A northern Minnesota nursing home failed to seek emergency medical attention for a resident who had vomited and whose condition had deteriorated after improper positioning in a special chair with a feeding tube, according to a state investigation report released Wednesday.

The nursing home, Grand Village of Grand Rapids, Minn., which offers skilled nursing care and rehabilitative services, was found responsible for neglect in the Jan. 10 death. The resident, who is not identified in the report, died 3½ hours after nursing home staffers identified a change in the client's physical condition.

A staff member at Grand Village declined to comment on the state's findings. The facility was ordered to correct several violations of state rules, including failure to immediately notify a physician about a significant change in physical condition. State investigators made an unannounced visit to the facility in June and found the violations were corrected.

The resident, who was dependent on a feeding tube, was placed in a V-shaped chair, with head and thighs elevated, as a way to provide comfort and ease pain. However, the nursing home had not obtained a physician's order to use the chair and the resident could not get out of it without assistance. Nursing home staffers had to reposition the resident several times because the resident slid down and became "scrunched up" in the chair, investigators found.

Early on Jan. 10, staff discovered that the resident's shirt was saturated with feeding formula. "The resident's lungs sounded congested and the resident's pulse, blood pressure and respiratory rate were all elevated after vomiting," the state report said. "The resident became more lethargic, cold to touch and breathing became shallower." A licensed practical nurse documented that the resident had "fluid overload."

Several staffers at the nursing home noticed the significant change in the resident's condition. Even so, vital signs were not rechecked and a physician was not notified until after the resident died, state investigators found.

In an interview with state investigators, the resident's physician said it would be a cause for concern if the feeding tube was running while a resident was in the special chair. The position could increase abdominal pressure and cause vomiting, thus increasing the risk of food getting caught in the lungs, the physician said.

State investigators found that the nursing home did not have a policy for use of the special chair and had not trained its staff on how to use it.

The facility is owned by Itasca County and managed by Ecumen, a large Shoreview-based provider of senior housing and services.

Chris Serres • 612-673-4308 @chrisserres