Minneapolis nursing-home death is second case of neglect

For the second time in less than a month, state officials have found evidence of neglect by a nursing home worker who failed to try to save a patient who was in distress and died.

In the latest case, a staffer at a Minneapolis nursing home did not administer cardiopulmonary resuscitation (CPR) after being called to the resident's room by employees who saw the man, who could not talk, "blink and take a last deep breath," according to the report released Tuesday detailing the death at Benedictine Health Center on the southern edge of downtown.

An e-mailed statement from Benedictine's administrator and CEO, Dave Brennan, said that the center's internal investigation led to the firing of the staff member. Brennan added that the state found that the nursing home's policies and procedures in connection with this case were in order. Brennan said he could not speculate about what would have happened if CPR had been administered.

It was the second investigation made public this month where a nursing home worker allowed a resident to die without trying resuscitation. An employee at a Waconia nursing home was tired "and not thinking clearly" after being called to the room of a female patient who was unresponsive on a toilet. The employee at the Good Samaritan Society nursing home in Waconia failed to call 911 or administer CPR and the woman died, according to the Minnesota Department of Health report released Feb. 6.

The woman, Luvern Kraft, was 85 but "wasn't ready to die," according to her son, Steve Kraft. She and her family had given resuscitation instructions to the nursing home, but employees failed to follow them, he said.

"They don't treat a person's life like it means anything, " he said. "They get so used to death. It's an everyday occurrence. They don't treat it like anything unusual."

The director of the Health Department unit that investigates claims of nursing home neglect and abuse said investigators didn't find evidence that the failure to administer CPR caused the deaths. Director Stella French said she can't recall a nursing home case where the failure to provide emergency care, such as CPR, caused a death. Still, workers who fail to provide proper care can receive an investigative finding of neglect, she said.

In both cases, state investigators didn't find the nursing homes responsible for the neglect. As is the practice, the Health Department withheld the identities of the residents and the cited staff members.

Investigators found other problems in the employee's actions in the Benedictine case. In addition to the failure to administer CPR, the neglectful staff member also failed to contact the man's doctor about a vomiting episode, as required. When questioned about the allegations by the nursing home's director of nursing, the staff member's "account of the resident's last night was noted to be different than what he had documented," the report read, including giving conflicting accounts about whether he knew of the vomiting. He also contended that he didn't know staff members had seen the man in his last dying moments.

The state's Office for the Ombudsman of Long-Term Care said any cases where nursing home patients fail to receive proper care are troubling. The consumer advocate office, which handles about 2,000 complaints annually, said cases like the one's released this month by the Health Department are uncommon.

"We do not see this on a regular basis," Deputy Ombudsman Cheryl Hennen said. "But certainly every nursing home patient's life is important. We would not want to see this happen to anybody."

The failure to provide CPR or emergency response may not be as common as other breakdowns in care and there are many instances where nursing home residents fail to receive the urgent medical care they need, said Joel Smith, a lawyer with Kosieradzki Smith, a Twin Cities firm that specializes in nursing home neglect cases.

brad.schrade@startribune.com 612-673-4777