Audit: Veterans Home Didn't Check Patients, Probe Complaints
By David Eggert, Associated Press
LANSING (AP) - Workers at a Michigan veterans home falsely claimed they were checking on patients after being alerted of possible falls, failed to properly investigate allegations of abuse and neglect, and took too long to fill prescriptions, the state auditor said Thursday.
The 415-bed Grand Rapids Home for Veterans, one of two state-run nursing homes for veterans, provided insufficient care and continued with inadequate staffing levels even as the state filed four complaints over a 1 ½-year period against the contractor hired to supply nursing aides, according to the audit. The report flagged a host of problems and issued five "material" findings — the most serious that can be levied.
Auditors looked at third-shift surveillance video to show that only about a half of required room checks and one-third of fall-alarm checks were done, even though the home produced documentation that the checks occurred. The audit found that of 38 abuse or neglect complaints made over a 23-month period, nine were not forwarded to the nursing director and stayed with managers of departments against which the complaints were lodged — a violation of policy.
About one-third of prescriptions were filled late, and problems also were flagged with tracking medication inventories and insurance billing.
The audit was made public by the Michigan Veterans Affairs Agency on Thursday, a day before its scheduled release by Auditor General Doug Ringler, after outraged lawmakers began issuing statements and promising oversight hearings.
Sen. David Knezek, a Dearborn Heights Democrat and a Marine Corps veteran, said he was "devastated" by the auditor's conclusions.
"We owe our veterans and their families a debt of gratitude — not a legacy of heartbreak and mismanaged care," he said.
The agency agreed with the findings and said it is making changes to comply with recommendations and bring the home in line with industry best practices.
"There is room for improvement. We have placed our focus on improving the quality of care," Veterans Affairs Director Jeff Barnes told The Associated Press in a phone interview.
In the fall, he appointed Leslie Shanlian, a nursing home administrator, as chief executive officer of the new Michigan Veteran Health System to coordinate operations in Grand Rapids and at the D.J. Jacobetti Home for Veterans in Marquette. An electronic medical records system should be ready within months, he said, and an automated dispensing system will help better control and oversee medications.
The home will discontinue the use of fall-alarm sensors in beds and wheelchairs after reviewing research indicating that the pressure-sensitive devices can increase rates of falling and limit mobility. Shanlian said inspectors are spot-checking surveillance video now to see if the proper checks have been done, and workers have been warned that they could be fired for falsifying records.
In his budget presentation last week, Gov. Rick Snyder proposed $8 million to pursue certification from the federal Centers for Medicare and Medicaid Services — which would qualify the state for more health care funding and bring additional inspections. It includes $6.1 million to remodel a floor at the Grand Rapids home.
"It gives us the ability to provide services that we currently cannot," Barnes said.
Rep. Holly Hughes, a Montague Republican, promised to "get to the bottom of this and demand accountability from the people responsible, whether that be further inquiry, reprimands or job termination."
The audit said the company that supplies about 150 nursing aides, J2S Group-HealthForce in Grand Rapids, filed a complaint against the state after the state complained for a fourth time in October about the firm not meeting required staffing.
Barnes said Thursday the Michigan attorney general's office and company lawyers are close to finishing a contract change, including a potential pay-for-performance bonus incentive each time staff levels are at 100 percent for 30 consecutive days.
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