A Minnesota Department of Health report released at the end of May concluded Thorne Crest Retirement Community in Albert Lea is responsible for neglect of one of its residents last November.

The report stated a woman had severe respiratory and anxiety symptoms for 12 hours in November before she was taken by ambulance to a hospital, where she died shortly after.

“In addition, the facility failed to ensure that they were provided physician assistance in managing (the resident’s) crisis medical situation,” the report continued.

The conclusion came following a state Department of Health investigation in December into the events, which took place Nov. 5 and 6, 2008. The woman died Nov. 6.

The investigation included a review of the resident’s medical record, a review of several of the policies and procedures at the facility, along with observational rounds of residents who receive oxygen therapy.

It also included interviews of staff, the involved physician and other unspecified people; a focused review of two additional resident medical records; and a review of nursing staff schedules.

While reviewing the medical records, investigators found that the woman had a diagnosis of a restrictive lung disease with chronic hypercapnic respiratory failure. This condition is when there is an increased amount of carbon dioxide in the blood.

The resident was admitted to the nursing home from a regional hospital on Nov. 5, 2008. Her admitting physician’s orders state her oxygen saturation level needed to be maintained between 88 and 90 percent, according to the report.

(A normal level is greater than 95 percent, and a possible critical level is less than 75 percent.)

A machine that assists respiration was to be used at night, the orders state.

Medical records from Nov. 6, 2008, at 6 a.m. indicate that the resident had been awake most of the night before. At 3 a.m., her oxygen saturation was 82 percent, and by 4:30 a.m. it had decreased to 71 percent.

According to the Department of Health report, the woman resisted using the respiratory machine.

Records indicates a nurse sent a fax to the resident’s primary physician at 6:30 a.m., informing him of the oxygen saturation levels in the woman and her anxiety. The fax also asked for clarification on the delivery of the resident’s oxygen. It requested a return call immediately.

The physician responded at 10:20 a.m. by fax and requested the resident’s hospital discharge summary be sent to him, according to the report.

A second fax was sent to the physician at 11:30 a.m. stating the resident’s oxygen levels were ranging between 62 and 76 percent and asked whether the physician wanted the resident to use the respiration machine, the report continued. The physician responded in the affirmative in a fax dated 3:45 p.m. that day.

At 1:45 p.m. the oxygen levels in the woman were between 61 and 62 percent, and just after 3:20 p.m. the woman became unresponsive, according to the report. Nursing staff put the respiration machine on her, after which her oxygen levels rose from 49 percent to 57 percent.

She was transported to the hospital at 4 p.m. at the request of her family and died at 9:15 p.m., the report states.

Interviews with employees indicated during the night of Nov. 5, 2008, the resident was “alert, very short of breath and anxious, putting her call light on frequently during the night,” according to the report. Nursing staff did use the respiration machine but the resident wouldn’t leave it on.

One employee stated that the night system for the facility enables the night nurse to speak directly with the doctor on call and that when there’s an emergency, she will just dial 911.

Another employee who worked during the day on Nov. 6, 2008, said, in the report, the system that is used by the clinic that the physician is affiliated with requirements that all calls go to a triage nurse, which can sometimes be frustrating.

“She did attempt a telephone call to follow up on the fax that she had sent at 11:34 a.m. when she did not hear back on the fax, but was told by the triage nurse that the doctor would not be getting back to the nursing home, regarding resident No. 1, until after 2 p.m.,” according to the report.

A third employee, who on Nov. 6, 2008, served in the dual role of administration and nurse manager, said the facility tried many times to contact the physician but had difficulty.

“She wishes in retrospect they had just sent resident No. 1 into the hospital,” the Department of Health report states. “She believes the clinic’s system of responding needs to be addressed with the medical director.”

During an interview with the involved physician, that physician stated he thought the resident should have been sent to the hospital sooner than she was, according to the report.

He stated if his clinic is contacted with an emergency event, the triage nurse will come to him right away.

Thorne Crest Administrator Shanna Eckberg said following the incident, the nursing home developed a correction plan that was approved by the state. Thorne Crest was found to be in full regulatory compliance when it was surveyed during a follow-up visit.

Eckberg said she hired an experienced director of nursing and former nurse consultant in January. The director of nursing audited the entire facility for residents with similar diagnosis.

The nursing also home reviewed and revised policy and procedures regarding oxygen administration and monitoring, educated staff on that new policy and has been closely supervising the staff.

In addition, the administrator said the pre-employment and post-employment practices were revised and implemented to demonstrate strong judgment and skills. The facility also revised and implemented policies related to physician contact during an emergency event.