Feb. 28: 3 die at Vets Home after errors

State inspectors said Tuesday that three men died at the Minneapolis Veterans Home after neglect or medication errors last month, and Gov. Tim Pawlenty promptly ordered the Minnesota Department of Health to begin monitoring day-to-day operations of the state-owned nursing home.

The governor's action was prompted by the deaths, two years of "not so good" inspections that found scores of infractions, and the threat by federal officials on Friday to cut off about $7 million in payments for the care of veterans at the Minneapolis facility, said Health Commissioner Dianne Mandernach.

Two of the men who died were in hospice care; one was given penicillin and the other morphine sulfate when they were allergic to the drugs. Investigators said they did not determine whether the medication errors caused the deaths.

The third man was a diabetic who died after five nurses improperly monitored his plunging blood sugar.

One nurse gave him a medication that lowered his blood sugar further.

None of the men who died was identified in the two investigation reports by the department's Office of Health Facility Complaints, dated Monday and given to the Minneapolis home Tuesday morning. The home was cited for three rules violations in connection with the deaths.

"We're very concerned about the care of the veterans at the home," Mandernach said. "The governor ordered this action, and I fully agree."

The action was taken so quickly that many of the top officials of the Minneapolis home and its governing board had only sketchy details Tuesday night.

Starting today, Health Department officials will closely monitor care given at the 418-bed facility. Within two weeks, the home must hire a long-term care consultant to assume responsibility for operating the home, as least for a time, Mandernach said.

In addition, Pawlenty will issue an executive order within days to set up a Veterans Long Term Care Commission to determine how the state's system of five veterans homes should be administered and operated.

"There are a lot of unanswered questions. We just made these decisions this afternoon and we're still fine-tuning everything," Mandernach said Tuesday.

History of problems

Operation of the homes was transferred to a new Minnesota Veterans Homes Board in 1988 from the state Department of Veterans Affairs after the state investigated several deaths at the Minneapolis home and inspectors cited it for 36 violations.

In December, state inspectors cited the home for 34 infractions found during an annual inspection. The year before, when inspectors found 27 violations, the governing board fired the home's four top administrators and hired a consultant to help fix the problems.

On Tuesday, Board Chairman Jeff Johnson said, "I welcome the action the governor has taken. I had hoped we were in a better place, but it looks like we'll take all the help we can get."

In recent weeks Johnson told legislators that he thought the Minneapolis home's care deficiencies had been corrected, thanks to strong board oversight and new administrators.

But on Tuesday afternoon, as Mandernach described the state's intervention in the home's operations, inspectors met with the administrators and told them their re-inspection over the past week had found 10 rule violations, including two new ones, Johnson said.

"This has not been a very good day for us. The other homes are doing very well, but Minneapolis is still a problem, I guess," Johnson said.

Federal concerns

In two letters Friday to the Minneapolis home's administrator, Bob Wikan, the U.S. Department of Veterans Affairs said it "most likely will take steps" to end daily payments for the care of veterans -- about 20 percent of the home's revenue. The home has more than half of the 598 nursing home beds in the state system, and the VA pays about $14 million a year to help with care in all five homes.

The action was threatened because a separate VA inspection in November found 33 standards for care that were not met or partly met, and federal officials were dissatisfied when the home did not show evidence of how it had corrected those deficiencies.

"I'm not aware of the governor's action, so I don't know just what that will mean," said Steven Kleinglass, director of the federally run Minneapolis Veterans Medical Center, who wrote the letter to the state-run Minneapolis Veterans Home.

"We have some concerns, and our concerns are for the care and safety of veterans," he said.

He said the VA immediately will stop referring veterans to the home. However, the home stopped taking new residents Dec. 14.

Admissions resumed Jan. 22 for the 77-bed boarding care portion of the Minneapolis campus, but not for the 341-bed nursing home.

Three deaths

While the state doesn't know if the medication errors killed the two men who were dying in hospice care, it found that a series of nursing failures led to the death of a diabetic veteran after episodes of low blood sugar over more than 30 hours.

At least five nurses failed to adequately monitor the man's worsening condition and incorrectly implemented the home's procedures for hypoglycemia, investigators found.

"The facility is responsible for the neglect, as evidenced by systemic failure to meet the most basic needs of diabetic residents," the investigators concluded.

Investigators said that during the diabetic man's final three days, the nurses:

• Did not check the man's blood-sugar level as often as required by the home's policy.

• Failed to notify his physician when his blood sugar fell below the 80-100 normal range and his condition worsened.

• Did not send him to a hospital when the man experienced severe hypoglycemia, with blood sugar falling to 44 three days before his death.

• When he was found comatose and not breathing at 3:30 a.m. Jan. 4, did not try to resuscitate him as required by his advance directive.

Warren Wolfe • 612-673-7253 • wolfe@startribune.com