Neglect killed two residents a few months apart at a west metro nursing home, state investigators have determined.

The findings released by the Minnesota Health Department implicate the facility, the Good Samaritan Society nursing home in Waconia, in one death and the actions of a staff member in the other.

Details of the most recent death attributed to neglect were released last week. A staff member used the wrong lifting mechanism and failed to get the required assistance, leading to the resident falling and suffering fatal injuries, state investigators concluded in a report on the July incident.

In the earlier case at the Waconia home, a resident's directive on file was overlooked and lifesaving measures were not taken during cardiopulmonary arrest in late February. The resident, identified by a son as an 85-year-old woman from St. Bonaficius, died at the facility.

A telephone message was left Tuesday with the home's administration seeking reaction to the state's findings in both cases, and there was no reply.

In the death involving the resident falling, according to the state:

The resident required two staff members and a hydraulic sling lift for transfers, but just one staff member was assisting the resident and used a simpler standing apparatus for a visit to the bathroom.

The resident lost strength in one leg, slipped out of the device and fell on top of the staff member. The resident suffered a broken hip and arm, and died at the hospital.

Even though the resident's care instructions were on file, the staff member acknowledged failing to review them. The staff member was put on leave, retrained on proper transfer procedures and was put under monitoring for compliance.

In the earlier death at the facility, resuscitation efforts were started when the resident went into cardiopulmonary arrest, but were halted when a nurse "waved the ... form" and mistakenly said that such lifesaving actions went against the resident's directive.

The nurse admitted to misunderstanding the wishes of the resident, believing that "no CPR was to be done," the state report read.

In assigning responsibility to the facility for the death, the state concluded that "multiple staff were involved in the decline of the resident and the care related to CPR."

Along with the nurse's misinterpretation, other staff failed to bring an automated external defibrillator to the resident during the cardiopulmonary arrest. Staff also put the resident at undue risk by performing CPR on the bed rather than on a firmer backboard.

State health officials directed the home's administrators to ensure that residents' wishes in health directives on file "are clearly indicated and followed by staff," the investigative report read.

As is the Health Department's practice, the identities of the residents and the staff members in both cases were not disclosed.