North-central Minnesota senior home blamed in resident's death

A north-central Minnesota senior home failed to seek proper medical attention for a resident who died last summer from septic shock brought on by an untreated foot infection, a state health investigation concluded.

The facility, Diamond Willow in Baxter, which provides memory care and assisted-living services for up to 26 residents, was found responsible for neglect for failing to monitor a wound on the resident's heel, and then not informing the resident's physician of the wound as it became badly infected. The female resident, who had Alzheimer's disease and is not identified in the report, was hospitalized in July and died five days later of septic shock, according to the state Department of Health investigative report issued Tuesday.

The state investigation pointed to deeper problems at the senior home, including a lack of staffing and inadequate training. A former nurse at the facility told state inspectors that she did not immediately contact the resident's physician when she observed the wound because she had received "no formal training, no guidance" on how to handle such situations. After two weeks working at Diamond Willow, the nurse resigned, citing a lack of training and concern for her license, the investigative report said.

Another nurse at Diamond Willow said there was "frequent turnover of staff" during the time the resident's wound developed, which made it difficult to keep up with tasks. The facility nurse, who is not identified in the report, said she had "been working 100 hours a pay period just trying to get new staff trained, keep the building intact."

"These kinds of serious wounds do not emerge overnight. They happen over a long duration of neglect, and that's what is apparent here," said Kristine Sundberg, executive director of Elder Voice Advocates, a group that advocates for quality care for older adults and people with disabilities. "I cannot imagine the suffering this woman endured."

Staff at Diamond Willow did not return calls on Wednesday. The facility is owned by Duluth-based Diamond Willow Assisted Living, which operates 11 senior homes in northern and western Minnesota. According to its website, Diamond Willow was created to be "a bridge between traditional assisted living and a traditional nursing home" and offers "small intimate community settings" of eight to 16 residents per home.

According to the investigation, a blister was observed on the resident's left heel seven weeks before her death. The blister then popped and became badly infected. In an interview with state investigators, a former nurse at the facility described the wound as "probably the size of a golf ball," the report said. "It was very concerning looking and looked extremely painful, I have no idea how no one was notified of it," the nurse told investigators.

The resident's family members said they had brought forward numerous complaints regarding the woman's care to staff, and had been told that the woman had a "little blister" after staff put on her shoe with socks. However, when they visited the senior home, they were surprised to discover that she had become unable to walk and required a lift for transfers. Family members told investigators they found the change "bizarre," and they did not know why the woman would have become immobile, according to the state report.

It was not until a few days before the woman was hospitalized that family members learned about her wound. Upon visiting the facility, a family member observed that the woman's bed sheets and dressing were "saturated with drainage," and her room smelled of a "foul wound." The family member decided to dress the woman's wound herself after observing that the bed sheets and dressing had not been changed. As the woman's condition worsened, the family member called 911, the report said.

Eight days before the woman's death, Diamond Willow's staff sent a fax message to her physician, indicating that a blister had "broken open and caused a large open area" on her heel. However, no response or follow-up with the physician was documented, state investigators found. "The facility failed to assess and monitor the resident's heel wound and failed to inform the physician of the wound as it worsened," the report said.

The resident was admitted to the hospital with several medical conditions, including a pressure ulcer to the left heel, dehydration and "failure to thrive with physical deconditioning." The woman's official cause of death was septic shock, a widespread infection causing organ failure and dangerously low blood pressure, the report said, citing the official death record.

The facility's former regional director of operations told investigators that she did not know why the facility staff sent a fax about the wound to the physician, rather than getting the resident to treatment.

The state investigative report did not list any actions taken by the facility to correct the problems.