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State finds neglect at Minneapolis nursing home after fatal breathing tube error

The family told state investigators they were "trying to protect him, and instead he had a terrible death."
Credit: Getty Images/iStockphoto

MINNEAPOLIS — A state investigation has determined that a Minneapolis nursing home and staff member are responsible for neglect that led to the death of a resident.

The Minnesota Department of Health investigated the death, which happened at the Benedictine Health Center of Minneapolis on Nov. 14, 2018.

The state visited the facility on Nov. 26, 2018, to investigate a report that a staff member had failed to deflate the tracheostomy cuff after capping a resident's tracheostomy. As a result the resident went into respiratory distress and died within 30 minutes, according to the state report.

The investigation found that the staff member who failed to deflate the cuff was responsible for neglect in the death. 

The report also found the facility responsible for failing to document that the staff member had been properly trained when they were re-hired after being gone for several months.

According to the report, a family member told investigators that the resident had been making progress and that "she struggles not to think about his death." The family told investigators they were "trying to protect him, and instead he had a terrible death."

Benedictine suspended the staff member who was responsible, and retrained all nurses on tracheostomy care, according to the report.

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