DULUTH – The Minnesota Department of Health found a local assisted-living facility neglected to properly provide care to a resident that was sexually assaulted by another, according to a report from the state agency's investigation.
The report said an unlicensed staff member found a male resident at the Benedictine Living Community of Duluth's Marywood home fondling a female resident in the early morning of July 28. Both residents had dementia.
The employee told a licensed practical nurse (LPN) on duty that she found the woman with her nightgown unbuttoned and her brief off while the man touched her breast and digitally penetrated her, according to the report. The LPN called two registered nurses at the time of the incident and set up checks on the two residents every 15 minutes while she awaited further instructions.
She woke both residents up to talk about the incident, but neither could remember it, the report said. The LPN had not had sexual assault examination training, but she checked the resident for bruises and did not find any.
The Benedictine Living Community of Duluth said in a statement Wednesday that it is disputing "several" of the Health Department's findings through an appeal process.
"Our long tradition of quality care and commitment to the safety and security of all our residents means we took this incident seriously," the statement said. " ... The published report contains details of the incident that are not accurately reported and are not consistent with witnesses' statements."
A spokesperson declined to say which findings were in dispute.
According to the report, nursing staff did not complete a full physical assessment of either resident after the incident. The following day, more than 24 hours after the incident, a registered nurse contacted law enforcement, the Minnesota Adult Abuse Reporting Center (MAARC) and family members of both residents. But in interviews, family members said they had not been made aware of the full extent of the sexual contact.
The Legislature last spring introduced sweeping reforms aimed at protecting vulnerable adults, including a policy highlighted in the Health Department's report that mandates immediate action in the case of a crime. Incidents must also be reported to the MAARC no longer than 24 hours after they occurred.
The Health Department investigator also pointed to a state policy requiring licensed facilities to conduct ongoing reassessments of clients to make updates as needed to abuse prevention plans. In interviews, staff at the Duluth facility said the male resident wandered naked into female residents' rooms and touched their faces after the July incident. One employee said "she monitored him like crazy, but his wander alert was delayed."
As the assisted-living industry has grown in recent years, facilities admitted sicker residents with a wider range of disabilities. Minnesota's consumer protections have struggled to keep pace with these changes and at times exposed residents to serious harm, according to a report compiled by advocacy groups last spring.
A Health Department investigation of another neglect complaint against Benedictine Living Community of Duluth's assisted-living facility in March found that staff failed to secure chemical cleaners that a resident died consuming.