The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. Facility staff failed to notify the resident’s primary provider of a change in condition, weight loss, and refusals of care, services, medications, food, and water. In addition, the facility failed to complete an assessment and/or implement interventions to address the resident’s needs. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, unlicensed staff and a physician. The investigation included review of the resident record, hospital records, facility incident reports, staff schedules, and related facility policy and procedures. Also, the investigator observed resident cares and staff interactions.

The report goes on to state that during an interview, management staff stated based on notes and daily meetings, the resident refused to eat and drink but management did not personally witness the continued refusals. If a resident’s PCP did not respond to faxes or communication, the nurse should have followed up daily. Management staff stated a change in condition assessment should have been completed if the resident required a change in services and that the assessment could be conducted via a phone system. During an interview, the resident’s family member stated the facility nurse should have been in constant communication with the resident’s PCP. The family stated the facility should have told them about the repeated refusals and weight loss and that the resident was not appropriate for assisted living.

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