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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: 1071033-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Danielle Morrison Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was not being taken care of. The VA was not eating or drinking regularly and had lost 30 pounds in a seven month period. The VA was not getting his/her undergarments changed and was soaked in urine. The VA was hospitalized for moderate malnourishment and severe dehydration. There were also two wounds on the VA’s bottom that staff were unaware of. Date of Incident(s): Prior to July 8, 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 15, 2022; from documentation at the facility and medical records; and through seven interviews conducted with two supervisory staff persons (P1 and P2), three facility staff persons (P3, P4, and P5), the VA’s case manager (CM), and the VA’s guardian (G). This investigator also reached out to additional staff persons (P6-P9) by various methods with no response. Another staff person (P10) declined to be interviewed. This investigator met with the VA, but s/he was not able to provide information pertinent to this investigation. The VA’s diagnoses included a brain injury, dementia, affective disorder, dysthymia (persistent depressive disorder), and frequent urinary tract infections (UTIs). The VA enjoyed going out to eat, drinking coffee, and shopping. The G provided the following information: · Sometime at the end of May/beginning of June 2022, the G received a call from P2 stating that the VA had not eaten or drank anything for three days and was just lying in bed. The G had the facility call an ambulance to take the VA to the hospital. At the hospital, bloodwork showed there was “nothing really wrong,” but the VA had “lost a lot of weight.” · On July 7, 2022, the G picked the VA up for a doctor’s appointment. The G asked the facility staff to have the VA ready to go and dressed with a dry absorbent undergarment on; however, when s/he arrived at the facility, it “reek[ed]” of urine. The G said the VA’s whole back was wet and s/he was not in a dry absorbent undergarment. · The VA was only able to take 40 little “stutter” steps with assistance and then had to stop and was out of breath, when s/he had previously been able to walk around the facility on his/her own. · On July 8, 2022, the VA was brought to the hospital where s/he was diagnosed with a septic UTI, dehydration, malnourishment, and Covid-19. · The hospital told the G that if someone was malnourished, dehydrated, and lying in bed, wounds can appear. The hospital staff were not “overly concerned,” but the wounds needed to be cared for. The CM provided the following information: · The VA had severe depression and had lost a lot of weight. The VA lay in bed and staff needed to get him/her up and bathed. · Sores were starting on the VA’s “bottom.” The staff did not assist the VA to change his/her absorbent undergarment, walked away if the VA refused baths, and did not offer bed baths. The staff let the VA just lay there, severely dehydrated, and did not push fluids. · The CM did not know of a medical reason for the weight loss. P1 said the VA had frequent UTIs and mental health issues. The VA refused most cares (bathing, changing, and eating). Staff attempted to bring the VA food and drinks into his/her room, but it was the VA’s choice if s/he ate. A few staff had “good luck” with the VA. P1 did not recall knowing about a sore before the VA went to the hospital as the VA was not compliant to letting the staff check him/her. P2 said the staff worked intensively to get the VA up, out of bed, bathed, and changed. When the VA went into the hospital, s/he was just starting to get up to eat and drink. Prior to that, staff brought food into the VA. P2 thought the VA’s decline might have been related to changes in the house. P3 said that the VA liked to stay in his/her room. When the VA came out of his/her room, s/he enjoyed reading magazines, watching television, and reading the paper. P3 asked the VA if s/he needed help and placed the VA’s clean clothes on the edge of the bed. P3 gave the VA privacy and came back to collect the VA’s dirty clothes. There were times when the VA changed his/her clothes, but did not change his/her absorbent undergarment. P3 reminded the VA that s/he needed to change that as well. The VA looked at P3 and then proceeded to change his/her absorbent undergarment. P3 said s/he encouraged the VA by asking the VA if it was going to be a good day, telling the VA s/he would get breakfast ready, and having the VA come out to breakfast. Once the VA came out of his/her bedroom, P3 went in to clean. P4 said s/he mostly worked overnights and the VA was asleep when P4 worked. When P4 worked a day shift, it depended on the VA’s mood how s/he ate. P4 said the VA was not comfortable with male staff, so the staff got clean clothes ready for the VA and then let him/her dress in privacy. P4 asked the VA if s/he could change the VA’s bedding. P4 said s/he helped the VA, redirected the VA, and encouraged the VA. P5 said the VA liked to do things on his/her own and on certain days the VA did not want to do anything. In the winter, the VA did not like to do anything, but when the weather started getting nice, s/he wanted to do more stuff. P5 encouraged the VA by persuading the VA with something s/he liked. If the VA refused, P5 gave the VA some time and then came back and asked the VA again. Progress notes from the facility from March 1 - July 8, 2022, documented when the VA refused to eat 41 times, bathe 23 times, change 20 times, or leave his/her room 20 times. The notes also detailed when the VA came out of his/her room, when s/he ate, bathed, read magazines, when his/her bedding was changed, and attempts made by staff to encourage the VA to do cares and eat. Facility records showed P2-P5 were trained on the Reporting of Maltreatment of Vulnerable Adults and the VA’s plans. Conclusion: The VA had a steady decline in his/her health from the beginning of 2022. The VA had lost approximately 30 pounds and ended up in the hospital on July 8, 2022, due to a septic UTI, malnourishment, severe dehydration, and Covid-19. P3, P4, and P5 stated that they all encouraged the VA using different approaches. Although there was a decline in the VA’s health, information showed that staff persons were aware of the VA’s refusals and attempts were made to encourage the VA to eat and do cares. When the VA showed increased signs of illness, medical attention was sought, therefore, there was not a preponderance of the evidence whether there was a failure to provide care and services in response to the VA’s needs. 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 found their policies and procedures were followed for the VA. Since the VA’s return from the hospital, the facility implemented a nursing care visit once a week for the VA to check for skin break downs, check the VA’s weight, and food/fluid intake. Action Taken by Department of Human Services, Office of Inspector General: No action taken.
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