thedrifter
03-10-07, 06:41 AM
Posted on Sat, Mar. 10, 2007
Pain, anger, promises in vets home testimony
State officials say they're solving ongoing problems, but legislators are skeptical
BY JEREMY OLSON
Pioneer Press
When relatives buried 82-year-old Harlan Jason in January, they felt comfort believing he died peacefully at the Minnesota Veterans Home of Minneapolis.
Days later, they suffered fresh grief when a state health investigator told them Jason's death Jan. 4 may have resulted from neglect and inattention by nursing staff. The diabetic died of hypoglycemia, a prolonged state of low blood sugar.
"At least five nurses failed to monitor my uncle's worsening condition that night," Joan Willshire said during a Minnesota Senate committee hearing Friday.
Willshire testified while showing a picture of Jason with his family — putting a face on the debate over the Minneapolis home and why state and federal inspections have cited it for inadequate and hazardous care.
Leaders of the state veterans homes board tried to assure senators during the hearing that they were making rapid improvements.
Nursing staff at the home have received extensive training over the past four weeks to improve care for residents with diabetes, reduce medication errors, prevent falls, eliminate bedsores and help residents maintain flexibility, said Chip Cox, interim executive director of the Minnesota Veterans Homes Board.
"(The problems) didn't get there overnight," he said, "but we need to fix them in a hurry."
Senators responded with hope, anger and suspicion. Sen. Sharon Erickson Ropes, DFL-Winona, remembered how vets home leaders testified in a Jan. 11 hearing that problems were being fixed and care was improving. There was no mention of Jason's death, which occurred seven days earlier.
"Well intentioned or not, I'm really struggling with how in the world you could sit before this committee and not tell us about that," she said.
Vets home leaders responded that the review of Jason's death wasn't complete at the time.
Jason's death was one of three at the home in January that state health inspectors reviewed. Results of those investigations, released in February, noted that nurses failed to follow the home's written policies for notifying a doctor when Jason's blood sugar dropped, or for sending him to a hospital when he suffered hypoglycemia.
The reports also noted that two other veterans received the wrong medications in the days before they died. It's unclear whether the errors caused or hastened the deaths.
Three of Jason's six children also attended Friday's hearing. They described the mechanical engineer who served in the Marines as content and happy during his year at the home. However, they said, they felt betrayed that the home's leaders didn't disclose the mistakes in his care, which they felt reflected deep-rooted problems.
"It wasn't just an error. It wasn't just some worker who made a quick mistake," said Margaret Gordon, one of Jason's daughters and a nurse who manages quality assurance at a hospital in Florida. "This is a system problem. This is a culture."
Willshire, Jason's niece, is executive director of Minnesota State Council on Disability. She was dismayed that nurses didn't have information at Jason's bedside about whether to resuscitate him from cardiac arrest. Nurses didn't perform CPR, though Jason's written directives allowed them to do so.
"One of the most feared issues we live with," she said, "is that medical professionals will not follow the health care directives we have written for ourselves."
Cox said the Minneapolis home needs the same electronic record-keeping systems that help organize care and prevent mistakes at the four other homes managed by the state veterans homes board. However, he said, long-range improvements are a lower priority than addressing the deficiencies cited in recent inspections by the state Health Department and the U.S. Department of Veterans Affairs.
The Minneapolis home had until Friday to correct problems the VA cited or risk losing millions of dollars from the federal agency. VA inspectors will show up sometime this month to determine if problems have been corrected, Cox said.
The state board also is paying $1,850 per day in fines to the state until the board addresses repeated violations found in November and February inspections.
Cox said a contractor, Health Dimensions, will offer guidance and management to the home starting Monday, under an order from Gov. Tim Pawlenty. He also said the home's leaders are trying to improve morale and consult workers on ways to improve care.
Pawlenty has budgeted an additional $15 million for the veterans homes board, in part to finance overdue maintenance at the 418-bed home in Minneapolis and four other state homes.
In a House committee hearing Friday, union leaders argued that more funding is needed to increase staffing at the Minneapolis home. They said nurses and support staff don't have time to meet residents' basic needs or to pass along important information on residents to the next shifts.
Mistakes are to be expected when nurses are exhausted by understaffing and forced to work overtime, said Mary Jo George, of the Minnesota Nurses Association. "Clearly nurses do not exercise good judgment in that environment."
Jeremy Olson can be reached at jolson@pioneerpress.comor 651-228-5583.
Ellie
Pain, anger, promises in vets home testimony
State officials say they're solving ongoing problems, but legislators are skeptical
BY JEREMY OLSON
Pioneer Press
When relatives buried 82-year-old Harlan Jason in January, they felt comfort believing he died peacefully at the Minnesota Veterans Home of Minneapolis.
Days later, they suffered fresh grief when a state health investigator told them Jason's death Jan. 4 may have resulted from neglect and inattention by nursing staff. The diabetic died of hypoglycemia, a prolonged state of low blood sugar.
"At least five nurses failed to monitor my uncle's worsening condition that night," Joan Willshire said during a Minnesota Senate committee hearing Friday.
Willshire testified while showing a picture of Jason with his family — putting a face on the debate over the Minneapolis home and why state and federal inspections have cited it for inadequate and hazardous care.
Leaders of the state veterans homes board tried to assure senators during the hearing that they were making rapid improvements.
Nursing staff at the home have received extensive training over the past four weeks to improve care for residents with diabetes, reduce medication errors, prevent falls, eliminate bedsores and help residents maintain flexibility, said Chip Cox, interim executive director of the Minnesota Veterans Homes Board.
"(The problems) didn't get there overnight," he said, "but we need to fix them in a hurry."
Senators responded with hope, anger and suspicion. Sen. Sharon Erickson Ropes, DFL-Winona, remembered how vets home leaders testified in a Jan. 11 hearing that problems were being fixed and care was improving. There was no mention of Jason's death, which occurred seven days earlier.
"Well intentioned or not, I'm really struggling with how in the world you could sit before this committee and not tell us about that," she said.
Vets home leaders responded that the review of Jason's death wasn't complete at the time.
Jason's death was one of three at the home in January that state health inspectors reviewed. Results of those investigations, released in February, noted that nurses failed to follow the home's written policies for notifying a doctor when Jason's blood sugar dropped, or for sending him to a hospital when he suffered hypoglycemia.
The reports also noted that two other veterans received the wrong medications in the days before they died. It's unclear whether the errors caused or hastened the deaths.
Three of Jason's six children also attended Friday's hearing. They described the mechanical engineer who served in the Marines as content and happy during his year at the home. However, they said, they felt betrayed that the home's leaders didn't disclose the mistakes in his care, which they felt reflected deep-rooted problems.
"It wasn't just an error. It wasn't just some worker who made a quick mistake," said Margaret Gordon, one of Jason's daughters and a nurse who manages quality assurance at a hospital in Florida. "This is a system problem. This is a culture."
Willshire, Jason's niece, is executive director of Minnesota State Council on Disability. She was dismayed that nurses didn't have information at Jason's bedside about whether to resuscitate him from cardiac arrest. Nurses didn't perform CPR, though Jason's written directives allowed them to do so.
"One of the most feared issues we live with," she said, "is that medical professionals will not follow the health care directives we have written for ourselves."
Cox said the Minneapolis home needs the same electronic record-keeping systems that help organize care and prevent mistakes at the four other homes managed by the state veterans homes board. However, he said, long-range improvements are a lower priority than addressing the deficiencies cited in recent inspections by the state Health Department and the U.S. Department of Veterans Affairs.
The Minneapolis home had until Friday to correct problems the VA cited or risk losing millions of dollars from the federal agency. VA inspectors will show up sometime this month to determine if problems have been corrected, Cox said.
The state board also is paying $1,850 per day in fines to the state until the board addresses repeated violations found in November and February inspections.
Cox said a contractor, Health Dimensions, will offer guidance and management to the home starting Monday, under an order from Gov. Tim Pawlenty. He also said the home's leaders are trying to improve morale and consult workers on ways to improve care.
Pawlenty has budgeted an additional $15 million for the veterans homes board, in part to finance overdue maintenance at the 418-bed home in Minneapolis and four other state homes.
In a House committee hearing Friday, union leaders argued that more funding is needed to increase staffing at the Minneapolis home. They said nurses and support staff don't have time to meet residents' basic needs or to pass along important information on residents to the next shifts.
Mistakes are to be expected when nurses are exhausted by understaffing and forced to work overtime, said Mary Jo George, of the Minnesota Nurses Association. "Clearly nurses do not exercise good judgment in that environment."
Jeremy Olson can be reached at jolson@pioneerpress.comor 651-228-5583.
Ellie