Report finds neglect led to death of resident in Winona assisted living facility

WINONA, Minn. (WKBT) -- A resident in hospice care died as a result of neglect.

That's according to a report from the Minnesota Department of Health. The report substantiated claims that neglect at Watkins Manor in Winona led to the death of a resident caused by the blunt force trauma of a fall.

The incident happened in July of 2023. According to the report, a registered nurse made the decision to transfer a resident from their bed to a wheelchair with assistance of a licensed practical nurse and another unlicensed personnel.

Interviews in the report indicate the decision was made based on insistence by the resident's family members, though the staff was uncomfortable transferring the patient due to her weakness at the time.

According to the report, following transfer, the personnel left the room. The resident was unconscious in the wheelchair. Members of the family went to talk to the registered nurse. At some point during this time, the resident fell and hit her head.

Staff came back to discover the resident on the floor with blood around them. They were sent to the hospital, where she later died of blunt force trauma to the head.

The report shows a documented history of falls, and that the resident scored an 8 on a fall risk assessment. A score of 4 or higher indicates a greater risk of falls.

The health department says the care facility failed policies regarding reporting maltreatment, assessments and monitoring, appropriate care and services, and freedom from maltreatment.

Watkins Manor falls under the umbrella of Winona Health. Winona Health says they plan to appeal:

"This was an extremely difficult and sad situation for all. 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."

See the Minnesota Department of Health's full report below:

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