A nursing home in Frazee, Minn., has been cited for neglect in the case of a resident who died of asphyxiation in October after a ventilator machine stopped working and the sole person on duty failed to respond to audible alarms.

Investigators found that a ventilator alarm rang for 5 to 10 minutes before a licensed nurse found the resident was dead and the tubing to the ventilator machine had disconnected, according to a Minnesota Health Department report released Thursday.

The resident suffered from Lou Gehrig’s disease, also known as amyotrophic lateral sclerosis, which causes the death of muscle cells in the brain and spinal cord and leads to difficulty in breathing. Because of the disease, the resident was unable to speak and unable to reattach the tubing.

Frazee Care Center, a 74-bed facility in Becker County owned by the nonprofit Legacy Senior Services of Minnetonka, was found responsible for neglect.

Andy Huhta, the facility’s executive director, said the nursing assistant who failed to respond to the ventilator alarms “is no longer working for us.”

“We did a comprehensive review of every policy and measure in our building,” Huhta said Thursday. “I can assure you that we have taken all measures to rectify the situation.” He added that the home has provided ventilator services for 25 years and “this is the first time this has happened.”

According to the investigation report, the resident’s ventilator tubing had been disconnected from the machine for 11 minutes. The machine was linked to two alarms, including one attached to the door frame of the resident’s room. However, even as both alarms sounded, the nursing assistant who was working alone early that morning did not respond.

A licensed nurse returned to the unit following a scheduled break and discovered that the resident’s “right arm was lying over the ventilator tubing,” the report said. The resident had no pulse and was pronounced dead at 3:05 a.m. on Oct. 24, 2013.

Investigators found the direct care staff person working alone was not trained to respond to ventilator alarms, and that the resident who died was not supervised by a licensed nurse as indicated by the nursing home’s policy.

The death marks at least the fourth time this year that a senior home in Minnesota has been found responsible by the state Department of Health for neglect following the death of an elderly resident.

In April, Goldfinch Estates, an assisted-living home in Fairmont, Minn., was cited after a resident suffering from dementia wandered outside an improperly secured memory care unit and died of hypothermia in minus-18 degrees windchill. A month earlier, a St. Cloud nursing home, St. Benedict’s Senior Community, was cited for neglect after staff members were found to have made no effort to resuscitate a resident who was unresponsive.


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