By Paul Walsh

Minneapolis Star Tribune

WINONA — A nursing home in southeastern Minnesota is being held responsible for the death of a resident who was left alone and broke her legs while dangling from a mechanical lift that was attached to the ceiling as she used a mobile toilet.

In findings released Tuesday, a Minnesota Department of Health investigation concluded that Lake Winona Manor failed to properly direct staff on how to supervise residents when connected to a mechanical lift and also did not follow the manufacturer’s guidelines, which say, “Never leave a patient unattended in a lifting position.”

That’s what occurred Dec. 29, when the resident was placed in the lift and positioned on a toilet in the middle of her room, the optimal location for the lift to be attached to the ceiling.

The two staff members who moved the woman then left her alone to give her privacy, the findings continued, and she was heard screaming in pain moments later.

“[She] was found suspended by the ceiling lift with the resident’s buttocks touching the floor,” the publicly disclosed portion of the investigation read. Staff had failed to lock the toilet’s wheels in place before leaving her alone, “and the commode rolled away from the resident,” the report continued.

After being taken to a hospital emergency room, the woman was returned to the nursing home and died there several days later.

While the resident’s death certificate noted that she died from complications from a stroke, it also noted that her injuries were “a significant condition that contributed to the death,” the state report read.

In response to the death, the nursing home directed its staff on proper safety measures when using a lift, and labels were placed on all transfer devices and lifts directing that residents not be left alone when using them. Labels also were put on portable commodes with directions to lock the wheels.

As is practice, the Health Department did not disclose the identity of the resident. Messages were left with nursing home representatives Wednesday seeking their response to the state’s findings.