Walker Methodist Health Center in Minneapolis has been cited for neglect after state investigators found that three of its nurses failed to take emergency measures last December to save a patient who had become unresponsive.
The nursing home at 37th Street and Bryant Avenue S., which has a history of regulatory violations, had no system to ensure that staff members followed a physician's signed order for lifesaving treatment, the Minnesota Department of Health said in an investigative report released Tuesday. The agency also found that the home failed to provide emergency services when the resident was found not breathing and without a pulse. Before being admitted to Walker Methodist in late 2016, the patient had a physician's order for lifesaving treatment, also known as a POLST, directing that cardiopulmonary resuscitation (CPR) be performed if the resident had no pulse and was not breathing. Despite the order, three nurses who cared for the resident failed to provide emergency services and no one at the facility called 911, according to the state report. The resident, who had Alzheimer's disease, was found sitting on the floor of Walker Methodist's dining room after lunch. Nurses brought the patient back to bed without checking for a pulse. One nurse walked back to the nurse's station to read the resident's physician's order, but still did not start CPR. Later, when a nursing supervisor entered the resident's room, the patient's skin was "blue in color, cool to the touch, and the resident was not breathing." Even so, emergency lifesaving measures were not taken, investigators found. The nursing supervisor later told state investigators that CPR was not initiated because the patient's assigned nurse indicated that the patient was "expected to pass away and the family knew the resident was declining." In an interview with state investigators, the family said they had considered a change to the resident's physician order, to do not resuscitate, but there was no change to the order at the time of the patient's death, the state report said. Since the patient's death, all nurses at Walker Methodist have been educated on emergency response guidelines, including what to do when a resident is found not breathing and without a pulse. The three nurses involved in the incident were also educated on how to read a physician's order for lifesaving treatment, and how to call a resident emergency response, the state report said. Administrators at Walker Methodist did not return calls Tuesday seeking comment. This marks the third time in recent years that Walker Methodist or its staff have been cited for maltreatment. In December 2014, a former male nursing assistant at the facility raped an 83-year-old woman who suffered from severe dementia and Alzheimer's disease. The aide, George Sumo Kpingbah, pleaded guilty and was sentenced to eight years in prison. In another incident, in late 2015, a patient who had been admitted for "acute confusion," went missing from the nursing home for approximately six hours before being returned to the facility by a passerby. While missing, the patient suffered multiple injuries from a fall and had to be hospitalized. State investigators found that Walker Methodist's staff had knowledge of a prior attempt by the patient to leave the facility but did not take extra security precautions.