Diamond Willow Assisted Living.

Finding: Substantiated, facility responsibility Nature of Visit: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Allegation(s): A facility staff member/ alleged perpetrator (AP) sexually abused the resident by inappropriately touching her on more than one occasion, causing bruising of the thighs and vagina. In addition, the facility neglected the resident when facility staff failed to assess, investigate, and implement new interventions when multiple occurrences of inner thigh bruising were observed on the resident. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. Due to incomplete and conflicting accounts, the cause of the bruising was not able to be determined, and an alleged perpetrator (AP) was not able to be identified. The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. Inner thigh bruising was observed on the resident on three separate occasions over a fifteen-week period. Neglect occurred when the facility failed to act on their awareness and knowledge of the multiple occurrences of unexplained bruising and An equal opportunity employer. failed to develop and/or implement new interventions to protect the resident’s health and safety. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also contacted law enforcement and the resident’s family. The investigation included review of hospital records, facility policies and procedures, incident reports, and the resident’s facility medical record including nursing assessments, service plans, and progress notes. At the time of the onsite visit, the investigator observed medication administration and staff assistance with activities of daily living, including transfer techniques. The resident resided in an assisted living memory care facility. The resident’s diagnoses included dementia with behavioral disturbance, hallucinations, and anticoagulant (blood thinner) use. The resident’s assessment identified the resident was cognitively impaired, able to verbally communicate her needs, had impaired decision making and was a poor historian, and had a history of progressive night terrors. The resident’s service plan directed staff to provide assistance with activities of daily living including bathing, grooming, dressing, toileting, and transfers. The service plan identified one person was required to assist with all cares however, the resident required a two-person assist and the use of a mechanical lift for transfers. The resident’s service plan included for staff to assist the resident weekly with bathing and a partial bed bath was to be given daily. Staff were directed to contact the nurse with any changes noted to the resident’s skin. Review of the resident’s record included a nursing note from a routine skin assessment which identified “small bruise noted under belly button and scant scattered bruises to the left thigh-unknown origin.” No further follow-up, monitoring, or investigation into the origin of the bruising was initiated by the facility. Approximately two weeks later, the resident’s family submitted a complaint to the facility when they observed bruises on the resident’s thighs. An incident report was completed, local police were notified, and an internal investigation was initiated by the facility. The resident was interviewed and reported she was sexually assaulted on more than one occasion when an unknown individual/alleged perpetrator (AP) entered her room in the night and inserted fingers into her vagina. The family requested for the resident to have no male caregivers and for the resident to be examined by a female physician. Five days later, after a family member questioned nursing staff about why the resident had not yet been examined by a physician, the resident was sent to the emergency room for a sexual assault examination. The sexual assault nurse examination (SANE) report identified four areas of bruising to the resident’s left thigh and periuvular (around the vulva) bruising. The resident was discharged back to the facility per the family’s request. Upon the resident’s return, no new interventions were developed or implemented to protect the resident’s health and safety. Three months later, a third instance of unexplained bruising on the resident’s thighs was reported by facility staff. Although the facility reported the incident, no further follow-up, monitoring, or investigation into the origin of the bruising was initiated and no new interventions were developed or implemented to prevent further occurrence. The resident’s medical record was not updated to include an intervention for two staff members to be present for all cares until one month after the third report of inner thigh bruising. During an interview with a resident’s family member, they recalled assisting the resident in the bathroom when they initially saw multiple circular bruises, in a line, along the resident’s inner thigh. They reported the bruising to facility staff and requested for no male staff to be assigned to care for the resident. Although no formal complaint was made, the family recalled the registered nurse made an entry in the resident’s record of the unknown injury. Approximately one week later, the resident made a request to the family member that she be put to bed with pants on because she “did not want them in there and it hurts inside.” During an interview with the resident, she stated she was sexually assaulted on more than one occasion when an unknown AP entered her room in the night and inserted fingers into her vagina. There were inconsistencies provided in description of the event(s) which occurred, and no specific AP could be identified. When asked about the third and most recent event, the resident denied any assault occurred and had no knowledge of the origin of the bruises. During an interview with a facility nurse, the nurse recalled the resident had a history of visual and auditory hallucinations and although the resident was able to follow directions, she would on occasion stiffen up when staff provided care. The nurse stated no additional interventions were placed on the resident’s care plan following the incidents, only that staff were instructed to use caution with the resident during cares due to a history of bruising easily. During an interview with the facility administrator, when asked about the delay in treatment or being transported to a hospital after the second incident, she deferred to nursing staff and denied knowledge the situation. In conclusion, the Minnesota Department of Health determined abuse was inconclusive and neglect was substantiated. Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or did not occur. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (a) An act against a vulnerable adult that constitutes a violation of, an attempt to violate, or aiding and abetting a violation of: (1) assault in the first through fifth degrees as defined in sections 609.221 to 609.224; (2) the use of drugs to injure or facilitate crime as defined in section 609.235; (3) the solicitation, inducement, and promotion of prostitution as defined in section 609.322; and (4) criminal sexual conduct in the first through fifth degrees as defined in sections 609.342 to 609.3451. A violation includes any action that meets the elements of the crime, regardless of whether there is a criminal proceeding or conviction. Substantiated: Minnesota Statues, section 626.5572, Subdivision 19. “Substantiated” means a preponderance of evidence shows that an act that meets the definition of maltreatment occurred. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) “Caregiver neglect” means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) Reasonable and necessary to obtain or maintain the vulnerable adult’s physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) Which is not the result of an accident or therapeutic conduct Vulnerable Adult interviewed: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: N/A Action taken by facility: The facility conducted an internal investigation into the allegations of sexual abuse. Action taken by the Minnesota Department of Health: The facility was found to be in noncompliance. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html If you are viewing this report on the MDH website, please see the attached Statement of Deficiencies.