Assisted living facility in Brooklyn Park neglected resident before her death, MDH report shows

State health officials say an assisted living facility in Brooklyn Park failed to provide a resident with the right amount of hydration, timely transfers and incontinence care before she died.

The Minnesota Department of Health (MDH) report states the resident had been at Second Horizon Living for about 10 weeks and that she was diagnosed with a stroke, dysphagia (difficulty swallowing), dysarthria (slurred speech), hemiparesis (partial paralysis), weakness, gastrostomy, with gastrointestinal appliance and device (feeding tube), and moderate protein-calorie malnutrition. The gastrostomy tube was the only way the resident received nutrition and liquids.

There were also instructions in the resident’s admission and provider orders to flush the gastrostomy tube with 180 ml of water every four hours and have tube feedings at 55 ml per hour for 20 hours a day through the gastrostomy tube. However, according to the MDH report, staff were directed to flush the tube every four hours with 30 ml of water, significantly less than what was ordered.

The investigator also found that the resident’s medication record showed several missed medication doses that indicated the medications were not available. The missed medications included eight days of Aspirin 81 mg one tablet every day, 21 days of Coreg 3.125 mg twice a day and four days of Lisinopril once a day, 14 days of Atorvastatin 80 mg and 27 days of Lansoprazole 30 mg every day.

A nurse said during an interview that there was a “miscommunication among staff and nursing” and that the medications were available but the staff did not recognize the generic names of the medications, so they weren’t administered. That same nurse said she did not see a decline in the resident’s condition before hospitalization.

The investigator also spoke to an unlicensed professional (ULP) who said they were not trained on tube feeding administration. That ULP also said management “assumed she was trained because she was a certified nursing assistant,” according to the MDH report. Additionally, the ULP said that staff members were flushing the gastrostomy tube when feedings were started and stopped, and after medications were administered. However, no other water besides what was being used to flush the tube was given to the resident. The ULP said she observed “the resident slowly declining and was not staying in her chair for long periods of time.”

Another ULP reported that the resident was moved “every few hours when they changed her or got her up in her chair” and that she did not notice a significant decline in the resident ahead of the hospitalization.

A family member also spoke to the MDH investigator. The report states that the resident was often still in bed even in the late afternoon. The family member said she questioned staff about how much water the resident was getting, and staff said they were only flushing the tube in between feedings and medications. The family member also told staff that the resident “did not look well and was not responding appropriately” and asked that the resident be taken to the hospital.

The resident’s death certificate states the primary cause of death included Escherichia coli (E coli) bacteria pneumonia, E coli urinary tract infection, and E coli sepsis (an extreme reaction to an infection).

Based on the evidence gathered, MDH “determined neglect was substantiated.” The investigation also concluded that “the facility was responsible for the maltreatment” and that for two months, the resident got less water than the provider ordered to be given through the gastrotomy tube.

MDH reports Second Horizon nursing staff members have since started a weekly audit of medication administration records. Second Horizon has a right to appeal the maltreatment finding after being found to be in noncompliance with state caregiver standards.

5 EYEWITNESS NEWS reached out to Second Horizon Living but has not yet heard back.