State investigators are blaming the operators of a Bloomington care center in the death of an elderly client who arrived for a week of rehab and ended up dead following her fourth fall within three days.

The Martin Luther Care Center was negligent because its nursing staff failed to notify the client’s doctor after the repeated late-night falls in early October, according to details of a state Health Department investigation released Wednesday.

The family identified the woman Thursday as Mary L. Baker, of Burnsville, who was 82 when she died on Oct. 5 at Fairview Southdale Hospital in Edina.

“I would think they would have kept better watch over her,” said Freda Ward, a sister who shared a home with Baker the last 26 years of her life. “I visited every day [at the center] and sat with her after dinner.”

Ward said she was there on Oct. 4 -- Baker had already fallen three times at the center -- and her sister complained “a little bit about a headache. … I told her to tell the nurse.” It was the last time Ward saw her sister alive.

Shortly after 10:30 p.m., Baker fell for her fourth time in three days and suffered what the state called a “catastrophic” brain injury. Staff waited for six hours after finding her on the bathroom floor before contacting Baker’s doctor, the investigators found.

The doctor ordered a nurse to get the resident to an emergency room. Paramedics arrived to find Baker unresponsive. She was taken to the hospital and was dead two hours later with severe bleeding on the brain, the report continued.

Even though the facility had policies in place addressing falls, “Neglect occurred when facility staff failed to initiate adequate safety interventions in response to the resident’s repeated falls.”

The investigation also pointed out that “leadership staff failed to ensure that the policies were followed.” The center’s director, Jody Barney, declined to comment about the report, referring media inquiries to a spokeswoman for Fairview Health Services, with operates the facility. The spokeswoman, Jennifer Amundson, also declined to address the findings.

In response to the investigation, the care center revised its policies, retrained staff and oversaw its employees’ compliance under the revisions.

According to the Health Department:

The visually impaired and often-confused client, who had a history of falling, entered the home for therapeutic rehabilitation after being hospitalized for a leg injury suffered in a fall at home. The plan called for Baker to return home in a week.

The falls at the care center all occurred at night. One involved Baker being left unattended on the toilet and trying to get up and into a wheelchair.

Despite the nurses knowing the client’s health history and injuries, no preventive actions were taken and Baker’s doctor was not notified.

The fourth and final fall occurred shortly after 10:30 p.m. on Oct. 4, and again she tumbled to the bathroom floor. Her blood pressure shot up and remained seriously high for three hours.

The resident was put to bed and 2 1/2 hours later was complaining of a headache. In response, staff gave the client Tylenol.

Thirty minutes later the resident vomited, and another blood pressure check found even higher levels. It was then that Baker’s doctor was contacted.