A nurse in New Ulm watched a nursing home resident’s final breath, then went into “panic mode” and failed to make any effort to follow the woman’s wishes and attempt to save her life, according to a state investigation released this week.

Oak Hills Living Center was found by the state Health Department to be responsible for the death in August, which occurred despite the resident’s stated desire to have lifesaving CPR efforts when necessary.

According to the investigation, a nursing assistant alerted the nurse after observing the resident in her room having difficulty breathing.

The nurse entered the room and later noted in the resident’s medical record that “no signs of life” were obtained.

The nurse then notified the resident’s family and attempted to reach her doctor.

“No CPR was initiated,” the report said, adding the nurse found out after it was too late that CPR efforts were wanted.

“The resident’s plan of care stated that the resident’s goal was to return home and indicated that staff were to perform CPR/call 911 in the event of a respiratory or cardiac arrest,” the report read.

The nurse explained “that this was his/her second death as a nurse and was in panic mode,” the report said.

Oak Hills was blamed for the death because the nurse “did not have documentation of orientation” of the residents at the facility.


Paul Walsh • 612-673-4482