On October 2025, the Minnesota Department of Health (MDH) substantiated an allegation of neglect involving a resident at an assisted living memory care facility. The investigation determined that an employee failed to provide scheduled care and supervision, resulting in a resident falling and breaking her leg.
According to the MDH report, the alleged perpetrator (AP) neglected the resident when she failed to assist her to the bathroom as outlined in the resident’s care plan. The resident, who had Alzheimer’s disease and required assistance with toileting and walking, attempted to go to the bathroom on her own, fell, and suffered a femur fracture.
Video surveillance showed the AP arrived for her shift in the memory care unit at 10:41 p.m. and spent the majority of the time in the activity room until the incident occurred at 1:24 a.m. The video confirmed that the AP did not complete the resident’s scheduled 11:00 p.m. safety check or 12:00 a.m. toileting assistance. The resident’s service plan required both tasks due to her high fall risk.
At 1:24 a.m., the AP reported hearing the resident “screaming” and found her on the floor of her apartment. The resident told the AP she had tried to walk to the bathroom, became dizzy, and heard a “cracking” sound when she fell. Emergency services were called, and the resident was transported to the hospital, where she was diagnosed with a broken femur requiring surgery. After several days, she was discharged to a transitional care unit.
The MDH investigation included staff interviews, facility records review, video footage, and observation of care practices. Investigators confirmed that the AP falsely documented having completed all scheduled services, including toileting and safety checks, which she later admitted she did not perform. She stated she intended to complete them later but failed to do so.
Facility management reported that staffing levels were adequate the night of the incident and that the AP had received all required training. The facility completed an internal investigation, and the AP no longer works there. MDH found that the facility provided proper training, supervision, and staffing but that the AP failed to follow established care plans and facility procedures.
As a result, MDH determined the allegation of neglect was substantiated, concluding that the caregiver failed to provide necessary supervision and care as required to maintain the resident’s safety. The facility was issued a correction order related to the resident’s right to be free from maltreatment.
Compliance Perspective
Issue
Facilities must ensure that residents receive care and services in accordance with their individualized care plans. This includes timely assistance with activities of daily living such as toileting, mobility, and safety checks, especially for residents identified as being at increased risk for falls. Staff are expected to follow all care plan interventions as written and accurately document the services provided. Failure to implement scheduled care or supervision can lead to preventable injuries and may constitute neglect. Facilities must have systems in place to ensure that staff adhere to residents’ care plans, maintain proper supervision, and provide quality care that promotes resident safety and well-being.
Discussion Points
- Review policies and procedures to ensure they clearly define staff responsibilities for implementing resident care plans, including scheduled assistance and safety interventions. Confirm that supervisory systems are in place to monitor compliance and documentation accuracy. Facilities may also benefit from periodically engaging a consultant to conduct focused mock reviews or policy evaluations to identify potential compliance gaps.
- Provide ongoing education for all direct care staff emphasizing adherence to individualized care plans, accurate documentation, and timely communication with nursing leadership. Med-Net Academy offers courses that support these goals, including Freedom from Abuse, Neglect, and Exploitation, which reviews staff responsibilities in recognizing, preventing, and reporting neglect, and Falls Management, which covers identifying risk factors, investigating incidents, and implementing interventions to prevent falls.
- Conduct regular audits to ensure that care plans are consistently followed and services are documented accurately. Audits should include review of safety checks, toileting schedules, and supervision logs to confirm that interventions are delivered as required. Facilities may choose to work collaboratively with a consultant to perform modified mock surveys or targeted audits focused on fall prevention or care plan adherence, allowing for proactive identification and correction of deficiencies.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*