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Neglect cited in Minnesota nursing facility death as 4 nurses failed to give CPR

Chris Jensen nursing home in Duluth is facing some state and federal sanctions. (Clint Austin / Forum News Service

DULUTH, Minn. — Four nurses at a Duluth assisted living facility neglected a resident when they failed to perform CPR after the resident was found unresponsive, a state agency has found.

The resident at Chris Jensen Health and Rehab Center died, according to a report by the Minnesota Department of Health's Office of Health Facility complaints.

The date of death is not listed in the report by special investigator Peggy Boeck, which the agency posted online Tuesday. The investigation concluded July 31 after site visits on June 12-13.

The report doesn't reveal if the resident was a man or a woman. The agency's policy is to never list genders of residents or staff to avoid providing identifying information.

In a statement, Chris Jensen executive director Amy Porter said she couldn't comment on a specific incident because of confidentiality reasons.

"We are committed to providing patient-centered care to our residents in a comfortable and respectful environment," Porter said. "At all times, the health, safety and privacy of our residents and our staff are our first priority."

According to the report:

The resident lived at the facility for more than a year before dying. The resident had been diagnosed with respiratory failure and a skin infection but had no cognitive difficulties and made decisions independently. The resident had an order, signed by a doctor, requesting CPR if the resident had no pulse or wasn't breathing.

On the day the resident died she/he went through the normal morning routine and laid down in bed after breakfast. A nursing assistant looked in about 40 minutes later, checked the resident's pulse and could not feel a heartbeat, and then ran for a nurse, who repeated the checks and then summoned a second nurse.

"Neither nurse started CPR," Boeck wrote in her report. "Two additional nurses arrived, looked at the resident's CPR status in the chart and did not start CPR. Nurse #4 called the on-call supervisor out of concern that no one started CPR. ... The resident died."

All four nurses were certified in CPR at the time, Boeck wrote.

The resident had no family to interview, she added.

Chris Jensen took steps to prevent a similar situation from occurring again, according to Boeck's report. Staff were retrained to check a resident's chart to determine his or her wishes in such a case and to carry out those wishes until EMS personnel arrive. Mock drills were conducted with staff as a reminder of how to respond to an emergency.