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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: 1072536-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Rebecca Mesto Suspected Maltreatment Reported: Allegation One: It was reported that in April 2022, after a vulnerable adult (VA) moved into the facility, the VA’s catheter was not adequately cared for, resulting in a urinary tract infection (UTI). Allegation Two: On May 27, 2022, the VA missed a surgical appointment for kidney stone removal. Allegation Three: On June 13, 2022, staff persons did not change the VA’s undergarments for hours. Allegation Four: The VA required supervision in the community and on July 5, 2022, s/he went to a medical appointment alone. Allegation Five: The VA had a history of choking and on July 14. 2022, s/he was found by him/herself, eating a whole pancake with a broken plastic fork. Date of Incident(s): April to July 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 August 2, 2022; from documentation at the facility; and through eight interviews conducted with an administrative staff person (P1), three facility staff persons (P2, P3, and P4), the VA’s case manager (CM), two of the VA’s guardians (G1 and G2), and a behavior analyst (BA) who worked with the VA. The VA enjoyed watching television and participating in art and gardening activities. The VA’s diagnoses included multiple sclerosis and depression. The VA utilized an electric wheelchair for mobility. The VA’s Emergency Data Form stated that the VA’s food was to be cut into bite sized pieces and s/he was to be within sight of staff persons when eating, to monitor the VA for choking. The VA had no alone time in the community and needed staff person’s accompaniment unless s/he was going to his/her day program. The VA’s Coordinated Services and Supports Plan stated that the facility was to transport the VA to medical appointments and “attend all appointments” with the VA. The VA “repeatedly” called for help from staff persons and could be “angry” with staff persons if s/he needed to wait. Staff persons were to perform catheter care daily to reduce the risk of infection to the VA. The VA’s Coordinated Service and Support Plan Addendum Summary stated that the VA required assistance with meal preparation, medication and treatment administration, activities of daily living, and appointment/transportation management. The VA’s Intensive Support Self-Management Assessment stated that the facility was to schedule all medical and dental appointments and ensure transportation was scheduled. Due to the VA’s diagnosis and limited range of motion, s/he was reliant on staff persons “full assistance” with transfers. The VA had no community alone time and needed staff persons with her at all times, with the exception of attending his/her day program. The facility was a one story home with a basement. The VA had a large bedroom in the basement. There was a Hoyer lift in the VA’s bedroom, which was utilized by staff persons when the VA needed to be transferred in and out of his/her bed. Outside of the VA’s bedroom was a living area. There was a wheelchair stair lift that the VA utilized to go up and down the stairs, with assistance from staff persons. The CM stated that the VA could be a reliable reporter but may get things “mixed up.” G1 stated that the VA was a reliable reporter of “some things.” The BA stated that the VA was diagnosed with dementia, but was a reliable reporter and sometimes his/her responses seemed “exaggerated.” The facility’s Program Abuse Prevention Plan stated that staff persons were trained on the Maltreatment of Vulnerable Adults Act. The facility served clients with a variety of high medical and behavioral needs and created an implemented person centered programs for each client. Facility documentation showed that each staff person interviewed for this investigation received training on the facility’s policies and the Reporting of Maltreatment of Vulnerable Adults Act. P2 and P3 each received training on the VA’s plans. P4 was a substitute staff person and there was no documentation that s/he received training on the VA’s plans. Relevant Rules and/or Statutes:
Allegation One: In April, 2022, after the VA moved into the facility, the VA’s catheter was not adequately cared for, resulting in a UTI. G1 stated that prior to moving to the facility, the VA liked his/her other residence. After the VA moved into the facility in April 2022, a supervisor quit and then there was a consistent lack of communication. After two weeks of moving in, G1 was notified that the VA had a urinary tract infection because the facility did not obtain the correct irrigation supplies for the VA’s catheter from the pharmacy. The VA’s catheter was supposed to be flushed/irrigated two times per day. After G1 was aware of the issue, s/he contacted the VA’s insurance company and was able to solve the issue, but that took an additional two weeks. G2 and the CM each stated that after the VA moved into the facility, there was an issue with the VA’s catheter not being flushed adequately. The facility said that the doctor’s orders that they received did not indicate specifics regarding catheter care. The facility’s Internal Review stated that after the VA moved in, there was an issue with the VA’s catheter care plans because the order received from the VA’s doctor was not detailed enough for the VA’s insurance to cover the supplies needed and was therefore denied. Also at that time, the VA was switching urologists and required an in person appointment prior to completing new orders for the catheter care supplies. The facility did not have any information that the VA sustained a UTI as a result of not having his/her catheter flushed. P1 stated that when the VA moved in to the facility, there were issues with the VA’s doctor’s orders and the VA’s insurance company covering the supplies needed to irrigate the VA’s catheter. P1 assisted in following up with the doctor, the VA’s guardians, and the pharmacy and it was sorted out within a month. P1 was not aware of the VA sustaining a UTI as a result of the catheter not being flushed. P2 and P3 each stated that staff persons flushed the VA’s catheter daily. The VA could not recall any issues with his/her catheter. Conclusion for Allegation One: Consistent information from G1, G2, the CM, and the Internal Review stated that the VA’s catheter was not flushed as needed and that there were issues with the VA’s insurance and doctor’s orders that may have resulted in the catheter not being cared for adequately in the month after the VA moved in in April 2022. Although G1 stated that the VA sustained a UTI as a result, the facility was unaware of the VA having a UTI. In addition, although there was a delay or lack of care provided in regard to the VA’s catheter for a few weeks, it was unclear whether the lack of irrigation of the catheter resulted in additional health issues. Given that the facility attempted to address the VA’s catheter care, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services which were reasonable and necessary to maintain the VA’s physical health. 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). Allegation Two: On May 27, 2022, the VA missed a surgical appointment for kidney stone removal. The Internal Review stated that on May 27, 2022, the VA missed a surgery for kidney stone removal. Documentation showed that all pre-surgery requirements were completed and prior to the date, a former staff person (P5) emailed the VA’s support team, saying the VA was ready for his/her appointment. The reason for the missed surgery was unknown. The VA’s surgery was rescheduled and was completed on July 22, 2022.
The CM was aware that the VA missed a surgical appointment but did not have any information as to why it was missed. The surgery was rescheduled. G1 stated that day prior to the VA’s appointment, G1 communicated with the facility and they said they were ready for the appointment. Later, on the day of the missed appointment, G1 found out that the VA did not go because someone at the facility had an “emergency.” P2 could not recall the VA missing any medical appointments. P3 stated that s/he was aware the VA missed a surgical appointment, but was unaware why. Conclusion for Allegation Two: Consistent information was provided that on May 27, 2022, the VA missed his/her kidney stone removal surgery, but the reason was unknown. Although concerning that the VA missed a surgery appointment, given that the VA’s surgery was rescheduled and completed two months later and there was no information that the delay led to or exacerbated any health concerns, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services which were necessary to maintain the VA’s physical health, which was not the result of an accident or therapeutic conduct. 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). Allegation Three: On June 13, 2022, staff persons did not change the VA’s undergarments for hours. The VA stated that s/he had a call button located on a necklace that s/he wore around his/her neck that s/he used to let staff persons know when s/he required assistance. There were times when the VA had to wait “a long time” for staff persons to help change him/her, but s/he could not recall a time when a staff person refused to change him/her. G2 stated that on the evening of June 13, 2022, s/he received a call from the VA. The VA said that things were not going well at the facility and that s/he had a bowel movement and needed to be changed but staff persons were not changing him/her. G2 went to the facility and it took over an hour for staff persons to change the VA because staff persons were assisting other residents. G2 stated that the facility was “short staffed.” The CM stated that on July 14, 2022, when s/he was visiting the VA, the VA told him/her that on an unknown day, a staff person (the VA did not say the staff person’s name) changed him/her and shortly after, the VA needed to be changed again, but the unnamed staff person refused to change him/her. The CM talked to the VA about staff persons assisting him/her with changing and the VA said that s/he wanted staff persons to change him/her within ten minutes of the VA calling for assistance and then agreed that 20 minutes would be an adequate amount of time. The BA met with the VA at the facility once a week. The VA told the BA that one time, an unnamed staff person “made” him/her sit in his/her soiled clothing for 30 minutes. Two staff persons were needed to transfer the VA into his/her bed to be changed. One day, when the BA was working with the VA, the VA had to wait 15 minutes to be changed because a second staff person was unavailable. The VA was “pretty rigid” in his/her thoughts and wanted to move out one day because a staff person forgot to do the VA’s laundry. The VA sometimes was “flustered and emotional” when s/he did not get what s/he wanted. P1 stated that the VA had a call button that s/he utilized to gain attention of staff persons when s/he needed assistance. Staff persons were to check on the VA “as needed” during the day and every two hours at night. P1 was not aware of any issues with the VA not being changed adequately on June 13, 2022. P2 was not aware of a time when s/he or any other staff person took over an hour to assist the VA when s/he needed to be changed. When the VA called for staff persons, sometimes they were in the middle of helping other residents, but would tell the VA that they would assist him/her in five minutes. Sometimes, it may have taken 20-25 minutes to get back to the VA. If the VA was in his/her wheelchair and needed to be changed, staff persons had to transfer him/her to the bed in order to do so, which took longer. P2 was unaware of a time when any staff person refused to change the VA. P3 stated that the VA was changed two to three times per day and when the VA called for assistance, staff persons assisted him/her. There were times when staff persons could not assist the VA at the time they were called because they were helping other residents, but attended to him/her as soon as they were able to. Sometimes the VA was not okay with waiting and would be “mad.” There were times that staff persons took an hour to change him/her because some staff persons needed assistance of a second staff person to transfer the VA from his/her wheelchair to the bed. P3 was not aware of any staff person refusing to change the VA. The Internal Review stated that due to staff persons no longer being employed at the facility during the time of the incident on June 13, 2022, they were unable to collect information regarding the VA not being changed in a timely manner. The facility was not aware of any staffing shortages or any other issues that occurred during that time. Conclusion for Allegation Three:
The VA had a call button that s/he used to alert staff persons when s/he required assistance. The VA stated that s/he sometimes had to wait “a long time” for staff persons to change him/her. G2 stated that on June 13, 2022, the VA called him/her and said s/he had had a bowel movement and needed to be changed, but staff were not attending to him/her. G2 went to the facility and said the facility was “short staffed” and it took over an hour for staff persons to change the VA because staff persons were assisting other residents. The BA stated that one day when s/he was at the facility, it took staff persons 15 minutes to change the VA because a second staff person was not available right away. P2 and P3 each stated that sometimes when the VA called for assistance, they could not attend to the VA at that moment because they were assisting other residents. P2 said that it may have taken 20-25 minutes to change the VA. P3 stated that it could take an hour to change the VA if other residents were needing assistance or if the VA needed to be transferred using the Hoyer lift because that required two staff persons. The CM stated that the VA told him/her that on an unknown day, the VA said that an unnamed staff person refused to change the VA. The BA stated that the VA told him/her that an unnamed staff person “made” him/her sit in his/her soiled clothing for 30 minutes. When this investigator interviewed the VA, the VA could not recall a time when staff persons refused to change him/her. No staff person interviewed was aware of anyone refusing to change the VA. Although it may have taken staff persons time to attend to the VA’s needs, either because the VA required two persons to change him/her, or that staff persons were attending to other residents, staff persons did assist the VA and since no ill effects were identified as a result of the length of time it took for staff persons to assist the VA, there was not a preponderance of the evidence whether staff persons failed to provide the VA with care or services necessary for his/her health care which was reasonable and necessary to obtain or maintain the VA’s physical or mental health, which was not a result of an accident or therapeutic conduct. 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). Allegation Four: The VA required supervision in the community and on July 5, 2022, s/he went to a medical appointment alone. The VA stated that one day, P5 was supposed to take him/her to a medical appointment, but that day, the VA took the bus and went to the appointment alone. When the VA’s appointment was done, s/he told a nurse that s/he did not know how to get home and the nurse connected him/her with the correct bus and driver to take him/her home. The VA had a cellphone that s/he carried with him/her, but sometimes s/he needed assistance to use the phone. The VA was not able to communicate his/her address. The CM stated that the VA was required to have supervision while in the community and needed a staff person to attend his/her medical appointments because s/he was unable to recall information and did not “report things well.” The VA was “extremely confused” at times and was unable to tell someone his/her address or phone number. The CM was told that the VA attended a medical appointment by him/herself. G1 stated that facility staff persons allowed the VA to go to a medical appointment on his/her own, but “anything could have happened” to the VA. The VA was unable to contact staff persons and did not know his/her address. After G1 found out that the VA attended a medical appointment by him/herself, someone from the facility told him/her that the supervisor that was supposed to accompany the VA had been in a car accident. G1 stated that if s/he had known about the issue, s/he could have attended the appointment with the VA. The BA stated that the VA told him/her that s/he went to a medical appointment on his/her own, which was “a lot” for the VA to do by him/herself. P1 stated that on July 5, 2022, the VA had a medical appointment scheduled. P5 was supposed to go to the appointment with the VA, but was in a car accident, so s/he assigned another (unknown) staff person to take the VA. That unknown staff person did not come to work that day and since there would have not been enough staff persons at the facility to care for the other residents, the staff persons who were working that day allowed the VA to go on the prescheduled bus to and from the appointment alone. After the incident, staff persons were retrained on the VA’s supervision requirements. P2 stated that a staff person was to accompany the VA to any medical appointment. P2 was unaware of a time when the VA went to an appointment on his/her own. P3 stated that one day, a staff person (P3 was not aware which staff person) was supposed to go with the VA to a medical appointment, but that staff person did not come to work that day. A bus had been prearranged to transport the VA to the appointment and when the bus arrived, the driver knocked on the facility’s door and took the VA to the appointment without staff accompaniment. Staff persons were to accompany the VA in the community, but because a staff person did not show up, the VA went alone. The Internal Review stated that on July 5, 2022, the VA had a medical appointment. The facility was “short staffed” and the staff person who was supposed to go with the VA did not come in for his/her shift and P5 was in a car accident, preventing him/her from coming to the facility also. Staff persons who were working at the facility sent the VA on the prearranged bus to his/her medical appointment. The VA attended his/her appointment and came back to the facility without incident. Staff persons were retrained on the VA’s plans and supervision requirements. Conclusion for Allegation Four: The VA’s plans stated that s/he was to have supervision while in the community and required a staff person to accompany him/her to medical appointments. On July 5, 2022, two staff persons did not come to the facility when scheduled, leaving the facility “short staffed.” Staff persons allowed the VA to attend a medical appointment alone by being transported to and from the facility via a prearranged bus, which was a violation of Minnesota Statutes section 245D.07, subdivision 1, paragraph (a). Although sending the VA alone to his/her appointment was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and not in accordance with the VA’s plans of supervision, given there were no adverse effects on the VA and all staff persons were reminded and retrained on the expectations, there was not a preponderance of the evidence whether there was a failure to supply the VA with the care necessary to maintain his/her physical or mental health, which was not a result of an accident or therapeutic conduct. 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). Allegation Five: The VA had a history of choking and on July 14, 2022, s/he was found by him/herself, eating a whole pancake with a broken plastic fork. The VA stated that staff persons “should” cut up his/her food, but at times, P2 did not do that adequately. In the past, the VA sometimes used plastic forks to eat, but one time it broke, so s/he used “regular” forks now. The VA ate meals in his/her room and/or the dining room. The CM and G1 each stated that one day (July 14, 2022), they came to the facility and found the VA sitting downstairs in his/her bedroom, eating a whole pancake, by him/herself. The VA was supposed to have his/her food cut up into bite sized pieces and was supposed to be supervised by staff persons while eating. The VA was using a broken plastic fork. Two staff persons (the CM did not know their names) were working upstairs. The CM went upstairs and asked one staff person for a fork and that staff person gave the CM a dirty fork from the dishwasher. The CM was told by staff persons that the VA did not like plastic forks and broke it on purpose.
P2 and P3 each stated that staff persons were to cut up the VA’s food before serving it to him/her. Neither P2 nor P3 could recall a time when the VA was served a whole pancake, ate alone, or used a plastic fork. Sometimes the VA ate breakfast in his/her room and staff persons were to sit with him/her while eating. P4 stated s/he had only worked at the facility once or twice and was unsure which other staff persons s/he worked with there. P4 recalled that one unknown morning, s/he brought pancakes and a plastic fork to the VA, who was in his/her bedroom downstairs, but could not recall if the pancakes were cut up or whole. There were people visiting with the VA at the time. At some point, the VA broke his/her plastic fork and called for assistance and P4 gave him/her a regular fork. The staff person (P2) who was working with P4 “walked” him/her through the routine and explained what s/he was supposed to do. P1 stated that after s/he was made aware of the incident, s/he talked to both staff persons (P2 and P4) and retrained them on the VA’s food requirements. P4 did not typically work at the facility and was taking instructions from P2 regarding what cares needed to be provided to the VA. The Internal Review stated that on the day of the incident, P4 was brought in from another site to assist with breakfast and morning routines. P4 was not trained on the VA’s food requirements or needs. P4 gave the VA and his/her visitor’s privacy and P4 “assumed” that the VA’s visitors would be able to monitor the VA’s eating. Conclusion for Allegation Five: The VA’s plans stated that the VA was to be monitored for choking while eating and his/her food was to be cut into bite sized pieces. The CM and G1 each stated that on July 14, 2022, they saw the VA eating a whole pancake with a broken plastic fork, alone in his/her bedroom. P4 could not recall if the pancakes s/he served to the VA on the day of the incident, were cut up or whole, but the VA had visitors at the time and P4 did not sit with the VA while eating, as required by his/her plans, which was a violation of Minnesota Statutes, section 245D.07, subdivision 1, paragraph (a). Although the CM and G1 observed the VA alone, eating pancakes which were not cut up into bite-sized pieces, as required by his/her plans, there was no evidence that P4’s action resulted in any injury to the VA. Therefore, there was not a preponderance of the evidence whether there was a lack of care or supervision to the VA, which was not a result of an accident or therapeutic conduct. 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 their policies and procedures were adequate but were not followed by staff persons. On July 5, 2022, a staff persons did not follow the VA’s plans when sending him/her to an appointment alone. On July 14, 2022, staff persons did not follow the VA’s dietary guidelines. The facility revised the VA’s plans to accurately reflect his/her needs and preferences. Staff persons completed retraining on the VA’s plans. In the future when staff persons are subbing at another location, staff persons were to “brief themselves” on each client’s plans. Action Taken by Department of Human Services, Office of Inspector General: On September 21, 2022, the facility was issued a Correction Order for the violation outlined in this report.
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