Despite alarms in place and a staff on alert, Lois Swanson suffered serious injuries in a fall and died 10 days later.
Even after dementia set in, Lois Swanson wasn't angry or hostile, her family said.
After laboring for a lifetime on her Buffalo, Minn., dairy farm, the 86-year-old was mostly quiet and happy for years inside the Lake Ridge Care Center nursing home.
But something suddenly changed on a spring night in 2007.
Swanson surprised the staff by trying to get to the bathroom herself. A report the nursing home sent to state investigators noted that "staff were shocked when they found her lying on the floor in her bathroom at 8:45 p.m. as she never transfers/ambulates alone." She hurt her right elbow, requiring a bandage.
About a half-hour later, the staff saw her try to get up again, the report said. They put an alarm on her and wheeled her to the lounge so they could watch her more closely.
A couple of hours later, at 11:30 p.m., Swanson unlocked her wheelchair brakes, stood up, set off the alarm and fell before three staff members nearby could reach her, the report said. That time, she wasn't injured. When she asked to go to bed past midnight, they put the alarm on her again and brought her to her room.
At 1:45 a.m., Swanson's alarm went off. The staff found her lying on the floor in the hallway without pants, bleeding. Her nose, wrist and fingers were broken. Her leg and knee were sprained.
Never a complainer, Swanson now lay in her bed moaning and crying, her family said. Pain medication seemed to wear off too quickly. They watched her writhe in pain for 10 days before she died.
Her family said they met with nursing home officials and complained to the state.
The Office of Health Facility Complaints reviewed information and "determined that no further action by this office is necessary at this time," according to a letter to the home. Darcy Miner, director of the compliance monitoring division at the Minnesota Health Department, said recently that information the office received showed the nursing home tried interventions each time she fell.
Lake Ridge Administrator Joel Nyquist said he couldn't discuss the case for confidentiality reasons.
Swanson's granddaughters say Lake Ridge staff called the family that night, but minimized her injuries. If they had known of her odd behavior, they said, family members would have come in and welcomed the use of restraints to get her through the night.
In July, the family filed a lawsuit. Recently, attorneys said they reached a confidential settlement agreement. Marshall Lichty, attorney for Lake Ridge, said no party has admitted liability or fault.
Granddaughter Jean Corona said money was not the motivation. "Our goal in this is to, you know, get this to the surface so people can see and understand what's happening out there," she said.
Those who didn't know her grandmother might think, "Well, she was old, she was going to die anyway," granddaughter Rita Sarvie said. But, she added, "no one deserves to die that way."