Case 7 - Gross Negligence and Abuse

Concerns Unsubstantiated


A family member’s mother had fallen at her long-term senior care residence, fracturing her shoulder. It was determined that she should be transferred to another provider that could give the additional care required while recovering from her fracture. Almost no other local providers would accept the mother due to her dementia diagnosis. She was therefore transferred from the hospital to this temporary care center until she could return to her long-term care center.


The cleanliness of the facility was poor. The family often found the mother wearing the same rumpled clothing that she had on the day before. She was not being bathed; and on several occasions the family found a meal tray left sitting in front of their mother for several hours. No one had stopped by to pick up the tray or to offer to help her eat—despite having a fractured right shoulder that left her unable to manage silverware or cut the food.


When the mother was transferred back to her long-term care center and the nursing staff gave her an exam they noted that her buttock area was enflamed and raw from being left in wet Depends®. They also noted her unclean skin and ordered medication to treat her buttock area. The nursing supervisor informed the daughter that she would be reporting the other senior care center to the MN Department of Health and that she was obligated to do so because of the obvious neglect. The family also wrote a lengthy complaint and sent that to the MN Department of Health. They were told that the complaint would be investigated. It took one full year to receive the report on the complaint. The MDH investigator said there wasn't sufficient evidence to prove neglect but later noted on the report that there was concern regarding this facility.

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