Minnesota Agency Failing To Protect Nursing Home Residents: Report

The state agency tasked with preventing nursing home neglect and abuse in Minnesota is failing to do its job, according to new findings by an oversight agency. 

The Minnesota Office of the Legislative Auditor (OLA) released a report (PDF) this month castigating the Office of Health Facility Complaints (OHFC), which is a part of the Minnesota Department of Health. OLA’s review of the OHFC’s practices and methods led to a conclusion that the office was failing to protect some of the state’s most vulnerable citizens due to a lack of resources, complex state laws and poor management.

“OHFC has not met its responsibilities to protect vulnerable adults in Minnesota,” according to a letter to the Legislative Audit Commission by Auditor James Nobles and Deputy Legislative Auditor Judy Randall. “The reasons for this failure are two-fold: poor internal operations at OJFC and Minnesota’s complex regulatory structure.”

The findings come several months after the publication of an investigative series by the Star Tribune, called “Left To Suffer”, which revealed that 97% of the 25,226 complaints, including more than 2,000 claims of nursing home physical and mental abuse, reported in 2016 were never even investigated.

OLA’s investigation indicates that in 2017, there were 24,100 allegation reports of problems in nursing homes, representating an increase of more than 50% from five years ago. However, it found that OHFC only did onsite investigations in five percent of those cases.

Investigators determined that the agency did not have an effective case management system, which has resulted in lost files and poor resource allocation. In addition, most of the staff do not have confidence in the OHFC’s leadership abilities, and that the agency does a poor job in managing its data, failing to identify trends or conduct prevention efforts.

The study also found that the office failed to warn vulnerable adults or their families of suspected mistreatment at long-term care facilities. This was due to the fact that the OHFC considered the health care facilities themselves to be protected by a law designed to keep those who report mistreatment anonymous.

The report came with a number of recommendations to improve OHFC’s response to nursing home abuse and neglect complaints. The report called for the office to implement an electronic case management system, to incorporate quality control measures into its triage and investigation processes, and better manage its data.

In addition, the OLA report also calls on the state legislature to take action by requiring the OHFC to regularly report on progress in meeting state and federal requirements; amend state laws to allow the office to inform vulnerable adults and family members about potential abuse; and require the OHFC to improve its website and post all investigation reports online.

The Center for Medicare and Medicaid Services (CMS), which oversees nursing home standards nationwide, has cited Minnesota for two years in a row for categorizing often grievous and horrific reports of abuse as non-urgent. And over the past five years, only two nursing homes have lost their licenses. There are nearly 1,800 senior care facilities licensed in the state.

The problem is just expected to get worse, as the large baby boomer population ages, and its likely an issue that is not limited to residents of Minnesota.

In September, U.S. Senator Orrin Hatch called on the head of the U.S. Department of Health and Human Services (DHHS), which oversees CMS, to explain how it plans to combat similar problems at nursing homes nationwide.

The letter came following an “Early Alert” (PDF) by the DHHS Office of Inspector General (OIG) on August 24, warning of potential abuse and neglect in nursing homes that are federally funded by Medicare. The report found 134 injuries of Medicare beneficiaries at skilled nursing facilities in 2016, which may have been the result of negligent care or abusive actions, but only 96 of those incidents were disclosed to the authorities.

The report raised concerns that many incidents at facilities that receive Medicare funding are going unreported, despite mandatory reporting requirements.