An audit of the North Dakota Veterans Home for the biennium that ended on June 30, 2025, has found several areas of concern within the agency which included:
Incorrect Meals Served to Residents, Lead to Death of Resident
After a resident died from a choking accident in which their physician ordered dietary plan was not followed, we reviewed dietary processes to ensure meals served matched doctor’s orders. Some residents have medical conditions that require special diets, so it is important their meals follow the doctor’s orders because serving regular food can put them at risk. Our team did an onsite visit and found during lunch service that one resident was served the incorrect diet because the dining system did not match the doctor’s orders.
Performance Evaluations Not Reflective of Past Performance
After a resident died from a choking incident, we reviewed the evaluations of the three staff involved and found that two of the annual evaluations did not mention disciplinary actions issued after the event, and both employees were still rated as “meeting expectations”. Performance evaluation ratings are used to determine salary increases.
$56,766 Paid in Overtime to One Salaried Employee
During the audit period, we found that $56,766 in overtime was paid to one salaried administrative leadership staff member. We reviewed timesheets compared to computer log-in access logs and there were inconsistencies in hours reported and computer activity.
Administrative Assistant Approving Their Manager’s Financial Transactions Totaling $9.7 Million
The administrative assistant role was responsible for approving accounting transactions entered by the accounting manager, even though the position would not have sufficient knowledge of agency operations needed to review those transactions effectively. Individuals approving accounting transactions should have sufficient knowledge and understanding of accounting and agency operations. During the audit, over $9.7 million of expenditures were approved by the administrative assistant.
The full audit report can be viewed here.