State Audit Finds Fiscal Lapses and Dietary Protocol Failures at ND Veterans Home

A state audit of the North Dakota Veterans Home has uncovered millions of dollars in unauthorized expenditures and a fatal failure to follow dietary protocols for a resident, KFYR reported.

The findings, released by the State Auditor, detail a pattern of administrative lapses ranging from financial mismanagement to serious lapses in patient care. The audit identified over $9.7 million in expenditures approved by an administrative assistant instead of higher-level management.

Beyond the financial oversight, the report highlights a tragic incident involving a resident who died after being fed the wrong meal. The death occurred during a choking incident after staff failed to follow a specific dietary plan ordered by the resident’s physician.

The audit also raised concerns regarding payroll integrity and staff accountability. One employee received $56,766 in overtime payments, a figure the audit suggests is inconsistent with the hours logged by the administrator.

The investigation into the fatal choking incident revealed further issues with how the facility manages staff accountability. Following the death, the facility conducted performance evaluations for the employees involved in the error.

However, the audit found that these evaluations did not reflect the severity of the incident. Instead of noting disciplinary actions, the evaluations for two of the staff members stated they “met expectations.”

Because these performance evaluations are the primary mechanism used to determine employee raises, the audit suggests that the failure to document the error directly impacted the facility’s disciplinary and compensation structures.

The following table summarizes the primary financial and administrative concerns identified in the State Auditor’s report:

Category of Concern	Specific Finding
Unauthorized Expenditures	Over $9.7 million approved by administrative assistant
Overtime Discrepancies	$56,766 paid to one employee with inconsistent logs
Staff Accountability	Employees involved in fatal error received “met expectations” ratings

The implications of these findings extend to both the fiscal stewardship of state resources and the fundamental safety of the veterans in the facility’s care. While the audit highlights systemic failures in oversight, it also points to a breakdown in the direct execution of medical and dietary orders essential for resident survival.

The North Dakota Veterans Home serves former service members; financial mismanagement and clinical errors affect both the residents and state oversight bodies.

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