MDH: 4 Nurses at Duluth Nursing Home Failed to Provide CPR to Unresponsive Resident

Minnesota Department of Health Photo: KSTP
Minnesota Department of Health

August 23, 2018 07:37 AM

The Minnesota Department of Health found a Duluth nursing home neglectful after four nurses did not provide emergency services to a resident who was found unresponsive and pronounced dead at the facility.

According to the MDH report, which does not identify the resident, a nursing assistant at the Chris Jensen Health and Rehab Center helped the resident lie down after breakfast and their morning routine on May 20. About 40 minutes later, the nursing assistant checked on the resident and noticed they did not move.


The resident had no pulse and the nursing assistant could not feel a heartbeat.

The nursing assistant asked for a nurse's help. A total of four nurses responded to the resident's room. The first nurse found the patient had no pulse or respiration and went to get a second nurse.

The second nurse looked at the resident's chart for their CPR status, according to the MDH report. Two more nurses responded and also looked at the CPR status. The report states the resident did request CPR.

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The fourth nurse to respond called the on-call supervisor "out of concern that no one started CPR," the report states, and the on-call supervisor told the nurse to call the nurse practitioner for an order to withhold CPR.

All four responding nurses had current certification in CPR, according to the MDH.

The MDH interviewed the nurses to determine why they did not perform CPR.

The first nurse said they "had no idea what to do when the nursing assistant found the resident without a pulse or respirations," and so they asked the second nurse for help.

The second nurse said the first asked for help with "a resident death" and they "assumed the resident did not request CPR." When the second nurse looked at the chart and saw the resident asked for CPR, the nurse felt it was too late to start it.

The third nurse said they were on break when the nursing assistant called them to help. The third and fourth responding nurses returned to the facility, but the third nurse said "it had been about 20 minutes since discovery" and they were "too upset to do anything, including CPR."

The resident had no family, according to the MDH, and had been at the facility for more than a year.

Since the resident's death, the facility has retrained its staff to check a patient's CPR status. The facility also conducted two mock emergency response drills.


Anthony Brousseau

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