According to the MDH report, the facility neglected the resident when the resident fell after a meal service. Staff failed to physically assist the resident who was trapped between the wall and his electric wheelchair. The resident passed away from the incident.

Minnesota Department of Health determined neglect was substantiated. The facility and alleged perpetrator (AP)2 were responsible for the maltreatment. The facility was aware of the resident’s recent falls in the dining room. The facility failed to enforce nursing staff (caregivers) remain in the dining room during meals to monitor the resident and provide standby assistance. Additionally, the facility fall policy directed an erroneous order to not touch a resident after a fall and did not direct staff to aide for life-threatening situations. AP2, a caregiver unlicensed personnel (ULP), and AP1, a dietary staff member, were in the dining room at the time of the incident. AP2 and AP1 watched idly as the resident struggled to get into his electric scooter for over several minutes and fall into a suffocating position between the wall and his scooter. AP2 failed to attempt to provide any physical assistance to the resident or to try to move his electric scooter. AP2 instructed dietary staff, including AP1 not to touch him. AP1 was not responsible for the maltreatment due to not receiving prior training on falls or transfer assistance and being instructed to not touch the residents. However, several staff including AP2 watched the resident without intervening or calling 911 after there was no longer signs of his chest rising and falling for breaths viewed on the video footage. The resident was dead when law enforcement arrived.

The MDH investigation continues to state that during an interview, a family member stated the resident had trouble walking due to knee and hip replacements, his size, and vertigo. The resident had several falls in his apartment and the dining room prior to the incident. During all that time, the facility never changed his plan of care, and he received no hands-on help with transfers. The facility’s fall policy and procedure directed staff to not touch a resident after a fall, but to call the nurse, observe for injury and take vital signs. If the nurse was not onsite and the resident was hurt, the policy directed staff to call 911, then notify the nurse. Minnesota Statute 604A.01, subdivision 1, Good Samaritan Law, duty to assist, indicates a person at the scene of an emergency who knows that another person is exposed to or has suffered grave physical harm shall give reasonable assistance to the exposed person. In conclusion, the Minnesota Department of Health determined neglect was substantiated.