Inhumane and Deadly Neglect Revealed in State Assisted Living Facilities Driven by Insufficient Funding for Regulatory Standards of Care and Oversight

Abstract

Elder Voice Family Advocates’(Elder Voice) review of substantiated investigations reveals shocking deaths and suffering that need urgent solutions that only the Minnesota Legislature can remedy. We undertook this review of publicly available investigations data from the Minnesota Department of Health’s (MDH) Office of Health Facilities Complaints (OHFC) to get a clearer picture of what is happening in assisted living facilities throughout Minnesota and why is it happening. Elder Voice reviewed OHFC Investigative Reports of maltreatment in Assisted Living Facilities and identified many systemic problems. The horrific cases of neglect revealed insubstantiated investigations point to several key failings in the assisted living industry. These failings result in serious harm and contribute to many premature, painful deaths. The key reasons for all this suffering and death include, in part, the following: Assisted living is accepting a wide range of care needs without credible authority and responsibility: No clear, consistent standards of care to guide the industry, residents or families. No nurse assessment of care needs prior to moving in to the facility. Poor communications among staff, management and other providers. Severe staffing issues include under-staffing, poor hiring practices, and training insufficiencies that result in: Medication errors and theft.oIgnored or untreated emergencies or changes of condition.oInadequateor lack of staff supervision. Falls as a result of staff not trained in theuseof equipment to performsafe transfers. Neglect of caresometimes leaving residents for many hours without food, water, toileting care, etc. or poor care of wounds that lead to severe and sometimes fatal infections. Sexual predators takingadvantage of elders and vulnerable residents. Inferior memory care standards result in: Unsafe facility practices and environments that allow dangerous wandering outside the facility and the person’s residence. Lack of adequate dementia care training leads to poor handling of common dementia related behaviors. Lack of meaningful engagement to calm residents living with dementia....Elder Voice reviewed 200O HFC Investigative Reports of substantiated maltreatment in assisted living facilities. Only substantiated investigations were reviewed, although the unsubstantiated and inconclusive categories are important and deserve future examination. Patterns emerged from this analysis showing the vast majority of these cases are preventable. For example, with proper nutrition and hydration,residents wouldn’t be malnourished and dehydrated. Additionally, attention to pressure sores would prevent the major infections have resulted in amputations in extreme cases. [CVRL Note: this report is advocating for specific legislation in Minnesota.] (Author Text)