The Minnesota Veterans Home in Minneapolis neglected to supervise a resident who was found dead in his room last year along with empty medication bottles, according to a state Health Department report.
After an inspection of the 2012 incident, the veterans home was ordered to implement corrective action relating to assessments of when residents can self-administer medicines, according to a report released Tuesday, April 16, by the Minnesota Department of Health.
“We did a follow-up visit, and the facility was found to be in compliance with state regulation,” said Stella French, director of the Office of Health Facility Complaints.
The Minnesota Veterans Home is operated by the state and includes a nursing home and a domiciliary program where residents can come and go as they please, said Anna Long, spokeswoman for the Department of Veterans Affairs. The resident in question was part of the domiciliary program, Long said.
“We were saddened by this loss of life,” said Michael Gallucci, deputy commissioner of veterans health care, in a statement. “After this incident, the home created and implemented a thorough corrective action plan focused on reviewing and revising the medication self-administration policy to include more frequent checks and medication reassessments.”
“When this incident occurred, the (veterans home) followed procedure and immediately self-reported,” Gallucci said.
Neglect of supervision occurred when the veterans home failed to ensure a resident was taking medicine as ordered by a physician, state inspectors concluded. As a result, the man died after an overdose of methadone, the report stated, adding that he had not been prescribed the medication.
The resident had a history of chronic pain and a depression diagnosis, the report stated, adding that he had received services at the Minnesota Veterans Home for more than a decade.
In February 2012, facility staff determined the man was not taking his medication as prescribed and had access to several medications without prescriptions, according to the report. Facility staff members also were aware of concerns that the resident was taking too much pain medicine, the report stated.
“There was no reassessment of his ability to safely self-administer his medications,” the report stated.
Inspectors concluded that the Minnesota Veterans Home was responsible for the neglect.
Current leadership at the veterans home was not in place at the time of the incident, said Long, the spokeswoman for the Department of Veterans Affairs. She said residents in the domiciliary programs often receive care and services related to mental health, rehabilitation and work-therapy programs.
“In this case, the county coroner’s report found methadone toxicity in the resident, which was not prescribed by the Minneapolis veterans home,” Long said in a statement. The medication “was not found in the resident’s belongings,” she added.
Christopher Snowbeck can be reached at 651-228-5479. Follow him at www.twitter.com/chrissnowbeck.
