Norbella Senior Living Prior L.

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 a resident when they failed to appropriately respond and provide necessary medical care when the resident was found unresponsive and in medical distress. The resident experienced a medical emergency, but the facility waited an hour before calling 911 which delayed the resident receiving necessary emergency medical care. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. Although facility staff were educated to contact the emergency number 911 if they found a resident unconscious, instead staff contacted leadership and an on-call nurse, and attempted to contact the resident’s family prior to contacting 911. That resulted in a delay of treatment for the resident of over one hour from the time when staff found the resident unresponsive until 911 was contacted. The resident was transported to the hospital where he later died from septic shock (life threatening condition) and aspiration pneumonia (accidentally inhaling food, liquid, or vomit into the lungs). The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family members, law enforcement, and the resident’s primary care provider. The investigation included review of the resident’s facility record, in-house provider’s record, police body cam footage and transcription, the resident’s death record, hospital record, facility internal investigation, personnel files, staff schedules, law enforcement report, ambulance run report, and related facility policy and procedures. Also, the investigator observed direct cares during the onsite investigation. The resident resided in an assisted living memory care unit. The resident’s diagnoses included emphysema (chronic lung disease), dementia, lymphoblastic lymphoma (aggressive cancer that affects the bone marrow), and diabetes with diabetic neuropathy (numbness and pain from nerve damage.) The resident’s service plan included assistance with personal cares, orientation for confusion, toileting, medication management, transfers, walking, insulin administration, and blood sugar checks four times per day. The resident was oriented to person and time and was unable to use a call pendant due to lacking the physical or cognitive capability. The resident had difficulty with communication but was able to make his needs known. The resident’s Physician Orders for Life Sustaining Treatment (POLST) indicated the resident wanted full resuscitation, and other treatments in the event of a medical emergency. A progress note indicated one early evening at 4:58 p.m., the facility nurse (who was the on-call nurse) received a call from unlicensed staff indicating the resident appeared lethargic (weak.) Vital signs indicated the resident’s heart rate was fast (tachycardic) at 124 beats per minute (normal 60-100) with a low blood sugar of 84 mg/dL (considered a low blood sugar reading for the resident). The on-call nurse advised staff to monitor the resident and update her of any changes in the resident’s status. Approximately 20 minutes later, staff contacted the on-call nurse to report the resident vomited and appeared to be feeling better. The on-call nurse directed staff to continue to monitor the resident. About 10 hours later, unlicensed staff contacted the on-call nurse to report the resident was cold, clammy, had vomited, with a change noticed in his breathing. The resident’s pulse was elevated at 102 and his blood sugar was 452 mg/dL (elevated.) The nurse advised staff to contact the resident’s family to confirm their preference of keeping the resident at the facility or being evaluated at a hospital. The nurse documented, “Unable to get ahold of family.” After staff’s few attempts to reach the family member, unlicensed staff called the on-call nurse again who directed staff to call 911. The documentation failed to indicate whether unlicensed staff reported to the on-call nurse they found the resident unresponsive. Review of the resident’s ambulance run report indicated early morning about one hour and 15 minutes after finding the resident unresponsive, emergency medical services were dispatched to the facility after receiving a call from unlicensed staff regarding the resident’s breathing problem. The report indicated unlicensed staff reported the resident was unresponsive, with cyanosis (bluish/purple skin due to low oxygen levels) and agonal breathing (gasping breathing signaling near death) for approximately one hour before 911 was called. Vital signs obtained from the emergency medical personnel indicated the resident’s oxygen saturation (level of oxygen in the blood) was at 54% on room air (normal readings 94%-100%). During the transfer to a hospital, the resident required supplemental oxygen and breathing treatments. Review of the police body cam footage and transcription indicated three facility staff stated two hours before finding the resident unresponsive, they opened the resident’s door to look at the resident but did not enter his room because he was “sleeping.” Staff stated two hours later when checking the resident, the resident had vomited and was gasping in distress. On the police body cam, the three unlicensed staff stated it was a facility policy to contact the on-call nurse first before contacting 911. The resident’s hospital record indicated the resident presented to the emergency department unresponsive, in respiratory distress, and high fever (102.2 Fahrenheit (F)). The resident was diagnosed with aspiration pneumonia and sepsis (rapid breathing, fast heart rate, fever, low blood pressure, and chills). Despite hospital staff’s attempts at treatment the resident was placed on comfort care and died hours later. The resident’s death certificate listed septic shock as the resident’s immediate cause of death. Review of employee files for facility staff indicated all staff were trained on when to call 911 and facility policies related to resident medical emergencies. A facility document titled Medical Emergencies, indicated if a resident was found unconscious, facility staff were to call 911 right away before calling the on-call nurse. The facility internal investigation indicated during the evening meal, resident appeared lethargic, so unlicensed staff called and updated the facility nurse on the resident’s condition. When interviewed, unlicensed staff stated the nurse thought the resident’s vitals seemed “okay” but said the nurse told them to keep an “eye” on the resident. The unlicensed staff member stated around 3:00 a.m., there were three unlicensed staff in the resident’s room trying to clean the resident after the resident vomited. The unlicensed staff member stated the resident had vomit coming from his mouth, down his chest, body, and “all over” his bed sheets. The unlicensed staff member observed the resident’s breathing was shallow and his hands were blue. After finding the resident in distress, staff immediately called facility leadership because they did not know who the on-call nurse was that night. Facility leadership instructed staff to obtain the resident’s vitals then call the on-call nurse. The on-call nurse documented the resident’s vitals were “stable, other than the resident’s pulse of 102 and blood sugar reading of 452 mg/dL.” The on-call nurse instructed staff to call the resident’s family member first, “to be sure they wanted to send the resident out.” After three unsuccessful attempts to contact the resident’s family member, unlicensed staff called the on-call nurse back who directed staff to call 911. During an interview, an unlicensed staff member stated at 3:00 a.m. they observed the resident was unresponsive with mottling (blotching skin) and his feet were cold. The unlicensed staff member contacted the on-call nurse who told her to call the resident’s family member. After not being able to contact the resident’s family, the unlicensed staff stated they called the on-call nurse back telling the on-call nurse “we need to call 911.” The unlicensed staff stated they called the on-call nurse back who agreed the resident should be evaluated at a hospital. During an interview, leadership stated they received a call from unlicensed staff between 3:00 a.m. and 3:15 a.m. reporting the resident vomited and appeared to not be well. Leadership stated unlicensed staff did not know who the on-call nurse was, so leadership advised staff to call the facility nurse who was the on-call nurse to update the nurse on the resident’s condition. When interviewed, the nurse stated she thought the resident had an upset stomach based on the information provided to her from unlicensed staff. The nurse stated she did tell staff to monitor the resident and update her regarding any change in his status.