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KARE 11 Investigates: A jail death, a missing nurse, a broken contract

A for-profit medical company routinely failed to staff MN jails the way its contracts require. It took a death for Anoka County to act.

ANOKA COUNTY, Minn. — At 1 a.m. on April 28, 2022, Anoka County Detention Deputy Jacob Chamberland was making inmate wellbeing checks. As he walked by the cell where Riley Domeier was housed, he noticed the 20-year-old appeared to have something in his mouth.

The guard couldn’t tell if the man was breathing.

He called for another guard to join him and went into the cell calling out Domeier’s name.

There was no response.

He pushed on the inmate’s shoulder. Still no response.

Incident reports detail how the guards saw foam in the man’s mouth and couldn’t find a pulse.

Deputy Tom Pacholl asked if there was a nurse on duty.

Chamberland responded, “I don’t think there is.”

There was supposed to be.

24/7 Nursing

In the fall of 2020, the Anoka County Board of Commissioners awarded Dr. Todd Leonard and his company – MEnD Correctional Care – a contract to provide medical care for inmates at the Anoka County jail.

A prior KARE 11 investigation exposed how Dr. Leonard and MEnD were given the Anoka contract after providing false and misleading information when they bid on the project. Information, the county failed to fact check.

The contract, worth more than $7.2 million, required MEnD to staff the jail with nurses seven days a week, 24 hours a day, 365 days a year.

Credit: KARE 11
No nurse was on duty when Riley Domeier died in the Anoka County jail.

The night Domeier died on the floor of the Anoka County jail, there was no MEnD nurse to be found.

A simple question

In the months leading up to Domeier’s death, KARE 11 had repeatedly emailed Anoka County asking a simple question about whether MEnD was fulfilling their contractual staffing obligations.

The county obfuscated and refused to answer the question.

The only response to the multiple emails about MEnD staffing came from Anoka County Communications Director Erik Thorson on Mar. 14: “Anoka County has a contract with MEnD Correctional Care for services at our correctional facilities effective October 2020 through the present.”

Communications obtained by KARE 11 through an open records request now reveal that lack of transparency covered up dangerous staffing shortages that Anoka County knew were putting people incarcerated in their jail at risk.

Simply unacceptable

On Dec. 7, 2021, Anoka County sent a letter to Dr. Leonard about staffing shortages and communication difficulties it labeled, “simply unacceptable.”

Among numerous issues cited, the letter raised concern about significant delays in mental health screenings for inmates at the jail.

MEnD was supposed to be providing 40 hours per week of mental health coverage, but the letter states Anoka had gone “several months with only having 2-3 times a week fill in services.”

“We are very concerned that these failings put our inmates at greater risk for suicide or other self-harm while in our facilities,” the letter states. It adds, “We have been paying for these services even though they haven’t been consistently provided.”

Credit: KARE 11
A January 2022 letter to Dr, Leonard emphasized that overnight nursing coverage was critical.

On Jan. 11, 2022, Anoka sent another letter to Dr. Leonard. This one flagged MEnD’s failure to staff the jail with nurses overnight. It states, The bottom line is that Anoka has contracted for and needs 24-hours per day nursing services at the Jail. The current situation of non-coverage from midnight to 6:00 AM cannot continue.”

Despite knowing that their jail was not being staffed appropriately, Anoka County refused to publicly acknowledge the problem when asked by KARE 11.

In contrast, Dakota County was transparent about their move to sign an emergency contract with another medical provider because MEnD was failing to provide required round-the-clock nursing services and was billing for services not provided.

It took a death

Three and a half months after Anoka’s letter to MEnD about “24-hours per day nursing services,” Deputies Chamberland and Pacholl entered Riley Domeier’s cell to see if he was ok.

Incident reports detail how the guards did everything in their power to save the man as they realized there was no nurse on duty.

They tried to clear his airway, began chest compressions and administered oxygen and Narcan, an opioid overdose treatment.

It took close to 15 minutes for EMS to arrive and take over life-saving measures.

At 1:51 a.m. paramedics announced time of death and Riley Domeier, lying on the jail floor, was covered with a white sheet.

Three days later, on May 1, the Anoka County Sheriff’s Office sent out a press release announcing an investigation into the death was underway and was being handled by the Sherburne County Sheriff’s Office.

Credit: KARE 11
The press release about the jail death did not disclose there was no nurse on duty.

“This is a tragic situation in which we anxiously await the results of the investigation and the report from the medical examiner. Our thoughts and prayers remain with the family during this difficult time,” stated Sheriff James Stuart in the release.

Acting on a tip from a source about no nurse being on duty when Domeier had a medical emergency and died, KARE 11 again began asking Anoka County if MEnD was providing the staffing hours the contract mandated?

The question was simple and direct: “Was there a nurse on duty at the time of the death?”

The county spokesperson didn’t answer, citing the open death investigation.

So, without asking about that specific case, on May 5 KARE 11 repeated the question we had been asking repeatedly since early March: “Is MEnD providing the taxpayers of Anoka Co. the staffing hours it is contractually obliged to provide?”

Records would later reveal that on the same day – May 5 – one week after Domeier’s death, Anoka County sent Dr. Leonard a letter notifying him it was terminating the contract early because MEnD was in breach of its contract.

One of the issues cited, “Failure to provide required levels of staffing at all facilities.”

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