State investigators are faulting the operators of a Minneapolis assisted-living residence for the death of a 76-year-old dementia client who sneaked outside on a winter afternoon and was found hours later in a snowbank.

Kum Sun Melcher, 76, slipped out of the Golden Nest residence in early March and was located nearby suffering from extreme hypothermia.

She was taken to Hennepin County Medical Center and died there that night, the county Medical Examiner’s Office said.

Golden Nest “failed to properly assess the client’s needs, failed to properly secure an exterior door lock, and [a] staff member failed to properly secure an interior door lock,” according to the state Health Department’s findings released this week by the agency’s Office of Health Facilities Complaints (OHFC).

“The facility was not equipped to provide a secured environment for a client with dementia,” the report continued. “The facility did not immediately identify that the client was missing and did not promptly contact emergency services once the client’s absence was discovered.”

Video surveillance showed Melcher leaving through the lobby without a coat or her cane, the investigative report read. She was shown leaving the property about 2:40 p.m., the state report read. Two hours later, a nurse noticed her missing and wanted to call 911. But the nurse was told to wait while staff looked for Melcher.

The 911 call was made at 5:40 p.m., three hours after Melcher left.

The temperature was slightly above freezing when she walked away and in the low to mid-20s by the time she was found. She was located in an area a police report described as “treacherous,” dark and near train tracks.

The Health Department ordered Golden Nest to make corrections to ensure that such a lapse is not repeated.

New locking system

Golden Nest administrator Hongjoo Lee said Thursday that a new locking system has been installed at the building in the 1900 block of 19th Avenue NE., ensuring no client can leave undetected.

As for the state’s ruling of neglect, “I don’t agree with it,” said Lee, whose for-profit company also operates a residence in the 6700 block of Emerson Avenue in Richfield.

She said she missed the deadline for appealing the findings because she was traveling on a mission trip, but she is speaking with an attorney about her options.

The OHFC’s online database revealed one other finding against Golden Nest of neglect involving a death.

Left on a floor, bleeding

In late July last year, a client fell and was left by a staff member on the floor for four hours suffering from bleeding on the brain. The staffer gave the client a pillow and a blanket, left the room and failed to contact a nurse.

The client died three weeks later from the brain injury.

The Minnesota Department of Health has stepped up efforts to respond to allegations of maltreatment, following highly publicized reports that its system was slow and unreliable.

In recent years, abuse victims and their families could wait months for basic information as abuse investigations dragged on, according to a Star Tribune investigation last year. On average, it took the agency’s complaint office nearly 140 days to complete maltreatment investigations in the past fiscal year — more than double the 60 days allowed by law, according to a Legislative Auditor’s report this year.

The agency has sped up its response. It has virtually eliminated a giant backlog of uninvestigated complaints — reducing the tally from 3,147 cases to just one — since last November, by bringing in more staff and reducing a longtime reliance on paper records. The department is also communicating more regularly with victims of abuse, officials said.

Investigations speeding up

Since last year, the agency has slashed by nearly two-thirds the amount of time it takes to complete maltreatment investigations. Since April, the agency has been closing maltreatment cases within 58 days, on average, according to state data.

 

paul.walsh@startribune.com 612-673-4482 chris.serres@startribune.com 612-673-4308