Investigation found that the man, who had chronic lung disease and limited verbal skills, did not receive adequate care.
A state-operated care facility in Bloomington and one of its employees are being blamed for inadequate monitoring and failure to provide CPR, resulting in the death of a resident recovering from lung disease, according to a state investigation released this week.
Bruce D. Diersen, 54, who had been treated days earlier for chronic lung disease, died Sept. 17 at the facility in the 8600 block of Oakland Avenue after episodes of coughing and shortness of breath, according to the Health Department investigation.
An employee who tended the man did not check on him hourly, as required, and then called 911 at 6:30 a.m. but did not begin CPR after finding the client unresponsive, the report added. By the time police and paramedics arrived minutes later, the man was dead. Name of the employee was not disclosed in the public portion of the report.
Diersen's relatives, reached Thursday, said they have been struggling with his death and that questions about the quality of his care have sharpened the pain. They said the report has raised additional concerns about whether Diersen, who had Down syndrome and limited verbal skills, suffered in his final hours and whether more diligent attention would have saved him.
"What brought me to tears was reading that he was in bed struggling to breathe," said Leona Simonett, his sister. "With his history of lung problems, they should have called 911 when he was struggling to breathe. ... If the ambulance had come at 4 a.m. and taken him to the hospital, we think he would have a chance to make it."
The facility was cited for failing to properly monitor the vital signs of a client with bronchitis and a history of chronic lung disease. The employee fell short by not administering CPR, the state said.
The report also makes clear that the aide, who was a state employee, told contradictory stories about the care he provided. He first told fellow employees that he didn't administer CPR to Diersen, but later changed his story. Those contradictions have caused Diersen's family to wonder whether the aide was truthful on other matters, such as whether Diersen was given a nebulizer and was monitored regularly through the night, Simonett said.
The property, run by the State Operated Services division within the Department of Human Services (DHS), is an intermediate care facility and residence for people with developmental disabilities. Diersen's case was one of several in the second half of 2011 that raised questions about harm to patients and the quality of care offered by the division.
A severely disabled man drowned last August at a state-operated home in Braham after an aide left him alone in a bathtub. In September, a van driver working for the division was arrested for driving clients while intoxicated. In December, the Minnesota Security Hospital in St. Peter was placed on two years' probation and fined after investigators found patient abuse that occurred in 2010.
DHS spokeswoman Patrice Vick said Thursday that her department is not appealing the findings in the Diersen case and is taking the necessary corrective actions, including retraining staff and clarifying procedures. Vick added that the employee no longer works for the department.