Even when her children arrived with flowers or her favorite dessert, she did not respond. Or she would suddenly sit bolt upright, asking if her door and windows were shut.
This summer, nearly a year after Krause died, the family finally solved the mystery of her strange behavior. Late one night in May 2016, Krause, who was 78 and suffered from dementia, was sexually assaulted in her bed by a male nurse’s aide who appeared to be changing her underwear.
No one — not the senior home, police or state investigators — told the family.
“It haunts me, it haunts me, it haunts me … that my mother suffered and we could do nothing to help her,” said Robert Krause, 60, of Pequot Lakes, Minn.
The tragic case tells a larger story of anguish unfolding across Minnesota.
Every year, hundreds of
residents at senior care centers around the state are assaulted, raped
or robbed in crimes that leave lasting trauma and pain for the victims
and their families. Yet the vast majority of these crimes are never
resolved, and the perpetrators never punished, because state regulators
lack the staff and expertise to investigate them. And thousands of
complaints are simply ignored.
State records examined by the Star Tribune show the scale of the failure.
Last year alone, the
Minnesota Department of Health received 25,226 allegations of neglect,
physical abuse, unexplained serious injuries, and thefts in
state-licensed homes for the elderly.
Ninety-seven percent were never investigated.
That includes 2,025
allegations of physical or emotional abuse by staff, 4,100 reports of
altercations between residents and 300 reported drug thefts.
When the Health Department did investigate,
records show that it often neglected key steps in a criminal probe. In
dozens of those cases, for instance, no one interviewed the victim and
no one called the police.
Health Department documents
contain dire tales of residents being choked, punched, smothered with
pillows, fondled and forcibly restrained. At a nursing home in New Hope,
an 85-year-old patient with dementia was repeatedly struck in the face
and stomach over a span of months while other employees watched. At a
care home in Crookston, an angry staff member lifted a female patient
off her feet and threw her several feet to a bed, while calling her an
“old hag.” In Sartell, two nursing home employees witnessed a fellow
worker sexually molesting a patient; they did nothing and the worker
molested two more patients. And in Isanti County, an elderly woman with
dementia was placed in solitary confinement for seven hours, in a frigid
room with no lighting.
“We are putting up with a
level of criminality in senior facilities that would be unthinkable in
any other setting,” said Amy Sweasy, an assistant Hennepin County
attorney who handles elder abuse cases.
The state Health Department
has broad authority to intervene in such cases. It can order corrective
measures such as better training for staff, impose fines, or even revoke
a facility’s license and shut it down. The department is also required under state law to notify prosecuting authorities when it finds evidence of criminal abuse.
That system routinely breaks down, records show.
Investigations drag on for
months. Fines go uncollected. Resident-on-resident abuse is often
ignored, if reported at all. And prosecutors say they typically don’t
learn of state investigations until months after the abuse occurred,
which makes criminal charges difficult, and at times impossible.
Families of victims are
furious. They complain that the state will not tell them what
investigators have discovered about their cases. Sometimes, they say,
the state does not even notify them that an investigation is underway.
Some families also have found that when they report their concerns
directly to the facility’s owner or other residents, their loved ones
have been threatened with immediate eviction.
The result is that many of
the 85,000 Minnesotans who live in state-licensed homes for seniors are
denied equal access to the criminal justice system.
“It’s painful to think about how many of
these criminals are getting off the hook because we’re sending these
cases down an administrative black hole,” said Nancy Fitzsimons, a
professor at Minnesota State University, Mankato, who leads a state
committee on abuse and neglect of vulnerable adults. “We, as a state,
must recognize that these are crimes and they need to be treated as
crimes.”
Even executives in the
senior care industry fault the Health Department for its ineffective
response. They say facilities are deprived of vital information that
would enable them to make essential fixes, such as firing abusive
caregivers or increasing supervision.
Senior officials with the
Health Department acknowledge that the state’s inability to investigate
most abuse allegations has far-reaching consequences for resident safety
and care.
“The situation,” said Gil Acevedo, assistant health commissioner, “is no longer tenable.”
The volume of abuse
allegations reflects rapid growth in Minnesota’s elder care industry.
The state now licenses nearly 1,800 residential senior care facilities,
including hundreds of homes that provide specialized care for seniors
with dementia. Minnesota spends more than $1 billion annually in
Medicaid funds for senior care, in addition to tens of millions of
dollars paid by families. Both figures are likely to climb as
Minnesota’s population ages.
The industry is also
evolving in ways that are invisible to the public and difficult to
regulate. More elderly Minnesotans are opting against traditional
nursing homes and choosing to live their final years in
less-institutional settings known as assisted-living facilities, which
offer greater informality and independence.
The number of Minnesotans in
assisted-living facilities has doubled over the past decade, to nearly
60,000, while the nursing home population has receded to less than
30,000.
Seniors in assisted-living
centers are generally older, sicker and more volatile psychologically
than in past years, making them more vulnerable to criminal abuse. But
these facilities operate with much lighter state regulation than nursing
homes. For instance, they are not required to maintain minimum staffing
ratios, and they have fewer consumer protections, such as rules
preventing arbitrary evictions.
These industry shifts have
put Minnesota at risk of falling permanently behind the soaring number
of abuse allegations, warned Iris Freeman, board member of the Minnesota
Elder Justice Center and adjunct professor at the Mitchell Hamline
School of Law.
“We should all be appalled
by this picture,” Freeman said. “Minnesota used to be at the top of the
heap when it came to elder abuse enforcement, and now we’re becoming
known for being nonresponsive.”
‘It haunts me, it haunts me, it haunts me’ Robert
Krause, surrounded by family, sobbed outside the courthouse in July as
he heard that his mother's attacker had pleaded guilty to sexual
assault. The family didn't know about the attack until nearly a year
after she died.
Robert Krause wakes up every morning to the memory of his dead mother.
Portraits of Jean Krause
adorn nearly every wall and cabinet of his living room on the outskirts
of Pequot Lakes in north central Minnesota. In many of the photos,
Jean’s long blonde hair is tucked beneath the nurse’s cap that was part
of her working uniform for most of her adult life.
One morning last summer, he
received an unexpected phone call from a Crow Wing County assistant
attorney, Janine LePage, who calmly informed Krause about “an important
situation” involving his mother. Nearly a year had passed since her
death. Krause suspected that LePage was calling about some minor dispute
involving her estate.
He never expected to hear the words “sexual assault.”
About 9 p.m. on May 8, 2016,
Jean Krause was found curled up in a fetal position, naked below her
waist, in her bed at the Heritage House assisted-living complex in
Pequot Lakes, court records show. Just a few feet away, a male
caregiver, David DeLong, who was 59, stood sweating and breathing
heavily, with his jeans and underwear at his knees, according to an
eyewitness account described in a criminal complaint. When a female aide
spotted DeLong, he began awkwardly trying to pull up his pants and
underwear, the witness recalled.
Supervisors at Heritage
House waited nearly two hours after the assault before calling police,
and only did so after sending DeLong home for the night, according to
the police and a criminal complaint. Later, investigators discovered
that two crucial pieces of evidence — Krause’s red nightgown and
mattress pad — had been placed in the facility’s washing machine,
possibly by DeLong, police and prosecutors say.
“It’s infuriating,” Pequot
Lakes Police Chief Eric Klang said of the facility’s handling of the
case. “We had an eyewitness to a sexual assault of a frail woman with
dementia, and the perpetrator was kept there and sent home without
calling us. That’s not proper protocol.”
DeLong was never taken into
custody by local police, and insisted on his innocence until detectives
found DNA on the victim’s body that matched his. Months later, even
DeLong wondered why he was sent home on the night of the assault and not
treated more like a criminal.
“Why didn’t the people who saw me do it arrest me on the spot that night?” he asked, speaking from his home in Pine River, Minn.
After the police arrived,
Jean Krause was sent to the hospital for a sexual assault exam. When she
returned, Heritage House staff sent her back to the same room where
just hours earlier she had been attacked, police and family members
said.
In an interview with the
Star Tribune, the owner of Heritage House said staff “acted properly” in
sending DeLong home and then contacting police that night. She declined
to discuss the family’s complaint that no one contacted them about the
sexual assault.
“We are just very thankful
that it was caught and reported and is going through the judicial
system, and people can feel that some justice is done,” said Kathy
Birchem, the facility owner.
LePage, the Crow Wing County
prosecutor, said the facility’s “blatant tampering” with the crime
scene the night of the attack made it harder to prosecute DeLong. By
cleaning up the victim and her bed, the facility compromised crucial
physical evidence, making a serious charge difficult to prove, she said.
The failure to inform family
of the assault was another setback, because relatives often play a
major role in pressing for tougher sentences, she said.
DeLong eventually pleaded
guilty to one count of fourth-degree criminal sexual conduct, which
involves force or coercion, in a negotiated deal that is common when
prosecutors lack strong physical evidence. He agreed to a sentence of
one year in jail and 10 years’ probation.
In September, following Star
Tribune inquiries into its regulatory history, Heritage House
surrendered licenses for three of its properties under pressure from the
state Health Department. It was just the second time in four years that
a senior facility has surrendered its state license.
LePage said she sometimes
wonders whether the outcome would have been different had the victim
been a young girl instead of a 78-year-old woman who was unable to
speak.
“If it was an 8-year-old
girl, maybe someone would have rushed in and grabbed the girl, tried to
protect her in some way,” she said. “A protective instinct might kick in
that didn’t occur here.”
Robert Krause said he never would have let his mother stay at the facility had he known about the assault.
“How do you live with yourself knowing that your mother suffered but you did nothing to help?” said Krause, sobbing.
The Health
Department took four months to investigate the incident and then cleared
Heritage House of any wrongdoing. State investigators reached that
conclusion without interviewing Jean Krause or any of her family. The department’s final report made
no mention of the fact that Heritage House staff waited to report the
crime, even though state and federal law requires the immediate
reporting of maltreatment in state-licensed senior care facilities.
The state’s failure to issue
discipline in such incidents is the rule rather than the exception,
according to records reviewed by the Star Tribune. Even when the state
substantiates abuse, it frequently blames an individual employee, not a
breakdown in the facility’s management. The state has revoked the
licenses of only two senior care homes in the past five years.
“Our current staff is really
cracking under the pressure of our current caseload,” said Deputy
Health Commissioner Daniel Pollock, in testimony this spring before
lawmakers, who approved a small increase in the agency’s investigative
budget.
Given the high volume of
allegations filed each year, the department uses a triage system to sift
through complaints and investigate the most serious cases first. Yet
for two consecutive years, federal auditors from the Centers for
Medicare and Medicaid Services (CMS) have cited Minnesota for
incorrectly categorizing complaints as non-urgent, even when they
involved severe abuse. The agency also failed to notify victims of their
findings, the auditors said.
In recent audits obtained by
the Star Tribune through public-records requests, CMS uncovered nearly
two dozen allegations of serious harm and criminal abuse that were
received but never investigated by the Health Department.
In one case, the state
failed to respond to four separate reports of sexual abuse from a
nursing home patient in Duluth. In another case, a nursing home resident
had an unexplained black eye, a fractured foot and gangrene, but health
officials categorized the complaint as nonserious. In another, a
perpetrator confessed taking medications from patients in a nursing
home, yet the state still categorized the complaint as not requiring an
immediate investigation.
Minnesota’s
Department of Health has won accolades over the years for promoting
public health and investigating disease outbreaks. But the agency has
never put a high priority on fighting crime, advocacy groups for seniors
say.
Of the 27 Health Department staff who
investigate abuse and neglect at state-licensed senior facilities, only
one has a forensic background as a criminal investigator, agency
officials said. The others are registered nurses with backgrounds as
caregivers. The agency said it plans to hire three more investigators
with forensic experience by year’s end.
“We are overburdening a
state agency that was never designed to investigate criminal behavior,”
said Suzanne Scheller, a Champlin attorney and founder of Elder Voice
Family Advocates, a group of Minnesota families advocating for better
care for seniors.
To assess the state’s
handling of serious allegations of abuse, the Star Tribune reviewed a
sample of 300 investigations completed by the Health Department since
2014. They show that its inspectors failed to interview victims in
roughly half the cases and failed to notify police in nearly 40 percent.
Only a fraction of the cases ever reached a prosecutor’s desk,
according to county prosecutors interviewed by the Star Tribune.
In addition, completed
investigations are removed from the agency’s website every three years,
making it difficult for families to assess a facility’s safety record.
In 2011, concern over a
surge in elder abuse allegations led Minnesota lawmakers to pass new
criminal penalties, including prison time, for caregivers who
intentionally neglect seniors under their care. Yet on average, fewer
than 70 people are convicted each year under Minnesota’s vulnerable
adult statute — most of them for financial crimes, not physical abuse.
At the Star Tribune’s
request, a group of public prosecutors reviewed the 300 completed
investigation reports. These attorneys, including prosecutors from
Hennepin, Ramsey and Anoka counties, estimated that about one-third of
the incidents had enough evidence of criminal wrongdoing to warrant
charges or a formal criminal investigation.
“It’s a huge area of concern
that we’re not seeing these [elder abuse] cases reach our desk, because
the vulnerability of this population is huge,” said Tara Patet, senior
prosecutor in the St. Paul city attorney’s office. “We have to treat
elder abuse as the crime that it is, or otherwise it will keep
happening.”
Prosecutors also said the
investigations included dozens of suspicious deaths that warranted
forensic investigations but had not been treated as crimes.
In early 2015, for instance,
nurses at a facility in Bloomington watched and did nothing as an
elderly woman with neurological problems fell four times over three
days, and eventually died of a catastrophic brain injury. Multiple
nurses were aware of the patient’s injuries, yet they never called her
doctor, inspectors found.
In another case, in northern
St. Louis County, a woman with Alzheimer’s disease was found lying face
down in a pool of blood outside her nursing home. The woman had
unexplained facial fractures and died two days later in May 2016, state
records show.
And early this year, a
resident at an assisted-living facility in Maple Grove died from blunt
force injuries five days after being found at the bottom of a stairwell,
bleeding.
Prosecutors said that such
suspicious incidents would probably be investigated as crimes if they
occurred in a person’s home or other community setting. But because they
occurred in a state-licensed senior facility, they are routed through
the Health Department, where nurses with little or no training in law
enforcement review them as cases of medical neglect.
“Some of these cases would
be a prosecutor’s layup, but they never get to our desk,” said Sweasy,
the assistant Hennepin County district attorney.
She added, “If there was a
3-year-old child left standing in the middle of a busy intersection, we
would all rush to hold someone accountable. But if an 80-year-old is
physically or emotionally abused in a nursing home, then no one even
knows what to do.”
Officials with the Health Department say they are taking steps to respond more quickly to allegations of harm.
Over the past year, the
agency has streamlined its system for receiving and processing
complaints, eliminating unnecessary paperwork. As a result, it can now
launch a formal investigation within days after receiving a report of
abuse. Previously, it took the agency weeks or months just to assign a
case to investigators. In the coming year, the department will begin
discussions with city and county prosecutors on improving the flow of
cases and evidence. Currently, the agency shares details of its
investigations only when they are completed, which can be too late for
prosecutors to file charges.
“We feel very strongly that
every citizen out there deserves at least an acknowledgment that we’re
doing something, that we’re on the case,” said Acevedo, the deputy
health commissioner. “When someone files a complaint with us … we owe it
to the families to let them know that we take these allegations
seriously.”
Representatives of the
senior care industry are urging the state to be more transparent about
its investigations. Currently, the state collects data on categories of
abuse, such as drug thefts and resident-to-resident altercations, but
not on the types of facilities where they occur and who is targeted.
Industry representatives are
also seeking more consistency in the handling of abuse allegations.
Nursing homes, for instance, must submit written action plans to correct
violations, while assisted-living and home care providers do not.
“Frankly, we have a great
opportunity to address problems that have built up for decades,” said
Patti Cullen, president and chief executive of Care Providers of
Minnesota, an association that represents the senior care industry. “If
you keep throwing money at an agency that has systemic issues, then
you’re not getting at the root cause of why there are so many delays and
problems that are not getting fixed.”
Earlier this
year, a painful and mysterious affliction spread through Goldfinch
Estates, a spacious seniors’ complex that overlooks cornfields near
Fairmont, Minn.
Longtime residents
complained of nonstop pain, fatigue and loss of appetite. Normally
outgoing men and women suddenly were bedridden, too weak to participate
in the facility’s many group activities, from bake sales to games of gin
rummy. At least two residents were hospitalized.
Months passed before a
pharmacist discovered the cause. A nurse’s aide had been stealing full
containers of painkillers from medication carts, then hiding the thefts
by swapping them out with caffeine pills and other over-the-counter
drugs. In the days following the discovery, more than a half-dozen
residents came forward and complained of near-debilitating pain. They
demanded an investigation.
The employee accused of
taking the painkillers, Jennifer Ann Kiewiet, 28, was eventually charged
with theft, drug possession and mistreatment of residents. She died of
an apparent drug overdose just weeks before a scheduled court hearing,
and the Martin County attorney’s office closed the criminal
investigation.
To the frustration of
residents of Goldfinch Estates, that seemed to end the matter. At least
three residents told the Star Tribune that they filed formal complaints
with the Health Department. They hoped the state would uncover how
Kiewiet was able to steal the medications for so long, and order
Goldfinch to take steps to ensure it would not happen again.
While the agency launched a
formal investigation, residents said they have not been interviewed
since the thefts were uncovered nine months ago.
Meanwhile, Goldfinch Estates
sent every resident a short form letter asserting that, to the
facility’s knowledge, “no resident” was “negatively harmed” by the
incident.
“All I could do, night after
night, was pray to God to let me die, and they try to claim that no one
was even harmed?” said Delores Holz, 83, who estimates that she went
three months without painkillers for her chronic arthritis. “It’s like
we’re invisible.”
Elaine Cottew, 90, said she
found the letter “insulting.” She waved it with anger as she described
the agony of going without her pain medications.
“What do you mean, I wasn’t
harmed?” she said, her voice rising. “I was lying around like a zombie
for weeks … Of course I was harmed. We all were.”
Finally, last spring, about a
dozen residents and family members gathered in the ornate lobby of
Goldfinch Estates and demanded to speak with facility management about
the drug thefts. An administrator declined to meet with the group,
saying the issue was already handled, residents said.
“Residents just wanted some
assurance that it wouldn’t happen again, and they were just brushed
aside like little children,” said Gary Ricard, whose 91-year-old mother
lives at the facility. “The arrogance really upset people.”
Calvin Diekmann, executive
director of Goldfinch Estates, said in an interview that the facility
has taken steps to prevent another incident of residents receiving the
wrong medications. Before pills are administered, he said, staff are now
provided with a physical description of each drug to prevent mistakes.
Diekmann said he is still
not aware of anyone who had been harmed by the drug thefts. “I’ve never
gotten a doctor’s report saying that” a resident was hurt, he said.
Even as the
population of elderly Americans receiving long-term care has risen to
more than 8 million nationally, state and federal budgets for combating
elder abuse have declined slightly over the past five years.
Funding isn’t the only
challenge: A study by the National Institute of Justice found that the
older the victim of sexual abuse, the less likely it is that the
offender will actually be convicted. Investigators are also less likely
to believe older people if there is no physical evidence of abuse,
researchers found.
The surge in incidents of unchecked abuse has profound consequences for public health. A study published early this year
by two University of Chicago sociologists found that elder maltreatment
leads to significant declines in health, including greater anxiety,
feelings of loneliness and increased susceptibility to disease.
Lori Smetanka, executive
director of the Washington-based National Consumer Voice for Quality
Long-Term Care, said awareness of elder abuse is still decades behind
movements to stamp out domestic violence and child abuse. “We hear
regularly from families across the country, that any complaint they file
involving a [senior] facility goes down a black hole,” she said.
“Across the country, investigations are not happening in anywhere near
the numbers that they should.”
Nearly a year has passed since Marjory Aldrich’s encounter with an abusive nurse.
Aldrich, 80, was recovering
from pneumonia at a nursing home in New Hope and says she became
frightened when the facility stopped giving her antibiotics.
She said she could feel
fluid building up again in her lungs, and asked an aide about resuming
her medications. When she got no response, she asked that a nurse call a
doctor to renew her prescription. She said the nurse reacted by
slamming a phone against her chest so hard that she nearly passed out.
“I laid there for 20 minutes, too petrified to move,” she said.
A day later, Aldrich reported the incident to the Health Department, thinking someone would come to interview her.
No investigator came.
She called the agency three times to check on the status of her report.
No investigator returned her calls.
Last month, Aldrich received
a letter from the Health Department informing her that the state’s
investigation into her case had been delayed until later this year.
From her mobile home west of
the Twin Cities, Aldrich now wonders why she bothered to call the state
agency instead of 911 or local police.
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