Nurse Fails to Administer CPR, Leading to Resident’s Death

The Minnesota Department of Health has concluded an investigation into Hilltop Healthcare Rehabilitation and Skilled Nursing Center following an incident where a licensed nurse failed to provide CPR to a resident who was unresponsive. The incident occurred on January 14, 2023, and the findings of neglect were released on June 30, 2023.

During the investigation, it was revealed that the advanced practice nurse (AP) on duty found the resident unresponsive but still warm to the touch. According to the resident’s Physician Orders for Life-Sustaining Treatment, she had requested CPR if she was not breathing or lacked a pulse. Despite being recertified in CPR just two months prior to the incident, the AP did not initiate lifesaving efforts.

Timeline of Events During the Incident

On the evening of the incident, at 8:03 p.m., the AP entered the resident’s room for a welfare check. Shortly thereafter, at 8:07 p.m., the AP sent a text message to an off-duty, unlicensed staff member, asking for assistance. Video footage from the facility shows the AP making several trips between the resident’s room and the nurses’ station.

At 8:19 p.m., the AP spoke with the unlicensed staff member for over 11 minutes. It was not until 8:37 p.m. that the AP contacted the director of nursing, who promptly instructed her to start CPR. However, by 8:40 p.m., the AP had yet to take action and instead was seen seated at the nurses’ station.

Evidence collected during the investigation included text messages from the AP, one of which stated, “I’m not taking the blame for this.” According to the health department’s report, the nurse manager indicated that the AP should have taken charge of the situation, as she was the only licensed staff member present.

Consequences and Future Actions

The facility’s internal investigation revealed that the AP admitted to not checking for signs of life, which played a significant role in the decision to recommend a civil money penalty against Hilltop Healthcare. Following the incident, the facility implemented immediate measures including mock drills, reeducation on CPR procedures, and audits of the Physician Orders for Life-Sustaining Treatment protocols.

As a result of these findings, Hilltop Healthcare faces restrictions, including a two-year ban on conducting Nurse Assistant Training programs, effective until January 17, 2027. The facility must also provide additional documentation to avoid termination from state insurance programs such as Medicare or Medicaid.

In a statement, Lisa Frey-Tykward, Administrator of Hilltop Healthcare, emphasized the company’s commitment to resident safety and care. “Our focus continues to be on providing safe, compassionate care and continuously improving our systems to prevent future occurrences,” she stated.

Since changing ownership in 2022, the facility, formerly known as Chris Jensen Health and Rehabilitation, has faced numerous investigations and complaints. The Minnesota Department of Health’s website lists 89 investigations related to the facility, raising concerns about its operational standards.

The tragic incident underscores the critical importance of timely and effective medical response in nursing care settings. Ongoing scrutiny from health authorities may lead to further reforms aimed at safeguarding the well-being of residents in care facilities.