State: 2 nurses failed to act in minutes before nursing home resident died

State investigators are blaming the sudden death of a Fergus Falls, Minn., nursing home resident on the facility because two of its nurses unwittingly went against his directive and failed to make lifesaving efforts in the minutes before and while the man gasped his last breath.

In details from its investigation released Tuesday, the Health Department pointed to what it said was the Pioneer Care Center's faulty system of tracking which residents want lifesaving efforts made and which do not, with an unauthorized nurses' "cheat sheet" among the questionable record-keeping documents.

"Both nurses failed to reference the medical record and failed to initiate CPR" as the man was dying in his bed on the morning of May 7, the state report read. The man entered the home in January for care after breaking his arm, then decided to remain there for the long-term and his physical condition was considered stable until his death, the report added.

"The facility staff used different systems to check for a resident's code status," the report continued. Code status is what tells medical personnel a resident's directive about whether to have lifesaving efforts such as cardiopulmonary resuscitation initiated.

One of those "systems" called into question was what the nurses referred to as a "cheat sheet," which listed residents' names and was kept in a three-ring binder at the central nurses' station, the report read. Residents whose names were highlighted in yellow required lifesaving efforts. Those not highlighted did not.

The home's registered nurse checked the unauthorized list about 30 minutes after the resident died and saw his name was not highlighted. The RN then checked the resident's consent form and found the discrepancy.

The home's director of nursing also found out later that the consent form had not been entered in the resident's electronic medical record, which nurses check for a code status.

The death certificate read that the resident died of coronary artery disease. As is practice, the Health Department did not disclose his identity.

A visit to the home in July by a Health Department official determined that the facility had made the necessary changes and was in regulatory compliance.

Nathan Johnson, the home's CEO, said Wednesday that Pioneer Care Center is appealing the state's finding of neglect because it's based "in large part" on the existence of the cheat sheet.

While acknowledging that "this incident should have never happened," Johnson also pointed out that the informal document played no role in the resident's death.

According to the investigation:

A nurse's aide checked on the resident at 7:20 a.m. and heard him snoring lightly, then returned 20 to 25 minutes later to find him gasping, breathing more slowly and showing uncharacteristic drooling around his mouth.

The aide alerted a licensed practical nurse, who entered the room at 7:45 a.m. and then called in a fellow LPN. The second LPN checked the resident's vital signs while the other nurse went to contact his family.

By 7:52 a.m., the resident drew his final breath and was dead, and the home's registered nurse was notified.

When the registered nurse asked the first LPN about the resident's code status, the first nurse responded that "she had forgotten to check," the report read. The second nurse said she was checking the resident's vital signs at the time of his death and did not attempt CPR.

Johnson said the home suspended the first nurse, who was the resident's primary caregiver. That nurse and all of the others at the home were retrained about response procedures, he added.

Paul Walsh • 612-673-4482