A state investigation into the death of a vulnerable adult in a group home in Detroit Lakes determined the facility failed to perform CPR when staff found the resident unresponsive with glazed over cloudy pupils, no pulse, a blue mouth and airways containing vomit.
The Lakes Homes and Program Development Inc. resident was suffering from a developmental disability, recurring bowel problems and post-traumatic stress disorder, according to a Minnesota Department of Human Services Office of Inspector General report released Wednesday.
The vulnerable adult had been sick for a few days and unable to keep food down prior to dying in March. One of the staff members who was watching the resident in the hours before the death said the vulnerable adult was weak and needed help walking when getting ready for bed.
When they got to the bedroom, the resident sat on the floor "curled up in a ball" complaining of stomach pain. A second staff person found the vulnerable adult unresponsive one hour later, according to the report.
Emergency responders arrived and took the resident to the hospital where doctors were able to regain a heartbeat, but not for long. The person died shortly after.
According to the investigation, one of the staff members said they did not perform CPR because emergency responders told them not to. A facility manager thought that was a "red flag." In an interview with management, the staff said one of them told the other not to perform CPR because the vulnerable adult was already "not alive" and was "already gone."
But given that staff documented the vulnerable adult was complaining of pain at 8:42 p.m., and that 18 minutes later the vulnerable adult was found unresponsive, investigators found evidence of neglect.
Investigators also learned from staff that the provider had known about the vulnerable adult's medical problems and that nursing staff "always waited too long" to take the resident to the hospital for stomach issues.
The provider's state license is still active. The Office of Inspector General did not disqualify staff from doing this type of work, but warned them they may be disqualified if they're ever involved in similar incidents in the future.
Lakes Homes and Program Development administrator Thomas Reiffenberger said Wednesday the two staff members involved in this incident are no longer employed by the provider. He said the provider continues to train staff in CPR and other preventative measures.
Lakes Homes and Program Development has several locations in Fergus Falls, Mahnomen and Detroit Lakes. In August of last year, the state issued another investigative memorandum finding neglect and maltreatment in response to another death in a separate group home operated by the same provider.
In that incident, staff took the vulnerable adult to a picnic and saw the vulnerable adult appeared sweaty, pale and gray. Staff took the person back to the group home then to the emergency room where the vulnerable adult was pronounced dead. That investigation determined staff knew the resident was severely ill prior to the death and neglected to seek medical attention immediately.