A Hastings nursing home failed to properly care for a resident who fell out of his wheelchair and suffered a fatal head injury last March, according to a state investigation released Wednesday.
Staff members at the Augustana Health Care Center "did not assess, monitor and treat [the resident] in a timely manner" after his March 8 fall, according to the Minnesota Health Department's Office of Health Facilities Complaints.
In addition to citing the home for neglect, the agency noted its history of "substantial past noncompliance" by failing to meet professional standards for handling head injuries. Messages left Wednesday with Augustana officials were not returned.
The man died March 10 of a "massive intracranial hemorrhage," or bleeding that put pressure on his brain and deprived him of oxygen, according to the report, which cited the resident's death certificate. However, the resident's primary doctor told state investigators that proper handling of treatment after the fall would not have saved the man's life.
At the time of the incident, the nursing home's policy was to check on fall victims every four hours, even if they had sustained head injuries. In this case, the man was assessed when he was found on the floor, then 30 minutes later and again three hours later, the report said.
Accepted nursing practices call for much more intense monitoring of fall victims, the report noted.
Four hours after the man fell, his condition deteriorated significantly. He was taken to a hospital and died two days later.
After the resident's death, the nursing home took several corrective steps, including revising its policies and procedures when handling falls involving head injuries and retraining nurses and nursing assistants.
The state report also noted that unspecified "disciplinary action" was taken with an employee in connection with this case.
Paul Walsh • 612-673-4482