Health Department Finds Neglect in Hilltop Healthcare CPR Incident

The Minnesota Department of Health has concluded that a nursing home staff member neglected to provide crucial CPR to an unresponsive resident at Hilltop Healthcare Rehabilitation and Skilled Nursing Center. The investigation, which wrapped up on June 30, revealed significant lapses in care during an incident that occurred on January 14, 2023.

The advanced practice nurse (AP) on duty entered the resident’s room at approximately 8:03 PM and found her unresponsive but still warm. According to the resident’s Physician Orders for Life-Sustaining Treatment, she had requested CPR if she was not breathing or had no pulse. Despite having completed CPR recertification just two months prior and participating in facility mock drills, the AP did not initiate any lifesaving measures for nearly 40 minutes.

During the internal investigation, the AP admitted to failing to assess the resident for signs of life. The timeline established by the federal surveyor showed that the AP contacted an off-duty staff member shortly after finding the resident, but did not inform nursing leadership until much later. At 8:37 PM, the AP called the director of nursing, who immediately instructed her to begin CPR, knowing the resident was a full code.

The video footage from the facility revealed a troubling sequence of events. After retrieving the physician’s order form at 8:40 PM, the AP remained at the nurses’ station instead of taking action. Text messages obtained during the investigation indicated that the AP expressed reluctance to take responsibility, stating, “I’m not taking the blame for this.”

At 8:58 PM, nursing leadership, recognizing the urgency of the situation, initiated CPR and called emergency services. Emergency medical personnel arrived at 9:10 PM and pronounced the resident deceased shortly thereafter.

Following the incident, the facility faced serious repercussions. The Minnesota Department of Health recommended a civil money penalty and stipulated that Hilltop Healthcare must provide additional information to avoid termination from state insurance programs such as Medicare and Medicaid. Furthermore, the facility is barred from offering Nurse Assistant Training or Competency Evaluation Programs for a period of two years, expiring on January 17, 2027.

In a statement, Hilltop Healthcare Administrator Lisa Frey-Tykward emphasized the company’s commitment to resident safety and care. “We are aware of the Minnesota Department of Health’s investigation related to the January 14 incident, which was self-reported by the facility, and we cooperated fully throughout the review process,” she said. The facility has since implemented measures including mock drills, CPR training, and audits of the Physician Orders for Life-Sustaining Treatment to enhance staff preparedness.

Since its ownership change in 2022, the facility, formerly known as Chris Jensen Health and Rehabilitation, has faced scrutiny, with 89 investigations and numerous substantiated complaints lodged with the Minnesota Department of Health. For more details, concerned parties can search for Hilltop on the department’s website.

As the facility works to address these serious findings, the focus remains on ensuring the safety and well-being of its residents.