A St. Anthony nursing home resident fell, hit her head, and died four days later, after an employee failed to follow basic safety precautions, according to state health investigators.
The Oct. 7 incident occurred after a nursing assistant at St. Anthony Health Center left the resident's room without setting a sensor alarm, lowering the bed, or placing a mat by the bed.
Staff had included these precautions in the resident's care plan, after determining that the resident was at risk of injury from falls.
An investigation by the Department of Health cited the employee for neglect, and determined that the facility was not at fault.
The resident, whose name has not been released, suffered a hematoma on her forehead from the fall. She appeared drowsy and weak after the incident. Within two days, her condition had worsened, and included "periods of unresponsiveness and apnea," the report said.
The resident was admitted to hospice on Oct. 9, where she died on Oct. 11. The death certificate lists the cause of death as heart disease.
St. Anthony Health Center suspended the nursing assistant one day after the incident. She was fired the day after the resident died.
The employee "admitted she used poor judgment," according to a report released Thursday by the Department of Health. Her name has not been released.
The facility reviewed safety procedures and other requirements with nursing staff on Oct. 8. The investigation found that the facility did not violate any federal or state licensing requirements.