Investigations May Not Always Hold The Answers To How A Nursing Home Injury Or Death Occurred
Like many families, Kenneth Gall sought a sense of closure with respect the circumstances surrounding his mother's death after she sustained an injury during her admission to Presbyterian Homes of Arden Hills. Unfortunately, more than a year after his mother's death, questions still remain as to the facilities role in the matter-- and how a disabled, primarily bed-bound-woman managed to fracture her neck while admitted to a nursing home.
Was it due to a fall? Was the fracture related to violence? Did Mrs. Gall get entangled in a bed rail?
What is known is that 91-year-old Gladys Gall died about two weeks following an incident in which she sustained a unusual type of fracture in her neck called a hangman's fracture and died from complications shortly thereafter.
The circumstances surrounding Mrs. Gall's death were investigated by the Minnesota Office of Health Facility Complaints (OHFC) and a determination was made by the agency that the incident was due to mistreatment. The state even consulted with a neurosurgeon who opined that the nature of Mrs. Gall's injury could only be caused from severe trauma.
Now however, after the nursing home appealed the states findings and presented evidence from their own investigation, the state has changed its findings relating to improper care from 'substantiated' to 'inconclusive'.
The role of state investigations into injury or death in a nursing home
Most states have agencies (usually associated with their health department) to investigate suspected mistreatment of patients in a nursing home. Investigators can quickly access the patient's chart and interview employees and other patients who may have knowledge of the incident. While certainly not always perfect, the investigations typically provide much sought after information to families asking 'how' and 'why' an incident occurred.
In most jurisdictions, the state investigative findings and the reports generated are not admissible in court proceedings related to a nursing home negligence lawsuit. Nonetheless, the information contained within the investigative report can be invaluable in the course of litigation.
In the case of Mrs. Galls death, I humbly suggest to her family to seek out an experienced lawyer to prosecute this matter and give them more information relating to the circumstances of their loved ones death.
Read more about this suspicious death in a Minnesota nursing home here.
Related:
Nursing Home Cited For Mistreatment Of Resident Following Investigation Of Resident's Fractured Neck
Falls Amongst The Elderly Can't Be Ignored
Nursing homes have an obligation to protect their patients from known dangers--- particularly those which may be self-inflicted.
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Nursing homes have a duty to protect their residents from harm inflicted by not just the staff and other residents at the facility--but also keeping residents from harming themselves. Rivera Healthcare Center, a California nursing home, failed to protect a resident from harming himself and consequently received a $100,000 fine-- the highest fine permissible under California law. 
Why in the world would I suggest the the people who are responsible for the care of our most vulnerable take a lesson from those responsible for most violent? The answer has to do with how nursing homes keep track of their residents. 
While in the fall mode, I came across this 
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Did the young perpetrator have a criminal record? Did the younger nursing home resident have a history of violence? Nursing home staff have a duty to keep their residents safe from intruders as well as from violence from other residents. Unfortunately, problems continually arise when nursing homes fail to segregate nursing home residents with drastic age differences and physical abilities. 
providing skilled nursing care to Alzheimer's and dementia patients. It is a common problem for Alzheimer's Had the facility taken the basic precaution of removing non-edible objects from the residents meal tray this incident would likely not have occurred. Moreover, had the staff properly monitored this man as he ate, the choking should have been caught and the ketchup packet removed from the man's throat.
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Big Rapids. The death of Comer lead to a 
