State investigators found that a stroke victim residing at an assisted living facility in Brooklyn Park did not receive enough water or her medication for several weeks before her death.
A report released Tuesday by the Department of Health’s Office of Health Facilities Complaints found that staff members at Second Horizon Living neglected the care of the woman, who died of pneumonia, sepsis and other infections.
As is standard in the agency’s public disclosures, the report did not identify the woman or indicate when she died.
Messages were left Wednesday with Second Horizon’s administration seeking a response to the allegations and whether it intended to appeal the agency’s findings. The report notes that facility management moved from monthly audits of its medication administration records to weekly reviews.
“Staff members failed to follow providers’ orders regarding the administration of water through the resident’s gastrotube,” the agency’s finding notes, “and as a result, the resident did not receive proper significant quantity of water over a two-month period.
According to the parts of the report made public:
The woman moved to Second Horizon after having a stroke that left her partially paralyzed and using “facial gestures and nodding to communicate with staff” during her 10-week stay.
She needed a feeding tube to feed and hydrate herself, and needed staff to help her take her medications and go to the bathroom.
A family member quickly requested a hospital evaluation for the woman after noticing a change in her condition. The examination revealed that she was suffering from respiratory and other system failure as well as septic shock.
The investigation revealed that the woman was not receiving the medication she needed and was not properly hydrated.
A nurse said “there was a communication problem between staff and the resident did not receive the water (6 ounces) ordered every four hours,” the report states. “The nurse said the previous nurse did not order water and the current two nurses did not catch this error.”
As for the woman’s medication being improperly administered, the report continues: “The nurse stated that the resident’s medications were available, however, the staff did not recognize the generic name of the medications and therefore did not administer medication.
“The nurse stated that staff did not report the resident’s forgotten medications until she performed a monthly audit of the medication administration record.”
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