DULUTH — The Minnesota Department of Health found an assisted living and memory care facility responsible for the negligence of a resident who fell four times, resulting in a brain bleed and skull fracture.
After an investigation regarding a report of maltreatment at the BeeHive Homes of Duluth, MDH substantiated the claims Oct. 14.
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The evaluation was performed by MDH special investigator Michele Larson following allegations that staff failed to provide the resident with the supervision and assistance for toileting and transferring required by their service care plan.
The resident was admitted to BeeHive on Jan. 10, 2023, with diagnoses of mild cognitive impairment with memory loss; pooling of blood between the brain and skull; long-term subdural hematoma; and sudden drop in blood pressure when standing up.
On March 2, 2023, changes were made to the resident’s service plan to include daily contact guard staff assistance with a gait belt when walking.
The resident’s care plan dated Jan. 11 indicated they would receive assistance with getting dressed, meals and medication management, as well as with transferring and toileting. According to the investigation findings, the plan failed to direct the facility’s staff on how often assistance was required.
According to the report, an assessment Jan. 11 indicated the resident was unable to use their call pendant (or medical alert system) appropriately due to a dementia diagnosis; however, it indicated the resident “could transfer without help” and “walked without assistance," which conflicted with the service plan instructions for staff to use a gait belt for transfers.
Based on interviews and records review, MDH concluded that BeeHive’s neglect of the resident resulted in four unwitnessed falls in five days.
Two days after the fourth fall, a family member brought the resident to the emergency room.
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One of the falls resulted in serious injuries, which led to a hospitalization Feb. 19-21, according to the report. A CT scan confirmed the resident incurred two brain bleeds and an approximate three-day-old skull bone fracture, in addition to a respiratory infection.
Upon the patient's discharge from the hospital, BeeHive failed to communicate to its staff the increased need for the resident's care until Feb. 23.
At the time of the complaint, 37 residents received licensed dementia care services from BeeHive Homes. The facility was issued a seven-day correction order.
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