Duluth, Minn.-based Chris Jensen Health and Rehabilitation Center was cited for neglect after Minnesota investigators found four nurses did not attempt resuscitation on an unresponsive patient who ultimately died, according to the StarTribune.
The 170-bed nursing home has a history of regulatory violations and did not have a system in place to ensure a patient's medical wishes were followed when found without a pulse or not breathing, according to the findings of a Minnesota Department of Health investigation released Aug. 22.
The deceased patient had a physician orders for life sustaining treatment for CPR from their physician. Despite this order, four nurses failed to provide basic life support after finding the person unresponsive, according to the investigation. One nurse assumed the patient did not have a CPR request. Another nurse knew the patient needed resuscitation, but felt it was too late to start emergency care, while a third nurse was too upset to perform CPR, investigators said. A nurse practitioner told investigators she gave an order to not administer CPR, after realizing the patient was dead.
The health department said the nurses' failure posed a health risk to the 45 other patients at the facility who indicated they'd like to receive CPR, if necessary. To correct the violation, the facility reeducated all its nurses on CPR and emergency response protocols by conducting mock emergency drills. The facility also reviewed every resident's medical records to ensure each patient has a physician's order for lifesaving treatment.
Amy Porter, executive director of Chris Jensen Health and Rehabilitation Center, declined StarTribune's request for comment on the patient death, but shared the following written statement with the publication:
"At all times, the health, safety and privacy of our residents and staff are our first priority," Ms. Porter said.