A Hastings nursing home patient fell from a toilet and suffered a fatal head injury while unaccompanied, despite care orders not to be left alone when out of bed, a state investigation has concluded.

The Minnesota Health Department said that the resident’s death at Regina Senior Living was the fault of the staff member and not the facility, because the home had trained the employee about how to safeguard against such incidents.

Even though alarms on the bed and wheelchair were set to detect any movement without staff supervision, the caregiver “left the resident unattended on the toilet, contrary to the resident’s care plan,” the agency investigation concluded.

The release of details from the report did not identify the resident or the caregiver. The department also did not disclose when the death occurred, noting only that an investigator visited the home on July 18.

According to the Health Department:

The caregiver assisted the resident onto the toilet, then left the bathroom with the door ajar “to give the resident privacy.” The employee moved about 7 feet and around a counter out of view of the bathroom, remaining away for 5 to 6 minutes until hearing a crashing sound of the resident falling from the toilet.

The staff member summoned a nurse, who found the resident unresponsive and with a bump on the back of the head. The resident was rushed to the hospital attached to the nursing home and stayed there for five days. After another five days, the resident was dead.

While the nursing home was not found to be negligent, it retrained all of its staff on how to prevent and react to falls.

The home’s administrator, Karrie Tipler, issued a statement Wednesday evening saying that the facility carried out an internal investigation, notified the proper agencies and “provided additional falls training” to the staff.