State investigation: Brooklyn Park assisted living facility’s neglect led to woman’s death
The Minnesota Department of Health says that, after an investigation, they believe an assisted living facility in Brooklyn Park neglected a resident, leading to her death.
A state report said that the resident at Second Horizon Living not given enough water, correct medications, timely transfers and incontinence care in the weeks before she died.
The woman had suffered a stroke and stayed at Second Horizon Living for about ten weeks. She was on a feeding tube for hydration and nutrients. The report states, over the course of her stay at the facility, that she was not given the amount of water that the doctor ordered and missed several doses of her medications.
One nurse interviewed in the report said that miscommunication among staff led to the gaps in care.
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The nurse said that one nurse did not put in an order for water, and the next nurses didn’t catch the error.
The nurse also stated that some caregivers did not recognize the generic names of the woman’s prescribed medication and did not administer them. They did not report the missed doses until a monthly audit of the medication administration record.
The investigation said these errors “limited the resident of a significant amount of water.”
She died of pneumonia, sepsis and a urinary tract infection. The state’s public report did not name the woman, or the date that she died.
The report states that when investigators completed their survey in August, there were three other patients receiving care at the facility.
Second Horizon Living did not immediately respond to a request for comment. The facility has the right to appeal the maltreatment finding. The report noted that the facility increased its medication log checks to weekly instead of monthly.