Questions about how Bruce Diersen died while in the state's care have cast more glare on an already troubled agency.
State authorities have opened two investigations into the sudden death in September of a developmentally disabled man living in a state-operated group home in Bloomington.
The death of Bruce D. Diersen, 54, has raised new questions about a troubled division at the state Department of Human Services responsible for thousands of disabled and vulnerable adults. The division's initial review of Diersen's case was so incomplete and poorly executed that top department officials ordered a second inquiry, according to sources with direct knowledge of the investigation.
A separate investigation is being conducted by the state Department of Health.
Investigators are reviewing whether the facility's staff properly administered Diersen's medications and whether CPR was administered when he was found not breathing early on Sept. 17, the morning of his death. An aide had checked on him less than three hours earlier, and Diersen was breathing at that point, according to Bloomington police records.
Diersen's case highlights the heightened level of scrutiny ordered by Human Services Commissioner Lucinda Jesson in the wake of a bathtub drowning last August at a state-operated group home in Braham, Minn. Jesson has said such breakdowns in care are unacceptable and ordered that every death at an agency facility receive a thorough inquiry.
"We are now reviewing every death," Deputy Human Services Commissioner Anne Barry said last week. "There was a period of time where we didn't review every single death. We now are.''
Whether different care could have prevented Diersen's death is unclear. Diersen, who had Down syndrome, bipolar disorder and other mental health diagnoses, suffered from a serious respiratory ailment identified two weeks before he died. A doctor had prescribed cough syrup and a nebulizer inhalant to help ease his breathing, which had become particularly difficult at night, family members said.
An aide at the facility, Bloomington ICF, told police he last administered nebulizer medication at 4 on the Saturday morning of Diersen's death. But family members were later told by an employee of the home that there were questions about whether it was done properly.
Diersen's relatives say they were also told by the staff member that CPR procedures were not followed the morning Diersen died. Siblings said the medical examiner determined their brother died from a severe case of pneumonia, but his family is still left with nagging questions.
"It's very disheartening," said Leona Simonett, a sister and co-guardian. "We will never know. Maybe the outcome would have been the same, because he did have strep pneumonia. But if those two things could have saved his life. ... If wishes would be true that's what we would wish for."
A week before his death, Diersen appeared relatively healthy and attended a wedding, his family said. Simonett said family members live with questions about whether they should have taken him for a follow-up doctor visit; they didn't because he showed few signs of illness apart from congestion and coughing.
"We fault ourselves because we didn't take him in," his sister said.
String of incidents
The Diersen investigation is the latest in a string of cases to raise questions about management and care provided by the State Operated Services (SOS) division in the past six months. An investigation into the drowning death in Braham last August found that an employee neglected a developmentally disabled resident by leaving him alone in a bathtub full of water for nearly 40 minutes, but the investigation also was critical of the division for the way it conducted an internal review.
Then, in September, a van driver working for the SOS division was arrested in Crow Wing County for driving while intoxicated after transporting a developmentally disabled client on a harrowing, high-speed ride. It was later determined that the driver had a history of speeding violations before he was hired.
In December, the Minnesota Security Hospital in St. Peter was placed on two years' probation and fined by the agency's licensing regulators after investigators found patient abuse that occurred in 2010. And earlier this week, the Star Tribune reported about a drug smuggling conspiracy inside the division's locked drug treatment center in Fergus Falls.
Jesson has expressed serious concerns about those events and recently directed Barry -- a former state health commissioner -- to take command of the division and overhaul it. Part of Barry's charge is to improve death reviews.
"I know how frustrated the family must be," Barry said. "I completely understand their frustration with not having answers to questions they have."
Staff writer Paul McEnroe contributed to this report. Brad Schrade • 612-673-4777