Feb. 28: 3 die at Vets Home after errors

  • Article by: Warren Wolfe , Star Tribune
  • Updated: February 28, 2007 - 10:35 PM

Three deaths and new rule violations prompted action; VA may cut $7 million in funding.

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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.

  • INVESTIGATIONS

    To read the state's reports on the investigation into the deaths of three veterans the Minneapolis Veterans Home, go to www. startribune.com/a2396

    To read the state's most recent annual inspection reports for the Minneapolis home and other state veterans homes, go to www.startribune.com/a2070

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