Care home resident died after ventilator stopped and nobody noticed, probe finds

The Minnesota Department of Health ruled the care home provider had been negligent.
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An investigation into the death of a Brooklyn Center care home resident has found the health provider was negligent.

The resident was found dead in his bed one morning in October 2017, with the Minnesota Department of Health finding that the ventilator that helped him breathe had stopped overnight.

He was living at a facility operated by Plateau Healthcare LLC, a comprehensive care provider that offers 24/7 nursing care.

The resident was able to communicate verbally, but was unable to move his arms and legs, and required 24-hour respiratory support.

In a report published on Tuesday, MDH said that Plateau "failed to follow the client's care plan, assess the client, or provide services that were essential to the client's health."

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The resident's doctor had ordered he have continuous ventilator use, which was subject to monitoring every four hours, including documenting of ventilator settings and readings.

But while the resident's chart, completed for that night by the nurse practitioner on duty, said that all the prescribed checks had been completed, the nurse changed their story in interview.

They said that the only checks they carried out was taking initial vitals at 8:41 p.m., noting that the resident didn't like being woken up in the middle of the night.

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The last time they were in his room, they said, was around 11 p.m., and he was found unresponsive in his bed at 6 a.m.

A ventilator log showed the machine had a low battery, which triggered alarms twice shortly after midnight, however none of the staff members on duty said they heard the alarm.

The MDH report said "it is unknown for how long the client had been deceased, as cares were not completed during the ordered times."

BMTN has reached out to Plateau for comment, but has not yet received a response.

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