A state Health Department investigation found that several employees at the Trails of Orono, an assisted-living facility, failed to respond to an activated bed alarm, and also failed to make regular checks on the resident on the night of her fall in August of last year.

The woman's health deteriorated after the fall and she died 26 days later, according to a state investigation report released Thursday.

A spokeswoman for Ebenezer, the Minneapolis-based unit of Fairview Health Services that manages the facility, said Friday it took "swift and immediate action" after reporting the incident to the Health Department. That includes changing its service schedule to include more frequent resident checks, monitoring sensors and reinforcing its standards of care through more staff training.

"We remain committed to protecting the health and safety of every resident we serve, and to providing employees the training and support they need to deliver exceptional care," the spokeswoman said.

The woman, who suffered from Alzheimer's disease and coronary heart disease, fell about 11 p.m. but was not found by staff until 8:45 a.m. the next day. The woman's bed alarm was activated at the time of her fall, but there was no evidence that anyone responded. In addition, staff failed to provide basic care and scheduled checks of the resident throughout the night, investigators found.

State inspectors found there were four separate occasions, between the time of the fall and when she was found, when a staff member should have entered the woman's room and found her lying on the floor, leaning against the metal bed frame. None of these routine checks occurred, and the woman remained on the floor next to her bed until morning, state investigators found. The identity of the resident was not disclosed in the report.

When staff eventually found the woman, she was "incontinent of urine, confused and in pain," according to the report. After the incident, she lost the ability to move about independently and was in so much pain she would scream when care attendants tried caring for her. She also required a wheelchair and a mechanical lift for transfers to and from bed. The woman was transferred to a hospital and was diagnosed with a urinary tract infection. Later, she was transferred to hospice and died 10 days later.

The official cause of her death was bronchopneumonia, state inspectors found.

Inspectors found the facility had an alarm system in place, in which pressure sensitive alarms attached to beds and doors would send messages to staff cellphones. On the night of the fall, the alarm records indicated that the notification to the staff phones went out at 11:10 p.m. However, based on staff interviews and records, investigators concluded that no staff member went to the client's room in response to the alarm.

Chris Serres • 612-673-4308 Twitter: @chrisserres