An incident report dated March 30, 2025, at 5:33 p.m., indicated ULP-D had been in the assisted living dining room, getting coffee and spoke with residents. Dietary staff (DS)-E informed ULP-D R1 fell off his scooter and was lying across his scooter with his neck being pinched between his scooter and the wall. ULP-D called 911 and reported the situation while R1 had been losing consciousness. ULP-D walked out of the dining room to make a call. While making the call, first responders arrived, disassembled the scooter, freed his neck, then laid him on the floor and performed cardiopulmonary resuscitation (CPR) until calling his time of death. The report did not indicate vital signs were taken by licensee staff during the incident.
Video footage provided by the licensee showed R1 got up from a dining room chair and walk to his electric scooter behind him. The scooter faced the corner of the room. In the dining room, DS-E bussed and cleaned tables. The resident held onto the steering wheel of the scooter while trying to transfer onto the scooter. The resident sat down on his scooter at an angle, with his upper half leaning towards the wall and legs stretched out toward the center of the room. DS-E appeared to look over at the resident before going back to his job duties. The resident continued to lean further, though he appeared to be attempting to get himself sat back up with a rocking motion. After about three minutes, the resident appeared to twist and fall headfirst, still holding onto the steering wheel with his right hand. The resident’s buttocks faced the ceiling, with his feet hanging over the right side of the scooter.
Toward the other side of the dining room, another resident pointed in R1’s direction and appeared to have informed someone, as R1 continued twisting and falling headfirst until becoming wedged head-down with his hips in between the steering column and seat, where feet would normally rest during operation. R1’s right hand released from the steering wheel. He continued to move his legs intermittently. Less than a minute later, ULP-D walked toward the resident but did not try to assist or touch him, and did not appear to talk to him. ULP-D walked out of view briefly but then returned, appearing to speak to DS-E, DS-G, and DS-H. R1’s right arm continued to move intermittently.
About a minute and a half after R1 became stuck, ULP-D began using a cell phone while speaking to DS-E, DS-G,
and DS-H, as they walked out of view. ULP-D faced away from the resident. R1’s back appeared to rise and fall for nearly two minutes in that position until rising and falling was no longer visible. ULP-D, still with her back to R1, walked out of view, making a phone call. R1 remained alone for about two minutes, until DS-G and DS-H returned into view.
ULP-F, and ULP-J followed behind and walked over to the resident. ULP-F tapped the resident on the back several
times, and ULP-J made a phone call. Less than one minute later, ULP-D walked back into view and began speaking to the two ULPs, DS-E, and DS-2. One minute later, ULP-D made another call while ULP-F and ULP-J stood over R1 and the scooter. About ten minutes after R1 became stuck, ULP-F and ULP-J briefly attempted to move R1 until ULP-D walked back into view and spoke to them. Less than two minutes later, law enforcement walked into view and approached R1.
The officer attempted to move R1 but was unable. The officer pushed the scooter backwards away from the corner and wall, and ULP-F again briefly attempted to help move R1. Less than one minute later, fire fighters walked into view. Law enforcement and fire fighters removed the scooter’s seat, and four responders lifted R1 off the scooter and onto the ground. Law enforcement began CPR until ambulatory services responders arrived and took over. Responders performed CPR for about twenty minutes.
R1’s death record identified R1’s cause of death as positional asphyxia.
The licensee’s policy Fall Incident and Procedure, dated November 20, 2024, directed staff to not move a resident after a fall, but to call the nurse, observe for injury and take vital signs. If the nurse was not onsite and the resident was hurt, the policy directed staff to call 911, then notify the nurse. The licensee failed to update the policy after the incident.
Findings include:
The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and the facility and an individual person were responsible for the maltreatment, in connection with incidents which occurred at the facility.
If you or a loved one suffered harm while a resident of an assisted living facility in Minnesota or in another U.S. state due to understaffing, neglect, negligence, or the failure to provide appropriate care for a vulnerable adult, you should promptly find an assisted living claim lawyer in Minnesota or in your state who may investigate your assisted living facility claim for you and file an assisted living claim on your behalf or behalf of your loved one, if appropriate.
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