State investigation of Fr. Tim Vakoc’s death finds negligence by nursing home staff

Fr. Tim VakocFr. Tim Vakoc

2 nursing assistants blamed for priest’s fall

Report: They gave “incongruous” explanations of an accident that led to the Army chaplain’s death.

By MAURA LERNER, 2 nursing assistants blamed for priest’s fall

Report: They gave “incongruous” explanations of an accident that led to the Army chaplain’s death.

By MAURA LERNER, Star Tribune

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.

Maura Lerner • 612-673-7384

5 Responses to State investigation of Fr. Tim Vakoc’s death finds negligence by nursing home staff

  1. Sactus Belle says:

    This is a very unfortunate incident. I was a staff hospital nurse for many years and am familiar with this equipement and procures for its use. Just as the article describes, what most likely happened is the person positioning the patient hooked up one side of the sling and forgot to hook up the other – then the other nursing assistant began to hoist the sling then they noticed the patient was about to roll off the bed, causing the “wait wait!”. His legs were caught in the device somehow but his torso slipped to the floor.

    These devices are truly good but need to be used with care. These CNA’s acted carelessly and negligently but most likely not with purposeful malicious intent. What happened to this poor priest is truly sad but these mistakes, although unnecessary – do happen. Every effort must be made to prevent these things. I am certain he has already forgiven them.

  2. shirley hill says:

    I have worked in many nursing homes and have seen several accidents similiar to what happened to the priest. Sad, but true. One place I worked did not care at all about an EZ lift issue, until someone got hurt. This manager would not listen to me no matter what, until I took drastic measures to be heard for the sake of the patients. This particular “Christian” manager would write me up every time I complained about faulty equipment. It took the state to intervene to get the faulty equipment fixed. Thank you for listening. P.S. I was told there were still falls, but not involving the EZ lift. Why they keep this manager is beyond me. She should have been fired the first time.

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