The woman was sent from a hospital to the Bloomington nursing home for what was supposed to be a short rehabilitation stay.
Instead, she rapidly gained weight, suffered breathing trouble and died in November 2013, less than a week after arriving at the Presbyterian Homes of Bloomington. Now state investigators are blaming the home for failing to adequately check on the woman and keep doctors informed of her acute health difficulties.
In a summary report released Wednesday, the Minnesota Department of Health found that the resident “was not adequately monitored” and alleged that “her call light was not answered timely” during shortness of breath and anxiousness.
Several staff members also neglected to notify her doctor of her health problems, which at times prompted the need for supplemental oxygen, the report continued.
The identity of the resident and the staff members involved were not disclosed, as is the Health Department’s practice. The agency also withheld when the death occurred; the home revealed it was November.
The home took several steps in the wake of the investigation, the report continued, among them: instructing staff on when to notify doctors as a resident’s condition changes and implementing hourly rounds to check on residents.
The home’s corporate office in Roseville relayed a statement Wednesday evening from Bloomington facility administrator Michelle Sullivan that read, in part: “The review [by the state] confirmed that this was a singular incident and overall standards for care, including monitoring and response times, are being upheld.”
The statement went on to say that the home is weighing whether to challenge any portions of the Health Department’s report.
According to the report:
The woman arrived from hospitalization and was admitted to the home for a “stay of less than a week,” before her anticipated return home. She had been suffering from pneumonia and cardiovascular disease.
At night, she became increasingly anxious and short of breath, prompting staff to supplement her oxygen supply.
During the morning of her last day alive, the staff failed to check her weight, as required. In her last 48 hours, she gained 9 pounds.
That evening, a staff member saw the woman sitting at the side of her bed, slumped over and unresponsive. Efforts to revive her failed.
Her doctor told investigators that staff “had an urgent reason” but did not alert the physician about the woman’s breathing trouble and other complications.
Family members told investigators they were troubled that they were not allowed to stay overnight with her and noted staff members’ “lack of response to call lights,” the report read.
A review of records showed that the resident’s call light was answered in an average of 3½ minutes and there was no call light activated in the time leading up to her death.