A finding of maltreatment was dropped after nursing home appealed.
Kenneth Gall's quest for closure on his mother's death has been a trip to official limbo.
After months of investigation, the Minnesota Office of Health Facility Complaints (OHFC) said in January that Gall's mother, a resident of an Arden Hills nursing home who sustained a serious neck fracture, had been maltreated.
That news was gratifying to Gall, whose 91-year-old mother, Gladys Gall, died about two weeks after a mysterious incident at Presbyterian Homes of Arden Hills left her with what is known as a hangman's fracture. A neurosurgeon told state investigators the April 2008 injury could only be caused by severe trauma.
"We were hoping that we could resolve something,'' Gall said. "We hoped that someone else would not have to go through what we went through."
But in May, the OHFC revised its finding after the nursing home appealed the initial decision. The evidence did show severe trauma, the OHFC said, but there was no evidence showing that the trauma had been the result of maltreatment. The OHFC changed its determination from substantiated to inconclusive.
"I was very disappointed," Gall said. "I wanted to see behind that veil to get at what actually happened."
Gall was back where he had been shortly after his mother's death, when a nurse hired by the nursing home to investigate the case told him that his mother had fallen on her own, injured her neck and then got herself back to bed.
Three different times, Gall said, the nurse pressed him to accept that version of events. "We almost had to throw him out of the house. He was very adamant in trying to make us think that was what happened," Gall said.
The suggestion that his mother got up on her own didn't make any sense to Gall. For 10 years, he had seen how osteoporosis made it difficult for his mother to do even the most common things.
"She couldn't get up on her own, couldn't stand on her own," he said. "It took all that she had to sit up in bed."
One nursing home employee told an OHFC investigator that Gladys Gall would not have been able to get back into bed if she had fallen. Although she shared a room with her husband, he didn't have the strength to help her either, the employee told investigators.
Unfortunately, Gladys Gall, who survived for about two weeks after the neck fracture, couldn't provide an answer because she had dementia.
The nursing home conducted a thorough investigation but could not determine the cause of the injury, said Traci Beach, director of operations for Presbyterian Homes Management & Services, the home's parent company. Some employees provided the OHFC with ideas about how the trauma occurred, which Beach characterized as speculation.
"We do not know if in fact she fell," Beach said.
After his mother died, Gall moved his father out of the nursing home.
It cost the couple about $13,000 a month to stay at the facility, money that came from a lifetime of saving by Gall's father, an auto mechanic, and his mother, a surgical nurse.
Gall's trust in the system was shaken. "With no closure, everything is up in the air," he said. "I don't think we've gone into the grieving process over my mother's death yet."