The abrupt firing of a senior regulator at the Minnesota Department of Health is unleashing a torrent of complaints by employees who describe dysfunction and disarray at the state agency responsible for protecting vulnerable adults at senior care facilities.
In interviews with the Star Tribune, employees described an office so overwhelmed by backlogged cases that workers dumped dozens of maltreatment complaints into recycling bins without reading them. Others said unread complaint forms piled up into stacks 2 feet high and went unexamined for months.
At one point, employees said, they were ordered to stop making phone calls to elderly victims and other individuals who reported nursing home abuse because it was too time-consuming. But that only angered families, hindered investigations and subverted office morale, they said.
“Day after day, people here are put in an impossible situation,” said Jessie Saavedra, who has worked at the Health Department for 23 years, including the past three years at its Office of Health Facility Complaints (OHFC).
Workers contacted the Star Tribune after learning that Nancy A. Omondi was terminated last month as director of the agency’s health regulation division. Her firing came just weeks after the Star Tribune published a five-part series documenting that hundreds of residents at senior care centers across Minnesota are beaten, sexually assaulted or robbed each year.
The employees’ accounts help explain why the Health Department suffered chronic breakdowns in investigating maltreatment complaints, holding facilities accountable and addressing the alarm and anxiety of worried families.
In an interview, Health Commissioner Dr. Ed Ehlinger said he was “really disturbed” by reports that employees may have destroyed complaint records and said he has already launched an investigation into those claims. He and other agency officials also emphasized that OHFC staff are expected to call individuals who report complaints, and that such calls are vital to families and the investigative process. An agency spokesman said any contrary guidance by a supervisor “would be unacceptable.”
“I admit that we have some dysfunction in OHFC,” Ehlinger said. “We acknowledge that we are not doing as good a job as we should. If we are going to be a resource that people can trust and come to, then we need to do a better job.”
Agency officials acknowledge they were caught off guard by a massive surge in abuse complaints in recent years, and they are now taking steps to reduce the backlog and streamline investigations. This includes a plan to double the OHFC’s investigative staff over the next four years by adding 27 investigators. The surge in complaints partly stemmed from the July 2015 launch and promotion of a new, centralized hot line for maltreatment reporting, which made it easier for seniors to report abuse.
The agency is also modernizing its computers so it can collect and share more information about abuse investigations electronically. Starting in January, agency staff will begin scanning maltreatment complaints into its computer system, an important step toward reducing the agency’s reliance on paper.
The number of maltreatment allegations received by the OHFC has swelled from about 4,000 in 2010 to more than 25,000 in 2016. Yet the unit has failed to keep pace with this surge, and last year it only investigated 3 percent of these cases on site, state records show.
“We were not ready for that kind of onslaught,” Ehlinger said.
However, former and current employees at OHFC say the problems in the unit are deep-rooted and unlikely to be solved through more funding or additional staff.
“The system is broken and it’s been broken so long that the people in charge can no longer see it,” Omondi said in an interview shortly after her termination.
OHFC employees said many of the unit’s problems stem from an archaic, paper-based reporting system. Even when complaints are sent electronically by other state and county agencies, staff must still create a special paper file. At times, the complaints are written out by hand and stuffed in the complaint files, workers said.
“You could fill up a whole baseball diamond with the tons of paper files waiting to be processed,” Saavedra said. “With that volume of paper, the chances of things getting lost and important things going missing is really, really high.”
Employees said files would sometimes go missing for months at a time or get permanently lost. The delays frustrated relatives who reported abuse because they couldn’t learn why their cases were not being investigated, workers said.
The result, as documented by the Star Tribune investigation, is that the vast majority of abuse allegations from senior care homes in Minnesota are never resolved and perpetrators are never punished.
Two former OHFC employees, who spoke on the condition of anonymity, said they recall written complaints being tossed in recycling bins, without being reviewed, because of pressure to reduce the backlog of unresolved cases. The practice, they said, contradicted the agency’s claim that it reviews every complaint.
Diane Konecny, a former complaint intake specialist, said she left the unit in 2013 after 16 years, partly because of guilt over not being able to respond to abuse complaints in a timely manner.
“People were in tears because we felt so bad for these families and these vulnerable adults,” said Konecny, who is retired. “We wanted to get these cases resolved. But obstacles were being thrown our way that made it impossible to do quality work.”
One of these obstacles, say former and current employees, was conflicting messages on whether to communicate with abuse victims and others who report abuse.
These interviews were often vital to determining exactly what happened in an incident and whether the allegation warranted a deeper investigation. The regular calls also put victims and their relatives at ease, indicating that the state took their allegations seriously, employees said.
But OHFC staff said they were told by administrators — at various points since 2013 — to stop calling individuals reporting abuse, as a way of speeding up investigations and reducing the backlog of unresolved cases. At other times, employees said they were encouraged to make such calls.
“I remember thinking, ‘Why are they putting a roadblock in front of us?’ ” Saavedra said. “People file these complaints because they have a serious concern, and we should be responding to [them] in a timely fashion.”
Crying in their cubicles
Omondi said she became concerned about a “dysfunctional work environment” at the OHFC soon after joining the agency in September 2016. She said she was told that some staff were “crying in their cubicles” because of the backlog of unresolved cases. The unit also suffered from high turnover, with more than a third of the staff leaving each year, she said.
“I walked into a lot of chaos,” she said. “People desperately wanted to do a good job, but their plate was overflowing. So how could they catch up?”
A number of OHFC staff said they have shared their concerns with top department administrators and the Minnesota Office of the Legislative Auditor. The auditor’s office is conducting an evaluation, expected for release in February.
Responding to the Star Tribune series, Gov. Mark Dayton has appointed a special work group led by a handful of consumer groups, which will make recommendations to the 2018 Legislature.
State legislators also have expressed concern. Last week Sen. Karin Housley, chairwoman of the Senate Aging and Long-Term Care Policy Committee, and two other lawmakers called for an investigation into management practices at the Health Department after receiving reports of bullying at the agency. Housley, a Republican from St. Marys Point near Afton, is also working with advocacy groups to craft legislation that would improve the speed and transparency of senior home investigations.
“We need to remember that elder abuse is a life-or-death issue,” said Sen. Jim Abeler, R-Anoka, chairman of the Senate Human Services Finance and Reform Committee. “If I ran the [Health] Department, I would be working overtime … to solve this problem.”