The report goes on to state that during an interview, the manager stated that she was new at the time of the incident. She said that a staff member was attempting to assist the resident with a transfer, but the resident insisted she could stand without help. The staff member trusted the resident and proceeded without using proper equipment, which resulted in the resident falling. The manager said she was unsure if the resident actually ended up on the floor. She said that the staff reported the incident to the triage line and that, at the time, the resident did not appear to have any injuries but was later sent to the hospital due to pain. The manager also said that she did not conduct the staff interviews herself but was aware that AP#1 and AP#2 were no longer employed at the facility.

During an interview, a family member stated that the resident was in her room and needed to use the bathroom. Two unlicensed caregivers [AP #1 and AP #2] were in the room with her. The caregivers used the sit-to-stand to transfer her to the toilet but did not use it to assist her to stand. Instead, they had the resident stand and hold onto the doorknob while they pulled up her pants. However, the resident was unable to hold onto the doorknob and stand for long, causing her to fall onto her knee. In the process, she also knocked over the toilet paper holder. The family member stated the resident sustained bruises and was in significant pain. The caregivers told the manager and the family member that the resident did not fall and never touched the ground, but due to her level of pain, the family member reviewed the video and discovered what actually happened.

 In conclusion, the Minnesota Department of Health determined neglect was substantiated.