A St. Cloud nursing home has been cited by state regulators in the case of a resident who became ill, then unresponsive, and died minutes later while staff made no effort at resuscitation.
The neglect occurred even though the resident declared on admission to St. Benedict’s Senior Community that resuscitation efforts should be made in life-threatening situations, according to a report released Wednesday by the Minnesota Department of Health.
The nursing home has objected to but did not appeal the findings, which placed responsibility for the death with the facility because three nurses failed to give emergency medical care or start cardiopulmonary resuscitation (CPR) on the resident, who died June 29.
The two nurses who checked the resident’s pulse were suspended on the day of the death and fired two days later, the report read. The supervising nurse received retraining in the relevant areas of policy and procedure.
“We provide a lot of training to our staff,” said Christine Bakke, the nursing home’s administrator, explaining the facility’s objection to the finding that St. Benedict’s was responsible. “We did everything we could do to prepare our staff for this situation.”
According to the report, the resident of the short-stay unit began feeling dizzy and was unresponsive after walking to the dining room for lunch. Staff checked for and detected a pulse, then moved the resident back to the room. Upon checking again, staff found no pulse. At that point, and even though the resident’s directive called for lifesaving measures, none were initiated and the resident died 10 minutes after first feeling dizzy.
A supervisory nurse was notified, and she said not to initiate CPR because “there was no witness to the resident’s last breath [and] too much time had gone by,” the report said.
The nurses who checked for a pulse felt CPR should have been initiated, but they followed the order of the supervisory nurse instead, the report said. The physician for the case agreed that CPR should have been started.
The report noted that the nursing home “objects to the allegations,” but agreed to take several corrective measures, including directing staff members to resuscitate all residents as their medical directives instruct.
St. Benedict’s is operated by CentraCare Health, a nonprofit whose central Minnesota network includes six hospitals, six nursing homes, senior housing in six communities and 17 clinics.