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Report: Allegation of neglect substantiated in death of Alzheimer's patient from fall at Minnetonka facility

Report: Allegation of neglect substantiated in death of Alzheimer's patient from fall at Minnetonka facility Photo: Public Domain Pictures/Pixabay

Updated: November 20, 2019 12:59 PM

A report released Tuesday substantiates an allegation that an elderly patient at a Minnetonka memory care facility fell and broke her femur while an attendant was asleep on the job.

The Office of Health Facilities concluded in its investigation that a staff member at Augustana Emerald Crest in Minnetonka was responsible for neglect in a fall-related injury that led to the death of a patient with Alzheimer's disease. This patient had a history of falls and was known to frequently wake up and wander around at night.

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The Hennepin County Medical Examiner's Office said Ethel Grover, 97, died July 20, nine days after she fell.

The state agency's report stated that based on its investigation of the fall and subsequent death, Emerald Crest had failed to meet the state's requirement to provide an environment that was free from maltreatment.

An initial internal incident report stated that the staffer was documenting Grover around on a laptop in the chair next to her around 3 a.m. July 11 and was unaware she had fallen until she heard Grover say, "I can't get up, help me." After Grover complained of pain, she was taken to the emergency room.

Post-incident documentation and surveillance footage show that the staff member was "on the sofa asleep, without movement, for over 30 minutes" when Grover fell against a medication cart at 3:25 a.m. and sustained a left femur fracture, according to the Office of Health Facilities report.

Her death certificate stated the cause of death was "complications of decreased mobility" from her injury.

The staff member who was supposed to be supervising Grover said in an interview two days after the incident that she had only worked at the facility for about one month. She said she had received comprehensive training and had access to all care policies and was aware of Grover's tendency to wander at night. She also said she knew that sleeping on the job was prohibited.

The resident director said in an interview with investigators that it was well known that Grover frequently walked around when awake at night and would walk into others' rooms and try to open exit doors. The resident director also said staff members are expected to remain awake when on the job and complete rounds "to ensure the safety of all patients at all times," the report stated.

A spokesperson for Cassia, the company that owns Emerald Crest, released the following statement in response to the report:

"This tragedy affected everyone at Emerald Crest and we want to express our deepest sorrow that it happened at all. Our primary concern is for the resident’s family and for the residents we serve. Their safety and wellbeing is our highest priority. To prevent this from happening again, we have reviewed all safety policies and procedures extensively and retrained staff members. Due to privacy concerns, we are not able to publicly discuss more details."

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Kyle Brown

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