A state investigation has found that two nursing assistants were responsible for the June accident that led to the death of the Rev. Tim Vakoc, a Roman Catholic priest and Army chaplain, at St. Therese nursing home in New Hope.
The two staffers, who were not identified, were attempting to transfer the paralyzed priest from his wheelchair to his bed when he fell to the floor and injured his head on June 20, according to the report, released Tuesday by the state Office of Health Facility Complaints.
This is the first detailed report of what happened to Vakoc, 49, who died that same day after he was rushed to a hospital. Vakoc, who was widely known as Father Tim, had needed round-the-clock care ever since a devastating head injury in 2004 from a roadside bomb in Iraq.
The investigation found no neglect by the nursing home, but blamed the two nursing assistants, saying they gave "incongruous" explanations of what happened that day.
The nursing assistants no longer work at the home, said administrator Denise Barnett.
Although the report did not identify the patient by name, the family confirmed that it was Vakoc.
His brother, Jeff Vakoc, issued a brief statement: "Regarding the premature loss of our son and brother, we have received the Minnesota Department of Health ... report and are currently reviewing it. At this point we are considering the findings contained in the report and, on advice of counsel, we cannot make further comment."
According to the investigation, Vakoc fell to the floor and hit his head while he was strapped in a device called an EZ Lift, which is used to move patients who can't stand by themselves.
One nursing assistant told investigators that she was operating the lift when the accident occurred, but did not remember what happened. The other said she turned her back to move his wheelchair and didn't see him fall.
Both told investigators that they had followed proper procedures in strapping him into the lift, and that they "checked the straps to be sure they were secure," according to the report.
However, two other staff members told investigators that when they entered the room moments after the accident, the straps were not attached on the left side of the device. One said she heard "a loud thud," and found the patient lying unconscious, with his head on the floor and his legs suspended in the device.
According to the nursing home, staff members are trained to make sure the sling is attached securely before using it.
The investigation found that there was nothing wrong with the lift, that it worked properly before and after the accident, according to the report.
There were also conflicting reports about whether one of the nursing assistants yelled "wait, wait" just before the accident. One of the nursing assistants allegedly told that to another witness, but during the investigation both nursing assistants denied that.
The investigation concluded "the statements made by the [nursing assistants] are incongruous with what happened." If they had followed procedure and monitored the patient properly, the report said, "they would have been able to describe what occurred."
The report found that the nursing home acted properly by suspending the use of the lift until the investigation was completed.
Barnett, the nursing home administrator, welcomed the findings. "It's quite evident we pride ourselves on the good systems and policies we have, and we continue to follow them," she said.
Under state law, the nursing assistants can be disqualified from caring for patients following a finding of neglect. The report said the staffers have the right to appeal. StarTribune
See articles posted on Stella Borealis about Fr. Tim
Even in the very best of care facilities mistakes can be made. This is so unfortunate.
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