Minnesota Nursing Home Resident Dies After Facility Staff Fail to Act
According to a Minnesota State Health Department investigation, the Foley Nursing Center, a nursing home located in Foley, Minnesota, was cited recently for failing to have "an adequate system in place whereby nurses notified the physician of the resident's deteriorating health status.
On March 3, 2009, a facility resident complained to a nurse that his chest was tight and his cough had "slight crackles". The nurse noted that the resident's oxygen saturation level had dropped to approximately 80%. The resident was administered oxygen and his saturation level climbed to 92%.
The following day, the resident attended a previously scheduled physician's appointment, where the physician detected shortness of breath. The man was taken to the hospital and admitted. The man died on March 8 from pneumonia.
The hospital physician doctor told state investigators that when the man's oxygen saturation level dropped to 80%, a nurse should have called a doctor. The state report found that one nurse failed to notify a physician of the "crackles" in the resident's lungs, a second nurse failed to act on that first nurse's concerns, and yet a third nurse didn't notify a doctor about the drop in oxygen saturation.
