A western Minnesota nursing home has been blamed for its staff failing to act quickly enough to save the life of a resident whose physical condition was rapidly deteriorating ahead of cardiac arrest , according to a state report released Thursday.
Sunwood Good Samaritan Society of Redwood Falls was found negligent in the death on Nov. 1, a state Health Department investigation determined.
Specifically, the investigation found, the home failed to have formal processes in place for monitoring and reacting to significant changes in a resident's condition.
According to the report:
On Oct. 31 during dinner, the resident coughed and gasped while eating. A nurse sent a fax to a doctor saying that the woman was having breathing problems. There was no evidence that the doctor responded to the fax or that staff followed up with the doctor that day.
The next day, the resident's breathing problems continued, she was lethargic and her appetite was poor.
That evening, the woman's "condition further declined." She exhibited symptoms of respiratory distress: Breathing became more difficult, her pulse was erratic and her fingertips turned dark blue. With a grimace on her face, she curled herself into a fetal position.
A nurse put her on oxygen and gave her a drug to ease her discomfort.
Additional faxes were sent to the doctor starting at 4:15 p.m. and marked "urgent." The doctor responded at 5 p.m. after the third one.
At 5:15 p.m., a nurse called for an ambulance but did not say it was an emergency situation. At 6:25 p.m., a second call was made for the ambulance by the same nurse, again without mentioning the situation's urgency.
By the time ambulance arrived at 6:30 p.m., the woman was in cardiac arrest. She died 26 minutes later. Her attending physician listed cardio-respiratory failure on her death certificate.
The physician said in an interview with the state that staff should have been quicker in notifying a doctor and in obtaining emergency medical assistance.
A followup visit in March by a state investigator determined that the home had taken the necessary corrective actions in addressing three federal deficiencies and three state licensing orders.
Those actions include:
• Making sure that staff call 911 -- and not sheriff's dispatch -- for all ambulance requests.
• Training of licensed nurses in how to respond to a resident's "significant change in condition."
• Putting systems in place for proper notification of the attending physician under such circumstances.
Telephone messages seeking reaction to the state report were left Thursday with the administrator of the nursing home and at the headquarters of the Good Samaritan Society in Sioux Falls, which operates the Redwood Falls facility and about 240 others nationwide.
