A faulty door at the Wildflower Lodge healthcare facility in Maple Grove, Minn., is being blamed for the death of a woman in a wheelchair who tumbled down a stairway, according to an article on the Star Tribune website.

For at least three years, the stairway door wouldn’t lock without extra attention, according to a state investigation. Repair orders went unfilled, even with signs on the door alerted staff to the problem.

According to findings from a state Health Department investigation, "direct care staff, maintenance staff, nurses and management were all aware that ... the door [was] not operating as intended, but no new interventions were put in place” to have it fixed.

Rather, the report read, signs were affixed to the door directing staff to “double check that door is locked before you walk away” and “wait for the click, 20-second delay for the lock to engage.”

Read the article.