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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1079030-HCBS (Home and Community-Based Services) Investigator(s): Beth Virden Suspected Maltreatment Reported: It was reported that staff called 9-1-1 for a vulnerable adult (VA) who was sick, and when emergency medical services (EMS) arrived, they found the VA lying in feces and vomit, and with “mottled” skin. The VA was taken via ambulance and died shortly thereafter. Concerns were raised regarding the living conditions at the VA’s apartment, and the overall care prior to the VA’s death. Date of Incident(s): January 17, 2022 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information for this investigation was obtained remotely, including documentation from the facility, law enforcement records and medical records; and through nine interviews conducted with the VA’s guardian (G) who was also the VA’s family member, the VA’s other family members (FM1-FM2), the VA’s case managers (CM1-CM2), facility staff persons (P2-P4), and a supervisory staff person (P1). Attempts by telephone were made to interview staff persons (P5-P6); however, neither responded to the messages left. The VA’s care plans provided the following information: · In April 2021, the VA moved into his/her own apartment. The facility provided at least one staff person, 24 hours a day, who worked at the VA’s apartment to provide in-home supports for the VA. (Note: The Lease Agreement stated that the VA co-leased the apartment with the facility.) · “[The VA] is living by [him/herself] for the first time and struggles with self-help needs. [The VA] does not appear to fully understand how to be independent in this area. Staff will demonstrate, by doing, typical household chores/maintenance as a way to teach [the VA] how to maintain a home.” · “[The VA] will receive support in managing [his/her] health and medical needs, personal assistance and self-care, home management, communication, transportation, cooking, personal security, cognitive and behavior supports, support with establishing and maintaining boundaries and risk mitigation, and engaging in a purposeful day … Staff will work with [the VA] on problem solving, de-escalation skills, coaching on maintaining boundaries and making positive choices. They will also provide items such as light housekeeping, supervision, and socialization provided to [the VA] in [his/her] home and in the community, and reinforcing skill development supports.” · The VA’s diagnoses included mild intellectual disability, cognitive disorder, and seizure disorder. (Note: The VA’s “last known seizure” was in December 2020.) The facility’s Policy and Procedure on Responding to and Reporting Incidents instructed staff to call 9-1-1 if they believed an individual was experiencing a medical emergency, unexpected serious illness, or significant unexpected change in illness or medical condition that may be life-threatening; and to provide any relevant facts and medical history to the 9-1-1 dispatcher. A Saint Paul Police Department Incident Report provided the following information: · On January 17, 2022, at 2:49 p.m., 9-1-1 dispatch received a call from P2 asking for an emergency response to the facility for a sick person; later identified as being the VA. Upon arriving, emergency medical services (EMS) observed “a strong smell of urine in [the VA’s] room, a pill [sic] of clothing at the foot of the bed, [the VA] had puke on the front of [his/her] shirt, soiled [his/her] pants, and was lying on a soiled pillow.” “[EMS] could tell the urine was not fresh due to the pungency of it in the room.” · EMS made contact with the VA, in the VA’s bedroom. The VA was talking and responsive; however, it was determined that s/he should be transported to an emergency room for further evaluation. The VA stood and started to walk out with EMS; however, the VA almost immediately went into cardiac arrest and became unresponsive. EMS transported the VA to the emergency room where s/he was pronounced deceased. · EMS requested that law enforcement officers (LEOs) complete a follow-up visit to the VA’s apartment to document “the living conditions.” · At 4:31 p.m., the LEOs arrived at the VA’s apartment as requested by EMS. Upon entering, the LEOs observed “a noticeable smell of urine in [the VA’s] room and a large pile of clothing and linen at the foot of the bed.” The VA’s bed did not have any bed sheets and was not on a bed frame. There were “brown stains on the pillows and some stains just below the pillows.” However, according to the LEOs, the VA’s bedroom “was not in disarray.” The windows were open and there was a portable fan running in the room. The rest of the apartment, according to the LEOs, “was clean.” The VA was pronounced deceased on January 17, 2022, at 4:05 p.m. The VA’s Autopsy stated that the cause of death was “natural causes” with contributing factors, including adrenal atrophy, calcified meninges, hepatic steatosis, and fatty infiltration of the right heart ventricle. Regarding the VA’s health leading up to his/her death on January 17, 2022: The G, FM1, FM2, CM1, and CM2 provided the following information: · On January 16, 2022, around 3 p.m., the G spoke with the VA on the phone. The VA told the G that s/he was not feeling well and described having a “scrappy throat.” The VA had asked staff to go to the emergency room, but, according to the VA, the staff declined stating that the emergency room would be “too busy” at that time of day. The G told the VA to “make [him/herself] comfortable in the living room.” The G was not aware of the VA having any other imminent health concerns at that time. · The G believed that since the VA had “24/7 staff … they would know if [the VA] was okay or not.” · However, the next day, January 17, 2022, the G was unable to get through on the VA’s cellphone. The G emailed P1 asking if staff could check on the VA. (Note: It was shortly after this email that staff called 9-1-1 for the VA, and then shortly thereafter that the VA was pronounced deceased.) · In hindsight, the G was concerned that staff did not take more immediate action to obtain medical attention for the VA; and that the VA’s death could have been prevented. · CM1-CM2 each said that the VA required 24 hour care and supervision, but that staff did not have to be within sight or hearing, rather they were supposed to check on the VA periodically. · CM1 wondered if staff believed the VA was “more capable” of taking care of him/herself than s/he actually was. CM1 was concerned that staff did not take more immediate action when the VA was not feeling well on January 16, 2022. CM1 said that due to the VA’s chronic health conditions, s/he was more susceptible to complications from illnesses. Historically, when the VA began sick, “It escalated rather quickly.” CM1 said that this information was shared with staff when the VA initially moved into his/her apartment. Facility documentation and P1-P4 provided the following information: · The facility’s staff schedule showed that between January 14 and 17, 2022, P1-P6 worked various shifts at the VA’s apartment with the VA. Each shift was approximately eight hours long and single-staffed. · On January 14, 2022, P2 worked the overnight hours, and P1 and P3 worked during the daytime hours. P1 said that the VA was his/her “same goofy self” on this day and did not show any signs of being sick. P2-P3 each said that the VA was talking and watching a movie, and did not say anything about feeling sick. · The facility’s progress notes, dated January 14, 2022, stated that staff helped the VA setup his/her medication organizer for the upcoming week. The VA helped staff clean his/her apartment and also spent time lying on a living room couch. There was no mention in the progress notes of the VA feeling sick or having symptoms of illness. · On January 15, 2022, P6 worked the overnight hours and P5 worked during the daytime hours. For the facility’s Internal Review, P5 said that the VA appeared “great” on this day and spent most of the time in his/her bedroom. According to P5, the VA did not want to be bothered in his/her bedroom, and asked P5 to leave him/her alone. P5 added that it was “a pretty normal and common” request for the VA to not be bothered when s/he was in his/her bedroom. · The facility’s progress notes, dated January 15, 2022, stated that the VA “refused” his/her “night meds,” and spent most of his/her time in his/her bedroom. There was no mention in the progress notes of the VA feeling sick or having symptoms of illness. · On January 16, 2022, P6 worked the overnight hours and P4 worked during the daytime hours. · At 11 a.m., P4 arrived for the start of his/her shift. The VA was in bed at that time. (Note: Consistent information was provided by P1-P4 that the VA preferred to stay up late at night and sleep-in during the day.) The VA got out of bed around 2:30 p.m., and told P4 that s/he had a headache and needed to go to the emergency room. According to P4, the VA “looked normal,” and was “walking and talking normal.” The VA appeared “good,” except for having a headache. P4 asked the VA if s/he was experiencing other symptoms in addition to the headache; and the VA said, “No.” P4 suggested that the VA take an over-the-counter pain medication for his/her headache; and that they go to the emergency room if the VA’s headache continued after that. The VA said, “No,” and then lay down on the living room couch. The VA fell asleep and remained sleeping on the couch throughout the remainder of P4’s shift. P4 checked on the VA about once an hour by waking the VA up. Each time, the VA declined an over-the-counter pain medication and also declined to take his/her morning medications. When P4 asked the VA if s/he still wanted to go to the emergency room, the VA said, “I’m okay.” [Note: The VA’s Standing Order Medication List stated that if the VA experienced “fever, pain, headache, dental pain, or cramps,” staff were supposed to offer over-the-counter pain medications. “Special Instructions” for this, included that staff were supposed to notify a healthcare professional if the VA had a temperature over 100 °F (degrees Fahrenheit) or under 97.6 °F; if the VA’s fever lasted longer than a 24 hour period; and/or if the VA had a sore throat or congestion.” It was not stated when staff were supposed to check the VA’s temperature and/or if a “headache” should prompt a check of the VA’s temperature.] · The facility’s progress notes, dated January 16, 2022, stated that the VA “refused” his/her “morning meds.” P4 repeatedly offered the VA his/her medications, but the VA “refused” each time. Later that same day, the VA “refused” his/her “night meds.” P4 also documented the VA’s headache in the progress notes, and the discussion about whether to go to the emergency room and the VA’s “refusal” of over-the-counter pain medications. · P1 added that regarding the VA having a headache on January 16, 2022, it was common practice for staff to first offer an over-the-counter pain medication, and “then observe for more concerns and take the person in if more concerns were present.” It was not common practice to take a person to the emergency room for having a headache with no other symptoms. When asked about CM1’s statement that the VA was more susceptible to complications from illnesses and had a history of “escalating quickly” when sick, P1 acknowledged being aware of this concern. However, P1 did not have concerns with how P4 handled the VA’s headache on January 16, 2022. The VA did not have any other symptoms, and staff were not aware of any other health concerns at that time. · On January 17, 2022, the day of the VA’s death, P6 worked the overnight hours, and P2 and P3 worked during the daytime hours. · At 8:30 a.m., P3 arrived for the start of his/her shift in relief of P6. P6 did not relay any noteworthy information to P3 about the VA’s health at that time. However, P3 read P4’s progress notes, from the day prior, about the VA’s headache. P3 went to check on the VA and found the VA using the bathroom. Upon exiting the bathroom, the VA yelled out to P3, “I need to go to the hospital.” P3 responded, “Okay. Let’s go.” However, the VA continued walking past P3, into his/her bedroom, “slamming” and locking the door behind him/her. The VA then yelled out to P3, “Leave me alone.” · When asked how the VA looked at that time, P3 said that s/he saw the VA “very briefly” and the lights were off in that area of the house. P3 could tell the VA was “upset,” but P3 did not observe anything else concerning. · P3 called P1 about the VA’s statement about going to the hospital. · P1 told P3 to bring the VA to the emergency room. However, when P3 told the VA to get ready to go, the VA declined and said that s/he did not want to go. P1 told P3 to continue to check on the VA and offer to bring him/her to the emergency room. (Note: P1 and P3 provided consistent information about what was discussed during this call.) · P3 said that for the remainder of his/her shift, s/he knocked on the VA’s bedroom door about once an hour. Each time, the VA responded, “Go away. Go away.” P3 later said, “I didn’t think [the VA] was that sick. I kept trying to check on [him/her].” · P1 said that at some point after the aforementioned call with P3, the G emailed P1 about the VA not feeling well. The G had spoken with the VA on the phone the day prior, and at that time, the VA was “not sounding good;” and since then, the G had been unable to get through on the VA’s cellphone. The G asked P1 if someone could check on the VA. P1 “immediately” called the house and P2 answered. (Note: P3’s shift had ended at this point, and P2 was now working.) P2 said that when P1 called the house, P2 had been simultaneously preparing to call P1 about the VA. · P2 said that s/he arrived for his/her shift around 2:12 p.m. At that time, P3 told him/her that the VA was not feeling well, and had locked him/herself in his/her bedroom. According to P2, this was “a pattern” for the VA. “[S/he] doesn’t want [staff] to bother [him/her]” in his/her bedroom. · Upon settling in for work, P2 saw feces on the bathroom floor near the toilet. P2 cleaned it up and then went to the VA’s bedroom door to check on him/her. P2 knocked and asked if it was okay to enter the room; the VA agreed. P2 unlocked the door and entered. The VA could not see P2 and asked him/her to move closer to the VA’s bed. · When asked what P2 observed, s/he said that the VA was talking and moving around on his/her bed without issue, but the VA’s skin tone looked “pure white.” P2 believed the VA needed to be seen by a doctor, but the VA was declining to leave. P2 called P1 and put on the speakerphone so that the VA could hear P1 on the other line. P1 told the VA to get up and get ready to go to the emergency room. The VA responded, “Okay. I’m getting ready.” · P2 then told P1 that s/he believed the VA needed to be transported via ambulance because s/he did not believe s/he would have been able to transport the VA in P2’s car. When asked further about this, P2 said, “I told [P1], from what I’m seeing, I don’t think I can bring [the VA] to the hospital.” (Note: P2 did not state whether this was due to the VA’s condition, P2’s car, or some other reason.) · P1 agreed with P2’s assessment to call an ambulance, and also told P2 to call the G. P1 was worried that the VA would change his/her mind about going to the emergency room when the ambulance arrived. P1 knew that if the G was on the phone, s/he would be able to convince the VA to go. · At 2:49 p.m., P2 called 9-1-1 to ask for an EMS response to transport the VA to the emergency room. When EMS arrived, they brought a wheelchair to the VA’s bed to aid in the transport. The VA stood up, but then immediately fell to the floor. P2 heard the VA “gasping for air.” EMS prepared the VA for transport and then loaded the VA into the back of the ambulance. P2 believed the VA was alive when the ambulance left; however, a few hours later, P2 was notified that the VA had passed away. P2 was “shocked.” P2 said that the VA was talking “normal” up until s/he stood up to walk out with EMS. · P1-P4 each said that they did not have any indication that the VA was “that sick” or at risk of serious health concerns. Regarding the VA’s apartment living conditions at the time of his/her death: The G, FM1, FM2, CM1, and CM2 provided the following information: · The G said that following the VA’s death, FM1-FM2 went to the VA’s apartment to clear out his/her belongings. At that time, FM1-FM2 had concerns about the apartment living conditions. The G became emotional when talking to this investigator and said, “[The VA] basically died sitting in urine and vomit.” · FM1-FM2 each said that they went to the VA’s apartment on January 25, 2022, to clear out the VA’s belongings. FM1 said, “Once we got inside, there was a terrible smell of vomit and urine. We started looking around. There was vomit stains everywhere, like no one cared to clean it up when [the VA] got sick. [Staff] just left [him/her] to lay in [his/her] own urine and vomit. It was pretty awful.” The vomit and urine stains started in the living room and continued into the VA’s bedroom. There was vomit on the floor by one of the living room couches. “Both couches were peed up pretty bad.” There were no bed linens on the VA’s bed. “There was urine and vomit everywhere.” According to FM1, the VA’s blanket was covered in “so much urine … it was stiff. And, I don’t think that would happen in a one day period there.” · FM1-FM2 photographed what they observed at the VA’s apartment and provided the photographs for this investigation. The photographs included the following: o Bathroom – 1) the bathtub was un-rinsed with an unknown white cloudy substance surrounding the drain; and 2) the floor mat was mostly covered with shards of toilet paper or other tissue with unknown brown and red stains on some of the shards. o Living Room – 1) the carpet in the front of the couch had unknown yellow, brown, and red stains; 2) the couch had fabric missing from the center cushion exposing the foam cushion underneath; 3) there were unopened food items, including pudding cups, fruit cups, and juice boxes, arranged on the floor near the couch; and 4) there were four or more blankets stacked loosely on the couch with no obvious stains on the blankets or couch based on the photographs. o Unidentified Doorframe – 1) there was a crack in the wood, which did not appear to interfere with the door opening or closing; o Bedroom – 1) the mattress pad was removed exposing a mattress with at least seven unidentified brownish-yellow stains about the size of a standard adult hand, including some stains along the side of the mattress; 2) there were two mostly yellow-stained pillows with no pillow cases or coverings; 3) there were at least two comforter-type blankets thrown loosely on the bed with no clear picture and so the cleanliness of blankets was unknown; 4) there was at least one blanket and other unidentified fabrics, possibly clothing, lying in pile on the floor near the foot of the bed; 5) there was a floor lamp; 6) a nightstand with lamp; and 7) minimal food items and beverage containers on the floor and nightstand. o Apartment Building Entryway – this area was shared with other apartments in same building – 1) there was an unknown number of used, discarded cigarette ends on floor; and 2) the radiator exchange was mostly covered with lint or dust. o Apartment Building Exterior – the exterior sidewalk and driveway were snow-covered and not shoveled. Facility documentation and P1-P4 provided the following information: · As previously stated, the VA moved into his/her apartment in April 2021. At that time, the VA’s care plans, including Individual Abuse Prevention Plan, were created and included the following information: o “[The VA] struggled with incontinence at night. Bridges staff will encourage [the VA] to use the restroom before bedtime. Bridges staff will support [the VA] with laundering any soiled bedding or clothing as needed.” o “Per [the VA], [s/he] has an aversion to showering and cleaning self/area after a urine/fecal incontinence issue. Staff will prompt and model to [the VA] how to clean the area (launder clothes/bedding, take out trash, etc.). Informal talks will occur about the importance of bodily cleanliness and how it relates to [the VA’s] physical and mental health.” o “When [the VA] is unwilling to clean the area (launder clothes/bedding, take out trash, etc.), staff will do it for [him/her]. Bridges staff will work with [the VA] on developing and maintaining a self-care schedule for bathing and grooming. Bridges staff will support [the VA] with strengthening [his/her] skills with bathing, practicing good hygiene, and verbally praise [him/her] for utilizing these skills. Bridges MN staff will verbally prompt [the VA] to use the restroom before bedtime.” · P2 said that the VA was “always” leaving feces around his/her apartment. “[The VA] doesn’t control [him/herself].” According to P2, staff would typically be the ones to clean up any feces left behind. P2 never saw vomit around the VA’s apartment. · P4 said that the VA’s apartment was “usually a mess.” Whenever P4 worked with the VA, s/he would ask the VA to help clean and the two of them would clean together. P4 was not aware of there being uncleaned vomit or feces around the VA’s apartment on January 16, 2022. · P3 said that it was “an everyday thing” for the VA to leave feces around his/her apartment. “I observe it all the time.” “Some staff clean it. Some staff don’t.” Regarding January 17, 2022, the day of the VA’s death, the VA “refused” to let P3 enter the VA’s bedroom. P3 did not know if there was any feces or vomit in the VA’s bedroom because s/he never entered the room. “I don’t know if [the VA] did that (feces and vomit) on my shift. I’m not sure. It could have been from over the weekend. It was a regular thing for [him/her].” · P2 said that when s/he entered the VA’s bedroom and eventually called 9-1-1 on January 17, 2022, s/he saw “watery … feces” on the VA’s bed. P2 did not see any vomit or other hygiene concerns around the apartment at that time. · When asked if there was any tracking at the facility regarding when or how often the VA’s bed linens were washed or the VA’s apartment was cleaned, the facility said that there was no official documentation for this; this was not something commonly tracked for the VA. (Note: In requesting documentation for this investigation, a quality assurance staff person said that they saw random mentions in the staff daily notes about asking the VA to do his/her laundry and the VA would sometimes agree or sometimes ask to wait. However this was not consistently tracked or recorded in the daily notes, and so the exact number of times staff asked about this is unknown.) Regarding the VA’s missed appointments and medications: The G, FM1, FM2, CM1, and CM2 provided the following information: · The G stated that prior to the VA’s death, staff had not been taking the VA to his/her medical appointments and that as a result, the VA had missed most appointments since moving into his/her apartment. · FM1 said that when s/he was clearing out the VA’s belongings on January 25, 2022, s/he came across the VA’s medication organizer. According to this, the VA had not taken his/her medications since the morning of January 15, 2022. (Note: The VA died around 3 p.m., on January 17, 2022.) The VA missed his/her evening medications on January 15, 2022; morning and evening medications on January 16, 2022; and morning medications on January 17, 2022. · The VA’s medications included: o Levothyroxine (thyroid hormones) 200 micrograms (mcg) – take one tablet every morning; o Levothyroxine (thyroid hormones) 50 mcg – take one tablet every morning; o Desmopressin (antidiuretic) 0.1 milligrams (mg) – take one tablet every morning; o Sertraline (antidepressant) 100 mg – take one tablet daily; o Carbamazepine (anticonvulsant) 200 mg – take two capsules twice daily; o Methylphenidate (central nervous stimulant) 40 mg – take once daily; o Omnitrope 5 mg (growth hormone) – inject 1.3 mg subcutaneously once daily; and o Over-the-counter vitamins and digestive supports. · The G said that s/he was supposed to be receiving weekly updates from the facility regarding the VA, including if the VA missed any medications. However, the G said that since the VA moved in, s/he had only received two or three weekly updates. The G was also never notified of the VA missing medications. (Note: This failure was in violation of Minnesota Statutes section 245D.05, subdivision 4, paragraph (b), clause (2), which states that the license holder must report a person's refusal or failure to take or receive medication or treatment as prescribed to the person's legal representative and case manager as they occur or as otherwise directed in the coordinated service and support plan or the coordinated service and support plan addendum.) Facility documentation and P1-P4 provided the following information: · The VA’s Individual Abuse Prevention Plan and Intensive Support Self-Management Assessment included the following: o “[The VA] is inconsistent with taking [his/her] medications. Staff will administer medications, track compliance, and work with [the VA] on making and attending appointments … When [the VA] declines medications, staff will ensure they are prompting 3 times and discussing the importance of maintaining a consistent routine with medications. If [the VA] continues to decline, staff will notify the nurse and document on appropriate forms. [The VA’s] team will be notified during the weekly updates. If [the VA] continues to decline medication, Bridges MN nurse and [a supervisor] will consult with the doctor to discuss alternatives and/or a team meeting will be requested.” o “[The VA] may not remember the frequency in which [s/he] should schedule [his/her] appointments. [S/he] will sleep through appointments based on how [s/he] feels that particular day.” o “Bridges staff will coordinate, schedule and transport [the VA] to [his/her] appointments.” o “The current amount of [the VA’s] medication refusals does put [his/her] health and mental health at risk. [The VA] neglects [his/her] medical health and physical health. Energy and motivation to care for self is a challenge for [the VA].” · According to the VA’s Medication Administration Records, staff marked that the VA “refused” his/her medications (listed above) on January 2, 3, 16, and 17, 2022. (Note: The VA’s Carbamazepine was also missed on January 15, 2022, which meant that the VA missed four doses in a row of this medication. All other medications were missed for two doses in a row.) · Note: The facility did not have documentation that the prescriber or nurse was ever notified of the VA’s missed medications. This failure was in violation of Minnesota Statutes section 245D.05, subdivision 2, paragraph (a), clause (5), which states that "medication administration" means reporting to the prescriber or a nurse any concerns about the medication or treatment, including side effects, effectiveness, or a pattern of the person refusing to take the medication or treatment as prescribed. · According to www.drugs.com, the following additional information was provided regarding the VA’s medications: o Sertraline (antidepressant) – Use exactly as prescribed by your doctor. If a dose is missed, skip the missed dose if it is almost time for your next dose. Do not take two doses at one time. Do not stop using sertraline suddenly, or you could have unpleasant symptoms (such as agitation, confusion, tingling or electric shock feelings). Ask your doctor before stopping the medicine. Seek medical attention right away if you have symptoms of serotonin syndrome, such as: agitation, hallucinations, fever, sweating, shivering, fast heart rate, muscle stiffness, twitching, loss of coordination, nausea, vomiting, or diarrhea. o Carbamazepine (anticonvulsant) – Use exactly as prescribed by your doctor. If a dose is missed, skip the missed dose if it is almost time for your next dose. Do not take two doses at one time. Do not stop using carbamazepine suddenly, even if you feel fine. Stopping suddenly may cause increased seizures. Follow your doctor's instructions about tapering your dose. Carbamazepine may cause serious blood problems or a life-threatening skin rash or allergic reaction. Call your doctor if you have a fever, unusual weakness, bleeding, bruising, or a skin rash that causes blistering and peeling. o Methylphenidate (central nervous stimulant) – Use exactly as prescribed by your doctor. If a dose is missed, skip the missed dose if it is almost time for your next dose. Do not take two doses at one time. Stimulants have caused stroke, heart attack, and sudden death in people with high blood pressure, heart disease, or a heart defect. Call your doctor right away if you have: signs of heart problems - chest pain, feeling light-headed or short of breath; signs of psychosis - paranoia, aggression, new behavior problems, seeing or hearing things that are not real; signs of circulation problems - unexplained wounds on your fingers or toes. o Omnitrope (growth hormone) – Use exactly as prescribed by your doctor. If a dose is missed, use the missed dose as soon as you remember. Skip the missed dose if it is almost time for your next scheduled dose. Do not use extra medicine to make up the missed dose. Call your doctor if you miss more than 3 doses in a row. · The VA’s Autopsy showed that at the time of his/her death, s/he had in his/her blood toxicology: Carbamazepine, Sertraline, Desmethylsertraline (a metabolite of the antidepressant drug sertraline), and Zonisamide (used in combination with other medications to treat certain types of seizures). · P1 added that the VA at times “refused” to go to his/her medical appointments. P1 was in charge of scheduling the VA’s appointments. P1 was not aware of outstanding or missed appointments at the time of the VA’s death. “[S/he] wasn’t missing any to the best of my knowledge.” · According to the VA’s medical appointment records, s/he attended an appointment with his/her primary doctor on June 24, 2021. The VA’s bloodwork was unremarkable. The VA’s Levothyroxine dosage was adjusted. The doctor ordered that the VA follow up with a doctor who treated a specific gender and complete additional bloodwork in six weeks to recheck his/her thyroid functioning. Nothing else of concern noted. · The VA attended another appointment on August 9, 2021. The VA’s Methylphenidate was refilled and s/he was ordered to schedule a three month follow-up appointment for another refill. The follow-up appointment could be virtual or in-person. (Note: This investigator did not find a record of this follow-up appointment; however, at the time of the VA’s death on January 17, 2022, the VA had a prescription for Methylphenidate, and therefore, it appeared this appointment was either attended or in some other way the VA’s Methylphenidate was refilled.) Facility documentation stated that the staff persons interviewed for this investigation received training on the VA’s care plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Minnesota Statutes and Rules: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (5) and paragraph (b), clauses (8) and (9), states that a person’s protection-related rights include the right to receive services in a clean and safe environment when the license holder was the owner, lessor, or tenant of the service site and the right to have a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects, and free from hazards that threaten the person’s health or safety. Minnesota Statutes 245D.07, subdivision 1, states that the license holder must provide services as assigned in the coordinated services and support plan. Minnesota Statutes 245D.09, subdivision 2, stated that the license holder must provide adequate supervision of staff providing direct support to ensure the health, safety, and protection of rights of each person and implementation of the responsibilities assigned to the license holder in each person's coordinated service and support plan or coordinated service and support plan addendum. Conclusion: A. Maltreatment On January 17, 2022, P2 called 9-1-1 for the VA, and shortly after EMS arrived, the VA became unresponsive and was later pronounced deceased. Concerns were raised regarding the VA’s overall care prior to the VA’s death and the living conditions at the VA’s apartment. Regarding the VA’s health leading up to January 17, 2022: P1-P4 and facility documentation provided consistent information that in the days leading up to the VA’s death, s/he did not show signs of illness or any indication of what was to come. The day prior to his/her death, the VA had a headache. P4 offered over-the-counter pain medication, which was consistent with the VA’s Standing Order Medication List, and when P4 later asked if the VA wanted to go to an emergency room, the VA declined and said, “I’m okay.” P3 worked with the VA during the morning on the day of his/her death. P3 observed that the VA was “upset” but did not observe anything else concerning. The VA initially told P3 that s/he wanted to go to the emergency room, but when P3 responded, the VA went into his/her bedroom and told P3, “Leave me alone.” P3 continued to knock on the VA’s bedroom door throughout the morning, and each time, the VA stated, “Go away.” P3 later said, “I didn’t think [the VA] was that sick. I kept trying to check on [him/her].” When P2 started work, s/he checked on the VA and had concerns with the VA’s skin tone. P2 did not believe that s/he would be able to transport the VA in his/her vehicle to the emergency room. P2 called 9-1-1, and then P1 and the G. P2’s actions were consistent with the facility’s Policy and Procedure on Responding to and Reporting Incidents. Given that staff checked on the VA approximately once an hour when s/he was in his/her bedroom or on the couch; that more than once the VA declined help from staff; and that staff did not initially observe anything concerning or signs of illness, but when they did observe these things, they called 9-1-1, there was not a preponderance of the evidence whether the staff actions could have prevented the outcome given that the VA’s cause of death was “natural causes,” and/or whether there was a failure by staff to supply the VA with care or services which were reasonable and necessary to obtain or maintain health or safety. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Regarding the VA’s apartment living conditions at the time of his/her death: The VA’s care plans provided information that: “[The VA] is living by [him/herself] for the first time and struggles with self-help needs. [The VA] does not appear to fully understand how to be independent in this area. Staff will demonstrate, by doing, typical household chores/maintenance as a way to teach [the VA] how to maintain a home.” The VA “will receive support in managing [his/her] ... self-care, home management, ... They will also provide light housekeeping, . . . and reinforcing skill development supports. When EMS arrived to the facility in response to the 9-1-1 call, EMS smelled a “strong smell of urine” that was “not fresh due to the pungency of it in the room.” EMS then requested the LEO to go to the facility to document the VA’s living conditions. Upon their arrival there was a “noticeable smell of urine and “brown stains on the pillow.” FM1 and FM2 went to the VA’s apartment and said there was a “terrible smell of vomit and urine,” both couches “were peed up pretty bad,” and the VA’s blanket was covered in “so much urine … it was stiff. And, I don’t think that would happen in a one day period.” Photos taken of the apartment supported that unknown substances, likely dried feces, vomit, and urine, were observed in inappropriate and unhygienic places in the VA’s apartment. The condition of the VA’s apartment that s/he co-leased with the facility was a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (5) and paragraph (b), clauses (8) and (9). P1-P4 each said that the VA struggled with hygiene and that this was a common occurrence. Staff would sometimes help the VA clean his/her apartment. Progress notes showed that a staff person and the VA cleaned the VA’s apartment on January 14, 2022; three days prior to the VA’s death. However, P1-P4 each said that the VA would “always” leave feces around. In the days prior to the VA’s death, the VA was in his/her bedroom with the door locked and declining staff access. P3 said that s/he did not enter the VA’s bedroom and so did not know if there was any uncleaned feces, vomit, or urine in the VA’s bedroom at the time of his/her death. However, the photo of the living room showed that there was likely urine, vomit, or feces on the carpet in front of the couch. The VA had at least one staff person in his/her home 24 hours a day. In addition, to the VA’s care plans as above, the VA’s Individual Service Plan stated, “When [the VA] is unwilling to clean the area (launder clothes/bedding, take out trash, etc.), staff will do it for [him/her].” Given the condition of the VA’s apartment as documented via photographs, there was an apparent lack of oversight and supervision for the staff assigned to work there in implementing the VA’s plans, which was a violation of Minnesota Statutes 245D.07, subdivision 1 and Minnesota Statutes 245D.09, subdivision 2. Given the observations of the condition of the VA’s apartment, including areas that according to staff persons, the VA had not been in for at least one day prior to his/her death, there was a preponderance of the evidence that the VA did not receive services as prescribed by his/her care plans which posed a serious risk of harm to the VA’s physical and mental health, and represented a failure to provide the VA with reasonable and necessary care or services. It was determined that neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct.). Regarding the VA’s missed appointments and medications: P1-P4 and facility documentation provided consistent information that the VA routinely “refused” to take his/her medications and/or to go to his/her medical appointments. P1 was in charge of scheduling the VA’s appointments and was not aware of outstanding or missed appointments at the time of the VA’s death. The VA’s medical appointment records showed that s/he attended at least two appointments in the seven months prior to his/her death; and there was no information during these appointments of any imminent medical concerns. The VA’s Medication Administration Records showed that the VA missed two doses in a row of most of his/her medications (January 16 and 17, 2022); and four doses of one of his/her medications (January 15 through 17, 2022). The VA had missed these same medications earlier in the month (January 2 and 3, 2022) without apparent issue. According to www.drugs.com, there were symptoms to watch for and when to seek medical attention; the VA did not appear to have any of these symptoms and only told staff about a headache on January 16, 2022. Given that there was no information the missed appointments or medications contributed to, or could have prevented, the outcome; and that there was no information staff observed symptoms of medication withdrawal or other concerns relating to the missed medications, there was not a preponderance of the evidence whether there was a failure by staff to supply the VA with care or services which were reasonable and necessary to obtain or maintain health or safety. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. Although it would have been reasonable for individual staff persons to implement the VA’s care plans and support the VA in the cleaning and maintaining his/her environment, given that the facility co-leased the apartment with the VA, the facility’s failure to monitor the implementation of the VA’s plans, which was a violation as outlined above, individual staff persons responsibility was mitigated and the facility was responsible for the maltreatment of the VA. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the facility was responsible did not meet statutory criteria to be determined as serious because there was no information that the condition of the VA’s apartment contributed to his/her death. Action Taken by Facility: The facility completed an internal review, and determined that policies and procedures were adequate and followed. Action Taken by Department of Human Services, Office of Inspector General: On June 27, 2022, the facility was issued a Determination of Maltreatment. Based on the determination of substantiated maltreatment and the nature, severity, and chronicity of licensing violations an Order of License Revocation was also issued. The maltreatment determination and the revocation are each subject to appeal.
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