Community cited for neglect after resident's fall not discovered for 10 hours

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The operators of a Minnesota assisted living and memory care community say they took “swift and immediate action” after a resident's fall reportedly went undetected for 10 hours and she later died.

The Trails of Orono in Orono, MN, was cited for neglect for the incident, which occurred in August, according to a report released Thursday by the state Department of Health. The resident, who had advanced dementia, was not named in the report.

State investigators said that the woman apparently fell in her room at approximately 11 p.m. Aug. 15 and was not discovered on the floor by staff until 8:45 a.m. the next day, even though four rounds of safety checks were scheduled to have taken place during that time.

The report also said that on the night of the resident's fall, the community's pressure-sensitive bed and door alarm system sent a notification to staff cellphones at 11:10 p.m., according to alarm system records. Based on those records and staff interviews, however, the investigators concluded that no staff member checked on the resident in response to the alarm.

After the incident, according to the report, the woman experienced pain and could not bear weight on her leg, necessitating the use of a wheelchair and a mechanical lift for transfers to and from her bed. She was transferred to a hospital, where a urinary tract infection was diagnosed, and subsequently was transferred to a hospice and died, 26 days after the fall. The official cause of death was bronchopneumonia, investigators said.

Ebenezer Management Services, which operates the community, had not responded to a request for comment from McKnight's Senior Living by the publication deadline, but a spokeswoman for the company told the Minneapolis Star Tribune that community employees took “swift and immediate action” after reporting the incident to the Health Department. That action, she added, included increasing the frequency of safety checks, adding more monitoring sensors and conducting additional staff training about standards of care.

“We remain committed to protecting the health and safety of every resident we serve and to providing employees the training and support they need to deliver exceptional care,” the spokeswoman said.

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