St. Paul nursing home cited in resident's death

Jan. 03--For the second time in a year, the state has faulted the same St. Paul nursing home for failing to respond in a timely manner to a the ventilator alarm of a patient that died.

According to a report made public this week, the Minnesota Department of Health investigated an allegation relating to an Aug. 19 incident at Bethel Care Center in which "a resident was neglected after facility staff found the resident unresponsive and alarms were sounding on the ventilator."

The department determined that the claim was true -- that staff at the 420 Marshall Ave. facility did not intervene for at least 39 minutes after the alarm sounded.

After those 39 minutes, a nurse found the resident, unresponsive and with a pulse, and called 911. The resident, who was dependent on the ventilator, died by the time paramedics arrived.

The report noted the resident suffered from "chronic respiratory failure, ventilator dependence, tracheostomy, and Parkinson's disease," and had limited movement.

The nurse on the resident's wing told inspectors that the facility had decreased staffing levels within a week or so of the resident's death. The floor, according to the facility's documentation, was supposed to have three nurses and two nursing assistants. The night the resident died, they only had one assistant, not two.

According to the report, following the death, the facility added an additional staff person to continuously monitor ventilator alarms, as well as adjusting its staffing plan "to address resident census on each unit."

The facility has a private owner, but is run by Edina-based Welcov Healthcare, which operates 22 facilities in Minnesota, Iowa, South Dakota and Wyoming.

Bethel's administrator, Cory Glad, declined comment on the report beyond a written statement prepared by Welcov.

The statement said Bethel, in response to incidents, "follows established protocols through its Quality Assurance and Performance Improvement program to ensure the continued safety of our residents."

It pointed to the new staffing plan, and said it also added training for staff.

In November, according to Bethel, the health department revisited the facility and found it to be in "substantial compliance." A health department official did not immediately return a call to confirm Bethel's statement.

In January of last year, the Bethel Care Center was also implicated in another death, when a resident's ventilator tube became detached and sounded an alarm during a worship service at the facility last summer, and there weren't any nursing staff around to help.

The Minnesota Department of Health said that a pastoral staff member claimed to hear the alarm, but had previously been instructed to ignore it. About an hour later, the same staff member noted poor color in the resident and called for help.

Bethel did not appeal the finding, but issued a statement at the time that it had updated its policies immediately following the incident. The policy required ventilator-trained staff be available at all activities that ventilator-dependent residents attend, according to the report.

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