State investigators found that a stroke victim residing at an assisted living facility in Brooklyn Park was not provided enough water, nor her medications for many weeks before she died.
A report released Tuesday by the Department of Health’s Office of Health Facility Complaints disclosed that Second Horizon Living’s staff members were neglectful in their care for the woman, who died from pneumonia, sepsis and other infections.
As is practice in the agency’s public disclosures, the report did not identify the woman or say when she died.
Messages were left Wednesday with Second Horizon’s administration seeking a response to the allegations and to find out whether it intends to appeal the agency’s conclusion. The report did point out that the facility’s management went from monthly audits of its medication administration records to weekly reviews.
“Staff members did not follow provider orders for the administration of water through the resident’s gastronomy tube,” the agency’s conclusion noted, “and as a result, the resident did not receive a significant amount of water over a two-month period.”
According to the publicly disclosed portions of the report:
The woman moved into Second Horizon after having a stroke that left her partly paralyzed and using “facial gestures and nodding to communication with staff” during her 10-week stay.
She required a feeding tube for nutrition and hydration, and needed staff to assist with her medication and bathroom requirements.
A family member soon requested a hospital evaluation for the woman after noticing a change in her condition. The examination found she was having respiratory and other system failure along with suffering from septic shock.
The investigation found that the woman was not receiving her necessary medications, nor was she being properly hydrated.
One nurse said “there was miscommunication among staff, and the resident did not receive the ordered [6 ounces] of water every four hours,” the report read. “The nurse stated the previous nurse did not put in the order for water, and the two current nurses did not catch this error.”
As for the misadministration of the woman’s medications, the report continued, “The nurse stated the resident’s medications were available, however, the staff did not recognize the generic name of the medications and therefore did not administer the medications.
“The nurse said staff did not report the medications missed by the resident until the nurse completed a monthly audit of the medication administration record.”
