A western Minnesota nursing home has been cited for neglect in the case of an elderly resident who died of pneumonia three days after he was rushed to a hospital “malnourished and dehydrated, with severe dry skin and multiple open sores.”

A state investigation released this week said staff at Golden LivingCenters Meadow Lane in Benson relied on Tylenol, cough syrup and supplemental oxygen to treat the man’s wild swings in body temperature and troubled breathing, but did not alert his doctor.

Dean Dokkebakken, 75, described by his family as a lifelong bachelor and farmer, arrived at the hospital unresponsive, with “no purposeful movement,” and died on Oct. 2, according to the Health Department investigation.

The incident is the eighth time since 2011 that the facility’s owner, Texas-based Golden LivingCenters, has been cited by the Minnesota Department of Health for incidents of abuse, neglect or financial exploitation, state records show.

A spokeswoman for the home’s national headquarters in suburban Dallas said Meadow Lane has submitted “a plan of correction that was accepted by the Department of Health and [was] found to be in compliance with the regulatory guidelines.” In addition, spokeswoman Kelli Luneborg said the firm “conducted re-education with our staff around physician notification,” and has improved communication with hospital referral personnel.

Golden LivingCenters, which operates 26 nursing homes in Minnesota and 294 nationally, has been cited before for neglect. In 2011, a resident at a Golden LivingCenters nursing home in Fridley was sent to a clinic appointment with a temperature of 102 degrees, an empty oxygen tank, an undressed pressure ulcer covered with feces, and drainage coming from a catheter tube inserted in her forearm. In addition, the woman was admitted to the clinic with a “Do Not Resuscitate” bracelet on her wrist, even though she had changed her status upon admission to the nursing home.

In another case, a resident at a Golden LivingCenters home in Olivia, Minn., suffered second-degree burns on his hand after he fell out of bed and was found lying next to an exposed, hot radiator pipe.

According to the report on last fall’s incident:

Dokkebakken was running a temperature of 102.3 degrees and had labored breathing on Sept. 28, the day before he went to the hospital. Nurses placed a cold cloth on his head, gave him multiple doses of Tylenol and cough syrup, and administered supplemental oxygen. His condition improved slightly but only for a few hours.

By 6 a.m. the next day, Dokkebakken’s temperature was 103.4, and his breathing sounded coarse from bronchial congestion. Thirty minutes later, he was on his way to the hospital, his doctor unaware of the situation.

After arriving, personnel there determined he had pneumonia, had had little to eat or drink in recent days and was suffering from “extremely poor” skin hygiene.

Interviewed by the Health Department about seven weeks later, Dokkebakken’s doctor said he “would have expected to be notified days before hospitalization” of his patient’s failing condition.

Dokkebakken’s brother Welton, 74, of Fergus Falls, said the nursing home failed to inform family members of the severity of Dean’s condition. On the night before Dean was sent to the hospital, a staff person told them he was suffering from a cold and an elevated temperature, Welton said.

“We really thought he’d be all right,” Welton said. No one at the home mentioned that his brother had pneumonia and open sores, he said. “To do something like this, and not have to answer for it, would not be very good.”


Staff writer Chris Serres contributed to this report.