Lake Song Assisted 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 staff failed to administer the resident’s medications according to physician orders and the resident required hospitalization. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. Facility staff failed to supervise administration of medication and the resident missed various medications over an approximate two-month period. The resident was hospitalized for fluid overload and NSTEMI (non-ST segment elevation myocardial infarction), a type of heart attack. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident’s records, death record, hospital records, facility internal investigation documentation, facility incident reports, staff schedules, hospital records, and related policies and procedures Also, the investigator observed medication administration at the facility. The resident resided in an assisted living facility. The resident’s diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), and type two diabetes. The resident’s service plan included assistance with bathing, medication administration, blood glucose monitoring, and daily weight monitoring. The resident’s assessment indicated the nurse set-up medications in a Medi-set box and staff administered the medication per the electronic medication administration record (eMAR) as delegated by the nurse and per physician’s orders. The resident’s medication administration record (MAR) documentation indicated all medications were administered as ordered. Approximately two months before the resident was hospitalized, the resident was prescribed an antibiotic to be taken twice a day for seven days. The MAR indicated all doses of the antibiotic were administered as ordered. Facility documentation indicated the resident reported chest tightness and trouble breathing and was transferred to the hospital. Three days after hospital admission, facility cleaning staff found “51 pills in and around her reclining chair…” 12 different types of medications were found. Eight pills which were prescribed for reducing extra fluid, four pills for reducing cholesterol/preventing heart attacks and strokes, and four antibiotic pills. Hospital records indicated the resident's admission diagnoses included severe hypertension (high blood pressure) with hypertensive emergency (acute elevation in blood pressure that is associated with signs of organ damage), acute NSTEMI (non-ST-elevation myocardial infarction, a type of heart attack that happens when heart's need for oxygen can't be met), ischemic cardiomyopathy (a condition of weakened heart muscles due to a heart attack or coronary heart disease), and atrial fibrillation (irregular heartbeat) and fluid overload. The resident was admitted to the intensive care unit (ICU) due to multiple organ failure and increasing weakness, debility, and frailty. The resident was hospitalized for nine days and later discharged to a facility that could provide a higher level of care. The resident died of heart failure a few weeks later. During an interview, a facility nurse stated staff were expected to watch the resident take her medications, but the resident put her medications on a blanket in her lap "so I assume that's how it got messed up." The nurse verified that staff did not administer medications according to facility protocol and did not ensure the resident swallowed all medications that staff provided. 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: No, deceased. Family/Responsible Party interviewed: Attempts to contact were unsuccessful. Alleged Perpetrator interviewed: Not Applicable the Action taken by facility: The facility reported the medication error to the primary care provider. 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 The responsible party will be notified of their right to appeal the maltreatment finding. If the maltreatment is substantiated against an identified employee, this report will be submitted to the nurse aide registry for possible inclusion of the finding on the abuse registry and/or to the Minnesota Department of Human Services for possible disqualification in accordance with the provisions of the background study requirements under Minnesota 245C. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities Mille Lacs County Attorney Onamia City Attorney Onamia Police Department PRINTED: 05/29/2024 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 _____________________________ 30547 04/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 206 NORTH ELM STREET LAKE SONG ASSISTED LIVING ONAMIA, MN 56359 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****** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER CORRECTION using federal software. Tag numbers have ORDER been assigned to Minnesota State Statutes for Assisted Living License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G.08 to 144G.95, these correction orders are appears in the far left column entitled "ID issued pursuant to a complaint investigation. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether a violation is corrected out of compliance is listed in the requires compliance with all requirements "Summary Statement of Deficiencies" provided at the statute number indicated below. column. This column also includes the When a Minnesota Statute contains several findings which are in violation of the state items, failure to comply with any of the items will requirement after the statement, "This be considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. #HL305479407M/ #HL305477205C PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On April 15, 2024, the Minnesota Department of STATES,"PROVIDER'S PLAN OF Health conducted a complaint investigation at the CORRECTION." THIS APPLIES TO above provider, and the following correction FEDERAL DEFICIENCIES ONLY. THIS orders are issued. At the time of the complaint WILL APPEAR ON EACH PAGE. investigation, there were 29 residents receiving services under the provider's Assisted Living with THERE IS NO REQUIREMENT TO Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE The following correction orders are issued for STATUTES. #HL305479407M/ #HL305477205C, tag identification 0620, 2320, 2360. The letter in the left column is used for tracking purposes and reflects the scope and level issued pursuant to 144G.31 subd. 1, 2, and 3. 0 620 144G.42 Subd. 6 (a) / 626.557, Subd. 3 0 620 SS=D Compliance with requirements for reporting ma (a) The assisted living facility must comply with LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 60FT11 If continuation sheet 1 of 11 PRINTED: 05/29/2024 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.