MDH alleges neglect at Winona facility led to resident's fatal fall

Neglect by staff at a Winona assisted living facility led to the death of a resident who died of head injuries after suffering a fall, a Minnesota Department of Health investigation alleges.

Conclusions from MDH's investigation released earlier this month allege neglect was substantiated at Watkins Manor in connection with the death of a resident who had recently been admitted to hospice care and was showing signs of approaching death.

According to the report, a registered nurse at the facility "failed to use her professional judgement and act in the resident’s best interest when she directed the licensed practical nurse (LPN) and unlicensed personnel (ULP) to transfer the resident out of bed and placed her into a wheelchair."

The investigative findings continue: "All three staff left the unconscious resident unattended. The resident fell, sustained facial injuries, went to the hospital, and died of blunt force trauma."

According to MDH, facility records indicated staff in the weeks prior to the resident's death began to terminate the resident's services and attempted to find an alternative placement for her when her care needs increased beyond what staff could provide.

The resident became more dependent upon others for her daily care needs and began calling out for help frequently, even when staff were present.

A facility manager allegedly told an investigator the resident required a safer environment and more care than the facility could provide, but the manager said the resident's family limited their options for placement of the resident and, throughout the process, the resident's health continued to decline.

Eventually, after suffering six previous falls and beginning dialysis, the resident requested hospice care.

The day of the fatal fall, a hospice nurse determined the resident was "transitional" and beginning the final stages of dying.

According to the report, the resident's family wanted the resident to get out of bed and be placed in a wheelchair.

Staff objected at first, but eventually moved the resident to a wheelchair.

Later, the resident was discovered lying face down on the floor with blood under her head. She was alert and calling out for help, per the report.

The was transported to the hospital, where she died the following day of blunt force injuries caused by the fall.

According to the Post Bulletin , Winona Health is appealing the investigation's findings.

"This was an extremely difficult and sad situation for all," a spokesperson told the newspaper. "Our leadership and staff fully participated in the investigation. Based on the investigation and findings, we firmly disagree with this determination and are appealing it."