According to the MDH report, during an interview, The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. At the time of the fall, facility staff failed to ensure the resident had a means to summon staff when the resident required assistance with transferring and toileting. The resident was required to holler for staff when needing assistance.

The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The resident was interviewed. The investigator contacted the resident’s legal guardian. The investigation included review of the resident’s facility record, hospital record, orthopedic record, facility fall incident reports, personnel files, staff  schedules, and related facility policy and procedures Also, the investigator observed direct cares with the resident and facility staff. The resident resided in the facility’s assisted living memory care unit. The resident’s diagnoses included unspecified intracranial injury with loss of consciousness (damage to the brain inside the skull and inability to be aware of oneself and surroundings), muscle weakness, epilepsy, unsteadiness of feet, and repeated falls.

The resident’s service plan included assistance with transfers and toileting, and hourly safety checks to help prevent frequent falls. The resident’s fall assessment score indicated she was at risk for falls. The resident was able to make her needs known and be understood, but her cognition was moderately impaired. The resident used a wheelchair and a walker for mobility.

When interviewed, the resident stated prior to her fall the facility did not have a call system on her, stating she “hollered” for staff assistance. The resident stated she did not recall how long she was without her call pendant but thought it was a week. The resident stated at times it took staff a while to respond to her yelling, stating she sometimes urinated on the floor because she had to wait for staff. The resident stated since the fracture she still had pain in her left arm and was unable to sleep on her left side. In conclusion, the Minnesota Department of Health determined neglect was substantiated.