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Duluth nursing home cited for neglect after four nurses fail to perform CPR

August 22, 2018

A Duluth nursing home has been cited for neglect after state investigators found that four of its nurses failed to attempt resuscitation last May of a patient who was found unresponsive and died.

The 170-bed nursing home, Chris Jensen Health Rehabilitation Center, which has a history of regulatory violations, also lacked a system to ensure that patients medical wishes were followed when they are found without a pulse and not breathing, according to a Minnesota Department of Health investigation that was made public Wednesday.

The patient, who is not identified in the report, had a physicians order for lifesaving treatment, also known as a POLST, directing that cardiopulmonary resuscitation (CPR) be performed if the resident had no pulse and was not breathing. Despite the physicians order, four nurses who cared for the patient failed to provide basic life support after finding the person was unresponsive, investigators found. One of the nurses assumed the patient did not request CPR, while another nurse knew the patient required resuscitation but felt it was too late to start emergency care, according to the state investigation. A third nurse who discovered the patient was too upset to do anything, including CPR, the investigators said.

The Health Department determined that the nurses failure posed an immediate health risk to 45 other patients at the nursing home who had requested CPR in case of need. The facility has since corrected the violation by educating all its nurses on CPR and emergency response, the state report said. In addition, all resident medical records were reviewed to ensure that each patient had a physicians order for lifesaving treatment, according to the state report.

Administrators at Chris Jensen Health Rehabilitation Center, which is owned by Health Dimensions Group of Minneapolis, did not return calls Wednesday.

Chris Serres 612-673-4308 Twitter: @chrisserres

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