Failure to correctly monitor the blood sugar levels of a diabetic assisted living resident in Aitkin amounted to neglect, the Minnesota Department of Health concluded.

Golden Horizons in Aitkin was the site of a March investigation determining the home care provider failed to comply with hospital orders to increase the number of blood sugar checks on an unidentified resident. The resident-a Type 2 diabetic with dementia-went to the hospital several times with high blood sugar before ultimately dying, a death partially attributed to diabetes and its complications. The state's Office of Health Facility Complaints reported its findings Tuesday, June 19.

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"Based on a preponderance of evidence, neglect is substantiated," the report stated. "The home care provider failed to implement hospital orders for increased monitoring of the client's blood sugars and therefore had insufficient information to provide to the client's physician when requesting changes to the client's insulin regimen."

A month after the resident was admitted to Golden Horizons, they showed elevated blood sugar. Within five days, the resident's blood sugar reached 540, a level at which they were unresponsive. At the hospital, the resident received a diagnosis of diabetic coma, and the hospital ordered blood sugar checks be increased from once to four times daily.

Evidence collected by the MDH investigator showed nursing staff failed to follow this directive, however, despite acknowledgement of the change in a note written by a nurse. Three additional hospital visits followed, including one for a broken clavicle attributed in part to the resident's lethargy brought on by high blood sugar.

Ten days after the hospital ordered the additional tests, the assisted living facility had yet to implement the regimen, the report stated. On the 11th day, records showed blood sugar testing was completed three times a day-although the provider failed to document the amount of insulin the resident received or the number of carbohydrate grams consumed in meals.

Elevated blood sugar remained an issue for the resident, records showed, and the final hospital stay indicated the resident was experiencing kidney failure. The resident was placed in hospice care after a four-day hospitalization, and died one week later.

As part of the investigation, a family member of the client said they were unaware of the incorrect procedures, but noted they thought staff provided good care and managed their family member's behavioral needs well.

Interviews with nurses at the facility pointed toward staffing issues as the culprit responsible for neglectful care.

"There was many transitions of new nurses starting and the primary nurse leaving," the report stated. "The primary nurse was completing training with new nurses and other nurses were going back and forth between two of the home care provider locations. Work was not assigned to any particular nurse and work was completed by whichever nurse came across it."

The lack of insulin reports was explained by technical issues with an electronic monitoring system, according to the report.

State law defines neglect as "the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care or supervision" or "the absence or likelihood of absence of care or services ... necessary to maintain the physical and mental health of the vulnerable adult, which a reasonable person would deem essential to obtain or maintain the vulnerable adult's health, safety or comfort."

According to records maintained by MDH, Golden Horizons in Aitkin was the subject of three other investigations yielding a substantiation of claims. In October 2016, a case involving multiple falls by a resident resulted in a neglect determination. Two investigations took place in October 2014: one involved inadequate supervision of residents, resulting in one injuring another, and the second investigation found a staff member abused two residents by forcing their movements and causing pain. The staff member was fired.

Five other Golden Horizons locations are in Crosslake, Preston, Sandstone, Worthington and Ida Grove, Iowa. None of the other Minnesota facilities, operated under the same comprehensive home care provider license, show substantiated investigations, according to the MDH database.

According to the company's website, the facilities are managed by Pequot Lakes-based KC Companies Inc. Chuck Lane, co-owner of KC Companies Inc., was reached by phone Wednesday and he asked for more time before commenting. A Thursday phone interview was scheduled with Lane, but he did not answer his phone nor returns calls.

 

***UPDATE***

When this story was first printed, Golden Horizons in Aitkin was referred to as a nursing home. The facility is considered an assisted living facility, rather than a nursing home.

The Dispatch regrets the error.