The Minnesota Star-Tribune reported the sad case of a resident who died when the nursing home staff failed to recognize the obvious signs of a cardiac arrest. State investigators concluded that the staff failed to act quickly enough to save the life of a resident whose condition was rapidly deteriorating. Sunwood Good Samaritan Society of Redwood Falls was found negligent in the death. Specifically, the investigation found, the home failed to have formal processes in place for monitoring and reacting to significant changes in a resident’s condition.
The report states:
On Oct. 31 during dinner, the resident coughed and gasped while eating. A nurse sent a fax to a doctor saying that the woman was having breathing problems. There was no evidence that the doctor responded to the fax or that staff followed up with the doctor that day.
The next day, the resident’s breathing problems continued, she was lethargic and her appetite was poor.
That evening, the woman’s “condition further declined.” She exhibited symptoms of respiratory distress: Breathing became more difficult, her pulse was erratic and her fingertips turned dark blue. With a grimace on her face, she curled herself into a fetal position.
A nurse put her on oxygen and gave her a drug to ease her discomfort.
Additional faxes were sent to the doctor starting at 4:15 p.m. and marked “urgent.” The doctor responded at 5 p.m. after the third one.
At 5:15 p.m., a nurse called for an ambulance but did not say it was an emergency situation. At 6:25 p.m., a second call was made for the ambulance by the same nurse, again without mentioning the situation’s urgency.
By the time ambulance arrived at 6:30 p.m., the woman was in cardiac arrest. She died 26 minutes later. Her attending physician listed cardio-respiratory failure on her death certificate.
The physician said in an interview with the state that staff should have been quicker in notifying a doctor and in obtaining emergency medical assistance.