Twenty-three-year-old Evan Fleming waited seven minutes before staff at DFW Nursing & Rehab began chest compressions after he stopped breathing. The delay cost Fleming his life.

Evan Fleming was severely injured in an August motor vehicle accident, when the car he was driving slammed into a metal pole. Fleming suffered broken bones and traumatic head injuries. After treatment at a local hospital, Fleming was moved to DFW Nursing & Rehab for rehabilitation. He had not yet awoken after his accident.

On the day of his death, a nurse aide found Fleming not breathing around 9:25 a.m. She summoned a nurse to the room. Records show that CPR was not commenced until 9:32 a.m.

During the seven minute delay, facility staff tried to frantically paged through Fleming’s medical records to try to figure out whether or not Fleming was to be resuscitated. Reportedly, a licensed vocational nurse called down the halll to a nurse and told her that Fleming was to be revived. Paramedics arrived and began CPR at 9:41 a.m. Fleming was pronounced dead at 10:03 a.m. He had been at the nursing home facility just one week.

According to the Tarrant County Medical Examiner, the official cause of death was trauma due to Fleming’s auto accident. Fleming’s father said he was told that the autopsy revealed that some brain swelling may have cut off impulses to breathe.

According to state officials, seven nurses at the facility did not have current CPR certification. Six resident rooms were labeled whether the resident should be provided with life-saving measures. Of those six rooms, four were labeled incorrectly. The facility’s emergency police indicated that a blood pressure cuff and stethoscope be placed on the crash cart in the event of an emergency. The cart did not have the necessary cuff and stethoscope and did not have functioning batteries for a flashlight.

According to Fleming’s family, “They (the facility) should have at least offered an apology of some sort. An e-mail, a phone call or a letter. It’s like they swept it under the rug.”