|
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: 1053472-RMI (Residential Treatment and Services for Adults with Mental Illness) Investigator(s): Sarah Schumacher Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was found in a bathroom bleeding from significant self-injurious cuts using a shaving razor. Date of Incident(s): July 13, 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 was obtained during a site visit conducted on July 26, 2022; from documentation at the facility; and through three interviews conducted with the VA and two facility supervisors (P1 and P2). The VA’s diagnoses included major depressive disorder, generalized anxiety disorder, and substance use disorder. On May 2, 2022, the VA was admitted to the facility. The VA had a history of suicide attempts. The VA was assessed to be a low risk for self-harm based on being in a controlled setting. Prior to the incident, the VA had a history of self-harm by “cutting” him/herself with the last incident of “cutting” a year prior to admission to the facility. The VA had two previous suicide attempts: one as “a teenager” and one on April 12, 2022, by swimming in a river. The VA reported “suicidal thoughts for years.” The VA’s strengths included being focused, honest, kind, hardworking, and trustworthy. The Critical Incident Reporting Form stated that on July 13, 2022, at 3:34 p.m. the VA was “found in the bathroom with cuts on [his/her] arms.” The VA’s cuts were “severe” and 9-1-1 was called. While waiting for the ambulance, staff persons applied pressure to the VA’s wounds and monitored the VA’s vital signs. When the ambulance arrived, they secured the VA’s wound dressings and transported the VA to the hospital. Concerns were reported regarding the VA’s supervision the day of the incident and the VA having a shaving razor in his/her possession. Regarding the VA’s supervision: Information from interviews and facility documentation was consistent that the VA was supervised as required. At the facility, all clients were checked on hourly but if the VA was “deemed a high enough risk that harm to self or others was probable to occur,” the VA would be placed on 30 minute safety checks and restricted to the facility until assessed by a mental health professional. The day of the incident, the VA required hourly checks and was not deemed a risk requiring 30 minutes checks. However, the VA’s demeanor was identified by P2 as different than usual so from 10:35 a.m. to 2:53 p.m., staff persons interacted with VA and offered therapy, meetings, and assistance with coping skills seven times all of which the VA refused for the exception of attending a group session from 11 to 11:50 a.m. At 3 p.m., P1, P2, a treatment director, a nurse, and a mental health practitioner, met to discuss how to support the VA and decided that the VA would be transported to an emergency room for evaluation. At 3:29 p.m., P2 and the treatment director went to tell the VA but the VA had locked him/herself in a bathroom and would not open the door so they obtained a tool to open the door and that was when they found the VA in the bathroom with cuts on his/her arms. Regarding the VA having a razor in his/her possession: Information from interviews and documentation was consistent that the VA had a shaving razor in his/her possession without staff person knowledge. The VA stated that upon admission, his/her belongings were searched and a shaving razor was removed and stored in the staff person office. The VA stated that s/he had a second shaving razor that s/he could not recall if s/he obtained by purchasing it while residing at the facility or if s/he had it upon admission in belongings where it was not found. Although the VA had a shaving razor in his/her possession which s/he used to make “severe” cuts in his/her arms resulting in hospital admission, given that the VA did not tell anyone s/he had thoughts of self-harm, that the VA was supervised as required, that upon admission the VA’s belongings were searched and one razor was taken, that the VA was in possession of a second razor that staff persons were unaware of, and when the VA was found with cuts, staff persons took immediate action to care for the VA, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. 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). Action Taken by Facility: The facility completed an Internal Review and determined that policies and procedures were adequate and were followed. The facility implemented additional procedures regarding shaving razors and inspections. All razors were replaced with electric type razors and the facility began keeping a physical record of razors and other items checked out and back in by clients. In addition, when clients returned from passes, staff persons were to complete a thorough bag inspection and document the inspection was completed on the client’s pass. Upon intake, staff persons will complete an intake inventory sheet of the client’s possessions so the facility had documentation. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
