Advocates: Staffing, medication issues core to Central Minnesota elder abuse investigations

ST. CLOUD — The Minnesota Office of Health Facility Complaints received 2,603 complaints of elder abuse in Central Minnesota last year, according to a new analysis by Elder Voice Family Advocates.

Only a handful of those complaints were investigated by the state Department of Health.

For Central Minnesota, in the last 26 months, officials investigated 89 complaints and half of them were unsubstantiated. 

The Elder Voice report reveals some St. Cloud-area facilities have been investigated several times in the past few years for problems such as sexual abuse, financial exploitation and theft of medication.

Staff issues, such as understaffing and poor training, were at the heart of many complaints against long-term care and assisted living facilities, according to the report "The State of Elder Care in Central Minnesota," which spanned Dec. 1, 2017 to Jan. 31, 2020, before the novel coronavirus reached Minnesota.

These problems are even more salient during the COVID-19 pandemic, said Kris Sundberg, executive director of Elder Voice Family Advocates.

"It was a recipe for disaster before, and COVID is now exposing how poorly staffed these facilities have been," she said. As of Monday, about 80% of the COVID-19 deaths in Minnesota were tied to long-term care facilities. 

The advocacy group reviewed investigations into facilities within about 40 miles of St. Cloud. Not all of the investigations were substantiated, but Elder Voice members want to highlight inconclusive and unsubstantiated investigations, too. 

"Some of these investigations raise more questions than answers," Sundberg said. 

Many senior victims don't feel comfortable reporting abuse in the first place, and the large majority of complaints in Minnesota are not investigated at all, according to the Elder Voice report.

In the 26-month period that Elder Voice reviewed, the state investigated 89 cases at 47 facilities in Central Minnesota. That means 44% of assisted living and nursing homes were investigated in the area.

"There were three incidents of sexual abuse, eleven cases of medication errors, and ten cases of falls as a result of improper transfers or supervision. There was one death directly attributable to the neglect and three other deaths where neglect may have been a contributing factor," according to the report. 

Of the 89 investigated complaints, 27 were substantiated, 17 inconclusive and 45 unsubstantiated.

Four facilities in St. Cloud, Sauk Rapids and Sartell were named "facilities of concern" for repeated state investigations. They all had deficiencies in federal reviews as well. Other "facilities of concern" on the list have closed or are located well outside St. Cloud.

Good Shepherd in Sauk Rapids

In the past two-plus years the state investigated Good Shepherd Lutheran Home six times, twice substantiating complaints of theft. One instance was the theft of medications from three residents, the other a theft of money from a resident. 

Good Shepherd declined to comment for this story. 

Four of the investigations ruled complaints unsubstantiated: one regarding resident violence, another on family member abuse, another on neglect of care and one on the ingestion of a foreign object.

Federal regulators through Medicare cited Good Shepherd for various issues in the past couple years, including four deficiencies reported in August 2019, including issues with staff members' hand hygiene and a failure to "provide separately locked, permanently affixed compartments for storage of controlled medications in 2 of 8 medication room refrigerators."

The entrance to St. Benedict's Senior Community in St. Cloud is pictured in this file photo.  (Photo: Gustin Schumacher, Gustin Schumacher, gschumache@st)

St. Benedict's in St. Cloud

St. Benedict's Senior Community made statewide news last year when a staff member was convicted of sexually abusing a resident.

The Department of Health also investigated the matter, ruled the employee responsible for the maltreatment and "issued a correction order regarding the vulnerable adult's right to be free from maltreatment," according to the Office of Health Facility Complaints July Investigative Public Report.

Jesus Manzanilla Alvarado, 23,
 is charged with sexual abuse
and mistreatment of a
vulnerable adult while working
at St. Benedict's Senior Community.
(Photo: Sherburne County Jail)

That was one of five state investigations into St. Benedict's Senior Community in the past 26 months, according to Elder Voice's report. The state also substantiated a complaint of improper restraint in late 2017. The state ruled another sexual abuse complaint as inconclusive, and two other investigations were unsubstantiated regarding the notification of a physician and a lack of daily activity.

CentraCare provided this statement Wednesday about the investigations: 

"The safety of our patients and residents is always our top priority, so when an incident occurs at one of our facilities, we take immediate action which often includes self-reporting to regulatory agencies. For each case, we conduct an internal review to determine what steps are needed to ensure an incident does not happen again. We are transparent with our families when an event occurs and report these cases publicly per Minnesota Department of Health and Joint Commission guidelines."

In early 2017, the facility was fined nearly $25,000 by federal regulators, and it was cited with multiple deficiencies since then, including five in March 2019. Some deficiencies, including the most severe one, in the recent Medicare report were tied to the sexual abuse incident one year ago.

"Based on interview and document review, the facility failed to thoroughly investigate allegations of abuse, and failed to protect the residents during the investigation," according to the federal report. "This practice had the potential to affect all 143 resident in the facility."

Talahi Nursing in St. Cloud

A coffee spill at Talahi Nursing and Rehab Center resulted in a second-degree burn and a ruling of neglect by the state. It was the only substantiated complaint at that center included in Elder Voice's analysis. 

The facility was investigated five times in the 26-month time frame. One resulted in an inconclusive ruling for alleged poor wound care. There were three unsubstantiated complaints for alleged poor supervision when a resident attempted to kill themself, medication error and poor wound care.

Elder Voice flagged Talahi Nursing for "so many unsubstantiated cases that were serious enough to trigger an onsite investigation."

The facility administrator did not return a Tuesday voicemail seeking comment. 

Talahi Nursing and Rehab Center was cited with eight deficiencies in October and many others in recent years. 

"Based on observation, interview, and record review, the facility failed to ensure proper wheelchair positioning for 2 of 2 residents observed with positioning concerns," according to the federal report. "In addition, the facility failed to provide appropriate care and services for 1 of 1 resident."

Edgewood Sartell

Last summer, the state investigated a report that an employee at Edgewood Sartell gave a resident the wrong medication, causing the client to be admitted to the hospital.

The Department of Health ruled the staff member responsible for neglect. It was one of three investigations into the facility since December 2017. 

Another investigation into an alleged drug theft led to an inconclusive ruling, and another medication error was unsubstantiated, according to Elder Voice's report. 

An employee at Edgewood Sartell would not comment, and no one responded to a request for an interview sent to company's general email box.

Medication errors should not happen, Sundberg said. People suffer when they don't get their medications, and clients can die if they receive the wrong drugs.

"With a really carefully managed and designed system, all of that should never have to occur," she said. 

How to use this information?

Elder Voice members conducted their analysis to identify the root causes of abuse, neglect and exploitation, according to the report. Members then lobby for policy change and support families who use long-term care or assisted living services.

It has long been a challenge to staff assisted living and nursing home facilities, because the work is difficult and the pay is relatively low. There's no "silver bullet fix," Sundberg said. 

"We really empathize with the caregiver," she said. "They're doing God's work, and most of them are doing a good job. But they're getting burned out. And they're getting sick."

Especially during the COVID-19 outbreak, when residents are cut off from visitors, communication is key, Sundberg said. 

She suggests people stay in touch with loved ones who are residents and use a camera to monitor their care and well-being.

Be patient when reaching out to facilities and try to understand the demands they're under, Sundberg said. "Have a really constructive dialogue with the facility management and staff."

And if you do learn of a problem, she said, report it. 

Full Article & Source:
Advocates: Staffing, medication issues core to Central Minnesota elder abuse investigations

State finds neglect in Aitkin assisted living facility

Failure to correctly monitor the blood sugar levels of a diabetic assisted living resident in Aitkin amounted to neglect, the Minnesota Department of Health concluded.

Golden Horizons in Aitkin was the site of a March investigation determining the home care provider failed to comply with hospital orders to increase the number of blood sugar checks on an unidentified resident. The resident—a Type 2 diabetic with dementia—went to the hospital several times with high blood sugar before ultimately dying, a death partially attributed to diabetes and its complications. The state's Office of Health Facility Complaints reported its findings Tuesday, June 19.

"Based on a preponderance of evidence, neglect is substantiated," the report stated. "The home care provider failed to implement hospital orders for increased monitoring of the client's blood sugars and therefore had insufficient information to provide to the client's physician when requesting changes to the client's insulin regimen."

A month after the resident was admitted to Golden Horizons, they showed elevated blood sugar. Within five days, the resident's blood sugar reached 540, a level at which they were unresponsive. At the hospital, the resident received a diagnosis of diabetic coma, and the hospital ordered blood sugar checks be increased from once to four times daily.

Evidence collected by the MDH investigator showed nursing staff failed to follow this directive, however, despite acknowledgement of the change in a note written by a nurse. Three additional hospital visits followed, including one for a broken clavicle attributed in part to the resident's lethargy brought on by high blood sugar.

Ten days after the hospital ordered the additional tests, the assisted living facility had yet to implement the regimen, the report stated. On the 11th day, records showed blood sugar testing was completed three times a day—although the provider failed to document the amount of insulin the resident received or the number of carbohydrate grams consumed in meals.

Elevated blood sugar remained an issue for the resident, records showed, and the final hospital stay indicated the resident was experiencing kidney failure. The resident was placed in hospice care after a four-day hospitalization, and died one week later.

As part of the investigation, a family member of the client said they were unaware of the incorrect procedures, but noted they thought staff provided good care and managed their family member's behavioral needs well.

Interviews with nurses at the facility pointed toward staffing issues as the culprit responsible for neglectful care.

"There was many transitions of new nurses starting and the primary nurse leaving," the report stated. "The primary nurse was completing training with new nurses and other nurses were going back and forth between two of the home care provider locations. Work was not assigned to any particular nurse and work was completed by whichever nurse came across it."

The lack of insulin reports was explained by technical issues with an electronic monitoring system, according to the report.

State law defines neglect as "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" or "the absence or likelihood of absence of care or services ... necessary to maintain the physical and mental health of the vulnerable adult, which a reasonable person would deem essential to obtain or maintain the vulnerable adult's health, safety or comfort."

According to records maintained by MDH, Golden Horizons in Aitkin was the subject of three other investigations yielding a substantiation of claims. In October 2016, a case involving multiple falls by a resident resulted in a neglect determination. Two investigations took place in October 2014: one involved inadequate supervision of residents, resulting in one injuring another, and the second investigation found a staff member abused two residents by forcing their movements and causing pain. The staff member was fired.

Five other Golden Horizons locations are in Crosslake, Preston, Sandstone, Worthington and Ida Grove, Iowa. None of the other Minnesota facilities, operated under the same comprehensive home care provider license, show substantiated investigations, according to the MDH database.

According to the company's website, the facilities are managed by Pequot Lakes-based KC Companies Inc. Chuck Lane, co-owner of KC Companies Inc., was reached by phone Wednesday and he asked for more time before commenting. A Thursday phone interview was scheduled with Lane, but he did not answer his phone nor returns calls.

***UPDATE***

When this story was first printed, Golden Horizons in Aitkin was referred to as a nursing home. The facility is considered an assisted living facility, rather than a nursing home.

The Dispatch regrets the error.

Full Article & Source:
State finds neglect in Aitkin assisted living facility