A nursing home in southeastern Minnesota is being held responsible for the death of a resident who was left alone and broke her legs while dangling from a mechanical lift that was attached to the ceiling as she used a mobile toilet.

In findings released Tuesday, a Minnesota Department of Health investigation concluded that Lake Winona Manor failed to properly direct staff on how to supervise residents when connected to a lift and did not follow the manufacturer's guidelines, which say, "Never leave a patient unattended in a lifting position."

That's what occurred Dec. 29, when the resident was placed in the lift and positioned on a toilet in the middle of her room, the optimal location for the lift to be attached to the ceiling.

The two staff members then left her alone to give her privacy, the findings continued, and she was heard screaming in pain moments later.

"[She] was found suspended by the ceiling lift with the resident's buttocks touching the floor," the publicly dislosed portion of the investigation read.

Staff had failed to lock the toilet's wheels in place before leaving her alone, "and the commode rolled away from the resident," the report continued.

She was taken to a hospital and returned to the nursing home, where she died on New Year's Day.

While the Health Department did not disclose the woman's name, the family identified her as 83-year-old Marlee Panek, who was married for 61 years until her death, raised five children and lived in nearby Dakota, Minn., before entering the nursing home several years ago.

Panek's death certificate noted that she died from complications from a stroke and that her injuries were "a significant condition that contributed to the death," the state report read.

In response to the death, the nursing home directed its staff on proper safety measures when using a lift, and labels were placed on all transfer devices and lifts directing that residents not be left alone when using them. Labels also were put on portable commodes with directions to lock the wheels.

Nursing home officials did not comment Wednesday. Lake Winona Manor is operated by the nonprofit Winona Health, which also runs a hospital and two assisted-living communities.

Paul Walsh • 612-673-4482