State ties death to Goldfinch

FAIRMONT – A resident died after wandering outside a secured memory unit at Goldfinch Estates in January, and the state has found the facility at fault after discovering that security doors malfunctioned and the client’s care plan was not followed.

The Minnesota Department of Health released the results of its investigation into the death on Wednesday. The resident who died was not identified.

According to the Department of Health’s investigation, neglect occurred when the client was able to leave through a secured exit unnoticed by staff, fell outside, and eventually died of hypothermia due to exposure.

The event occurred the evening of Jan. 16.

The report states that when EMTs responded to the scene shortly after 10:30 p.m., the air temperature was 5 degrees with a wind chill of minus 18.

The Department of Health report noted there had been issues with the doors to the memory care unit intermittently not locking, and the door could be opened without a code. Records show there were prior incidents of memory care unit doors unlocking five other times in the two months before the incident. While repairs were made, the report states the facility failed to establish a system to monitor the exit doors to ensure they were functioning properly.

The report also cites neglect on adequate policies and procedures to direct staff on what to do when a resident goes missing. While the policy indicated to search for the person, it was unclear to staff how long to search before notifying a supervisor and law enforcement.

The resident’s personal care plan also was not followed that evening, according to the investigation. The resident was diagnosed with dementia and was at risk for wandering away, and was to be checked on every two hours. It was indicated that staff last saw the resident in the dining room around 7 p.m. The resident could not be found at 9:30 when it was time to administer medications. The resident was found outside in the courtyard area shortly after 10:30 p.m.

Patrick Rafferty, chief operating officer at Vista Prairie Communities, which operates Goldfinch Estates, said the issues that led to the incident have been addressed.

“First, with this incident we are deeply saddened,” he said. “It was an isolated incident, and everyone at Goldfinch is very saddened by the event.”

Rafferty said there has been additional training and retraining implemented with staff members, and all residents must have a visual check every two hours.

“We’ve also updated an additional fail-safe system on the door alarms,” he said. “It was a mechanical latch that malfunctioned, and we’ve upgraded all systems. There are audio and visual alarms when a door malfunctions or is not locked. We’ve also implemented a daily check on all of those systems.”

While Vista Prairie originally requested a reconsideration of the maltreatment finding, it was denied by the Department of Health.

“We felt it was an accident and not in regard to maltreatment,” Rafferty said. “We could go to an appeal, but at this point I don’t think we will. We want to get past this, and all the changes needed have been in place for some time.”

No other penalties or citations are expected at this time, according to Rafferty.

“With Goldfinch, all the employees there take care of the residents more like family members,” he said. “Not only was this difficult for the family, but it was difficult for the staff and the rest of the residents too.”