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A nursing home resident who was strangled by his own nightgown — and whose roommate’s calls for help went ignored — will cost the facility $50,000.

Nurses at Aperion Care Moline reported confusion about a possible do not resuscitate order and admitted they incorrectly delayed resuscitation once the victim was discovered during the August incident. The event was not disclosed publicly until the state health department’s fourth-quarter report.

The resident was discovered unresponsive and not breathing on the floor at the foot of his bed at 8:27 p.m., according to the Dispatch Argus. The ties of his nightgown and wrapped around his foot board, strangling him.

State officials later interviewed the resident’s roommate, who told them he had pushed a call light for help when the resident got out of bed to get a coat from a closet. The roommate said it took “15 to 20 minutes” before help arrived.

A nurse’s aide said the man’s face and fingers were dark blue when she discovered him after returning from a break that night and loosened the nightgown strings. He began vomiting, and the aide turned him on his side.

The other aide had to track down the LPN on duty, searching two different nurse’s stations before returning to the room. According to state officials, the LPN said the resident might have a DNR and that they could not administer CPR anyway because he was vomiting.

Later, the LPN said she mistook DNR paperwork brought to the room. It actually belonged to another resident. By the time an ambulance arrived, staff realized the resident was “full code” and could be resuscitated.

“This was a fluke accident that occurred,” Frederick Frankel, general counsel for Aperion Care, told the newspaper. “Steps are taken to make sure nothing like this would happen at this facility again.”

The state also reported the facility’s crash cart lacked the medical equipment necessary for suctioning a patient and administering IV fluid. In addition, just three of the 16 CNAs on night shifts were trained in CPR, and three out of 23 CNAs on the day shift were, the newspaper reported.

“CPR training at the facility is fine. Whoever is required to be certified, is [certified],” Frankel said, adding, “I don’t believe CNAs are required.”