According to the Minnesota Department of Health, neglect has occurred at a Northfield facility where a resident fell in January and later died. Update: Victim now Identified as Karen Mare Johnson who was 63 when she died.

According to the report, the patient fell and then two weeks later suffered the second fall that killed the woman. Allegedly the report states that the woman was improperly transferred by an overnight staff member who was unlicensed and lacked knowledge of the patient’s care plan.

The woman's death occurred at Laura Baker Service Association’s campus located at 211 Oak Street.

MDH's report says "The facility failed to re-assess the client’s transfer needs after the first fall, failed to investigate the circumstances of both falls, and failed to evaluate the care giver’s competence to perform client care.”

There are several houses on the campus and each has one unlicensed caregiver, working on the overnights. The resident counselor did not use a transfer belt And was reluctant to perform two other transfers the night of Jan. 14 when the first fall occurred.

The report goes on to say “The client was weak and tired from standing at the grab bar so long; the counselor was also tired from trying to support the client at the grab bar,”

On Jan.21 she was in the bathroom, using the grab bar and was standing when she fell and landed sideways, on top of her arm and face down according to the report. There was reportedly a large number of secretions, she was not speaking and was in distress. The counselor then allegedly left her to call other home caregivers to assist but since they were the only ones in their homes, the could not leave. 15 minutes after the fall a 911 call was made.

First responders arrived and found the counselor was not giving assistance in any way. The counselor also did not know the woman’s care directive or where to find it and went to search, investigators learned. Responders started CPR but stopped when the directive was found and it had a DNR directive.

Laura Baker Service Associations President issued a statement to KSTP.

In January, a long-time resident at LBSA died. The person was in hospice and had DNR/DNI orders in place, so her death was not unexpected. We miss her and are mourning her loss. We care deeply for all of the people we support.

When the Health Department investigated her death after they received our required notification, they determined that we as an agency were neglectful.

We received, responded to, and implemented corrective actions addressing their findings. They have accepted our response and we have cleared all of the citations. We could appeal the finding; we are still making a final determination if we will do so.  

The client’s family is very supportive of our work with their sister. They are surprised by the finding, and would move their sister back to LBSA were she alive to do so. In fact, the person and her family asked that she be allowed to receive hospice care at her home at 211 Oak Street.

We believe that we always have room to improve and grow. Beyond mourning the loss of a client, we take this opportunity to continue to improve.

We stand behind our mission to support the life choices and dreams of people with intellectual and developmental disabilities and help them reach their goals.


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