MDH Finds St. Paul Nursing Home Employee Neglectful in Resident's Death

Minnesota Department of Health Photo: KSTP
Minnesota Department of Health

September 26, 2018 05:26 PM

The Minnesota Department of Health has found a St. Paul nursing home employee neglectful in the death of a resident in May.

According to the MDH report, the employee failed to notify the on-call physician or nurse practitioner when the resident had a seizure, and the resident later died.

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The report states the resident had multiple health problems when admitted to Shirley Chapman Sholom Home East, including a stroke, dementia and others, but the resident did not have a history of seizures.

On May 17, according to the MDH, the resident fell onto their bed and said they felt light-headed. The nurse notified the physician and received no new orders.

May 19, the resident reported feeling weaker and had a poor appetite. The nurse again notified the physician, who ordered intravenous fluids and labs drawn. The nurse practitioner reviewed lab results with the resident and ordered an additional lab draw, as well as monitoring for possible transfer to the hospital.


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On the day of the resident's death, they were still weak and lacked an appetite. The evening shift nurse told the neglectful employee, a licensed practical nurse, to watch the resident for "changes in condition" throughout the night.

Around midnight that night, a nursing assistant said they answered the resident's call light and saw the resident appearing to have a seizure, according to the report. That nursing assistant told the neglectful employee, who took the resident's vital signs. The nursing assistant said the resident had stopped shaking by the time they left the room.

The seizure lasted about 20 seconds. The neglectful employee went on break around 2:15 a.m., and when they returned the resident was dead, according to the report.

The MDH report states the night shift nurse supervisor said they were not notified of the seizure, but the neglectful employee did notify them of the resident's death. The supervisor found out about the seizure when reviewing the resident's chart.

The on-call physician said the resident had an order not to resuscitate if not breathing and without a pulse. The physician also said they would have sent the resident to the hospital had they been notified of the seizure.

A family member said they were not notified of the seizure, but were notified of the resident's death. That family member also said they got conflicting reports on how often the neglectful employee checked on the resident.

The neglectful employee did not return phone calls from the MDH or show up for a scheduled interview, according to the report. That employee was fired, and all nurses at the facility received re-education on the notification procedure for a change in a resident's condition.

The report states the facility did train the neglectful employee on residents' rights and their responsibility to communicate changes in condition.

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Anthony Brousseau

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