INVESTIGATION: Minnesota Failing to Investigate Nursing Home Complaints on Time

December 07, 2016 12:11 PM

Minnesota Department of Health investigators are failing to check a majority of maltreatment complaints filed at nursing homes, care facilities, and hospitals under the timeframe established by Minnesota law, according to public records.

In the last five years, state records show 60 percent to 84 percent of total complaints for maltreatment, neglect, and financial exploitation investigations by the health department were not finished under the 60-day timeframe established by the Minnesota Vulnerable Adults Act.


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“It doesn't feel good to see these numbers are real actual people," Assistant Health Commissioner Gil Acevedo said. “I actually understand the frustration the family members experience, with the length of time it's taking us."

State law does allow the state agency to pick a new date and try to finish it by then; Acevedo said complex cases require more time to thoroughly review.

"We're looking at our intake process, to do better case management, so we're more efficient," Acevedo said.

MDH said later in an email to 5 EYEWITNESS NEWS, “We understand the frustration families are feeling with the process, and we agree that MDH should complete these investigations in less time. As Minnesota has seen a dramatic increase in maltreatment allegations, we are taking steps to improve our processes, better communicate with families, and match resources to the growing demand.”

5 EYEWITNESS NEWS assembled completed investigative reports from available data from the Minnesota Department of Health to create this map of substantiated, inconclusive, and unsubstantiated complaints for nursing homes in the metro area.

One particular case, it took state investigators almost eight months to complete the investigation.

Alvera Solyst died in part due to inadvertent fentanyl intoxication, according to her death certificate from October 2014. At the time, she was residing at St. Mark’s Lutheran Home in Austin. 

"I trusted those people like they were my second family," her daughter, Lorri Solyst Terpeney, said. "I was just devastated and in shock when I found out what had happened."

State records show a caregiver failed to ensure old fentanyl patches were removed from her before applying new ones.

Fentanyl is the same opioid pain medication that Prince overdosed on. Experts say patches remain potent for extended periods.

The family filed a lawsuit against her former nursing home, alleging Solyst received possibly twice the prescribed dosage of fentanyl.

"The fact the department of health investigated and found there was nothing wrong is mind-boggling to me," said the Solyst lawyer, Mark Kosieradzki.

Kosieradzki said the state investigation into her death found the incident “does not meet the definition of neglect."

The report reviewed by 5 EYEWITNESS NEWS showed a nursing home health worker, “failed to ensure old fentanyl patches were removed prior to applying new fentanyl patches.”

"I find this absolutely stunning," Kosieradzki said. “Their job is to protect the citizens of our state so that the proper care is done."

MDH said they sent an inspector to the site to investigate within eight business days of the report. MDH interviewed the subject of the allegation in March 2015, but the final report wasn’t finished until the summer.

Officials from the Department of Health told 5 EYEWITNESS NEWS in an email its common investigative practice to interview the subject of an allegation after doing other interviews and collecting as much information as possible.

The Executive Director at St. Mark's Living in Austin would not comment due to the Solyst family's lawsuit against the home, only telling 5 EYEWITNESS NEWS the state investigation found no sign of neglect.

The state of Minnesota had 16,954 complaints filed by residents, families and healthcare facilities in one year, according to a March 2016 report to the Minnesota Legislature.

Minnesota Nursing Home Report Card

The Office of Health Facility Complaints has 18 investigators with 10 investigator vacancies leading to the remaining staff having tripled the case load of recent years. 

"Our staff will see some things are pretty heartbreaking at times as they investigate," Acevedo said leading to the openings in the departments.

"That's unacceptable, yes, a big problem,” said Dr. Charlene Harrington about the time it takes Minnesota to investigate cases. Harrington a professor emerita of sociology and nursing at UC-San Francisco “They won't be able to go back and track what happens in a lot of the cases."

Harrington says states should use tax dollars on the front-end to improve the quality, at care facilities, because no amount of money on the back-end will fix it. 

“I think right now these people in long term care are out of sight out of mind,” said Harrington. “So the legislature, Governor’s office, and Congress, they just look the other way until another crisis happens.”

Harrington said a recent state of California audit found a backlog of complaints leading the state to hire more investigators.

RELATED: Nursing Home Compare: Medicare

The Minnesota Department of Health had more than 20,000 complaints already filed by mid-October.


Eric Chaloux & Erik Altmann

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