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Woman died after not being treated and monitored

“When interviewed, the facility staff stated...they were short staffed.”


Date Concluded: January 12, 2021

Finding: Substantiated

Summary: Woman died after not being treated and monitored for a significant change in health.

The woman had an oxygen level of 77% and the “client also complained of severe headache and eye pain, and was requesting pain medication approximately every two to six hours.” The woman had a pain level of 9 out of 10 and was not checked for approximately 6 hours. She was found dead in her room.

“When interviewed, the facility staff stated the evening and overnight hours when the client experienced a significant change of condition they were short staffed.”

“In conclusion, neglect was substantiated. Multiple staff at the facility were aware of the client’s significant change of condition and did not follow up or monitor the client.”

Investigation done by the Minnesota Department of Health, the Office of Health Facilities Complaints

Carefree Living investigation report
Download PDF • 4.68MB

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