Client was deprived of CPR because staffers thought he was subject to a do-not-resuscitate order, a state report says.
A client who was choking at an assisted-living residence in Brooklyn Park was mistakenly deprived emergency resuscitation efforts and died as an ambulance waited outside, according to a state investigatory report released Wednesday.
The March 27 death at the group home for mentally diminished clients in the 7700 block of Humboldt Avenue N. is being blamed on the facility's operator, Dungarvin Minnesota of Mendota Heights, because a filing procedure led staff members to erroneously believe the man was subject to a do-not-resuscitate (DNR) order, the Health Department report found.
In actuality, staffers were basing their actions on another client's DNR order, the investigation said. A single binder held all clients' DNR orders, the report said.
The facility now keeps separate binders for each client, including resuscitation orders and other emergency information, according to the report.
As is practice with the public release of Health Department investigatory reports, the client's name was not disclosed. He had been at the facility since 2010 for hypertension and advanced kidney failure.
According to the report:
The staff checked on the man, who was coughing at night in his room, and soon called 911. Emergency personnel arrived and determined that cardiopulmonary resuscitation was needed.
Facility staffers checked what they thought was the man's DNR order, and efforts to revive him were halted; he died without ever being moved to the ambulance.
Dungarvin Minnesota is part of St. Paul-based Dungarvin LLC, which serves mentally diminished clients in many states.
Bob Longo, a regional director for Dungarvin, noted in a written statement that the state "accepted plan of corrections, and [we] are awaiting any further dialogue" with the Health Department.
"Dungarvin has a 35-year history of providing the highest quality of services," the statement continued, "and we ... take any issues such as this very seriously."
Paul Walsh • 612-673-4482