MDH: Health Facility Complaint

Protecting, Maintaining and Improving the Health of All Minnesotans
Office of Health Facility Complaints
Investigative Public Report
Report #: HL20169007 Date Concluded: January 24, 2019
Date of Visit: December 17, 2018
Name, Address, and County of Facility Name, Address, and County of Housing with
Investigated: Services Registration:
Shepard Park Home Care The Alton Memory Care
1306 Alton Street 1306 Alton Street
St. Paul, MN 55116 St. Paul, MN 55116
Ramsey County Ramsey County
Facility Type: Home Care Provider Investigator’s Name:
Yolanda Dawson, MSN, RN
Special Investigator
Finding: Substantiated, facility responsibility
Nature of Visit:
An unannounced visit was conducted to investigate an allegation of maltreatment, in
accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn.
Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider
type.
Allegations:
It is alleged that a client was neglected when the facility failed to properly secure an industrial
strength cleaning product, which the client ingested, resulting in her death.
Investigative Findings and Conclusion:
Neglect was substantiated. The facility was responsible for the maltreatment. The client, who
resided in the facility’s secured memory care unit, found an industrial strength cleaning supply
in an unlocked kitchen cabinet. The client ingested the contents of the package, which resulted
in a medical emergency. The client suffered chemical burns to her mouth and digestive tract.
The client died two days later as the result of her injuries.
The investigation included interviews with facility staff members, including administrative
staff, nursing staff, and unlicensed staff. In addition, law enforcement and the coroner’s
An equal opportunity employer.
Page 2 of 3
office were contacted. The investigator conducted a tour of the facility and reviewed facility
incident reports, client medical records, facility policies, facility personnel records, and video
surveillance.
The client’s diagnoses included frontotemporal dementia. The client resided in a secured
memory care unit. The client received assistance from the home care provider for behavior
intervention, incontinence cares, and medication assistance. The client’s service plan
indicated the client required safety checks every two hours. The client was documented as
having periods of disinhibited behavioral eating; therefore, the snack cupboard and
refrigerator were locked to prevent the client from overeating.
Review of video surveillance revealed that the client entered the kitchen during the night and
looked through several cabinets and drawers. The client took silverware and a placemat, and
set a table in the dining room. A pillar obstructed a full view of the table. The client returned
to the kitchen and opened an unlocked bottom cabinet door, removed a package of white
powder, and returned to the dining room and sat down. Minutes later, the client stood,
discarded the package, and attempted to rinse out her mouth in the kitchen sink.
The client’s nursing progress notes revealed the report from the hospital concluded the client
sustained chemical burns to her mouth and digestive tract. The facility was alerted that the
client died from her injuries on the second day of hospitalization.
The client’s death certificate concluded the cause of death was complications of caustic agent
ingestion.
During interviews, five staff members indicated it was well known that the client had a
history of excessive eating. A staff member stated that the client would eat anything she
could find, and had to be redirected from eating paper and artificial flowers. Staff members
also indicated that the cabinet the cleaning product was in was not a locked cabinet.
During an interview, a facility nurse said it was well known that the client liked to eat and
would attempt to take food from the dining cart. The nurse said she was aware that on one
occasion the client had eaten coffee grounds. The nurse said the cleaning product that the
client ingested was not in a locked cabinet. The nurse said that it was her understanding the
client passed away as a result of ingesting the cleaning product.
During an interview, a resident assistant (RA) said the client went into the kitchen like she
always does and got a glass of water. The RA said they did not see the client take the package
of cleaning product from the kitchen cabinet, and did not see her ingest the product. The RA
realized the client had gotten into the product when the client stood up and went to the
kitchen to rinse out her mouth.
In conclusion, neglect is substantiated.
Page 3 of 3
Neglect: Minnesota Statutes, section 626.5572, subdivision 17
"Neglect" means:
(a) The failure or omission by a caregiver to supply a vulnerable adult with care or services,
including but not limited to, food, clothing, shelter, health care, or supervision which is:
(1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental
health or safety, considering the physical and mental capacity or dysfunction of the vulnerable
adult; and
(2) which is not the result of an accident or therapeutic conduct.
(b) The absence or likelihood of absence of care or services, including but not limited to, food,
clothing, shelter, health care, or supervision necessary to maintain the physical and mental
health of the vulnerable adult which a reasonable person would deem essential to obtain or
maintain the vulnerable adult's health, safety, or comfort considering the physical or mental
capacity or dysfunction of the vulnerable adult.
Vulnerable Adult interviewed: No, deceased.
Family/Responsible Party interviewed: Yes
Alleged Perpetrator interviewed: Yes
Action taken by facility:
Facility staff members assessed and organized all 6 neighborhoods cupboards and drawers at
the Alton Memory Care. A schedule of cupboard safety checks has been established. A
document titled, “Environment Safety for Residents” was created.
Action taken by the Minnesota Department of Health:
The facility was found to be in noncompliance with Minnesota home care statutes regarding
clients rights, individual abuse prevention plans, and service plans. To view a copy of the
Statement of Deficiencies and/or correction orders, please visit:
http://www.health.state.mn.us/divs/fpc/directory/surveyapp/provcompselect.cfm, or call 651‐
201‐4890 to be provided a copy via mail or email. If you are viewing this report on the MDH
website, please see the attached Statement of Deficiencies.
The responsible party will be notified of their right to appeal the maltreatment finding.
cc: Health Regulation Division – Home Care and Assisted Living Program
The Office of Ombudsman for Long‐Term Care
Ramsey County Attorney
St. Paul City Attorney
St. Paul Medical Examiner
St. Paul Police Department
PRINTED: 02/05/2019
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: ______________________ COMPLETED
C
H20169 B. WING _____________________________
12/28/2018
SHEPARD PARK HOME CARE
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1306 ALTON ST
SAINT PAUL, MN 55116
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
0 000 Initial Comments 0 000
******ATTENTION****** Minnesota Department of Health is
documenting the State Licensing
Correction Orders using federal software.
HOME CARE PROVIDER LICENSING Tag numbers have been assigned to
CORRECTION ORDER Minnesota State Statutes for Home Care
Providers. The assigned tag number
In accordance with Minnesota Statutes, section appears in the far left column entitled "ID
144A.43 to 144A.482, this correction order(s) has Prefix Tag." The state Statute number and
been issued pursuant to a survey. the corresponding text of the state Statute
out of compliance is listed in the
Determination of whether a violation has been "Summary Statement of Deficiencies"
corrected requires compliance with all column. This column also includes the
requirements provided at the Statute number findings that are in violation of the state
indicated below. When Minnesota Statute requirement after the statement, "This
contains several items, failure to comply with any Minnesota requirement is not met as
of the items will be considered lack of evidenced by." Following the surveyors '
compliance. findings is the Time Period for Correction.
INITIAL COMMENTS: Please disregard the heading of the fourth
column which states "Provider ' s Plan of
On December 17, 2018, a complaint investigation Correction." This applies to federal
was initiated to investigate complaint deficiencies only. This will appear on each
#HL20169007. The following correction orders page. There is no requirement to submit a
are issued. plan of correction for violations of
Minnesota state statutes. However, home
care providers are required to document
any action taken to comply with these
correction orders, per Minn. Stat.
144A.474, Subd. 8(c).
The letter in the left column is used for
tracking purposes and reflects the scope
and level issued pursuant to Minn. Stat.
144A.474 Subd. 11 (b).
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
STATE FORM 6899
N8U011 If continuation sheet 1 of 12
PRINTED: 02/05/2019
FORM APPROVED
C
H20169 B. WING _____________________________
12/28/2018
1306 ALTON ST
DEFICIENCY)
0 325 Continued From page 1 0 325

0 325 144A.44, Subd. 1(14) Free From Maltreatment 0 325
SS=J
Subdivision 1. Statement of rights. A person who
receives home care services has these rights:
(14) the right to be free from physical and verbal
abuse, neglect, financial exploitation, and all
forms
of maltreatment covered under the Vulnerable
Adults Act and the Maltreatment of Minors Act;
This MN Requirement is not met as evidenced
by:
Based on interview and document review, the
licensee failed to ensure that 1 of 1 client (C1),
was free from maltreatment (neglect) when the
client ingested a cleaning substance and died.
The licensee failed to ensure that all cleaning
supplies were properly stored in a secure area.
This practice resulted in a level four violation (a
violation that results in serious injury, impairment,
or death), and was issued at an isolated scope
(when one or a limited number of clients are
affected or one or a limited number of staff are
involved or the situation has occurred only
occasionally).
Findings include:
C1's medical record was reviewed. C1 was
admitted to the Licensee on May 11, 2015 with
diagnoses that included frontotemperal dementia,
depression, and bilateral primary osteoarthritis of
knee. C1's service agreement, dated November
20, 2017, indicated C1 received services from
the comprehensive home care provider for
behavior intervention, toileting assistance,
bathing and grooming assistance, and
medication management.
STATE FORM 6899
PRINTED: 02/05/2019
FORM APPROVED
C
H20169 B. WING _____________________________
12/28/2018
1306 ALTON ST
DEFICIENCY)
A document review, titled Vulnerability
Assessment / Abuse Prevention Plan, dated May
10, 2018 indicated C1 was vulnerable related to
frontotemperal dementia and required a secure
environment with 24 hour supervision.
A document review, titled 90 Day Assessment,
dated September 27, 2018, indicated C1 had
periods of disinhibited behavioral eating and
would eat anything and everything. Staff reported
C1 had eaten coffee grounds.
A document review, titled Service Checkoff List,
dated November 2018, indicated C1 received
safety checks every two hours.
Review of product photos showed EcoLab stain
blaster Power Pak Plus Reclaim White, laundry
machine stain treatment for white linen.
Reserved for industrial and professional use.
Product back label reads; Keep out of reach of
children. Danger harmful if swallowed. Causes
severe skin burns and eye damage. May cause
respiratory irritation. If swallowed call a poison
center / doctor if you fee unwell. Rinse mouth do
not induce vomiting.
Review of EcoLab safety data sheet indicates the
hazard identification for this product as a
category 4 acute toxicity (oral). For storage, store
in a well ventilated place. Keep container tightly
closed. Store locked up.
Review of video dated November 14, 2018 at
1:08 a.m. showed a resident assistant sit down in
dining room behind a pillar, out of view. At 1:30
a.m. C1 entered the kitchen and handle dishes,
look in a microwave, look inside an unlocked
STATE FORM 6899
PRINTED: 02/05/2019
FORM APPROVED
C
H20169 B. WING _____________________________
12/28/2018
1306 ALTON ST
DEFICIENCY)
bottom left cabinet, open drawers and remove
what appears to be utensils. At 1:32 a.m. C1
appeared to fill a cup with water, grab placemats,
walk into the dining room, and set the table. At
1:33 a.m. C1 reentered the kitchen, reached into
the bottom left unlocked cabinet and removed a
package of white powder, return to the dining
area, and sit down at table. Two minutes later, at
1:35 a.m., C1 stood with a white package in her
hands, and spilled the contents on the floor as
she walked. C1 discarded the package, entered
the kitchen, and leaned her head into the sink. At
1:35 a.m., the resident assistant stood and
investigated the situation.
A document review, titled Documentation of
Death, dated November 16, 2018, indicated the
cause of client death as complications of caustic
agent ingestion.
During an interview with a registered nurse
(RN)1 on December 17, 2018 at 12:41 p.m.,
RN1 said C1 was free to move around the
common area which included the kitchen. RN1
said the cabinet in which C1 removed the laundry
stain remover was an unlocked cabinet in the
kitchen. RN1 said the laundry stain remover
was not a current order item and the product was
not in use by housekeeping.
(RN)2 on December 17, 2018 at 2:12 p.m., RN2
said it was well known that that C1 liked to eat.
Because of C1's history of consuming large
amounts of food at a time, locks were put on the
snack cabinet and refrigerator. RN2 said that
approximately six months ago, C1 had eaten
coffee grounds. RN2 said it was her
understanding that C1 had passed away as the
STATE FORM 6899
PRINTED: 02/05/2019
FORM APPROVED
C
H20169 B. WING _____________________________
12/28/2018
1306 ALTON ST
DEFICIENCY)
result of ingesting the laundry powder.
During an interview with a resident assistant
(RA)1 on January 7, 2019 at 11:40 a.m., RA1
said they had to redirect C1 from trying to eat
paper and artificial flowers. RA1 said that they
remembered seeing the powder in the laundry
room years ago, but had never seen it in the
kitchen.
said they were required to perform a safety check
on C1 every two hours. The evening in question,
RA2 said C1 came out of her room and got a
glass of water and sat down at the table with her
back to her. RA2 said that they did not see or
hear C1 take the powder from the kitchen
cabinet. RA2 said they did not realize what C1
was eating until after she had ingested the
powder. RA2 said they did not receive training
on where and how to store cleaning supplies,
however, did acknowledge that current supplies
were locked with a childproof lock under the
kitchen sink.
At the time of the incident, there was not a facility
policy directly related to environmental safety for
clients.
A policy tilted, Vulnerable Adult Assessment
dated May 10, 2018, indicated that, the
vulnerable adult act requires home care
providers to 1) assess each client to identify any
areas of vulnerability or potential risk they pose
to other vulnerable adults and 2) develop an
abuse prevention plan for each client that
address those identified issues. The abuse
prevention plan must include the specific
STATE FORM 6899
PRINTED: 02/05/2019
FORM APPROVED
C
H20169 B. WING _____________________________
12/28/2018
1306 ALTON ST
DEFICIENCY)
measures to be taken to minimize the risk of
maltreatment of a vulnerable client or to minimize
the risk the client poses to other vulnerable
adults. The nursing assessment of a client's
areas of vulnerablity or potential risk to other
vulnerable adults may be documented in a
separate form such as this, or the documentation
may be incorporated into the form used for the
general nursing assessment. However this
assessment is conducted and documented, the
abuse prevention plan (i.e., identified
interventions that are needed) that is based on
the assessment should be incorporated into the
client's care plan and should be reflected in
assignment sheets or other documents used to
direct staff as they are providing services to the
client.
TIME PERIOD FOR CORRECTION: Seven (7)
Days
0 810 144A.479, Subd. 6(b) Individual Abuse 0 810

SS=D Prevention Plan
(b) Each home care provider must develop and
implement an individual abuse prevention plan
for
each vulnerable minor or adult for whom home
care services are provided by a home care
provider. The
plan shall contain an individualized review or
assessment of the person's susceptibility to
abuse by
another individual, including other vulnerable
adults or minors; the person's risk of abusing
other
vulnerable adults or minors; and statements of
the specific measures to be taken to minimize
STATE FORM 6899
PRINTED: 02/05/2019
FORM APPROVED
C
H20169 B. WING _____________________________
12/28/2018
1306 ALTON ST
DEFICIENCY)
the risk of
abuse to that person and other vulnerable adults
or minors. For purposes of the abuse prevention
plan, the term abuse includes selfabuse.
by:
Based on document review and interviews, the
licensee failed to ensure the individual abuse
prevention plan was revised and/or included the
client's disinhibited eating behavior and
susceptibility to selfabuse. The Licensee failed
to provide statements of the specific measures to
be taken to minimize the risk of selfabuse.
This practice resulted in a level two violation (a
violation that did not harm a client's health or
safety but had the potential to have harmed a
client's health or safety) and was issued at an
isolated scope (when one or a limited number of
clients are affected or one or a limited number of
staff are involved or the situation has occurred
only occasionally).
Findings include:
C1's medical record was reviewed. C1 was
admitted to the Licensee on May 11, 2015 with
diagnoses that included frontotemperal dementia,
depression, and bilateral primary osteoarthritis of
knee. C1's service agreement, dated November
20, 2017, indicated C1 received services from
the comprehensive home care provider for
behavior intervention, toileting assistance,
Bathing and grooming assistance, and
medication management
C1's vulnerability and safety assessment dated
STATE FORM 6899
PRINTED: 02/05/2019
FORM APPROVED
C
H20169 B. WING _____________________________
12/28/2018
1306 ALTON ST
DEFICIENCY)
May 10, 2018, lacked identification of the client's
disinhibited behavioral eating and history of
consuming such items as coffee grounds, paper
and artificial flowers. In addition, the plan lacked
specific interventions to minimize the risk of
selfabuse and associated history of eating
anything she could get her hands on.
said it was well known that that C1 liked to eat.
amounts of food at a time, locks were put on the
snack cabinet and refrigerator. RN2 said that
approximately six months ago C1 had eaten
coffee grounds.
paper and artificial flowers.
A policy tilted, "Vulnerable Adult Assessment"
dated May 10, 2018, indicated that, the
vulnerable adult act requires home care
providers to 1) assess each client to identify any
areas of vulnerability or potential risk they pose
to other vulnerable adults and 2) develop an
abuse prevention plan for each client that
address those identified issues. The abuse
prevention plan must include the specific
measures to be taken to minimize the risk of
maltreatment of a vulnerable client or to minimize
the risk the client poses to other vulnerable
adults. The nursing assessment of a client's
areas of vulnerablity or potential risk to other
vulnerable adults may be documented in a
separate form such as this, or the documentation
may be incorporated into the form used for the
STATE FORM 6899
PRINTED: 02/05/2019
FORM APPROVED
C
H20169 B. WING _____________________________
12/28/2018
1306 ALTON ST
DEFICIENCY)
general nursing assessment. However this
assessment is conducted and documented, the
abuse prevention plan (i.e., identified
interventions that are needed) that is based on
the assessment should be incorporated into the
client's care plan and should be reflected in
assignment sheets or other documents used to
direct staff as they are providing services to the
client.
Days
0 865 144A.4791, Subd. 9(ae) Service Plan, 0 865

SS=D Implementation & Revisions
Subd. 9. Service plan, implementation, and
revisions to service plan. (a) No later than 14
days
after the initiation of services, a home care
provider shall finalize a current written service
plan.
(b) The service plan and any revisions must
include a signature or other authentication by the
home
care provider and by the client or the client's
representative documenting agreement on the
services to be
provided. The service plan must be revised, if
needed, based on client review or reassessment
under
subdivisions 7 and 8. The provider must provide
information to the client about changes to the
provider's
fee for services and how to contact the Office of
the Ombudsman for LongTerm Care.
(c) The home care provider must implement and
STATE FORM 6899
PRINTED: 02/05/2019
FORM APPROVED
C
H20169 B. WING _____________________________
12/28/2018
1306 ALTON ST
DEFICIENCY)
provide all services required by the current
service
plan.
(d) The service plan and revised service plan
must be entered into the client's record, including
notice of a change in a client's fees when
applicable.
(e) Staff providing home care services must be
informed of the current written service plan.
by:
Based on document review and interviews, the
licensee failed to update the client's service plan
to reflect a disinhibited eating behavior that was
well known among staff for 1 of 3 clients (C1)
reviewed.
This practice resulted in a level two violation (a
violation that did not harm a client's health or
safety but had the potential to have harmed a
client's health or safety) and was issued at an
isolated scope (when one or a limited number of
clients are affected or one or a limited number of
staff are involved or the situation has occurred
only occasionally).
Findings include:
The investigation reviewed C1's medical record.
C1 admitted to the Licensee on May 11, 2015
with diagnoses that included frontotemperal
dementia, depression, and bilateral primary
osteoarthritis of knee. C1's service agreement,
dated November 20, 2017, indicated C1 received
STATE FORM 6899
PRINTED: 02/05/2019
FORM APPROVED
C
H20169 B. WING _____________________________
12/28/2018
1306 ALTON ST
DEFICIENCY)
services from the comprehensive home care
provider for behavior intervention, toileting
assistance, Bathing and grooming assistance,
and medication management.
Review of C1's 90day assessment, dated
September 27, 2018, indicated C1 had periods of
disinhibited behavioral eating and would eat
anything and everything. Staff reported C1 had
eaten coffee grounds.
Review of C1's service plan dated January 1,
2019, lacked information regarding the client's
disinhibited behavioral eating.
said it was well known that C1 liked to eat.
amounts of food at a time, administration had
locks placed on the snack cabinet and
refrigerator. RN2 said that approximately six
months ago C1 had eaten coffee grounds.
paper and artificial flowers.
During interviews with two resident assistance,
the guardian, and a family member, each person
acknowledged that food was secured to keep C1
from overeating.
A policy titled, "Development and Revision of the
Service Plan" undated, indicted the following:
Each client's service plan is reviewed by the RN,
or other licensed health professional (as
applicable), as follows:
STATE FORM 6899
PRINTED: 02/05/2019
FORM APPROVED
C
H20169 B. WING _____________________________
12/28/2018
1306 ALTON ST
DEFICIENCY)
a. i. During each regular client monitoring visit,
which occurs at least every 90 days, ii. Whenever
changes are needed to the services to be
provided because of a change in the client's
condition, after receipt of new or revised orders
from the client's physician or other prescribing
provider, following an incident, or following the
client's return from a hospital or nursing home.
b. If a review of the service plan indicates that
the client's service plan needs modification based
on the client's needs, preferences, or changes in
fees, the RN, therapist and/or other licensed
health professional (as applicable) makes
necessary changes to the service plan, signs the
revised service plan with name, title and date,
and requests that the client and/or the client's
representative sign and date the revised service
plan.
Days
STATE FORM 6899

MDH: Health Facility Complaint

Uploaded by

Document Information

Copyright

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

MDH: Health Facility Complaint

Uploaded by

Copyright:

Protecting, Maintaining and Improving the Health of All Minnesotans

0 000 Initial Comments 0 000

0 325 Continued From page 1 0 325

0 325 Continued From page 2 0 325

0 325 Continued From page 3 0 325

0 325 Continued From page 4 0 325

0 325 Continued From page 5 0 325

0 810 144A.479, Subd. 6(b) Individual Abuse 0 810

0 810 Continued From page 6 0 810

0 810 Continued From page 7 0 810

0 810 Continued From page 8 0 810

0 865 144A.4791, Subd. 9(ae) Service Plan, 0 865

0 865 Continued From page 9 0 865

0 865 Continued From page 10 0 865

0 865 Continued From page 11 0 865

You might also like

MDH: Health Facility Complaint

Uploaded by

Document Information

Copyright

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

MDH: Health Facility Complaint

Uploaded by

Copyright:

Protecting, Maintaining and Improving the Health of All Minnesotans

0 000 Initial Comments 0 000

0 325 Continued From page 1 0 325

0 325 Continued From page 2 0 325

0 325 Continued From page 3 0 325

0 325 Continued From page 4 0 325

0 325 Continued From page 5 0 325

0 810 144A.479, Subd. 6(b) Individual Abuse 0 810

0 810 Continued From page 6 0 810

0 810 Continued From page 7 0 810

0 810 Continued From page 8 0 810

0 865 144A.4791, Subd. 9(a­e) Service Plan, 0 865

0 865 Continued From page 9 0 865

0 865 Continued From page 10 0 865

0 865 Continued From page 11 0 865

You might also like

0 865 144A.4791, Subd. 9(ae) Service Plan, 0 865