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Advocates: Staffing, medication issues core to Central Minnesota elder abuse investigations

ST. CLOUD — The Minnesota Office of Health Facility Complaints received 2,603 complaints of elder abuse in Central Minnesota last year, according to a new analysis by Elder Voice Family Advocates.

Only a handful of those complaints were investigated by the state Department of Health.

For Central Minnesota, in the last 26 months, officials investigated 89 complaints and half of them were unsubstantiated. 

The Elder Voice report reveals some St. Cloud-area facilities have been investigated several times in the past few years for problems such as sexual abuse, financial exploitation and theft of medication.

Staff issues, such as understaffing and poor training, were at the heart of many complaints against long-term care and assisted living facilities, according to the report "The State of Elder Care in Central Minnesota," which spanned Dec. 1, 2017 to Jan. 31, 2020, before the novel coronavirus reached Minnesota.

These problems are even more salient during the COVID-19 pandemic, said Kris Sundberg, executive director of Elder Voice Family Advocates.

"It was a recipe for disaster before, and COVID is now exposing how poorly staffed these facilities have been," she said. As of Monday, about 80% of the COVID-19 deaths in Minnesota were tied to long-term care facilities. 

The advocacy group reviewed investigations into facilities within about 40 miles of St. Cloud. Not all of the investigations were substantiated, but Elder Voice members want to highlight inconclusive and unsubstantiated investigations, too. 

"Some of these investigations raise more questions than answers," Sundberg said. 

Many senior victims don't feel comfortable reporting abuse in the first place, and the large majority of complaints in Minnesota are not investigated at all, according to the Elder Voice report.

In the 26-month period that Elder Voice reviewed, the state investigated 89 cases at 47 facilities in Central Minnesota. That means 44% of assisted living and nursing homes were investigated in the area.

"There were three incidents of sexual abuse, eleven cases of medication errors, and ten cases of falls as a result of improper transfers or supervision. There was one death directly attributable to the neglect and three other deaths where neglect may have been a contributing factor," according to the report.

Of the 89 investigated complaints, 27 were substantiated, 17 inconclusive and 45 unsubstantiated.

Four facilities in St. Cloud, Sauk Rapids and Sartell were named "facilities of concern" for repeated state investigations. They all had deficiencies in federal reviews as well. Other "facilities of concern" on the list have closed or are located well outside St. Cloud.

Good Shepherd in Sauk Rapids

In the past two-plus years the state investigated Good Shepherd Lutheran Home six times, twice substantiating complaints of theft. One instance was the theft of medications from three residents, the other a theft of money from a resident. 

Good Shepherd declined to comment for this story. 

Four of the investigations ruled complaints unsubstantiated: one regarding resident violence, another on family member abuse, another on neglect of care and one on the ingestion of a foreign object.

Federal regulators through Medicare cited Good Shepherd for various issues in the past couple years, including four deficiencies reported in August 2019, including issues with staff members' hand hygiene and a failure to "provide separately locked, permanently affixed compartments for storage of controlled medications in 2 of 8 medication room refrigerators."

St. Benedict's in St. Cloud

St. Benedict's Senior Community made statewide news last year when a staff member was convicted of sexually abusing a resident.

The Department of Health also investigated the matter, ruled the employee responsible for the maltreatment and "issued a correction order regarding the vulnerable adult's right to be free from maltreatment," according to the Office of Health Facility Complaints July Investigative Public Report.

Jesus Manzanilla Alvarado, 23, is charged with sexual abuse and mistreatment of a vulnerable adult while working at St. Benedict's Senior Community. (Photo: Sherburne County Jail)

That was one of five state investigations into St. Benedict's Senior Community in the past 26 months, according to Elder Voice's report. The state also substantiated a complaint of improper restraint in late 2017. The state ruled another sexual abuse complaint as inconclusive, and two other investigations were unsubstantiated regarding the notification of a physician and a lack of daily activity.

CentraCare provided this statement Wednesday about the investigations: 

"The safety of our patients and residents is always our top priority, so when an incident occurs at one of our facilities, we take immediate action which often includes self-reporting to regulatory agencies. For each case, we conduct an internal review to determine what steps are needed to ensure an incident does not happen again. We are transparent with our families when an event occurs and report these cases publicly per Minnesota Department of Health and Joint Commission guidelines."

In early 2017, the facility was fined nearly $25,000 by federal regulators, and it was cited with multiple deficiencies since then, including five in March 2019. Some deficiencies, including the most severe one, in the recent Medicare report were tied to the sexual abuse incident one year ago.

"Based on interview and document review, the facility failed to thoroughly investigate

allegations of abuse, and failed to protect the residents during the investigation," according to the federal report. "This practice had the potential to affect all 143 resident in the facility."

Talahi Nursing in St. Cloud

A coffee spill at Talahi Nursing and Rehab Center resulted in a second-degree burn and a ruling of neglect by the state. It was the only substantiated complaint at that center included in Elder Voice's analysis. 

The facility was investigated five times in the 26-month time frame. One resulted in an inconclusive ruling for alleged poor wound care. There were three unsubstantiated complaints for alleged poor supervision when a resident attempted to kill themself, medication error and poor wound care.

Elder Voice flagged Talahi Nursing for "so many unsubstantiated cases that were serious enough to trigger an onsite investigation."

The facility administrator did not return a Tuesday voicemail seeking comment. 

Talahi Nursing and Rehab Center was cited with eight deficiencies in October and many others in recent years

"Based on observation, interview, and record review, the facility failed to ensure proper

wheelchair positioning for 2 of 2 residents observed with positioning concerns," according to the federal report. "In addition, the facility failed to provide appropriate care and services for 1 of 1 resident."

Edgewood Sartell

Last summer, the state investigated a report that an employee at Edgewood Sartell gave a resident the wrong medication, causing the client to be admitted to the hospital.

The Department of Health ruled the staff member responsible for neglect. It was one of three investigations into the facility since December 2017. 

Another investigation into an alleged drug theft led to an inconclusive ruling, and another medication error was unsubstantiated, according to Elder Voice's report. 

An employee at Edgewood Sartell would not comment, and no one responded to a request for an interview sent to company's general email box.

Medication errors should not happen, Sundberg said. People suffer when they don't get their medications, and clients can die if they receive the wrong drugs.

How to use this information?

Elder Voice members conducted their analysis to identify the root causes of abuse, neglect and exploitation, according to the report. Members then lobby for policy change and support families who use long-term care or assisted living services.

It has long been a challenge to staff assisted living and nursing home facilities, because the work is difficult and the pay is relatively low. There's no "silver bullet fix," Sundberg said. 

"We really empathize with the caregiver," she said. "They're doing God's work, and most of them are doing a good job. But they're getting burned out. And they're getting sick."

Especially during the COVID-19 outbreak, when residents are cut off from visitors, communication is key, Sundberg said. 

She suggests people stay in touch with loved ones who are residents and use a camera to monitor their care and well-being.

Be patient when reaching out to facilities and try to understand the demands they're under, Sundberg said. "Have a really constructive dialogue with the facility management and staff."

And if you do learn of a problem, she said, report it

Nora Hertel is the government watchdog reporter for the St. Cloud Times. Reach her at 320-428-1404 or Follow her on Twitter @nghertel.

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