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Patient with Trouble Breathing Was Neglected by Nurse

Patient with Trouble Breathing Was Neglected by Nurse

Star Tribune, Minneapolis

March 25, 2010

Mar. 16—A nursing home resident in northern Minnesota died hours after a nurse saw he was having trouble breathing but failed to alert the proper medical professionals, according to a state report released Tuesday. The man’s death occurred on Oct. 1 at the Littlefork Medical Center, and state investigators are blaming the licensed practical nurse for not contacting a registered nurse when the resident’s oxygen level was seriously low.

The nurse, described in the state report as a longtime employee at the medical center and “very dependable,” was suspended for five days without pay following the death and completed training on what situations need immediate reporting.

In an interview with investigators, the nurse said the resident’s breathing was labored at about 12:40 a.m. and his oxygen level was 62 percent.

She said she connected him to supplemental oxygen, which raised the level to 82 percent and he appeared comfortable. She said she found the same situation when she checked on him again at about 1:40 and 3:30 a.m. while he continued to receive oxygen.

But when she came to his room at 5 a.m., the resident was dead.

When asked by investigators why she did not alert the registered nurse on duty, she said she thought the RN would only tell her to do just what she had done.

“She stated that [the resident] seemed better after an hour, so she believed he would be OK until morning,” the report read.

The report concluded that the nurse “failed to fully evaluate the resident, to notify the registered nurse on call, notify the physician directly or notify the resident’s family of his change in status.”

The report did not identify the nurse or the resident.

Paul Walsh —612-673-4482

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