River Grand Senior Living.

Finding: Substantiated, facility responsibility Nature of Investigation: 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. Initial Investigation Allegation(s): The facility neglected the resident when the facility failed to ensure the resident’s safety with bed rail use. The resident became entrapped. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility failed to assess the resident for safety risk with a hospital style bed rail until after the resident’s head was entrapped between the mattress and side rail during a fall. The investigator conducted interviews with facility staff members, including administrative staff and nursing staff. The investigation included review of the resident record, bed rail assessments, bed rail consent forms, facility internal investigation, facility incident report, and related facility policy and procedures. Also, the investigator toured the facility. The resident resided in an assisted living facility which also had a memory care unit. The resident’s diagnoses included a stroke. The resident’s service plan included assistance with transferring, turning, and repositioning in bed as needed. The resident was alert and oriented. The resident’s record indicated the resident had an unwitnessed fall out of bed. The resident slid out of bed and her head was caught between the bedrail and mattress. The resident was unable to get her head out but was able to use the call pendant for staff assistance. Staff removed the resident’s head from between the bed mattress and the side rail. The resident complained of left leg pain and was sent to the emergency room for evaluation. The resident was diagnosed with a hip and ankle contusion (bruise). The resident’s most current assessment for siderail safety was dated five days prior to the resident’s entrapment and was completed for a grab bar, not the hospital style bed rails. During an interview, a nurse stated because licensed staff were not made aware of the resident’s new hospital bed with bed rails, licensed staff failed to assess the bedrails for resident safety. The nurse stated one night the resident fell out of bed and the resident’s head was entrapped during the fall. The resident used the call pendant for staff assistance. Staff were able to get the resident’s head out from between the bedrail and mattress. The resident complained of left leg pain and was evaluated at a hospital. The resident sustained a hip contusion. During an interview, a family member stated the bed rails were hospital style bed rails that came with the resident’s new hospital bed. After the incident, the facility staff spoke to the resident about removal. The resident chose not to have the bed rails removed. During an interview, the resident said the facility nurse spoke to her about bed rails and about safety. The resident said she felt safe and had no concerns with the bed rails on her bed. In conclusion, the Minnesota Department of Health determined neglect was substantiated. Substantiated: Minnesota Statutes, 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: Not Applicable. Action taken by facility: The facility staff responded to the resident’s request for assistance following the entrapment and sent the resident to the emergency room for evaluation. The facility assessed the resident’s hospital style bed rails and educated the resident on risk verses benefits of use. The facility offered alternatives and interventions to mitigate safety risks. 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. You may also call 651-201-4200 to receive a copy via mail or email cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities Itasca County Attorney Grand Rapids City Attorney Grand Rapids Police Department PRINTED: 09/10/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 28963 06/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 355 RIVER ROAD RIVER GRAND SENIOR LIVING GRAND RAPIDS, MN 55744 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ******ATTENTION****** ASSISTED LIVING PROVIDER CORRECTION ORDER In accordance with Minnesota Statutes, section 144G.08 to 144G.95, these correction orders are issued pursuant to a complaint investigation. Determination of whether a violation is corrected requires compliance with all requirements provided at the statute number indicated below. When a Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL COMMENTS: #HL289639784C/#HL289631980M On June 25, 2024, the Minnesota Department of Health conducted a complaint investigation at the above provider, and the following correction orders are issued. At the time of the complaint investigation, there were 69 residents receiving services under the provider's Assisted Living with Dementia Care license. The following correction orders are issued for #HL289639784C/#HL289631980M, tag identification 2310 and 2360. 02310 144G.91 Subd. 4 (a) Appropriate care and 02310 SS=G services (a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 G4CR11 If continuation sheet 1 of 5 PRINTED: 09/10/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 28963 06/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 355 RIVER ROAD RIVER GRAND SENIOR LIVING GRAND RAPIDS, MN 55744 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 02310 Continued From page 1 02310 standards. This MN Requirement is not met as evidenced by: Based on interview and record review, the Minnesota Department of Health is licensee failed to provide care and services documenting the State Correction Orders according to acceptable health care, medical, or using federal software. Tag numbers have nursing standards for one of one resident (R1) been assigned to Minnesota State with hospital style bed rails. The licensee nurse Statutes for Assisted Living Facilities. The was not aware R1 had two upper hospital-style assigned tag number appears in the far bed rails until an incident of entrapment occurred. left column entitled "ID Prefix Tag." The The failure had the potential to lead to serious state Statute number and the injury, impairment, or death. corresponding text of the state Statute out of compliance is listed in the "Summary This practice resulted in a level three violation (a Statement of Deficiencies" column. This violation that harmed a resident's health or safety, column also includes the findings which not including serious injury, impairment, or death, are in violation of the state requirement or a violation that has the potential to lead to after the statement, "This Minnesota serious injury, impairment, or death) and was requirement is not met as evidenced by.