Woodstone Senior Living.

Finding: Substantiated, individual 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 resident was neglected when the alleged perpetrator (AP) failed to provide care, services, and supervision as indicated in the resident’s service/care plan. After the resident fell, the AP failed to check on the resident, as a result the resident laid on the floor for 6 hours. The resident was transferred to the hospital. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The AP was responsible for the maltreatment. The resident fell at 8:29 p.m. The AP came on shift at 10:00 p.m. The AP failed to completed wellness checks on the resident. The resident was found on the floor in her room six hours after the fall. The resident was sent to the emergency room. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement, and the resident’s family members. The investigation included review of the resident record(s), hospital records, facility internal investigation, facility incident reports, personnel files, staff schedules, law enforcement report, video evidence, and related facility policy and procedures. Also, the investigator observed resident’s and staff in the facility. The resident resided in an assisted living facility secure memory care unit with diagnoses including Alzheimer’s Disease, dementia, and anxiety. The resident’s assessment indicated the resident was severely cognitively impaired, disoriented to person, place, time, and unable to use a call light system to alert staff or communicate her needs. The assessment indicated staff would provide routine wellness checks on the resident. The resident’s individualized abuse prevention plan (IAPP) indicated the resident was at risk for abuse and neglect secondary to impaired cognition. The IAPP indicated staff were to provide wellness checks per service plan, anticipate the resident’s needs, and report any concerns to the nurse. The IAPP identified the resident had electronic monitoring in her room which recorded video and audio. The resident’s service/care plan identified the resident was at a risk for falls, unable to use a call light system to alert staff in the event of an emergency, and indicated staff were to complete wellness checks 7 times daily including times scheduled at 10:00 p.m. and 12:00 a.m. during the AP’s shift. A facility incident report indicated during change of shift quality rounds at 2:30 a.m. the resident was found lying face down on the floor next to her bed. The resident complained of pain and was transferred by ambulance to the emergency department (ED) for evaluation and treatment. The ED and hospital record indicated the resident had an unwitnessed fall and was found on the floor during rounds. The record indicated the resident had extensive imaging with no evidence of acute traumatic injury or fractures. The record indicated the resident had a transient elevation in her creatinine kinase (CK) blood test (a possible indicator of skeletal muscle damage or degeneration) which resolved with intravenous fluids. The resident record indicated the night of the incident the resident refused assistance with evening cares. The resident record indicated the AP documented completing wellness checks at 10:39 p.m., and 12:26 a.m. In addition, the AP documented completing a change of shift quality check on all residents on the unit at 11:05 p.m. The resident record indicated the resident had no other scheduled services between the evening cares (documented as refused) and the first wellness check scheduled at 10:00 p.m. on the AP’s shift. The facility investigation indicated the AP was scheduled to work on the secure memory care unit from 10:00 p.m. till 2:00 a.m. The investigation indicated the AP documented completing wellness checks on the resident, but the resident’s continuous electronic video monitoring system showed no checks were completed. As a result, the resident was not found by staff until change of shift quality rounds at 2:30 a.m. When interviewed by facility leadership the AP stated she did not complete change of shift quality rounds at 10:00 p.m. because staff told her everyone was in bed. The facility investigation indicated the AP was unable to recall if she opened the top of the resident’s door around 12:00 a.m. to complete a wellness check or not, and stated, “I know I should have gone all the way in”. The facility investigation indicated surveillance cameras from common areas were reviewed by leadership staff during the time of the incident and showed none of the wellness checks were completed by the AP. A police report, officers body camera video interview with the AP, and images/videos provided indicated the AP told the officer that she assumed her duties at the start of her shift at 10:00 p.m. and change of shift quality rounds and wellness checks were her responsibility at that time. The AP verified she documented completing change of shift quality rounds but did not do them. The AP stated she “should have checked on the resident, no one deserved to lay on the floor that long”. During the interview with law enforcement the AP stated she had documented completing the checks but did not check on the resident. The police report indicated video footage provided by the resident’s family was reviewed and the resident was observed to fall on the floor around 8:30 p.m., with no staff observed enter the resident’s room until 2:30 a.m., 6 hours after the resident fell. When interviewed the AP stated she completed a wellness check on the resident around 12:00 a.m., opened the top portion of the resident’s door a little bit, and saw the resident laying in her bed under the covers with the lights in her room off. The AP indicated she was not responsible for neglect because the resident fell before her shift started. The AP admitted she did not complete wellness checks as documented. When interviewed several facility staff stated they always completed change of shift quality rounds to ensure all residents were ok at the start of each shift. One staff stated the night of the incident the AP refused to complete change of shift quality rounds because she was “tired and had just finished working an evening shift on another unit”. Although the change of shift rounds was not completed, the AP was assigned to perform a wellness check on the resident at 10:00 p.m. per the service agreement and care plan and admitted she did not. When interviewed facility leadership stated the AP was the only staff assigned to work the secure memory care unit from 10:00 p.m. until 2:00 a.m. Leadership staff stated the AP was assigned to complete the change of shift quality rounds at 10:00 p.m. but did not do them. Leadership staff stated when they reviewed facility surveillance video, the AP was observed sitting in the common area at the times wellness checks were documented. A review of continuous video footage from the video monitoring system in the resident’s room showed the resident’s room lights on, her bed made, and the resident’s door closed. The resident was observed fully dressed laying on top of her made bed, not under the covers as the AP stated she observed during wellness rounds. The resident was observed to fall at 8:29 p.m., and the AP never completed checks on the resident as documented. The video does not show the AP cracking the top of the resident’s door open as stated, or at any point prior to the resident being found by staff at 2:30 a.m., 6 hours after the resident fell. Discrepancies in the AP’s statements, and what was observed on the video footage indicated the AP did not complete any of the wellness checks on the resident as documented or as stated. When interviewed the resident’s family members stated the resident fell, was unable to get up, and was heard calling out for help until staff found her 6 hours later. The family stated the ED provider reported the resident had abnormal lab values caused by muscle damage from the resident laying on the floor for a prolonged period of time. In conclusion, the Minnesota Department of Health determined neglect was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19.