A resident at a senior home in Fairmont, Minn., died of hypothermia in January after wandering outside a secure memory care unit that staff had failed to properly lock, according to a Minnesota Health Department investigation released Wednesday.
The resident, who suffered from dementia, was found outside with a walker in temperatures of 5 degrees with a windchill of 18 below. The assisted-living facility, Goldfinch Estates, was cited for neglect by the Health Department.
"The [facility] failed to have a system in place to ensure the exit doors on a secured memory care unit remained locked," the investigation found.
The incident is the latest in a string of abuse and neglect cases involving Minnesota-based assisted-living homes, an area of senior housing that operates under less regulatory scrutiny than traditional nursing homes. In February, two state lawmakers called for an investigation after an 89-year-old woman was drugged and raped last year at an assisted-living home in Hermantown, Minn.
An executive at Vista Prairie Communities, a Hopkins-based company that owns Goldfinch, said the firm was "deeply saddened" by the resident's death and had taken steps to heighten the supervision of residents at the 130-room home.
"This is not the service that we want to see happen at all," said Patrick Rafferty, chief operating officer at Vista Prairie, which owns seven assisted-living homes in Minnesota and two homes in Iowa. "The care and safety of our residents is the number one thing on our minds."
The resident, who is not identified in the report, suffered from severe memory loss and was at risk of wandering off, the report said. The resident lived in a locked memory care unit designed for people diagnosed with Alzheimer's or other forms of dementia.
At 9:30 p.m. on Jan. 16, a staff person at Goldfinch Estates could not find the resident to administer medications. The worker searched the facility's rooms and outside. An hour later, the resident was found on the ground in the courtyard area outside the memory care unit, the report noted. The resident died soon after emergency personnel arrived.
According to an assignment sheet cited by investigators, the resident was to be assisted with daily living activities, such as toileting, at 7 p.m., 8 p.m. and 9 p.m. However, none of these scheduled services were provided on the evening of the resident's death, it noted.
Investigators found problems with the exit doors on the memory care unit. The doors periodically unlocked without notice five times just before the incident. Although repairs were made, Goldfinch did not establish a system to monitor the exit doors to ensure they continued to function.
Since the fatality, staff at Goldfinch visually count every resident at the assisted-living home every two hours and then audit these counts every two weeks to ensure the procedure is being followed. The facility also installed a new security system that sounds an alarm through the entire building if a secure door malfunctions, Rafferty said.
Goldfinch Estates offers studio apartments with private bathrooms "in a secure community designed for residents living with a memory-related illness," according to an online marketing brochure.
Advocates for the elderly have raised concerns in recent years about assisted-living homes admitting people with more acute medical conditions without increasing their staffing levels. Many older people with dementia, who years ago would have been admitted to more tightly regulated nursing homes, are now living out their final years in assisted-living homes with specialized memory care units.
In cases when the memory care units are not properly secure, confused residents have wandered off into harm's way.
Last fall, state investigators cited a senior home in Rogers for neglect after an 84-year-old man was found unresponsive in 91-degree weather outside. The man, who lived in a memory care unit, had a temperature of 104.9 degrees and was admitted to the hospital intensive care unit with heat stroke. In addition, hospital records indicated that the man was expected to suffer "further cognitive decline" as a result of the incident and would require ongoing physical therapy.
The state Health Department, which oversees more than 2,000 state-licensed entities, including nursing homes and assisted-living centers, received 12,262 complaints of maltreatment and self-reported incidents in 2011, up 20 percent from 2009. The state investigated 1,023 of these reports and substantiated maltreatment in 226 cases.