Grim details emerge in Minnesota Vets Home probe

09/02/2005

Warren Wolfe,
Star Tribune
September 2, 2005


As a state inspector watched, an aide fastened a fleece sling under a “mostly naked” nursing-home resident and hoisted him by his armpits with a mechanical lift. The man dangled over a trash can while the aide removed the man’s soiled incontinence pads and cleaned him.

Two days later, the aide did it again. “What the hell do you think you’re doing?” the resident demanded.

Those and other incidents led the Minnesota Department of Health to cite the Minneapolis Veterans Home for 37 rule violations, made public Thursday against the state-operated nursing home.

Among the other incidents at the home for 418 aged veterans:

Some residents were left unchecked for hours as they sat in their own feces and urine; catheter bags were not emptied until after they had overflowed.

One man had not seen a dentist in his five years there.

Another sat with his cooling breakfast for 35 minutes before an inspector asked an aide to help the man eat. The aide did not offer to reheat the food.

The 42-page report described dozens of incidents that inspectors witnessed during a four-day unannounced annual inspection.

The violations included inadequate care, soiled walls and floors, inadequate supervision and staff shortages.

The top four administrators of the home were asked to resign this week because of the inspection results and “other leadership problems,” said Stephen Musser, executive director of the nine-member Minnesota Veterans Homes Board, which oversees five state-operated nursing homes. The four administrators left this week.

Shocked by report

“Yes, I was shocked by the extent of problems,” said Musser, who took over as temporary administrator of the home, established by the Legislature in 1887 to care for Civil War veterans.

“We knew there were problems, but we thought they were being solved,” he said. “Clearly, they were not. They still are not, but I am certain we will be in compliance” with state regulations by Wednesday, when he files a response to the inspection report that he received Monday.

David Giese, who oversees Health Department inspections, said the number and wide range of violations were “very unusual,” but noted that the care issues have not put residents at grave health risk.

“We’re concerned. We want these problems fixed,” Giese said. “But this is nowhere as bad as the situation in 1987,” when regulators took over management of the home for a time because of severe care problems.

That 1987 incident led the state to take the veterans homes from the state Department of Veterans Affairs and create the new Veterans Homes Board.

Health officials were particularly concerned about staffing problems at the home—an issue that two unions representing nurses and aides have complained about for months.

A nurse manager told investigators during the annual inspection July 26 to 29 that there were 56 vacant shifts for the next two weeks, and 67 vacant shifts for the two weeks after that.

Musser agreed that staffing has been a problem—“not the number so much as where we have them.”

He said that the home, which has about 460 workers, also has about 35 staff vacancies and is in the process of hiring about 24 new workers.

He said that the home spent $1 million last year on temporary staff members and that it tried to ease that problem by requiring workers to work overtime shifts when needed.

That brought strong protests from some workers, especially part-time staff members with second jobs, those with child-care issues and some who said the stress on staff was hurting resident care.

Musser acknowledged that several workers were fired for refusing to work overtime.

The Minnesota Nurses Association, which represents licensed nurses at the home, said 18 to 20 nurses resigned in the past few months because of the overtime rule and other management issues.

Earlier investigation

Administrators knew that the Health Department was investigating allegations of poor care at the home even before the inspectors entered the home last month.

On June 15, the department’s Office of Health Facilities Complaints sent an investigator to look at claims that two incontinent residents with bed sores were not getting inadequate care.

The investigator found two additional residents with similar problems and cited the home for three care violations and for having inadequate staff to complete the work.

Fewer than five weeks later, the annual inspection found that those problems still existed and uncovered numerous others. That inspection resulted in 33 more citations.