Stillwater Facility Found Negligent in Resident’s Death

January 10, 2018 12:20 PM

A nursing staff member at a Stillwater nursing and assisted living facility is alleged to have blocked a resident’s lungs with a speaking valve, which prevented air intake and eventually led to the resident’s death, according to a state investigation.

The Minnesota Department of Health found the facility, The Estates at Greeley, negligent in the resident’s death in part because it did not provide training for staff in the use of the speaking valve in conjunction with a tracheostomy, or a tube in a windpipe to assist in breathing.

On June 12, 2017, the nursing staff member performed tracheostomy care on the resident and left the room, according to the report. That care was supposed to include deflating a cuff around the tracheostomy tube and placing the speaking valve on the tube’s hub.

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The nurse later told an MDH investigator she had forgotten to deflate the cuff, the report shows.

A speech therapist who entered the room later on June 12 noticed the resident was pale, did not respond to questions and did not appear to be breathing.

The nurse who performed the care responded and confirmed the resident had no pulse and was not breathing. Nurses performed CPR before an ambulance arrived and continued life-saving measures, the report says. The resident was taken to a hospital and treated for critical heart arrhythmias with medication and electric shock before he died at 5:57 p.m.

The Estates at Greeley Administrator Jay Wobig released a statement Wednesday reading, in part: “We want to provide the best care possible to our residents and we feel so bad that this occurred. It was a mistake and we are so sorry for the loss of this resident and for his family.

“Our mission is to provide loving care to all of our residents and we will continue to make every effort to ensure their comfort and safety. However, in light of this one-time incident, we have reviewed our policies, procedures, and staff training to ensure something like this does not happen again.”

The report says the resident had been at the facility for a month, and that the nurse who caused the blockage had performed the same task nine times previously as doctors ordered.

The nurse said the facility had not trained her on the speaking valve, but that she had learned by observing another nurse. The nurse said she did not feel comfortable placing the speaking valve bud did not express that to her supervisor.

The facility’s director of nursing said he/she believed nurses had been trained with written materials on speaking valve placement, but could not provide documentation, the report says.

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Three staff members told an MDH investigator they heard the nurse say she forgot to remove the speaking valve from the resident, according to the report. At least one other nurse interviewed by an investigator confirmed the facility had not trained staff on use of the speaking valve.

If maltreatment is substantiated against the nurse, the investigative report would be sent to the nurse aide registry for possible inclusion on a state abuse registry and/or the Department of Human Services for possible disqualification, the report says.

The facility was issued a corrective order, and would face a fine or fines if violations are not corrected.

Editor’s Note: An earlier version of this article said the facility was owned by Monarch Healthcare Management. Rather, Monarch is a management company providing consulting services to the facility.