A 90-year-old Minneapolis nursing home resident who constantly mentioned her desire to die followed through and tied a bag over her head in an act that the home could have prevented, according to a state investigative report released on Thursday.

The woman was found on Oct. 21 dead in her bed at the Jones-Harrison Residence on Cedar Lake Road, and her suffocation followed a recent assessment during which she said she was "a failure, or let herself or her family down," according to the state Health Department report.

The resident, admitted to the home in July for rehabilitation after a fall, added that she had thoughts almost daily for two weeks "that she would be better off dead" or at least wanted to hurt herself, the report said.

A nursing home employee said the resident's doctor was not notified of the woman's depressed state of mind nor had anyone else in a position to intervene been alerted, according to the report.

"Yes, we should've called the doctor, and we didn't call the doctor," Lowell Berggren, the home's president and CEO, said in interview on Thursday.

The home was found to be responsible for the death because "there was no clear indication for staff to follow when the resident answered the questions indicating depression," the report concluded.

Two federal deficiencies and two state licensing orders were issued against the home. A state investigator's follow-up visit found that the home had made the necessary corrections. Berggren said those corrections involved retraining for staff members and policy revisions.

"It's just tragic when someone makes a decision like that," he said. "It affects everybody, and we're doing everything we can to make sure it won't happen again."

As is the Health Department's practice, the name of the resident was not included in the public release of its findings.

Paul Walsh • 612-673-4482