STL Post-Dispatch: Messenger: Veterans ‘died alone’ in woefully understaffed St. Louis home, report says

Tony Messenger is the metro columnist for the St. Louis Post-Dispatch.

It was “like a prison.”

The residents who live there — veterans who served their country — often “die alone.”

Staffing was deficient. Care was negligent. The administrator was a bully.


These are among the dramatic findings in the investigation into the care at the St. Louis Veterans Home sparked by months of complaints from veterans, family members and advocates who urged Gov. Eric Greitens to clean house at the state-run facility in north St. Louis County.

In December, Greitens called for changes at the top of the Missouri Veterans Commission and at the St. Louis facility after releasing the executive summary of the investigation conducted by Harmony Healthcare International.

Those changes came swiftly.

The governor replaced five members of the commission. Those members coordinated the resignation of Gen. Larry Kay, the longtime executive director of the commission, at their first meeting. They appointed Col. Grace Link as interim director, and she has since recommended that the administrator of the St. Louis Veterans Home, Rolando Carter, be fired.

The full investigation by Harmony Healthcare, obtained by the Post-Dispatch in a Sunshine Law request from the governor’s office, indicates that should have happened long ago. And key to the problems at the home were poor management practices that led to understaffing and poor morale.

“Residents die alone because no one is able to sit with them,” says the report. “Residents who are bedridden are not getting attention. Many residents have pressure ulcers because they are not getting turned and repositioned.”

Over nine days, the investigators interviewed 144 veterans, family members and employees. Only six of those interviews reported “positive” experiences at the home. The rest — 96 percent — told of problems with medications, response time, poor hydration, weight loss, safety problems, high turnover and a hostile work environment.

The turnover — spurred in part by a policy referred to by the employees as “mandation” in which double shifts were often forced — led to massive understaffing.

In August, investigators found there were 23 nursing vacancies, including nine registered nurses and nine certified nursing assistants. By September, the vacancies rose to 45. In October, there were 66 unfilled positions providing direct nursing care to the veterans.

That’s when I first wrote about the problems, talking to Jim Luebbert, whose father had died, and Cheri DeJournette, whose father hadn’t been given a bath in two weeks. When she tried to do something about it, Carter had her removed from the building by police.

These days, DeJournette is happy.

She says the changes brought about by the investigation and the governor’s replacement of commission members are bearing fruit.


“The new team is making headway,” she says. “Change is slow, but the staff, families and vets are hopeful.”

Indeed, while Greitens was slow to react to the complaints brought to his attention — or duped by underlings who accepted sham inquiries intended to whitewash the problem — his decisions in late December are an indication of what can happen when government officials take public accountability seriously.

That’s a message that hasn’t yet sunk in to everybody at the Missouri Veterans Commission.

If it were up to the commission, the full investigative report on the problems at the St. Louis Veterans Home wouldn’t have been released. Unlike the governor’s office, the commission denied my Sunshine Law request for the report, citing both state Sunshine Law and federal health laws. When I appealed to the new chair of the commission, Tim Noonan, he backed the commission’s attorney, Kevin Hall, who denied the public an opportunity to see the report.

At least one commissioner, state Sen. Jill Schupp, D-Creve Coeur, believed the report should be made public. So did House budget chairman, state Rep. Scott Fitzpatrick, R-Shell Knob, who suggested the veterans commission might end up with funding issues if it didn’t release the report.

Luckily, we now know that the rate of prescriptions for antipsychotic drugs is significantly higher at the St. Louis Veterans home than both state and national averages, because the governor’s office released the report. We know that far too many veterans are given catheters because of convenience, not medical necessity, and that pressure injuries are rampant.

Elderly men who served their country suffered through months of inadequate care because some state employees were more worried about protecting their jobs than doing them. If the problem isn’t going to be repeated, those who seek to hold their government accountable to the people they are supposed to serve have more work to do.

This post was written by