An elderly woman at a special care home in Hässleholm had to go nearly three days with an untreated fracture. Her reports of having fallen were dismissed, with reference to her dementia. The case is one of a long series of reported abuses at the Björksäter special care home, where five Lex Maria reports and 13 Lex Sarah reports have been filed over two years. This is reported by Norra Skåne.
Before the incident, the woman was able to get around on her own with a walker. But after one night, her condition changed drastically. In the morning, she had great difficulty standing and walking, and told staff she had fallen during the night.
No one had witnessed the fall, but the woman had severe pain and visible bruising on, among other places, her hip, buttock, and shin. Despite this, no proper examination was done.
According to the report later filed, a nurse is said to have told the staff that the woman’s account should not be taken seriously because she had dementia. The bruising was at the same time considered to have arisen without any particular reason.
Pain Treated – But Cause Not Investigated
When the woman could no longer walk, she had to use a wheelchair. More problems then emerged. Due to the pain, she had difficulty urinating and was fitted with a catheter. When the pain persisted, she was treated with morphine, which in turn led to constipation, treated with laxatives.
When the woman became restless, she was also given high doses of narcotic sedatives. The measures thus focused on the consequences of her condition, while the underlying cause of her severe pain remained undiscovered.
It was only when the woman’s catheter later stopped working that another nurse came to examine her. A clear sign of a serious injury was immediately noticed. “I immediately see that the right leg and foot are outwardly rotated,” the nurse wrote.
It was suspected that the woman had broken her hip. An ambulance was called and at the hospital, it was confirmed that her femur was broken. The woman underwent surgery after living with the fracture for almost three days.
The incident has been reported by Hässleholm municipality’s social care administration to the Inspectorate for Health and Care Services (Ivo) as a serious care injury under Lex Maria. According to Norra Skåne, not only did at least one nurse, but also two doctors, fail to investigate the cause of the woman’s pain.
The nurse who finally raised the alarm assessed that the delay had caused the woman great suffering and that the situation could have become so serious that surgery would no longer have been possible. When asked if something similar could happen again, the nurse replied “yes”.
The municipality’s investigation into the incident has not yet been concluded.
Elderly Left Soaked In Urine – Without Lunch
The case of the broken hip is far from the only serious incident reported at the Björksäter special care home.
In July, an employee discovered two elderly residents still in bed at 4 p.m., despite staff saying it was extremely hot. They were still in their nightclothes, incontinence pads had not been changed during the day, and they had not received any lunch.
The employee ensured they received clean pads, food, and drink, and then contacted a nurse. The incident was reported under Lex Sarah.
A similar situation had been discovered just a week earlier. Then, residents still wore nightclothes and old incontinence pads well into the afternoon. In one case, lunch remained in the room, while towels and trash were left unattended.
Maria Persson, social responsibility coordinator at Hässleholm’s social care administration, is investigating the incidents with the home’s unit manager. “It is obviously not good,” she told Norra Skåne, but also emphasized that the municipality needs to investigate the underlying causes to prevent similar situations from happening again.
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According to Persson, deficiencies may be due to issues with communication, training, routines, processes, or technology. However, she does not want to claim that the number of reports in itself shows that Björksäter has general problems, since a Lex Sarah report does not automatically mean that a shortcoming is ultimately confirmed.
18 Reported Incidents In Two Years
Over the past two years, according to information obtained by Kristianstadsbladet/Norra Skåne, there have been 13 Lex Sarah reports and five Lex Maria reports connected to Björksäter.
Among the most serious cases are several incidents where residents have been injured, been subjected to degrading treatment, or where failings in care have had very serious consequences.
Selection of Reports at Björksäter
Over a two-year period, five Lex Maria reports and 13 Lex Sarah reports were filed in connection with the home. Here is a selection of the most serious reported incidents:
- Death after missed antibiotics: A person treated in hospital for sepsis did not receive their prescribed continued antibiotics. The person became seriously ill again and later died.
- MRSA after lack of hygiene: A resident was infected with the antibiotic-resistant MRSA bacteria. According to the report, hygiene routines had broken down, and clean and dirty materials were stored together.
- Broken arm after fall: A woman fell during the night but was not examined by a nurse. Later it was confirmed she had broken her arm.
- Death after hip fracture: A resident was pushed by another person and broke their hip. The person later died from complications.
- Incorrect medication with Parkinson’s: A man with Parkinson’s worsened quickly after moving in. He had received too low a drug dose and medicines were also administered at incorrect times.
- Resident chased with cleaning tool: When a person tried to avoid an incontinence pad change, an employee followed with a coarse pipe brush, poked the resident with it, and laughed.
- Woman fell and broke her wrist: While being assisted during a toilet visit, staff let go of the woman’s arm. She fell and broke her wrist.
- Physical intervention against resident: An employee is said to have seen a colleague pinch a resident’s arm and hold a hand over her mouth. The explanation was: “Sometimes you have to be firm.”
- Resident barricaded with furniture: Furniture was placed in front of a resident’s room so the person could not get out.
- Photographed with Snapchat filter: An employee photographed residents and used filters that altered their appearance. The pictures were then shown to a colleague.
- Left in urine-soaked armchair: A resident was left in the same armchair for a day. The armchair became soaked in urine, evening medicine was not given, and a floor alarm was not activated.
Additionally, there are reports of rough treatment during personal hygiene, a resident who was forced to change into nightclothes as early as the afternoon against their will, shortcomings with movement alarms, and several instances where basic care such as meals, changing clothes, and incontinence pads have not functioned.
In summary, this is therefore not an isolated report. Over the two-year period, 18 different incidents have led to either a Lex Sarah or Lex Maria report at the same special care home.
The municipality has at the same time stressed that a report under Lex Sarah does not in itself mean the investigation will ultimately conclude that abuse took place. As a result, the municipality has not yet drawn any overall conclusions about whether Björksäter has more general problems.