Two SNF residents died from neglect

Two residents at the Good Samaritan Society nursing home in Waconia, Minnesota died from neglect in 2016, state investigators have determined.

The Minnesota Health Department released the findings on the July death last week. State investigators concluded a staff member did not seek assistance for a lift and used a simpler standing apparatus intended for bathroom visits instead of a hydraulic sling lift for transfers. The resident lost strength, slipped out of the device and fell on top of the staff member. The resident suffered a broken hip and arm and later died at the hospital.

The staff member was put on leave, retrained on proper transfer procedures and was put under monitoring for compliance.

In a second incident in February, a resident went into cardiopulmonary arrest. Resuscitation effort were started, then halted when a nurse “waved the…form” and mistakenly said that such lifesaving actions went against the resident’s directive. The report stated the nurse admitted to misunderstanding the wishes of the resident, believing that “no CPR was to be done.”

State investigators concluded “multiple staff were involved in the decline of the resident and the care related to CPR,” as other staff failed to bring an automated external defibrillator to the resident and put the resident at undue risk by performing CPR on the bed rather than on a firmer backboard.



Topics: Facility management , Risk Management