MDH: neglect claims substantiated in Rochester assisted living facility

(ABC 6 News) – According to a Minnesota Department of Health (MDH) investigation, a resident at a Rochester assisted living facility spent approximately 10 hours lying in her own blood with injuries to her neck, head, ribs, and limbs due to a system malfunction.

According to the state’s public investigative report, the incident occurred at the Waters on Mayowood on the night of June 10, 2023. During interviews with both the resident and their family members, a MDH investigator learned that at approximately 9 p.m. on the 10th, the resident suffered a fall that resulted in serious injuries.

The resident then attempted to use a call pendant that was intended to alert staff to an emergency. But, despite using the pendant as instructed, staff failed to respond.

At approximately 7:30 a.m. on June 11, 2023, more than 10 hours after the resident was reportedly first injured, a staff member heard her yelling from inside her apartment. Staff then entered her unit and found her “on the bathroom floor with blood around her, head wounds, scrapes on her arms and legs”.

The resident was later transported to the hospital for evaluation. According to hospital records, she was diagnosed with head trauma, neck fractures, multiple rib fractures, and significant pain.

The resident declined surgical intervention and was later placed on comfort care.

She died approximately one month later.

The facility later conducted an internal investigation that found the resident’s call pendant was not functional at the time of her fall. The Waters on Mayowood would go on to test additional pendants during their investigation, and found several others that were not functioning as intended.

According to facility documents, the non-functional units were replaced, and staff were directed to monitor the functionality of the call pendant system.

But, during an onsite visit one month after the resident fell, an MDH investigator identified additional call pendants that did not work as intended. The facility was notified of the malfunction and conducted an audit, which uncovered seven additional malfunctioning pendants.

The facility’s registered nurse (RN) later stated that the root cause of the malfunction was not identified until a representative of the call pendant company came to the facility one day after the investigator’s onsite visit.

The facility’s lease agreement included three available options for call pendant response services. One was complimentary, another was included with scheduled assisted living services and the third option included a cost of $275 per month that required staff to respond in cases of emergency and required a facility assessment to be completed on the resident in question.

The resident who suffered the injuries on the night of June 10, 2023 paid the $275 per month fee.

The facility’s Licensed Assisted Living Director (LALD) told the investigator that the call pendant system had been installed approximately 10 months prior to the resident’s fall, and acknowledged that some pendants had not been setup correctly by facility staff.

Following the incident, MDH conducted a maltreatment investigation and determined that a claim of neglect was substantiated.

The report’s findings and conclusions are as follows:

“The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility was aware of call pendant system malfunctions but failed to to ensure proper functionality of the system. The resident fell and, despite activating her call pendant for assistance, remained on the floor for approximately ten hours before being found by staff the next morning. The resident sustained head trauma, multiple rib and cervical fractures, and died approximately one month later. The facility identified the resident’s call pendant was not functional at the time of the fall and discovered additional call pendant functionality issues but failed to establish interventions to ensure system repairs were made and the system remained in proper working order.”

As a result of the state investigation, the Waters on Mayowood were issued a number of correction orders, one of which mandated that the facility ensure their call pendant system is monitored and remains functional.

Another correction order was issued under Minnesota Statute 144G.50 Subd. 5, which states:

“The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. The contract must not include any provision that the facility knows or should know to be deceptive, unlawful, or unenforceable under state or federal law, nor include any provision that requires or implies a lesser standard of care or responsibility than is required by law.”

The facility was found to be in noncompliance of those requirements after it was discovered that the resident’s lease agreement included a provision that stated: “the licensee [The Waters on Mayowood] does not warrant that the operation of the notification pendant will be uninterrupted or error free. The residents bear the entire risk as to the performance of the pendant should the service prove defective or incomprehensible.”

Under Minnesota state law, assisted living facilities are prohibited from including provisions in contracts that waive the facility’s liability in matters that involve the health and safety of a resident. The facility was mandated to correct the issue and gain compliance immediately.

ABC 6 News reached out to the Waters on Mayowood and received this statement:

“The Waters is so sincerely sad to have lost one if its residents who enjoyed interacting with a group of loving friends in the year and a half she was with us. Any time a resident passes away, our team feels the loss because of how we come to know our residents. At the time of the incident, The Waters was not aware of any potential malfunction of the call pendant. Immediately following the incident, The Waters tested all resident pendants to ensure proper functioning. Since opening in the Spring of 2015, we have demonstrated a long history of successfully ensuring the health and wellbeing of our residents and we will continue with this commitment.”