WINONA, Minn. – A state investigator found the Watkins Manor nursing home in Winona was culpable for the death of a patient who fell and died in July. The investigator, Kris Detsch, blamed a nurse for failing “to use her professional judgment.” Detsch named neither the patient nor the nurse in her report. This is what happened according to Detsch’s investigation and other sources:
> The patient arrived for hospice care at Winona Manor with kidney and heat failure and signs of approaching death.
> At the family’s insistence, aides moved the patient from a bed into wheelchair, even though a supervising nurse said the wheelchair wasn’t a good idea but deferred to the family.
> Either later in the day or the next day, a hospice nurse noted the patient was minimally responsive and staring at the ceiling. The nurse noted dry, pale skin and that the patient flinched from stomach pain when touched.
> Mental health medications were discontinued and replaced with pain and anxiety medicine, In retrospect this constituted over-medication
> Three hours later the patient, unattended, fell and suffered a head injury.
> The patient was transferred a few blocks to the Winona hospital and died of a blunt-force head trauma.
Watkins Manor. An assted-living facility operated by Winna Health, whose umbrella of medical sevices include the Winona hospital, clinic ad nursing homes. Winona Manor has 60 apartments for senior ciuzens and also has hospice services that focus on caring, not curing. The Jacobethan building, at 175 East Wabasha Street, is on the National Register Historic Places. It was built n 1927 for Paul Watkins, a scion to the fortune if products manufactuer J.R. Watkins.
Verbatim
Detsch, state Health Department investigator: “The facility and a registered bhrse were responsible for the maltreatment. The resident had signs of approaching death when the nurse failed to use her professional judgment and act in the resident’s best interest when she directed a licensed practical nurse and an aide to transfer the resident out of bed and placed her into a wheelchair. All three staff left the unconscious resident unattended.”