A Duluth nursing facility was responsible for maltreatment of a client who died after swallowing a chemical cleaner, according to a state agency.
Westwood of Duluth, an assisted living facility that's part of the Benedictine Living Community of Duluth, "failed to implement safety precautions when the client had (a) history of climbing over the kitchen gate" and "failed to otherwise secure chemical cleaners," according to the report from Kathie Siemsen, a special investigator with the Minnesota Department of Health's Office of Health Facility Complaints.
It stated that neglect was substantiated.
The report, which was posted online Tuesday, concluded on March 26 after an unannounced visit to the facility on March 7.
In a statement, Barb Wessberg, CEO of the Benedictine Living Community of Duluth, said, "We grieve with the family over their loss and have extended our deepest sympathy to them.
"We have a long tradition of quality care and have taken this situation very seriously. We immediately launched an internal investigation, reported the incident to all appropriate agencies and cooperated with their investigations. Across our campus, we have evaluated and implemented additional safety and security measures to protect our residents.
"The Minnesota Department of Health has inspected the measures in place and determined that our policies and procedures are in compliance."
The investigator's report didn't include the client's identity, the date of the incident or the date of death. It referred to the client as a male.
According to Siemsen's report, the client was diagnosed with a form of dementia and lived in Westwood's secure memory unit. The client walked independently, and "had known behaviors of stepping over the locked gate to the kitchen, and eating and drinking any food or liquids not secured with a lock."
The report said the incident occurred one morning when the client emerged from the kitchen carrying a cup of liquid and handed it to a resident assistant. The RA said the client looked nauseous. Two RAs helped guide him to his room.
"The client (proceeded) to vomit a dark brown liquid and had a slightly raspy voice," the report continued. "The client kept closing his eyes. The staff sent the client to the hospital."
At the hospital, the client was given critical care for life-threatening deterioration, according to the report. He was drooling, retching and vomiting. His lips were bloody, his eyes were closed tightly and his teeth were clenched. Expected to die within hours, the client was transferred to comfort care.
The client died three days after the incident. The death record indicated that the client died from complications of chemical ingestion, according to the report.
Westwood's own investigation found that chemical cleaners were unsecured in a kitchen cabinet under the sink, the report stated.
The RA told the investigator that the cup contained a fluorescent yellow-colored liquid. Some of it was on the floor in front of the sink, and when she wiped it up, "the liquid felt hot, like burning on her skin."
Since the incident, Westwood removed chemicals from under the kitchen sink and applied locks to all cabinets, the report stated.