Central Minnesota senior facility cited for neglect of unattended man
CROSBY, Minn. - The Minnesota Department of Health found a central Minnesota senior facility responsible for neglect in the case of a memory care resident who suffered sunburn and heat exposure when left outside unattended for hours.
The state's Office of Health Facility Complaints recently released results of an investigation substantiating neglect, finding a senior housing assistant failed to check on the dementia patient within a prescribed two-hour window, as stated in the resident's care plan. The Heartwood Senior Living Community in Crosby also had an outdated and incomplete policy concerning outdoor time for memory care patients, the state found.
The incident resulting in the hospitalization of a resident at Heartwood took place May 28, the sixth consecutive day of temperatures exceeding 80 degrees in a particularly hot stretch of late spring. The resident, an unidentified man diagnosed with Parkinson's disease and dementia, was seen eating lunch in a shaded pergola about 11:30 a.m. The next time staff saw the man, according to the report, was three hours later, lying in the grass in full sun as the thermometer read 88 degrees.
While the door to the patio required a security code to open it, staff members and a more cognitively intact client told the investigator it was common for the door to be propped open for clients to come and go throughout the day. The man who suffered sunburn was known to wander and often laid down on couches, the floor and in the grass—although this behavior was not documented in his assessment, according to the report.
The man—wearing short sleeves, long pants and no hat—bore a body temperature of 101.7 degrees and appeared sunburned on his arm, according to the staff member who found him. The resident was disoriented and unable to stand on his own, requiring three staff members to hoist the normally mobile man into a wheelchair. A hospital evaluation found the resident's nose, chin and left arm were sunburned, and 500 milliliters of fluids were provided intravenously.
While prolonged sun exposure is dangerous for anyone, the Centers for Disease Control and Prevention reports those 65 and older are more prone to heat stress. Chronic conditions and medications can interfere with the body's ability to adjust to temperature changes.
The outdoor policy was 6 years old at the time of the incident, MDH reported. It stated clients must have the ability to summon staff or have access to get back into the building, and each client must be assessed for their ability to use the outdoor area independently. The policy stated it was not recommended for residents to use the outdoor area if the temperature or heat index exceeded 100 degrees or in the case of severe weather.
"The policy lacked any parameters for monitoring clients who were not independently or cognitively able to summon staff, nor did it indicate any protocol for applying sunscreen or providing hydration," the report stated.
A nurse interviewed as part of the investigation said she thought 100 degrees was too hot for the clients, and a policy should be in place specific to memory care. A new policy was in the works, the nurse said, but required approval from both companies that own the facility. Cuyuna Regional Medical Center owns Heartwood jointly with Presbyterian Homes and Services.
The man's physician told the investigator his physical condition—weak, disoriented and underweight—would put him at risk for heat exposure and quick dehydration, and recommended no more than 30 minutes outside at the temperature and humidity the man was found in that day.
One of the man's family members told the state they were unhappy with staff turnover and the client's care and were seeking alternative placement.
As a result of the investigation, the state found the facility responsible for neglect and ordered the comprehensive home care provider to correct practices in which it failed to meet state requirements.
State law defines neglect as "the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care or supervision" or "the absence or likelihood of absence of care or services ... necessary to maintain the physical and mental health of the vulnerable adult, which a reasonable person would deem essential to obtain or maintain the vulnerable adult's health, safety or comfort."
When reached for comment Wednesday, Oct. 31, campus administrator Mike Hall emailed a statement expressing regret for what he called an isolated incident.
"The health, safety and well-being of residents are Heartwood's utmost priority," Hall wrote. "We strive to uphold the freedom and choices of those we serve while also providing the right protocols to ensure their safety.
"We regret that this incident happened and responded immediately with a corrective action plan which was accepted by the Department of Health. The state now considers us in full compliance."
According to MDH records, no previous complaints about the facility have been substantiated.