Minnesota Veterans Home has been found negligent in the supervision of a resident who was found dead in his room in 2012, along with empty medicine bottles, according to a report by the state Health Department.
After an inspection resulting in the self-inflicted and wrongful death of the man, the home was ordered to put corrective measures in place relating to how residents are assessed and how they self-administer their medications, according to an April 16 report.
The Minnesota Department of Health did a follow-up visit and the facility was found to be in compliance with state regulations.
The Minnesota Veterans Home is operated by the state and consists of a domiciliary program, which allows residents the freedom to come and go, as well as a nursing home. The resident who was found dead was part of the domiciliary program.
After the incident, the home created a corrective action plan that is focused on the review and revision of the self-administrative of medication. The new policy includes doing more checks and reassessing medication.
When the incident occurred, the home followed procedure and self-reported the incident. The neglect occurred when the home failed to make sure the resident was taking their medication as order by a doctor. As a result, the man overdosed on methadone, which was a medication that he had not been prescribed.
The resident had a history of depression and chronic pain, according to the report. In addition, he had been receiving services at the veteran’s home for over 10 years.
In February of 2012, the facility staff found that the man was not taking his medication as he was supposed to. They also found that he had access to a number of medications he didn’t have prescriptions for. The facility staff was also aware that the resident may have been taking too much pain medicine.
The report stated that there was no reassessment of his ability to administer his medications on his own.
The inspectors concluded that the home was responsible for this neglect.
Nonetheless, the current leadership was not in place at the home when the incident occurred, according to the Department of Veterans Affairs. They said that the residents in the domiciliary program often receive care and services that are related to rehabilitation, mental health, and work-therapy programs.
In this particular case, the coroner found methadone toxicity, which was not prescribed for the man. The medication was also not found in the resident’s belongings.