In 2007, an unidentified man living at Hillcrest Senior Living in Red Lake Falls, Minn., fell out of bed and became wedged between his bed and the room's heat register.
By the time staff discovered him, he had sustained second-degree burns stretching from his right hip to his ankle.
The case was one of 22 confirmed instances of neglect, abuse or financial exploitation reported to the Minnesota Department of Health's Health Facility Complaint Office between 2005 and 2014 in Kittson, Marshall, Pennington, Polk, Red Lake and Roseau counties.
An investigation by the office concluded the resident's bed should have been at least 24 inches away from the heater.
"Due to a failure of the facility to provide for the safety of residents related to heat registers, it was determined that a serious threat to resident health and safety existed," special investigator Marilyn Norling wrote in a report about the incident.
Staff at Hillcrest Senior Living did not return calls for comment.
In other confirmed cases of maltreatment published in state reports, staff stole medication and money from patients, caused physical harm through hitting and did not initiate CPR when patient records said it should be performed, which resulted in the death of at least two patients.
At a REM Northstar facility in Crookston, a client received first- and second-degree burns on her left leg when she was left unsupervised and spilled hot coffee on herself in October 2010.
Executive Director Connie Menne said the company has zero tolerance for neglect and abuse and has a number of training protocols to prevent maltreatment.
"On at least an annual basis, each individual's supervision levels are reviewed by the care team," she said. "These discussions are outlined in a risk plan, and all employees are trained on these plans."
At least 40 hours of training and orientation are required of new employees, Menne said.
Keeping updated standard practices, such as patient care procedures, is advocated by organizations such as Care Providers of Minnesota — a nonprofit membership organization for care facilities such as nursing homes.
"If there are problems out there, we want to see them resolved," said Doug Beardsley, vice president of member services for Care Providers. "Standards of practice keep changing and require higher and higher expectations, which is appropriate. We don't want people in pain."
Those facilities include nursing homes, hospitals, boarding care homes, supervised-living facilities, home care providers, hospice programs and residences, assisted-living providers and freestanding outpatient surgical facilities.
Alleged incidents of maltreatment at all Minnesota facilities generated 1,345 complaints statewide in 2013, according to the most recent annual "Allegations of Maltreatment in Minnesota Health Care Facilities" report submitted to the Minnesota State Legislature.
Complaints are not as prevalent in northwestern Minnesota as they are in more urban areas, but dozens were filed between 2005 and 2014.
Total, 58 complaints were received during that timeframe for facilities in the six aforementioned northwest counties. While 22 allegations were substantiated, 36 were not confirmed or the investigation was inconclusive.
Complaints: List of northwest Minnesota county complaints
Allegations of maltreatment — accidents are not reportable — can be submitted to the complaint office by residents, by someone on their behalf or by "provider-initiated" reports, which means the care provider brings allegations forward for investigation.
REM received six complaints during that 10-year time period, though only one involving the client burned by coffee was confirmed by investigators.
Even unconfirmed allegations prompt action, according to Menne.
"In these situations, we do review the incident and — consistent with our high standard for quality — we routinely re-train our employees and revise our protocols as warranted," she said.
Complaints constituted only 7 percent of maltreatment incidents reported to the state.
Incidents coming out of facility self-reports represent an overwhelming majority of those filed with the Health Facility Complaint Office.
More than 19,500 allegations of maltreatment came to the state through these reports in 2013. That number represents a 527 percent increase in the number of maltreatment allegations since 2010.
"It tells that people aren't trying to hide something. They're not waiting for a complaint or a family or community member," Beardsley said of the number of self-reports. "They're saying 'Hey, we caught something or something less than desirable happened. We are going to do our own internal investigation, and we believe it's appropriate and required for an external agency to look at it.'" (Continue Reading)
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Analysis shows dozens of complaints lodged against northwest Minnesota health facilities in past decade