ROCHESTER, Minn. — It was after 3 a.m. on Sept. 21, 2021, when Caleb Malek showed up at the door of Zumbro Valley Health Center’s detox unit.
He’d been brought there by staff at his sober home after testing positive for the powerful opioid fentanyl.
Seven hours later, Caleb would be pronounced dead at the very place his mother thinks he should have been the safest.
An investigation would later reveal falsified wellness checks and failures to offer lifesaving care.
At a time when drug overdose deaths continue to plague our nation, advocates for people struggling with substance abuse disorder say they deserve better than the care Caleb received.
Drugs derail athletic promise
Jill Adams recalls with tears in her eyes how her son was carrying a ball as soon as he could walk.
“He loved sports,” she said. “Baseball was his favorite.”
By the time Caleb was at Northfield High School, his talent drew the attention of Major League scouts and offers to play college baseball.
But despite his success, Jill says the pressure took its toll.
“He’s big in size, but he was very tender-hearted and shy,” she remembered.
Caleb turned to the drug Xanax and got hooked. His struggles with substances caused him to return home from college.
“And then somebody introduced him to OxyContin and that was very quick,” Jill said. “He just fell in love instantly.”
Sept. 10, 2021
That’s how, after multiple stints in rehab, Caleb Malek found himself at the door of Zumbro Valley Health Center’s detox unit in the middle of the night.
At his sober home, Caleb admitted taking a drug known as a “Perc 30” — a type of Oxycodone. But counterfeit Percocet pills are sometimes laced with powerful fentanyl. When Caleb tested positive for that, he opted to go to detox to get clean.
His counselor brought him to Zumbro Valley.
For Jill, news that her son was in a detox unit was a relief. It meant she would sleep soundly knowing her son was being cared for. “When he was in detox, I felt safe. I felt like he’s being medically supervised,” she said.
Detox was the last place Jill thought her son would die.
Death investigation
On the night Caleb to came to Zumbro Valley, the agency’s policy stated a staff member should have checked on him at regular intervals.
Jill wondered: If that happened, how could her son have died from the effects of fentanyl seven hours after he arrived?
“I was desperate for an investigation because I knew something wasn’t right,” she said.
For months, Jill called and emailed, demanding that the Minnesota Department of Human Services investigate her son’s death. DHS licenses detox units.
Finally, a year and a half after Caleb died, DHS produced an investigative memorandum finding several failures the night Caleb died. The details were gutting.
Surveillance video showed Caleb did not receive the care promised. Caleb should have been checked on every 15 minutes at first — or hourly later. Neither happened.
Failed wellness checks
The videos showed Caleb entering detox at 3:39 a.m. He’s checked in and then led to his room.
At 3:51 a.m. he went into a bathroom and stayed there for 40 minutes. No one checked on him.
At 6:41 a.m. his roommate left because of Caleb’s loud snoring — a possible sign of respiratory distress.
Again, the video shows no one went to check on him. In fact, according to the DHS report, investigators saw no staff member go near his room between 6:29 and 8 a.m.
Documents show the detox staff logged that they checked on him at 7, 7:30, 8:30 and 9:30 a.m. — even though the state found no one entered his room at all.
Once at 8:16 a.m. a staff member is seen peeking in the room and shutting the door, but they never went inside.
Another two full hours passed without staff checking on Caleb.
At 10:19 a.m. records show Caleb received a phone call on the unit. Another client went to his room to tell him, found he wasn’t breathing and alerted the staff.
“There’s no doubt in my mind had they made even one check, he’d be alive,” Jill said.
Narcan not used
The missed safety checks weren’t the only problems state investigators found.
The DHS investigation concluded that although “staff persons, including a registered nurse, were immediately made aware” that Caleb was not breathing, they “failed to start CPR until five minutes later.”
By not starting CPR quickly, the state found the detox staff failed to supply Caleb with care that was “both reasonable and necessary.”
Caleb was at the detox facility for a possible opioid overdose. For years, the common treatment to reverse an opioid overdose has been to administer naloxone — also known as Narcan.
Despite being a detox facility, the staff didn’t use Narcan to try to revive him.
Staffers, including a registered nurse, told a state investigator they didn’t know how to use it.
“I can’t imagine it”
Alicia House is executive director of Steve Rummler Hope Network, a nonprofit who hands out Narcan and trains people how use the lifesaving drug.
She was shocked that a facility dedicated to helping people safely handle substance withdrawal wouldn’t know how to use Narcan. “I can’t imagine it. I honestly can’t,” she told KARE 11.
As an advocate for people living with substance abuse disorder, Caleb’s case disturbed her. She says quality detoxification treatment is increasingly vital as Minnesota deals with an opioid epidemic.
“I can’t imagine someone dying of an overdose in medical care, especially in a facility that’s meant to specifically monitor them safely during that withdrawal process,” she said. “I think there would be a level of accountability.”
But Jill says there’s been little accountability. The state fined Zumbro Valley Detox just $2,200 for delaying CPR and for falsifying wellness check records.
They weren’t cited for not knowing how to use Narcan. DHS tells KARE 11 Investigates detox facilities weren’t even required to have the drug on premises at that time, even though by 2021 it was widely available.
In 2023, lawmakers finally mandated that detox facilities keep naloxone on hand.
Seeking Justice
Zumbro Valley Health Center declined to do an interview with KARE 11 Investigates. In an email, CEO Beth Krehbeil wrote Zumbro Valley “does not fully agree with the DHS findings related to this matter.”
She went on to say, “Our compassionate and talented staff continues to address the very best ways to manage complex situations, which present themselves especially as the fentanyl crisis grows in our country.”
Jill is still seeking accountability for the failures DHS found.
“I can’t imagine my dog going to a kennel and being treated like this and not being completely appalled. And this is a human life that was suffering,” she said.
She is suing Zumbro Valley for wrongful death. The facility is fighting the suit in court.
Surrounded by her son’s things — his medals from football and weightlifting, a grand slam baseball, his childhood stuffed animal — Jill can’t help but think the stigma surrounding substance use disorder impacted the way Caleb was treated both in life and in death.
“I want justice for my son. He mattered. I feel like he was treated like a sack of garbage in a facility that should have been caring for him.”
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