Health Department Finds Madelia Facility Negligent in Resident's Death

Minnesota Department of Health Photo: KSTP
Minnesota Department of Health

September 05, 2018 04:12 PM

A Minnesota Department of Health investigation found a Madelia nursing home negligent in the death of a resident after facility staff failed to initiate CPR. 

According to an investigative report, Luther Memorial Home failed to "ensure staff understood and implemented CPR and advance care planning policies and producers."

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According to the report, the resident had a severe cognitive impairment and had a risk of falls. Staff was required to check on the resident every 15 minutes due to his or her risk of falls. MDH does not reveal the gender of patients in its reports.

The resident also had Provider Orders for Life-Sustaining Treatment (POLST) to initiate CPR if the resident had no pulse or was not breathing. 

The report said the night before the resident's death, the resident was found sliding out of a wheelchair. After it was found the resident did not suffer any injuries, the resident was put to bed, the report details. 

Later in the evening, staff members heard the resident call out. When the staff checked on the resident, the resident was found sleeping. 

The report said staff returned 30 minutes later to check the resident's vitals and found the resident struggling to breathe.

A nurse was alerted as staff attempted to put an oxygen mask on the resident. According to the report, a staff member said the resident took his or her last breath as the nurse entered the room. The staff member told investigators he or she did not know if the nurse heard the resident take the last breath. 

The report said the nurse checked for a pulse but found the resident had no pulse and was not breathing. 


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The report said the nurse left to check the resident's chart, which indicated the resident requested CPR. The nurse then called 911, according to the report. 

The nurse was called back into the resident's room after staff noticed the resident's color had begun to change. Because the nurse was being called back to the resident's room, the nurse hung up the phone before the 911 dispatcher could answer. The nurse then determined the resident had died, according to the report. 

A 911 dispatcher called back, however, the nurse told the dispatcher an ambulance was not needed, according to the report. 

The MDH report said the resident died from sudden cardiac arrest.

MDH said when the resident's family was interviewed, the family said a POLST had been completed for the resident requesting CPR. The family was also unaware there were situations where CPR would not be performed on the resident. 

The report said staff interviews indicated, "not all staff were knowledgeable about the facilities policies and procedures on CPR and advance directives." 

A doctor told MDH investigators that if a resident requested CPR, they would expect staff to initiate it. 

The report also found the Luther Memorial Home's policy indicates, "CPR will not be performed if a death is unwitnessed and more than five minutes has passed since the resident was last witnessed alive." 

Luther Memorial Home issued a statement following the release of the report, saying it cooperated with the MDH investigation. 

"We strive to provide the type of high quality, compassionate care that patients, residents and their families want, expect and deserve," Luther Memorial Home Administrator Dawn Campbell said. "Our first priority -- always -- is to provide quality care and to keep residents safe. We are sorry for the pain this family feels."

The statement added the home has made changes to its CPR protocols, and staff has been retrained.

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Ben Rodgers

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