Neglect by the Heritage House of Pequot Lakes led to the death of a client living at the assisted living facility, the Minnesota Department of Health reported.

An investigation completed by the state agency substantiated charges of neglect, described as improper catheter care and an unclean environment leading to death by a complex urinary tract infection.

"The home care provider is responsible for the neglect because it was not monitoring home health aides and their work performance," the report stated. "The facility ... failed to ensure that ordered and necessary cares were provided."

According to the report compiled by the Office of Health Facility Complaints at MDH, an investigator in February visited Heritage House, 5384 Country Care Lane, Pequot Lakes. Through interviews with staff, examinations of documents and observations of the facility, the investigator found a preponderance of evidence supporting a neglect finding. This included a failure to flush and change the client's catheter and a failure to maintain infection control on the catheter equipment.

Although not identified in the report, the Star Tribune reported the client who died at Heritage House within days of the investigation was 86-year-old Ralph Ford. Ford was admitted with diagnoses of Alzheimer's disease and a neurogenic bladder, or a lack of bladder control. This latter condition required a catheter inserted directly into the bladder through the abdomen.

Ford had a history of urinary tract infections and ongoing issues with his catheter becoming blocked, the report stated. Four months before Ford's death, a nurse practitioner ordered lab work and additional catheter flushes. Those orders were not processed by the provider, however, meaning they did not become part of the client's administration record.

The flushes were not completed, leading to further catheter blockages, the report stated. About seven weeks before Ford's death, a routine catheter change was performed by a urologist, who requested Heritage House instruct a nurse to change the catheter monthly going forward. A change was due three weeks before his death, although no records supported the change occurred.

Two weeks later, Ford became lethargic and had a low-grade fever, soon diagnosed with another urinary tract infection at the emergency room. The investigator was able to meet with Ford, who could make eye contact but was unable to communicate. While on site, the investigator observed a catheter bag hanging on a shower hand rail in the shared bathroom attached to Ford's room. The tip of the bag, which connects to the tube leading to the bladder, was seen touching the bathroom floor. Ford died within a week of the investigator's visit.

Nurses interviewed by the MDH said a sudden and recent departure by a nursing director made it "confusing for the remaining two RNs (registered nurses) to figure out when things were due." The nurse said she thought the urologist was changing Ford's catheter.

Twenty-one pages attached to the report outline specific violations noted and the degree to which violations were considered serious. Among those were two Level 4 violations, denoting when a violation results in serious injury, impairment or death. These violations were of state statutes preserving the right of a person receiving home care services "to be served by people who are properly trained and competent to perform their duties," and "the right to be free from physical and verbal abuse, neglect, financial exploitation and all forms of maltreatment."

Within the details of these violations, the care of several other clients was called into question. Staff care for eight of 12 clients showed a failure to ensure care orders and lab tests were completed, along with a failure to provide a clean environment. The investigator noted a strong urine smell in Ford's room, and urine left on the toilet seat in a shared bathroom among two other clients.

"None of the units observed had an available disinfectant to be used in any of the shared bathrooms between use," the report stated.

When interviewed, unlicensed personnel stated toilets were cleaned at the end of each shift, while a nurse stated they were cleaned after each use. The nurse said urine odors could be from spills from the catheter bag, although staff was supposed to lay down a towel. Unlicensed personnel were tasked with washing catheters, although a nurse told the investigator they'd had no time to monitor this practice since the nursing director left.

Several other Level 2 violations were noted-those that did not harm a client's health or safety, but had the potential to.

Ford's daughter, Constance Ford of Park Rapids, told the Star Tribune she'd long been concerned about her father's care and hygiene at Heritage House. She said she wanted him moved, but a guardian with legal authority over her father opposed the move.

An obituary for Ralph Ford posted on described his death as occurring while "confined at the Heritage House of Pequot Lakes."

"Those who love him believe it is an injustice that a man who worked his entire life supporting the lives of others was not permitted to live out his life as he chose," Ford's obituary stated.

The substantiated neglect in this case comes on the heels of another serious incident at Heritage House. In August, a former employee pleaded guilty to sexually assaulting a 78-year-old woman with Alzheimer's disease in an incident occurring in May 2016. The woman was nonverbal, wheelchair-bound and unable to feed herself, requiring around-the-clock care, the complaint stated.

In June, a fire at the facility forcing the evacuation of more than 30 residents was determined to be arson, although there was not enough evidence to make an arrest, Pequot Lakes Police Chief Eric Klang reported.