A young Somali woman with psychiatric disorders and a history of self-injury was hospitalized with serious injuries last fall after she hammered two nails into her scalp, nails that stayed undetected for nearly a month.

State health regulators blamed poor oversight at the Twin Cities care facility where she lived.

Salams Care Residential LLC, which operates a small assisted-living facility in Maplewood, was found responsible for neglect for failing to provide adequate supervision of the resident, who had to have the nails surgically removed from her skull and undergo weeks of medication, according to a Minnesota Department of Health investigation released this week.

The 21-year-old resident, who also has an intellectual disability, was taken to the hospital in October after a suicide attempt. Physicians there noted swelling around her forehead, and a brain scan revealed two "foreign bodies extending from the scalp," which were later determined to be nails. The woman told a doctor that she inserted the nails into her skull a month earlier using the heel of her shoe. A surgeon had to remove part of her skull to extricate the nails, and she required four weeks of intravenous antibiotic treatments, the state report said.

The woman told a social worker that she obtained the nails simply by walking to the care facility's garage.

The disturbing case underscores the need for stronger rules around the admission of residents to assisted-living facilities, a large and fast-growing segment of the long-term care industry, some advocates said. Once designed almost exclusively for seniors, these facilities have begun caring for a more diverse mix of clients, including younger people with serious mental illnesses and developmental disabilities.

A state law passed last spring would license Minnesota's 1,200 assisted-living facilities for the first time, starting in August 2021. Elder care advocates are pushing for new standards that would require the facilities to conduct a comprehensive health and behavioral evaluation for every new resident to prevent them from ending up in facilities where they will be underserved and at risk.

"There were major, major warning signs here that could and should have been detected" through a preadmission health evaluation, said Eilon Caspi, a gerontologist and adjunct faculty member at the University of Minnesota's School of Nursing. "It is a miracle that this incident did not end up in a more serious tragedy."

Ibrahim Sheikh, administrator of Salams Care, said staff members underestimated the severity of the woman's mental health problems when she moved into the facility last spring to be closer to relatives in St. Paul. As her behavior became more and more abusive, toward herself and others, the facility's staff struggled to find her a different home that could provide a higher level of oversight. However, the woman's history and frequent interactions with police made other facilities reluctant to accept her. That resulted in her staying at the five-room Maplewood facility longer than anticipated, Sheikh said.

"Our hands were tied," Sheikh said. "We were not trained to provide the level of care that she needed, and it just got worse and worse and worse."

History of self-harm

The woman's medical history showed that she had an extensive history of self-harm and required constant supervision. Just four months before she inserted the nails, she required surgery to remove a key ring inserted in her right leg. She also inserted four paper clips and a ballpoint pen in her leg.

Facility records also show that the resident repeatedly banged her head against a wall, screamed that she wanted to die, punched fellow residents and staff, attempted to strangle herself, wandered away from the facility with her luggage, and jumped out a second-floor window. Staff members barricaded the window to prevent her from jumping again and put special alarms on the doors, Sheikh said.

Management staff told state investigators that they were not equipped with the tools to keep the woman safe and lacked training in how to respond to her self-injurious behavior.

"The staff reports that they are not trained in crisis or intervention and that they are only set up for housing and food," according to records from a social worker cited in the state report. One staff member said the facility's response to a suicidal resident was simply to talk to the person. There was no mention of calling 911 or contacting a medical provider or crisis intervention team, according to the state report.

Despite knowing they could not handle the resident, Salams Care staff members repeatedly accepted the woman when she returned from the hospital after each episode, state investigators found. The home's staff also failed to respond to visible signs of a head injury after the woman inserted the nails.

According to the state report, a member of the woman's mental health team said there were many times when the woman would complain of a headache and staff would not respond. Hospital notes indicate that, on Oct. 12, 2019, she had drainage from a forehead wound, yet was discharged back to the assisted-living facility. The nails were not discovered until a CT scan weeks later.

One nail was nearly 5 centimeters in length, while the other measured 6.2 centimeters.

"The nails were in the client's head for nearly one month," the report said.

A hospital social worker who knew the woman and had been with her through several hospitalizations said she was too high a risk to be left alone and required one-on-one staffing at all times. The social worker said she reiterated this to staff at Salams Care every time the woman was discharged from the hospital.

"The facility did not provide adequate supervision or initiate appropriate interventions to ensure the safety of the client," the state Department of Health concluded.

Chris Serres • 612-673-4308 Twitter: @chrisserres