When a St. Paul nursing home resident’s ventilator tube became detached and sounded an alarm during a worship service at the facility last summer, there weren’t any nursing staff around to help, according to a report by the Minnesota Department of Health.

Staff didn’t notice the detached tube for an hour, at which point it was too late to save the resident, the report said.

The department blames Bethel Care Center for neglecting the resident, which led to his death.

Bethel, located on Marshall Avenue in the Summit-University neighborhood, does not plan to appeal the finding, but it issued a statement saying it updated its policies immediately following the incident.

“The final result (of the Department’s report) indicated that no other residents were at risk of the situation recurring as a result of the immediate interventions implemented by Bethel Healthcare Community staff,” a spokesperson said in a statement.

The man who died was a long-term resident of the facility and was dependent on the ventilator at all times, according to the state’s report.

“Facility staff were required to anticipate all of the resident’s needs,” the report said.

According to the Health Department:

Around 2 p.m. on July 16, 2017, the resident was brought to a church service in the nursing home. His ventilator was functioning properly. Two minutes later, his ventilator alarm sounded. A pastoral staff member claimed to hear the alarm, but he or she had previously been instructed to ignore it. About an hour later, the same staff member noted poor color in the resident and called for help.

Nursing staff arrived, reconnected the tubing and called emergency services. At 3:36 p.m., emergency medical services pronounced the resident dead.

The resident’s cause of death was listed as asphyxia due to disconnection of the ventilator tubing. The resident physician said he had recently examined the man and thought it unlikely he would have died otherwise, the report said.

In response to the incident, the facility created a policy requiring ventilator-trained staff be available at all activities that ventilator-dependent residents attend, the report said.

“When an unfortunate incident occurs, the team at Bethel — supported by additional nursing, medical, and professional staff — systematically reviews all processes and procedures related to the incident,” the Bethel spokesperson said in the statement. “From that review, any changes determined necessary are implemented immediately and without delay, in order to assure no other residents are placed at risk.”