Audit at North Dakota Veterans Home raises some concerns

The routine rhythms of life at the North Dakota Veterans Home in Lisbon were tragically disrupted this year after an audit revealed a choking death stemming from a critical error: a resident was served an incorrect meal, violating their physician-ordered dietary plan. This incident, alongside concerns about payroll practices and financial oversight, has prompted scrutiny of the facility responsible for caring for our state’s veterans. The North Dakota State Auditor's Office released findings from the audit covering the biennium ending June 30, 2025, on Thursday, November 12th, highlighting issues that demand immediate attention and a renewed commitment to resident safety and accountability.

The Fatal Error and Dietary Concerns

The audit’s most serious finding centers on the death of a resident due to choking. According to the North Dakota State Auditor's Office, the incident occurred because the veteran was served a meal that didn’t align with their prescribed dietary restrictions. This underscores a vital point: residents of long-term care facilities often have complex medical needs, and adherence to physician-ordered diets is paramount to their health and well-being. Following this tragic event, the auditor's office initiated a review of the Veterans Home’s dietary processes to understand how such an error could occur and to prevent future incidents. The audit revealed that one resident was served the incorrect diet during lunch service because the dining system was not aligned with individual resident doctor’s orders.

The importance of following dietary plans is especially critical for residents in facilities like the Veterans Home, many of whom have medical conditions requiring specific meal modifications. Failing to adhere to these plans can have serious health consequences, as tragically demonstrated in this case. The audit highlighted the need for a more robust system to ensure meals consistently match doctor's orders, emphasizing that resident safety must be the top priority.

Performance Evaluations and Payroll Irregularities

Beyond the dietary error, the audit uncovered further concerns related to staff performance evaluations and payroll practices. Two staff members involved in the incident leading to the resident's death received annual evaluations that failed to note any disciplinary action. Both were rated as “meeting expectations,” despite their involvement in a situation resulting in a fatality. This raises questions about the thoroughness and effectiveness of performance reviews within the facility, particularly when dealing with critical care responsibilities. The audit also revealed that one salaried administrative leadership staff member received $56,766 in overtime pay.

A review of the staff member's timesheets compared to computer log-in access logs showed inconsistencies, suggesting potential inaccuracies in reported hours. This raises concerns about the integrity of payroll records and the potential for misuse of funds. Furthermore, an administrative assistant approved over $9.7 million in expenditures despite lacking sufficient knowledge of the agency's operations to properly review accounting transactions—a critical responsibility requiring a clear understanding of financial processes and agency protocols.

Financial Oversight Concerns

The fact that an administrative assistant, without adequate training or understanding of accounting principles, was approving such a significant volume of expenditures—over $9.7 million—is deeply concerning. This highlights a potential breakdown in internal controls and a lack of oversight within the Veterans Home’s financial operations. The audit's findings suggest a need for stricter controls and better-defined roles and responsibilities to prevent future errors and potential fraud.

Community Reaction and the Human Cost

While formal statements from families and Lisbon residents have yet to be released, the news of the audit’s findings has undoubtedly sparked concern within the community. The North Dakota Veterans Home serves a vital role in providing care and support for veterans who have selflessly served our nation, and the revelation of such serious errors is deeply unsettling. Residents of Fargo and surrounding communities value the dignity and respect afforded to those who have defended our freedoms, and this incident raises questions about whether that standard of care is consistently being met. The emphasis on the importance of proper dietary plans for vulnerable residents resonates with families across the state, as it underscores the need for vigilance in ensuring the safety and well-being of those entrusted to long-term care facilities.

The Human Cost

More than dollars and cents, this audit highlights the devastating human cost of systemic failures. While administrative errors can be corrected, the loss of a life is irreversible. The grief experienced by the resident’s family and the broader veteran community is immeasurable. It serves as a stark reminder that behind every statistic, every audit finding, there is a person deserving of dignity and respect in their final years.

Looking Ahead: Accountability and Reform

The North Dakota State Auditor's Office has made its findings public, initiating a process of accountability and potential reform. The Veterans Home administration has not yet released a formal statement addressing the audit's concerns, but it is expected that they will be implementing corrective actions to address the identified deficiencies. These actions may include reviewing and revising dietary protocols, strengthening staff training and performance evaluations, and reinforcing internal financial controls. The State Legislature will likely review the audit findings during upcoming sessions, potentially leading to increased oversight and legislative action to ensure the safety and well-being of residents at the Veterans Home. North Dakota Department of Veterans Affairs

Tommy's Take: A Debt of Gratitude and a Call for Action

As a community, we owe a debt of gratitude to our veterans, and that debt extends beyond ceremonial gestures. It demands tangible support, reliable care, and unwavering accountability when those entrusted with their well-being fall short. This audit isn’t just about dollars and cents; it's about the promise we make to those who served. The fact that a preventable error led to a resident’s death is deeply troubling, particularly in light of the inconsistencies found in staff evaluations and financial oversight. The potential for systemic failures within institutions like the Veterans Home highlights the importance of robust oversight, rigorous training, and a culture of accountability at every level. It also underscores the essential role that strong families and committed communities play in supporting our veterans – ensuring they receive not only professional care, but also the compassion and respect they deserve.

The financial irregularities detailed in the audit—the excessive overtime and inadequate review of expenditures—are symptoms of a larger problem: a lack of effective management and internal controls. It’s easy to point fingers, but true reform requires a commitment to transparency, ethical behavior, and a willingness to acknowledge and correct systemic weaknesses. We need to ask ourselves: are we adequately supporting the individuals who are responsible for caring for our most vulnerable citizens? Are we providing them with the resources and training they need to succeed? These are not simply questions for administrators and policymakers; they are questions that each of us, as members of this community, must consider.

Ultimately, the goal isn’t just to fix the problems identified in this audit; it's to build a culture of excellence within the North Dakota Veterans Home—a place where veterans can feel safe, respected, and cared for with unwavering commitment. It’s a challenge that demands our collective attention and action.

Resources for Veterans and Families

For residents and families seeking more information about the North Dakota Veterans Home or wanting to advocate for improvements in veteran care, several resources are available. The North Dakota Department of Veterans Affairs provides information about services and programs offered to veterans and their families. The Fargo Chamber of Commerce can connect residents with local businesses and organizations that support veteran initiatives. For those interested in advocating for policy changes, contacting state legislators through the North Dakota Legislative Council is a crucial step.

Additionally, the North Dakota State Auditor's Office website provides access to audit reports and information about the auditing process. Families who have concerns about the care their loved ones are receiving at any long-term care facility should contact the North Dakota Adult Protective Services for assistance and guidance. The importance of supporting our veterans extends beyond government agencies—it requires a commitment from every member of our community to ensure they receive the care and respect they deserve.

Closing paragraph: The issues highlighted in this audit are a stark reminder of the responsibility we have to protect our most vulnerable citizens. While corrective actions are underway, ongoing vigilance and accountability are essential to ensuring that the North Dakota Veterans Home lives up to its promise of providing dignified care for those who served our nation. As a community, we must remain engaged and committed to supporting our veterans and demanding the highest standards of care.