff failed to immediately protect other residents by restricting three unruly residents’ access to them after they consumed alcohol or became verbally or physically aggressive, inspectors found.

The home failed to devise care plans that addressed a resident’s abusive or inappropriate behavior, including physical aggression, uncontrolled behaviors, swearing and hollering.

One resident has a history of alcohol and drug abuse and a history of leaving the facility and coming back intoxicated, according to the inspection report. Liquor bottles have been found in his room.

In May 2018 he was found outside, lying on his back on the ground just beyond the doors under the influence of alcohol, with slurred speech, the report said. He became physical and grabbed a nursing aide, cupping her breast and swung at her, pulling down her shirt, almost ripping it off, according to the inspection report.

The next day, the same resident was seen leaving the home and getting into a pickup truck, returning after 35 to 40 minutes. He and another resident passed around a Gatorade bottle containing alcohol, and fell down a short time later.

In another case, in May 2018, a local bar reported that a different resident was buying alcohol. On another occasion, that resident was seen walking east of Dunseith and escorted back to the facility by a sheriff's deputy. Later that day, the resident was “very intoxicated, yelling, making noise, swearing, being very disruptive to other clients,” the report said.

Police were called — a resident in the next room was dying. When a police officer arrived, he told the resident to go to his room and said, according to an inspection report, “This is ridiculous to be called how many times today because of you. Let’s go to your room or you’re going to jail.”

“My only comment would be that we’re aware of these issues and all the deficiencies have been corrected,” said Terill Brenno, administrator of Dunseith Community Nursing Home. “The Dunseith Community Nursing Home was found back in compliance by the North Dakota Department of Health on these matters. We work very hard to give each resident at the Dunseith Community Nursing Home the best care possible. We have moved forward.”

'Paperwork issues'

The Richardton Health Center in Richardton, inspected in December 2018 , was cited for a resident with moisture-associated skin damage and the lack of adequate care plans for several patients, resulting in skin wounds, inadequate smoker intervention, urinary tract infection and failing to address Alzheimer’s with behavioral disturbances.

The home failed to ensure proper antibiotic use, which could result in antibiotic resistance, and failed to have a registered nurse on duty two days in one month.

Michelle Antoine, an administrator who was hired in November, said the center already was addressing problems when she came on board.

“They were all paperwork issues,” she said. “We actually have done quite well. We have a new team here.”

A correction plan was approved “months ago,” and managers continue monitoring to ensure compliance, Antoine said. The center is striving to establish a reputation as a “premier place of employment” to attract and keep good staff members, she said.

“It is difficult,” Antoine said, to hire in a small rural town, but the home now has adequate registered nursing coverage.

Failing to respect residents' dignity

Minot Health and Rehabilitation, inspected in August 2018 , was cited for failing to properly prime insulin pens for two of three sampled residents, a failure that could result in inaccurate doses and did not meet professional standards.

For six of 18 sampled residents, staff failed to provide care in a manner and environment that respects each resident’s dignity. For example, by failing to knock before entering a room or neglecting to pull a privacy curtain, the inspection report said.

Residents complained that food is usually cold or that the home served “terrible food,” according to the report.

Other deficiencies inspectors found included failing to provide adequate infection prevention and control, and giving a resident unnecessary opiate medication because of a failure to ensure that duplicate therapy of pain medications was not given.

"North Shore Healthcare and its affiliated centers take pride in the care we provide our residents," spokeswoman Kristi Mueller said in a statement. "One of our core values is continuous improvement, and our recent achievements in receiving quality awards has shown that the systems we've put in place, the teams we've established, and our dedication to improve has benefited centers across our organization, including at Minot Health & Rehab. As always we focus on ensuring the quality of care and services we deliver to our residents."

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