Investigation finds emotional abuse, neglect at Duluth group homes

State licensing officials are scrutinizing a Duluth company that runs four group homes for adults with mental illness, after a client turned over a 64-minute audio recording of an employee berating clients and a state investigation found the facility neglected two clients in the hours leading up to their deaths.

The licensing division of the Minnesota Department of Human Services placed the group homes, all operated by Heartland Homes of Duluth, on conditional licenses last week, according to documents posted Thursday on the department's website. The decision means the facilities will be under closer scrutiny by licensing officials and could have their licenses suspended or revoked if more violations occur.

"We'll be monitoring to make sure that this provider does take this very seriously and responds appropriately," said DHS Inspector General Jerry Kerber, who oversees the licensing division.

State documents recount the disturbing details of violations at two of the company's group homes, including a report on how employees failed to seek immediate medical attention for two clients with breathing problems.

The investigation dates back to March 2011, when two clients at the four-bed facility died within two days of each other. The investigation of those deaths was followed three months later by allegations that an employee verbally abused three clients and threw a pizza box and soda at them. During that conversation, which was recorded by a client on her cell phone, an employee warned the clients not to put themselves "on the same plateau" and noted, "I am already in hell. I am here."

Company co-owner Jennifer Klaas said she plans to appeal the agency's decision to place the facilities on conditional licenses. She declined to comment on most details of the investigation, but said, "It's absolutely a safe place or we would not be up and running."

The DHS licensing division faulted the company for its handling of the incidents. "The facility's internal review process is grossly inadequate and increases the likelihood that similar events will occur in the future," DHS licensing division supervisor Maura McNellis-Kubat wrote inan April 25, 2012 order that placed all four of the group homes' licenses on a conditional status.


In the early morning hours of March 19, 2011, according to an investigative memorandum, employees noticed a client who suffered from asthma was "wheezing" and having trouble breathing. At 4 a.m., the client used an inhaler, but the wheezing continued. At 6:30 a.m., the client refused an inhaler, ate breakfast, and went to her bedroom after an employee told her she could not lie on the couch.

When an employee checked on the client 90 minutes later, she was unresponsive. An employee immediately called 911 and went to look for a CPR mask. In the meantime, another employee called 911 again. The dispatcher told the employee to move the client onto the floor. The employees had not yet begun CPR by the time the paramedics arrived. The paramedics attempted CPR without success and called a doctor, who pronounced the patient dead via telephone. An autopsy report later found the cause of death was "a combination of pneumonia and aspiration."

The next death occurred the following morning.

Unlike the previous day's death, this time, the employees never called 911. Instead, they called each other for advice and considered the client's medical complaints to be a "behavioral problem," the licensing investigation found.

The client's breathing problems attracted the attention of an employee around 8 a.m., who later told investigators the woman was "breathing heavy" with a "gurgle noise."

The employee did not call 911 and instead waited for another employee to show up for work about 30 minutes later. The two employees discussed the client's symptoms. The second employee opted not to call 911 and instead called another employee. The third employee also did not call 911 and instead traveled to the facility and then called yet another employee. The fourth employee instructed staff to take the client to the emergency room.

By that point, the client "was moving slowly and needed staff persons' assistance to stand up and to walk," according to the investigative memorandum. The walk from the client's bedroom to a facility van took 20 minutes and required the assistance of three employees. As the client walked out of the building, she "grabbed the screen door and ripped it off the hinges," the memorandum said.

The employees still did not call 911.

Instead, one of the employees began to drive the client to the nearest hospital about five miles away. They had only traveled about five blocks when the employee pulled over because the client's condition was deteriorating. Her pulse was weak and her breathing shallow. The employee conferred with another employee who was following in a separate car. They discussed calling 911, but decided it would be faster to drive as quickly as possible to the hospital.

They arrived at the hospital at 10:54 a.m. — about three hours since employees first noticed the client's symptoms. The client was pronounced dead 21 minutes later. An autopsy found the client died of severe pneumonia. According to the autopsy report, the timing of the two deaths was "a coincidence rather than a contagious situation."

In just two days, half of the residents of the facility had died.


Five days passed before the DHS licensing division began interviewing employees. It took another six days for investigators to visit the facility. The investigation took almost five months to complete.

"Ideally, this would've been done sooner," said Kerber, the DHS inspector general.

However, Kerber noted that the licensing division relies on 20 employees to investigate about 900 maltreatment allegations each year.

"We're doing the best we can with the resources we have," he said.

At the end of the investigation, DHS found the facility at fault for the maltreatment of both clients and ordered the facility to pay a $2,000 fine and provide employee training on first aid and emergency response.

The investigation did not determine whether the deaths would have been prevented if the employees have responded differently. "Some deaths are obviously more preventable than others," Kerber said. "But where you have people who have some respiratory conditions that preceded this event, it's not always that clear."

The company did not appeal the initial finding, but Klaas said she regrets that decision. "It definitely, absolutely, 100 percent should have been appealed," she said.

Klaas said the facility handled both incidents correctly, although she added that she does not recall the details of either death. "It's a year ago," she said.


The problems at the company's group homes continued. In June, licensing officials responded to an allegation that an employee threw a pizza box and a soda at a client and made derogatory comments. The employee denied it, but the client had evidence. She had recorded the 64-minute exchange on her cell phone.

Investigators listened to the audio recording and found confirmation of the client's claims. In the recording, the client asks the employee why she threw the soda. The employee denied it, and said she merely tried to take it away. The client then asked the employee not to "come close" to the clients. The employee responded by saying, " Ooooh, who's going what what? Huh? Who's going what what?"

The client then asked the employee if she was drunk. The employee said, "I wish. I don't drink though."

The conversation continued, and the employee noted that, unlike the clients, she was able to live with her child. The employee went on to say, "Don't put yourself on the same plateau, which is completely different."

She asked another client if she knew what the word "plateau" meant.

The client replied, "It means you should go to hell."

The employee responded, "I am already in hell. I am here."

The client then asked, "If you are already in hell, didn't you say you loved your life and stuff?"

"I do," the employee said. "Everything is mine. What can you say about you? What can you say about you?"

One of the clients later told the employee, "I feel degraded every time you talk to me." The employee replied, "I am so very sorry you feel that way, but you know what? I have been doing this for 14 years."

At the end of the conversation, the employee asked several of the clients what she could do to improve the situation.

"Never come in the house again and throw soda on us," one client replied.

The client added, "We feel like s--- for being here and to have you come and say don't put yourself on my pedestal, hurt."

"That does hurt," the employee said.

When a state investigator asked the employee about the conversation, she denied making the statements. When the investigator played sections of the recording, the employee said the comments were taken out of context and that she "felt trapped" the report said, "as if the [clients] planned this incident."

Sue Abderholden, the executive director of NAMI-Minnesota, an advocacy group for people with mental illness, praised the client for recording the conversation.

"I thought that was really good thinking because you're taking someone who's vulnerable, maybe who has a serious mental illness, and saying, 'Well, who are you going to believe?' " she said. "Are you going to believe the person with a serious mental illness, or are you going to believe the staff person? And so by this individual recording, they're able to prove what was going on."

The licensing division found the employee emotionally abused the three clients and disqualified her from providing direct care services. The employee was fired as a result of the licensing finding, Klaas, the company's co-owner, said.

Licensing officials faulted the facility for how it responded to the patient deaths and the allegations of emotional abuse. Facility administrators only listened to the first five minutes of the audio recording, the memorandum said. The facility's internal review found administrators could "only assume" that the employee was complying with facility policies because the employee and the client made "contradicting" comments and the client "had a history of fabrication," the licensing investigation found.

Klaas disputes this account. She said the client only allowed the administrators to listen to the first five minutes of the recording.

Klaas said she's confident the order will be successfully appealed, and she criticized DHS for the lengthy investigation.

"It took them a year to get back to us on this last incident and we have ten days to appeal," she said.

She added, "It is very frustrating."

Read the state investigative documents

Investigative Memorandum: Facility neglected two clients in the hours before they died

Investigative Memorandum: Employee emotionally abused three clients

Order for Conditional License: Facility's internal review process is "grossly inadequate"

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