Littlefork nursing home resident died following September incident
A nurse employed by the Littlefork Medical Center has been found by the Minnesota Department of Health to have acted with neglect within that facility.
The licensed practical nurse failed to follow the facility’s policies and procedures when LMC resident Paul F. Reuter Jr. began to show significant changes in breathing in the early morning hours of Sept. 30, 2009, an investigation found. The 85-year-old died later that morning at 5 a.m.
The report did not place blame on the Littlefork Medical Center, which after investigating the incident within its nursing home, forwarded a report to the Office of Health Facility Complaints in conjunction with the Vulnerable Adult Act.
The licensed practical nurse, who is not named, is still employed at the center, LMC Administrator Calvin Olson told The Journal by phone Wednesday. During the investigation, LMC cooperated fully with the MDH and allowed the investigation to complete itself, Olson said.
The investigation concluded that the nurse was responsible for neglect when she failed to follow proper procedures (in which she had been trained) when Reuter’s oxygen levels suddenly dropped.
The long-term employee told investigators that when she discovered Reuter’s low oxygen levels at about 12:40 a.m., she connected him to supplemental oxygen which appeared to be raising his levels to a more comfortable reading. The nurse said she checked twice more on the resident, at one-hour intervals, and he appeared to be breathing easier. At approximately 5 a.m. on Sept. 30, Reuter was found dead in his bed.
“(The employee) 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 states.
When investigators asked the individual why she did not contact the registered nurse, according to the finding, she stated that she thought the RN would tell her to put oxygen on the resident and monitor him so that is what she did. She said she believed Reuter would be okay and did not feel she neglected him.
The employee was disciplined and suspended for five days without pay, according to an LMC press release. Before returning to work, she was required to complete training on appropriate reporting and to watch a video regarding critical thinking.
Olson said he did not believe that Reuter’s family was aware of the investigation, and he noted that he had been trying to reach them by phone.
A life-long resident of International Falls, Reuter was born on the Fourth of July in 1924, and served in the South Pacific with the U.S. Army in World War II. He was awarded the Purple Heart for twice being wounded, according to his obituary.
The investigation report showed that Reuter had been in his usual state of health, alert and oriented and had been on a facility shopping trip that afternoon.
Since the allegation has been found substantiated, the report will be submitted to the Minnesota Department of Human Services for possible disqualification in accordance with state law, said the report.
By mandate, LMC was obligated to report the incident after its discovery, Olson told The Journal. The investigation also shows a 2008 employee review which found the nurse to be a “very dependable employee and met all expectations.” Olson said it is his understanding that the nurse, who has the right to challenge the finding, is appealing it.
“Even though the Littlefork Medical Center as a facility was cleared of blame by the investigation, we need to acknowledge that an employee was found to be negligent and we need to address that issue through the proper channels,” Olson said in a release statement. “We need to continue evaluating how we serve our residents on a daily basis.”
