State investigation substantiates reports of neglect at Edgewood East Grand Forks Senior Living

Sep. 29—EAST GRAND FORKS — Two residents of Edgewood East Grand Forks Senior Living experienced harm due to neglect, an investigation by Minnesota's Department of Health Office of Health Facility Complaints found.

Investigation into the incidents began in July and concluded Sept. 11.

The first complaint was about a resident who spent five days in March hospitalized with four different infections. The woman, as well as all other parties involved, are unidentified by name in the report.

An exposed wound on the woman's ankle became infected and worsened over time. According to the report, the clinical nurse supervisor (CNS) was notified of the resident's condition the day before and failed to seek immediate treatment, notify her provider or supply additional monitoring of her condition — such as checking the woman's vitals or marking the red area around the wound to see if it spread overnight.

The woman's primary care provider said time is always of the essence when an infection has been identified, especially when the person is elderly, because they're at a higher risk.

"You (have) a population that can't advocate for themselves, and family is dependent on eyes and ears of staff and assuming, rightfully so, that their best interests are being kept on the forefront," the primary care provider said.

After the woman was released from the hospital, the facility failed to investigate the delay in her care or submit a report to the Minnesota Adult Abuse Reporting Center, according to the investigative report.

The resident had been hospitalized for a UTI two months prior, and the care she was supposed to receive afterward was not properly documented. The resident's power of attorney (POA) said they raised concerns after her initial hospitalization, but felt staff minimized their concerns and tried to absolve themselves of guilt.

"I left that meeting thinking, 'Wow, am I dumb for thinking that's a concern?'" the POA was recorded saying in the report. "... Then a month and-a-half later, she's in the hospital again."

The night before the resident was hospitalized, the POA called to ask if she needed to be taken to the hospital that night. The POA said the CNS claimed it wasn't that bad and would be checked out in the morning. When interviewed during the course of the investigation, the CNS said he gave the resident's daughter — who appears to be the POA, although it is not directly specified in the report — the option to bring her mother to the ER that evening, but she asked to wait until the morning.

Conflicting reports such as this came up more than once throughout the investigation.

When the CNS was asked whether the facility investigated the resident's repeated UTIs and related concerns, he said women are more prone to getting UTIs and that the resident was resistant to receiving assistance with hygiene, according to the report.

This is inconsistent with the resident's service recap summaries from January, February and March, which indicate no history of refusing any assistance with hygiene care, the report said.

"She was in the hospital for a week," the POA said. "... They dress her every night, it should have been noticed and if they noticed and told anyone, no one else said anything. I left her in the hospital thinking she was going to die."

According to the report, the resident's leg redness had been reported by some staff members up to two weeks before her hospitalization.

Unlicensed staff said they also reported the resident's worsening condition a few days before her hospitalization, as well as the night before, according to the report.

"He's (an) RN, he's a nurse," the staff said. "I'd expect him to be on top of things, but I feel like he just (kind of) waits for things to happen almost. ... There (have) been multiple times I've gone to him with a concern and it's just, 'OK, thanks for letting me know,' and I never see him get up from his office to go see what I'm talking about."

Another unlicensed staff member said management had been aware of hygiene issues previously resulting in multiple residents developing rashes, and failed to educate staff on how to treat and prevent them, leaving unlicensed staff to do their best with no guidance.

The other incident recently investigated by the Office of Health Facility Complaints was for a resident who fell due to grogginess believed to be caused by an extra dose of Ativan.

Despite experiencing significant knee and hip pain that caused him to scream, as well as the fact that he couldn't bear weight on the leg, he was not taken to the emergency room until approximately two days later, the report said.

The resident's hip was fractured in two places. He underwent surgery to repair the fracture and remained in the hospital for 12 days. Once discharged, he did not return to Edgewood. Instead, he relocated to a skilled nursing facility, according to the report.

"My dad laid there with a broken hip for a little over 36 hours," the resident's son said. "It's complete incompetence."

In the meantime, the resident was given Tylenol, though staff notes indicated the medication was ineffective. Facility staff failed to notify the registered nurse and primary care provider, and failed to assess a change in condition, the report said.

An unlicensed staff said they disagreed with the decision to not send the resident to the hospital, and found it shocking. They said facility policy is that unlicensed staff cannot override the nurse if they disagree with a decision to not send a resident to the hospital. Another unlicensed staff said they considered calling the ambulance without permission, but didn't because they knew the CNS would've been upset.

The day after the fall, the staff reached out to the on-call nurse again and was told to call the resident's daughter to have her take him to the hospital.

The daughter said she was told to call the ambulance. She asked why it was necessary for her to be the one to call, but was unable to get a clear answer, according to the report. She said if staff felt her father needed to go to the hospital, they should have called the ambulance.

The incident was not reported to the Minnesota Adult Abuse Reporting Center until 11 days after the fall, and Edgewood failed to initiate an internal investigation of neglect, according to the report.

The resident's son reached out to the facility to get more information about the fall and requested documentation related to it. The MAARC report was filed the next day, but made no mention of alleged neglect, the investigative report said.

The investigation revealed conflicting statements about what would be done to care for the resident, when the MAARC report was filed, whether the Tylenol helped his pain and who knew what about the resident's fall.

The CNS confirmed he did not investigate why the resident reacted the way he did to the Ativan dose and how that may have contributed to his fall. He said the facility had no other information, since the resident relocated elsewhere, but, "I suppose we should have done some follow up on that."

According to the report, the facility failed to report things they should have, provide appropriate care and services, keep residents free from maltreatment and properly document their grievances and inquiries.

The report states the responsible party will receive notification of their right to appeal the maltreatment finding. When a specific employee is identified as the source of maltreatment, the report is sent to the nurse aide registry for potential inclusion on the abuse registry. The Minnesota Department of Human Services may disqualify the employee.

No specific penalties are explained in the report. The Herald reached out to the Office of Health Facility Complaints for clarification but did not receive a response in time for publication.

The Herald got in contact with Edgewood Healthcare CEO Phil Gisi. He declined to comment on the findings of this investigation but sent a statement Friday morning, Sept. 27.

In it, Gisi said the rapidly increasing demand for care for people with Alzheimer's disease, alongside worker shortages in all industries, is a challenge all health care providers are responding to.

Edgewood Healthcare, a 32-year-old company, operates 64 assisted living facilities across the Midwest.

The company has made significant investments to improve resident access to primary care and support services, he said, including hiring physicians and nurse practitioners to work within facilities as medical directors and direct caregivers with training in geriatrics and chronic care management.

"Edgewood Healthcare is the first company in the upper Midwest to hire physicians and nurse practitioners (who) work exclusively in assisted living environments," Gisi said. "Think of it as 'urgent care clinic access' within the residents' home."

This practice is fully implemented in a dozen Edgewood facilities, including the south Grand Forks assisted living facility. It is being implemented in the East Grand Forks facility, he said.

There have also been investments in technology, increased telehealth services, on-call and triage support and research initiatives to improve technology and chronic care management capabilities, Gisi said.

The East Grand Forks facility opened in December 2016 and, since then, has served more than 500 residents with memory-related illnesses.

"We are proud of the quality of services provided," Gisi said.