Care Facility Cited for Ignoring Aides' Concerns Prior to Woman's Death

BY: CLARK KAUFFMAN 
A Clarinda nursing home is facing potential fines for allegedly ignoring the concerns of two nursing assistants about a resident who subsequently died.

On Nov. 27, 2023, two certified nursing assistants at Azria Health informed the home’s on-duty nurse that a female resident had experienced a significant change in her mental and physical condition. The two CNAs had noticed the woman’s oxygen saturation levels had dropped to 63%, well below the 88% level that typically calls for immediate medical intervention. In addition, the woman’s blood pressure had dropped to 79/39 — a dangerously low level.

When the nurse was notified, she told the CNAs to place the woman on bottled oxygen. The CNAs did so but after 20 minutes, the woman’s oxygen saturation was at 92% — still abnormally low — and the woman was confused and appeared to be in pain. The two CNAs reported their concerns to the nurse again but, according to state inspectors, the nurse did not seem worried or concerned and simply replied, “OK.”

Later in the day, when the woman’s oxygen levels dropped to 72%, the nurse asked the CNAs to increase the flow of bottled oxygen to the resident. The aides allegedly did so and then reported the resident’s vital signs never improved for the rest of their shift.

When the overnight nurse came on duty at 10 p.m., one of the CNAs pulled her aside, told her what was happening and stated the woman needed to go to the hospital. According to inspectors, the overnight nurse agreed and the resident was sent to the emergency room at 10:30 p.m., four hours after the aides had first reported their concerns. Within 24 hours, the resident was dead, with the cause of death listed as congestive heart failure.

Later, in talking to state inspectors, the nurse who was alleged to have been dismissive of the aides’ concerns denied being told any such concerns. When asked if anyone on the staff had told her the woman’s blood pressure was low, the nurse said no. Inspectors alleged that when asked if anyone had reported the woman’s oxygen saturation levels were low, the nurse said no, but then said maybe.

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Care Facility Cited for Ignoring Aides' Concerns Prior to Woman's Death

State faults Eagan assisted living facility after resident’s body apparently not discovered for 2 days

Debbie Singer walked up to her mother’s apartment at an Eagan senior living community to find multiple packages and two newspapers outside the door. Her mother’s bed and bathroom looked as if they hadn’t been used in days. Medication for the past two days had not been taken, and her mother was wearing the same clothing she’d been in two days earlier.

June Alice Thompson was 92 years old when she died in October 2017 at The Commons on Marice in Eagan. Her daughter described her as a “fiery redhead” who loved animals, dancing, golfing, singing, and fishing. (Courtesy of Debbie Singer).

June Alice Thompson, 92, was dead, and most likely had been for two days.

But Commons on Marice, a senior living community in Eagan, hadn’t noticed because staff had neglected to check on Thompson for two days, according to allegations in a state Health Department report released Tuesday.

Commons on Marice said Tuesday it has appealed the findings.

“Our hearts go out to this resident’s family and friends and we are deeply sorry for their loss,” executive director David Salmon said in a statement. “As a senior living community, we sometimes have residents pass away while living with us, and our intent is to always handle those events with respect and sensitivity.”

Singer said she was pleased with the state’s findings.

The Health Department alleges that while Thompson’s death was most likely natural, Commons on Marice failed to complete the daily checks the privately operated facility advertises and did not notice Thompson’s death for two days. The name of the victim and her daughter were included in the Eagan Police Department report on the incident, but not in the state report.

Thompson had terminal esophageal cancer and was classified as “assisted living,” but she was independent enough to use her own feeding tube and administer her own medications, the police report said.

“Her condition was changing, but she was incredibly intelligent and vibrant, and she was very in tune to what was going on in the world,” Singer said. “She would listen to politics on both sides, and she had high hopes for the Vikings winning the Super Bowl. She would discuss their plays and knew who was being traded.”

Thompson had attended a meeting with family on Oct. 24. Singer told investigators her mother was alert, oriented, involved in the meeting and able to move about.

“I love you and I’ll see you in a couple of days,” Singer and her mother told each other before Singer left.

A housekeeper arrived as the family was leaving. Thompson told the housekeeper she was excited to meet the housekeeper’s children at a Halloween party later that evening. She had decorated her walker for the event — as she always did for holidays — Singer said.

When the housekeeper left in the afternoon, Thompson was standing in the kitchen, the state report said.

“See you later,” Thompson told the housekeeper. The housekeeper was possibly the last person to see Thompson alive, the police report said.

Singer returned on Oct. 26 to find her mother in a reclining chair with the footrest extended, leaning in horizontal position. The shades were not closed, the lights had not been turned on, and the newspaper — dated Oct. 24 — was folded on the left side of Thompson along with a pair of eyeglasses. It was immediately evident to Singer that her mother was dead, the state report said.

“I just knew something was wrong because she never missed her daily newspaper,” Singer said. “There were all kinds of indications that she didn’t die peacefully.”

Thompson’s death appeared to be natural, according to the medical examiner. Her death certificate lists her time of death as 6 p.m. Oct. 26, 2017 — when she was found.

The Hennepin County medical examiner’s office did not conduct an autopsy because Thompson had a terminal illness, the office said. Although there were still some unanswered questions about the death, the office did not categorize it as accidental, suicidal or homicidal, a spokesperson said.

An investigator narrowed down the time of Thompson’s death to between 3 and 7 p.m. Oct. 24, the police report said.

The Commons on Marice functions more as an apartment building with daily check-ins by staff than as a nursing home. Thompson had been living there for more than four years, and received additional hospice care visits twice weekly from Allina Health.

The facility had a daily “I’m OK” program, used to document that each client was checked on daily by a staff member. Once clients were seen or called each day, they received check marks by their names on a client roster kept in the receptionist’s desk.

Commons on Marice could not provide the state with documentation that Thompson had been checked on either Oct. 24 or Oct. 25. She had an “I’m OK” daily check for Oct. 26th, but the state said it was falsely documented because the client was no longer alive.

A senior leader at Commons on Marice told investigators that since the incident, the facility had implemented a new process for the “I’m OK” checks.

“Since this incident, we immediately reviewed our existing policies and procedures and strengthened our process for conducting resident welfare checks,” Salmon said. “The care our residents receive is our top priority.”

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State faults Eagan assisted living facility after resident’s body apparently not discovered for 2 days