Oak Hills negligent in patient’s death

NEW ULM – Oak Hills living Center has been found negligent in the death of a patient who died last August when a nurse failed to deliver cardio-pulmonary resuscitation.

The Minnesota Department of Health conducted an investigation of the death and found that the nursing home was negligent because the nurse was not aware that the patient had an order for life sustaining treatment, which called for CPR when the patient had no pulse and was not breathing. The nurse was also not aware of the nursing home’s policy to start CPR for any resident, unless a decision to NOT initiate CPR had been previously recorded as a doctor’s order.

According to the investigation, the patient had been admitted to Oak Hills’ short term rehabilitation unit in July, with the goal of returning home. The patient signed a Provider Orders for Life Sustaining Treatment on July 1, directing the staff to provide CPR in case the patient had no pulse or was not breathing.

On Aug. 18, a nursing assistant noticed the resident was breathing irregularly at 2:30 a.m. and notified the nursing staff. The nurse, a licensed practical nurse, went into the patient’s room, and, according to the LPN, the patient “took one last breath” and was unresponsive. The LPN called the patient’s family and the patient’s physician to inform them of the death, but did not provide CPR.

The LPN said she looked at the resident’s code status after the death and realized CPR should have been started, but this was the LPN’s “second death as a new nurse and was in panic mode.”

The nurse was suspended the next day pending an internal investigation, and Oak Hills Living Center sent a Vulnerable Adult report to the state. After the investigation was completed, the LPN was terminated, and the details of the investigation were sent to the state. Oak Hills has undertaking extra training with staff on CPR policies and is conducting quarterly code blue drills, according to the report.

“It was very unfortunate that something like this happened,” said Candas Schouvieller, administrator at Oak Hills. “We have our systems in place in place, and we had a person who was new as a nurse, and that person panicked.”

Schouvieller said Oak Hills makes the care and safety of its residents its top priority, and it addressed the situation immediately the next day, a Sunday, with administrative staff coming in, starting the investigation and reporting the incident immediately to the state.”

“We have increased our training, making people more aware of our policies. We are holding code blue drills and have updated our policies and procedures to make sure this never happens again.”

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