An unchecked infection claims a life.
"The physician stated that if the client was treated for the illness earlier, s/he may have had a different outcome."
A burn goes untreated and takes another.
"The resident's primary physician ... stated she did not receive notifications of the changes in the burn size and condition."
These are among the most serious recent write-ups the Minnesota Department of Health has handed out to health facilities in St. Louis County. Since 2015, the state investigated more than 160 allegations of elder neglect, abuse and financial exploitation at nursing homes and other care providers here - 24 of which were substantiated, including five deaths.
The bottom line in many of those cases? They could have been avoided.
"It's an issue that impacts all areas of our state, and Duluth is not immune to that," said Rep. Liz Olson, DFL-Duluth. "It's time to be serious in how we prevent this from happening."
In 2019 the Legislature will again take up reforms aimed at keeping vulnerable and elderly Minnesotans safe and holding accountable those who are charged with their care. Efforts to do so earlier this year failed.
Olson, who will be the majority whip in the DFL-controlled House when the Legislature convenes in a month, said she's hopeful her chamber and the Republican-controlled Senate will come together to create meaningful change. So are her fellow lawmakers.
"We don't have another year to put this issue on the backburner," said Sen. Karin Housley, R-St. Mary's Point. "Everyone has been working on it in the interim here - I think the best ideas come from the grassroots, not from us legislators down."
Following a Star Tribune investigation last fall that found very few reported allegations of elder abuse were being fully investigated, a consumer-led task force in January called for "far-reaching policy and agency practice changes to prevent and deter abuse. ... The problems in the regulatory system demand immediate and dramatic fixes."
Specifically, the group recommended:
-Strengthening and expanding rights of older and vulnerable adults and their families
-Enhancing criminal and civil enforcement
-Developing new licensure frameworks for assisted living and dementia care
-Improving licensing regulation, enforcement, investigations and reporting
A bill born of those recommendations did not get a hearing.
The Office of the Legislative Auditor wrote in March that the Office of Health Facility Complaints "has not met its responsibilities to protect vulnerable adults in Minnesota. The reasons for this failure are two-fold: poor internal operations at OHFC and Minnesota's complex regulatory structure."
Housley, chair of the Senate Aging and Long-Term Care Committee, shepherded a bill to allow electronic monitoring of residents, require residents and family members be notified of abuse investigations, increase oversight of the Office of Health Facility Complaints and expand the Home Care Bill of Rights, among other initiatives.
Gov. Mark Dayton vetoed the bill that measure was a part of as the session crashed to a close in May.
Since then, diverse groups of stakeholders across six working groups have been working closely to find common ground.
"We'll start over, and hear bills early on where there's agreement and work out the details where there isn't," said Rep. Jen Schultz, DFL-Duluth, who will be chair of the House Subcommittee on Long Term Care.
Requiring assisted living facilities to be licensed is one issue where there is now industry support.
"I do think we absolutely need to have a licensing structure for assisted living facilities. Minnesota is way behind the rest of the country on that particular measure," said state Sen. Tony Lourey, DFL-Kerrick.
Gov.-elect Tim Walz agreed there is a need for better oversight.
"In many cases it's an industry that has grown rapidly with an aging population, and we haven't quite figured out how to keep up with that," he told the News Tribune while visiting Duluth earlier this week.
Housley said she'll consider all proposals the House sends over.
"Some of the things I'm hearing go too far for me and my constituents," she said, "but I'm always going to have that discussion, and absolutely we'll sit down and work together."
'We've got to straighten out these laws'
Seven days newspapers piled up. Seven days he was missing from meals.
It took seven days for someone to realize that Kristine Sundberg's father had died at his home in a senior living facility.
In the months that followed, Sundberg found she had little recourse to hold the facility accountable through the state.
"I went to start looking at who are the authorities? I was blown away you could have no oversight of a facility like that," she told the East Pine County Wanderers at the senior group's meeting at the Arna Town Hall last month. "My first thought was, we've got to straighten out these laws. There's something wrong here."
Sundberg is now the board president of Elder Voice Advocates, a relatively new consumer advocacy group that was part of the coalition that called for "far-reaching" reforms in January.
Industry group LeadingAge Minnesota, which represents more than 1,100 senior care-focused organizations, is open to a number of changes.
"We believe the working groups have provided the foundation from which to build, particularly in the areas of assisted living licensure, dementia care standards and electronic monitoring," LeadingAge Minnesota CEO Gayle Kvenvold said. "It has really been heartening to see consumers and providers and policymakers and regulators come together."
That broader coalition should signal success early in the session, Kvenvold said.
"When we get to the details, that it is perhaps where it is most difficult to find that consensus, but I'm more than hopeful, in fact I'm optimistic, that we have broad enough agreements around some of the core principles," she said.
Schultz and Housley, who as committee chairs will have enormous influence over any reforms that make it to the governor's desk, both said the issue goes beyond partisan politics, and it will be treated as such.
"I think (leadership) is going to let the chairs work through this, and not make it political," Schultz said. "I'm glad they've agreed to that, and hopefully that will hold."
Elder abuse resources
- Call 911
- Call the Minnesota Adult Abuse Reporting Center at 1-844-880-1574
- Call the Ombudsman for Long-Term Care at 651-431-2555
- Reach the Office of Health Facility Complaints at 651-201-4200 or here.