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.