State: Minneapolis Veterans Home blamed for resident's fatal overdose

A 61-year-old resident of the Minneapolis Veterans Home obtained illicit doses of methadone last year and died of a subsequent overdose, according to state investigators who have cited the home for negligent care.

The resident, identified by relatives as Gerald Bain, was found dead in his room on Feb. 15, 2012, along with empty and unlabeled medication bottles.

Bain, an Air Force veteran from the Vietnam era, was also an employee of the home and was a popular fixture at its coffee shop. Bain suffered from chronic back pain, according to his mother, Elaine Bain, who said his back "was killing him all the time."

A state Health Department investigation released this week found that staff members failed to monitor Bain's pain-management needs adequately. An autopsy found that he died of acute methadone toxicity.

The incident reopens questions about patient care and management of the Minneapolis home, which was opened in 1887 for Civil War veterans. The home was cited a decade ago for multiple cases of medical errors and abusive and demeaning treatment of residents. In 2007, Gov. Tim Pawlenty moved authority for the system of five state-owned veterans homes from an independent board to the state Department of Veterans Affairs, with oversight from a new health care advisory council.

In late 2011, the state's supervisor for nursing home inspections concluded that the Minneapolis home had made dramatic improvements in resident care.

In a statement issued Thursday, Michael Gallucci, deputy commissioner of veterans health care, said the home was taking steps to address the case.

Advisory council member Dennis Johnson, who was appointed by Gov. Mark Dayton last year, said that he could not comment on the latest investigation but that he believes the veterans home system had made improvements.

"A lot of those concerns have been addressed and my sense is that things are operating pretty smoothly," Johnson said. "Of course, there are always things that come up when you are dealing with health care and seniors. Things happen from time to time, but my sense is that it is substantially better than it was five, six, seven years ago."

In the report released this week, investigators concluded that the home's staff found on Feb. 10, 2012, that Bain was not taking his anti-anxiety medication, was taking too much of a prescribed painkiller and also that he had numerous unprescribed medications in his room.

Despite these irregularities, the home's staff failed to reassess his ability to take medication on his own, the report added. Five days later, he overdosed and died.

Veterans Affairs spokeswoman Anna Long explained that he lived under the home's domiciliary program, which allowed for a "more independent" life than most others at the residence. The home's 50 domiciliary residents can come and go as they please and have other freedoms, Long said. Skilled nursing care is given to the facility's other 341 residents, she said.

Elaine Bain said that her son moved into the home 10 years before his death and that he began working at the coffee shop right away.

"The women volunteers thought the world of him," she said. "I think he sneaked them a cup of coffee every now and then."

Elaine Bain said she had just received a valentine in the mail from her son and was planning to call him that day to thank him for the gesture.

"I sure miss him," she said. "He used to call every morning. I still wait for that phone to ring."

Staff writer Mark Brunswick contributed to this story.