Minnesota health regulators can't keep up with abuse reports

Nearly two years after launching a statewide abuse reporting hot line, Minnesota regulators are overwhelmed by a deluge of new reports alleging abuse and neglect of vulnerable adults in nursing homes, hospitals and other state-licensed facilities.

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."

Chris Serres • 612-673-4308

Twitter: @chrisserres