Bain’s family remains angry at how his case was handled.
“They’ve had so many problems this was just the nail in the coffin,” said Bain’s brother. “My brother wasn’t going to die.”
Bain’s death was the only one investigated in which a complaint was substantiated. Investigators ruled the other three complaints “inconclusive” or “unsubstantiated.”
One complaint involved the 2010 death of an 86-year-old woman with dementia who fell and fractured her hip. An alarm system fell off her collar and failed to alert staff. She died five days later. A Health Department report said VA staff gave investigators conflicting and inconsistent information and there was no witness to the fall.
In another neglect complaint, a resident was heard crying for help and staff found him lying face down in front of his wheelchair. He was taken to the hospital where a large hemorrhage was found in his brain. He was discharged back to the vets home two days later and died in hospice care the following day. The death certificate said he died from bleeding on the brain. A doctor at the home told investigators he believed the resident had a spontaneous brain hemorrhage and then fell from the chair.
For the 10 months he was a resident of the Minneapolis Veterans Home, Dick Cashman’s family thought he was getting the best of care. They thought that right up until the night in October 2011 when a nurse injected him with 10 times the amount of morphine a doctor prescribed. The 86-year-old Cashman, who had survived a German prisoner of war camp, died 10 hours later.
A doctor working at the vets’ home said it was unlikely the overdose led to Cashman’s death. He had prostate cancer and Alzheimer’s disease. But there was no way of knowing for certain. His body was released to a funeral home so quickly that the medical examiner never had a chance to examine the body.
“The little nurse who was taking care of Dick that night tried to be so on the ball,” Dick Cashman’s widow, Virginia, recalled. “I don’t know what happened. Something unfortunate.”
The home was faulted for the medication error and the home’s failure to report Cashman’s death to the medical examiner following a significant medication error.
In the Cashman case, the state veterans affairs department said it “was deeply saddened by the loss of life in 2011” and said it immediately self-reported the incident to the state Health Department and federal VA officials.
After the incident, the home revised its medication policy, including retraining and a new requirement that two nurses check every medication dosage calculation.
In the other cases, the VA office said it took action to identify areas of improvement even though the findings were inconclusive.
“Often what we do and the changes we implement go above and beyond what the Department of Health or the federal Department of Veterans Affairs recommends. We view this as a method to continuously improve our health care delivery system,” the state veterans office said in a statement.
Mistakes harder to find
Even if any of the families wanted to file a complaint or sue, it would have been difficult. Officials and advocates say it is getting harder to do.
Family members frequently have not been informed that a loved one’s death triggered an investigation, a policy that only recently changed. The Department of Health’s public reports of investigations do not include names.
More recently, the department stopped including the date of the incident in its reports. The director of the Office of Health Facility Complaints said it dropped the dates to protect vulnerable subjects and their families.
“We discovered that the public would use the incident date and back into a police report,” the director, Stella French, wrote in an e-mailed response to an inquiry by the Star Tribune.