The hot
line has produced a surge in maltreatment complaints that far exceeds
the investigative resources of the Minnesota Department of Health. As a
result, thousands of injuries, assaults, thefts and medical errors
alleged by friends and relatives are going uninvestigated — depriving
families and facility managers of vital evidence that could be used to
improve care.
Health
investigators have fallen so far behind that Minnesota is running afoul
of state and federal laws requiring prompt reviews. Abuse victims and
their families are now waiting an average of six months for the Health
Department to complete investigations, which is three times the 60-day
deadline mandated under the Minnesota Vulnerable Adults Act.
In 85 percent of the cases, the agency is failing to complete its
investigations within statutory time frames, state data shows.
“We feel
this is not acceptable,” Gilbert Acevedo, assistant state health
commissioner, said in an interview last week. “We want to resolve these
cases in a timely fashion and get answers. A lot of times family members
are left not knowing ... what truly happened.”
Whether
the surge reflects an actual increase in abuse and neglect incidents or
just more vigilant reporting by family and friends is unclear. State
health officials said it stems from a combination of factors, including
greater awareness of abuse, a shortage of caregivers, and reforms that
make it easier for victims to report maltreatment.
In July 2015, the state and counties began promoting a single, centralized hot line
for maltreatment reporting, replacing a county-based response system
long criticized as unwieldy and inefficient. Since 2010, the Health
Department has seen a sevenfold increase in maltreatment allegations,
from less than 500 to nearly 3,500.
But
regulators have been caught unprepared. In the last fiscal year,
complaints that were not investigated included 4,031
resident-to-resident altercations, 2,867 unexplained injuries, 963
incidents of abuse by staff and 341 unexplained fractures, state records
show. Only 10 percent of complaints involving state-licensed health
facilities are being investigated onsite, down from 73 percent in 2010.
To speed up investigations, Gov. Mark Dayton is seeking millions of dollars in new state funding in his proposed budget,
as well as higher fees from licensed facilities, to hire inspectors and
complete more investigations within statutory deadlines. “We can’t keep
up with the volume,” Acevedo said.
But some
elder care advocates say more funding will not overcome long-standing
shortcomings in the way reports are handled. They are calling for more
fundamental reforms, including regular engagement with victims’ families
and the referral of more cases to criminal justice authorities rather
than social service agencies.
“The
vulnerable adults reporting system in this state is broken and you can’t
fix it by throwing more money at the problem,” said Nancy Fitzsimons, a
professor of social work at Minnesota State University in Mankato.
“We’re not really holding people accountable in this state.”
Minnesota’s
adult abuse response system had problems even before the launch of the
hot line. A 2015 regulatory review by the U.S. Centers for Medicare and
Medicaid Services (CMS) found that the Health Department failed to meet
minimum federal standards for conducting investigations of nursing home
complaints. CMS found more than two dozen cases in which the state
agency determined no onsite investigation was necessary even after
nursing home residents complained of serious maltreatment, including
physical and sexual abuse.
In one
case, allegations involved a nursing home resident with an unexplained
black eye, a fractured foot, gangrene, lack of food and dehydration —
yet state investigators determined that no onsite investigation was
necessary. In another case, a person was found in soiled underwear on
the floor with a yeast infection, yet officials determined it was an
“isolated event” and again did not investigate onsite. Another person
alleged sexual, emotional and physical abuse, when staff threatened him
and “inappropriately handled his testicles.”
CMS
reviewed a sample of 40 alleged maltreatment cases, and found that the
department violated federal guidelines in 25, records show.
“It’s
incomprehensible the number of cases that involve blatant criminal
behavior where the Department of Health says, ‘No big deal,’ and the
perpetrators are not held accountable,” said Mark Kosieradzki, a
Plymouth attorney who specializes in elder abuse cases.
Since that
review, the Health Department has revamped its process for prioritizing
and tracking maltreatment complaints. The changes included hiring new
staff, including medical professionals, and requiring that supervisors
review all complaints identified as not requiring onsite investigations.
The agency also created a process for investigating outstanding
complaints as part of scheduled, onsite visits of health facilities.
After a
follow-up survey last year, CMS notified the department that it has
“shown great progress” in meeting federal guidelines.
“We take
all allegations seriously, but our resource limitations mean we have to
focus our investigators’ time on the most serious ones,” said department
spokesman Scott Smith.
Still, for many families, the long waits for completed investigations prolong the anguish of losing a loved one.
Kevin
Passmore, 40, of St. Paul, said staff at a Twin Cities-area nursing home
failed to provide proper medical care after his mother fell out of her
wheelchair last August. Instead of checking her vital signs, they
wheeled her to the home’s dining room, where she died hours later of a
heart attack, Passmore said. “My mom would still be here today had they
sought immediate medical attention,” after the fall, Passmore said.
But nearly
six months have passed since the incident, and the investigation
remains incomplete. Passmore said he has received three official letters
from the agency, each one notifying him that the investigation has been
delayed and the results would be pushed back. “I’m on pins and
needles,” he said. “Every day I wake up and I wonder what the outcome
will be. I can’t move on with my life.”
Lorri
Solyst Terpeney, 60, of Apple Valley, is still perplexed by the state’s
investigation into her mother’s death. In October 2014, a nurse at St.
Mark’s Lutheran Home in Austin placed patches containing the narcotic
Fentanyl on her mother Alvera Solyst’s body without ensuring that the
old patches had been removed. The excessive patches were not discovered
until Solyst became unresponsive, and she died three days later of heart
failure from the overdose. It was later found that St. Mark’s had an
emergency supply of Narcan, an antidote for overdoses, but it was never
used.
Just weeks
earlier, Solyst had been in high spirits, putting on her best makeup
and jewelry, for lunch with family at a restaurant in Austin. “To find
mom lying there in intensive care, unresponsive, I nearly fainted from
the shock,” Terpeney said. “They were pulling off the patches in the ER
and all I could think was, `How could anyone in their right mind let
that happen’?”
After she
filed a complaint, Terpeney said, it took state investigators more than
four months to interview her and the nurse involved. When the state
finally issued its findings — eight months after Solyst’s death — the
agency found no evidence of neglect or any other wrongdoing. A spokesman
for St. Mark’s declined to comment on the incident, but pointed to the
state’s findings of no neglect.
Terpeney
and her attorney recently asked the state to reconsider its conclusion,
based on new court testimony pointing to other problems at St. Mark’s,
but was told that she missed the statutory deadline for making such a
request. She called the denial “hypocritical,” noting that the agency
did not issue its own investigation report until nearly six months after
the statutory deadline.
“My mom
was not ready to die,” said Terpeney, who teared up as she flipped
through photos of her mother. “Until someone is held responsible,
preventable deaths like this will keep happening.”
Full Article & Source:
Minnesota health regulators can't keep up with abuse reports
