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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: 1098882-HCBS (Home and Community-Based Services) Investigator(s): Lindsay Arth Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) missed multiple medical appointments with his/her psychiatrist. As a result, the VA was “discharged” from seeing his/her psychiatrist and had an increase in “intense” seizures. Date of Incident(s): Prior to June 9, 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 September 7, 2022; from documentation at the facility and medical records; and through seven interviews conducted with the VA, three supervisory staff persons (SP1, SP2, and SP3), the VA’s case manager (CM), a staff person from the VA’s current home (the P), and a staff person from the VA’s day program (the D). Attempts were made to contact and interview the VA’s medical doctor (MD) who was a psychiatrist, but the attempts were not successful. However, this investigator obtained medical records from the MD’s office and that information is provided below. The facility provided crisis respite to clients, including the VA, in a hotel. The clients had their own bedrooms, a small living room, and kitchen area. The VA was diagnosed with cerebral palsy and unspecified mood disorder. The VA also had a history of pseudo seizures (often stressed induced unlike epileptic seizures). The VA liked video games, wrestling, and his/her faith. The VA was not subject to guardianship. The VA’s Coordinated Services and Supports Plan Addendum Intensive Services provided the following information: · The VA received crisis respite services from the facility while a long-term foster care placement was “identified and secured.” The VA received 24/7 services or as needed. Staff persons were to assist the VA with getting ready each morning, including for his/her day program during the week. Additionally, staff persons assisted the VA when s/he returned from his/her day program. · The VA was “dependent” on the facility for all his/her medical appointments and the facility was responsible for scheduling and facilitating all appointments. · The VA was non-verbal and used a “tablet” to communicate. · The VA had pseudo seizures that were triggered by stress and environmental factors. Staff persons were trained in seizure reduction measures and the VA’s seizure protocol. The VA’s Service Plan said that the VA was a “good reporter” but that it was “difficult” for the VA to communicate. The VA was “not resistant” to care. The VA “leans on [his/her] staff” to make appointments and “facilitate” appointments for him/her. The CM provided the following information: · The VA lived at the facility from November 4, 2021, to June 6, 2022. The VA had staff scheduled with him/her at various times but had a “few hours” of unsupervised time without staff persons. However, the VA could reach staff persons via email when needed. · The VA was a “pretty accurate” reporter but may “leave details out.” · The facility, including SP2, was “responsible” for “taking charge” regarding the VA’s medical appointments. This included providing coordination and transportation so that the VA was “supported” with doctor’s visits to ensure the VA’s health and safety needs were met.
· The VA had a “long history” of pseudo seizures which were typically “triggered” by stress. These seizures caused the VA to be fatigued. While at the facility, the VA “did not get along” with some staff persons which caused an increase in pseudo seizures. The VA saw the MD for this and was prescribed Depakote. The MD “requested” for appointments to be scheduled with him/her with “help” from the facility. This included an appointment that the facility “agreed” to take the VA to on March 2, 2022. However, the CM did not know if the VA attended that appointment and at some point after, the VA was “discharged” from the MD’s care due to the “amount of missed appointments.” The VA then had an increase in pseudo seizures. The CM said that the facility “neglected” the VA’s medical needs which caused the VA “further harm.” · The CM said that the P tried to “appeal” to get the VA back to see the MD but did “not succeed.” Additionally, the P “pursued” other psychiatrists but it was “difficult” to get the VA into one. · The VA had worked with his/her doctors a “very long time” and did not have a history of refusing any appointments. The facility never notified the CM of any missed appointments or that the VA refused to attend appointments. The VA’s health was “very important” to the VA and the VA “knows [s/he] needs to see [his/her] doctor regularly.” · On June 6, 2022, the VA moved to another facility where the VA started to have “more violent” pseudo seizures lasting 30 minutes each, including some that required hospitalizations. During one “intense” seizure, the VA broke a recliner chair. Another time, the VA had a pseudo seizure while in the bathroom and fell and hit his/her head on the floor. The VA’s pseudo seizures were “getting more out of hand.” · On August 1, 2022, the VA was admitted to the hospital for a “very intense” pseudo seizure lasting 30 minutes. A doctor at the hospital noted that the VA was “under treated” and made a referral for the VA to see a new psychiatrist. The VA said staff persons scheduled appointments for him/her. The VA did not see the MD while s/he lived at the facility and did not know why. The VA did not know how many appointments with the MD s/he missed. The VA had seizures as a result of the missed appointments with the MD. Medical records from Allina Health and the Chronology Item Summary from the CM provided the following information: · The VA’s “communication method” was via “MyChart [Online medical platform where upcoming appointments, appointment reminders, and appointment summaries were located],” which the VA was “active on.” The VA was “instructed” that medical “results and communications” would be made via MyChart. · Medical records showed that the VA had been seeing the MD since at least September 29, 2020, prior to living at the facility. · On January 18, 2022, it was noted by the VA’s therapist that s/he was “requesting psychiatry consult” for the VA (Note: There was no additional information provided regarding this). The VA had been seen by the MD prior so contact information for the MD’s office was provided so that staff persons could schedule an appointment with the MD. · On February 14, 2022, the VA had a telehealth appointment scheduled with the MD (Note: It was not noted who scheduled this appointment). However, the VA “failed” to attend the appointment and had a “late cancel” due to “conflict.” · On February 15, 2022, the MD sent the VA a letter stating that the appointment on February 14, 2022, was cancelled within 24 hours of the appointment time. The letter further stated that attending appointments as “clinically indicated” was an integral part of treatment. Therefore, patients who missed an appointment or cancelled within 24 hours were notified via a letter. Patients who missed three appointments may be unable to continue care. This was the VA’s “first follow up late cancelled visit.” There may also be a $50 charge for missed or late cancelled appointments (Note: It was not known if the VA was billed for this). · On February 20, 2022, the VA was seen in the emergency room for seizures. The VA was to follow up with his/her primary doctor in “one week.” It was also noted that “per chart review, [the VA] missed a recent appointment with [his/her] psychiatrist [the MD].” A team meeting to discuss “coordination of care and general treatment” was scheduled for February 24, 2022. · On February 24, 2022, the VA was seen for increased pseudo seizures with his/her primary doctor. The MD, the CM, SP1, and SP2 were also present. During this appointment, the VA’s pseudo seizures were discussed, including how to manage them. The MD said that the VA’s seizures were likely caused by “mental health struggles.” The VA was to start Depakote and the VA was to also see “neurology” to “rule out any other concerns or true seizures” with an electroencephalogram (EEG). The MD also signed a “seizure plan of care” at this time. · The Chronology Item Summary from the CM showed that SP1 “shared” via an email that the MD scheduled a virtual appointment with the VA for March 2, 2022, at 3:30 p.m. · On February 26, 2022, the VA was sent an “appointment reminder” about an upcoming appointment but the date of the upcoming appointment was not noted. The “appointment reminder” was “not read.” · On March 2, 2022, the VA had a “failed [telehealth] appointment” for medication management with the MD. This was a “failed appointment no show.” The plan was to schedule the next visit in person. · On March 9, 2022, the VA saw the MD for “medication management.” The VA had an increased frequency of “uncontrolled motor activity thought to be pseudo seizures in recent months.” The MD “re-started” the VA on Depakote approximately one week prior and the MD was told by staff persons that the “frequency of such episodes” had decreased “considerably” over the last week. The VA said that s/he “tolerated” the Depakote “well.” The VA was to see the MD again in two months via “video” and three to four months in person (Note: It was not noted if these had been scheduled at that time). · On May 19, 2022, the VA had a virtual appointment with the MD for follow up for “medication management.” The “auto confirm status” noted that the appointment was “confirmed.” However, the VA “cancelled” due to “illness.” · On June 8, 2022, the VA had a “failed appointment no show” with the MD and the reason for the missed appointment was “unknown.” On June 9, 2022, the VA was “dismissed from psychiatry.” On this date, the MD sent the VA a letter stating that it was “in regards” to an appointment with the MD on June 8, 2022, that was “missed.” As had been “discussed” with the VA previously, regular attendance to appointments was an integral part of the VA’s care. Because the VA had been unable to adhere to the MD’s “attendance policy,” the VA was no longer able to schedule appointments with the MD or “any other psychiatrist with the Allina Mental Health clinics.” If the VA had additional visits scheduled, those had been “cancelled.” If the VA wanted to “re-establish care with an Allina Mental Health Psychiatrist,” the VA could “consider” writing a letter outlining the reasons why the VA would now be able to attend his/her appointments. · On June 28, 2022, it was noted that the VA had seizures “very frequently,” up to 15 times per day, which were “frequent enough to be concerning.” However, the VA took medications for seizures that “help[ed].” It was noted that the VA needed a referral for a psychiatrist due to the VA’s seizures. The VA’s prior clinic (the MD) discharged the VA as a client “due to no shows” because the facility was “unable” to get the VA to appointments and the VA “missed too many appointments.” The P was trying to get the VA into a new psychiatrist. · On August 1, 2022, it noted that the VA had been “struggling” to get to appointments when s/he lived at the facility. The MD prescribed Depakote “early this spring with reduction in episodes.” However, the VA was “discharged” from the MD’s office due to “frequent missed appointments” and had not had “follow up” for his/her seizures since March 2022. The P provided the following information: · The VA moved to the P’s home on June 6, 2022. When the VA moved, the facility emailed the P a list of the VA’s upcoming medical appointments so that the P could “take over.” However, the VA had a scheduled appointment with the MD on June 8 or 9, 2022, which the facility had not told the P about so the VA missed that appointment. As a result, the MD said that s/he could no longer “accept” the VA as a patient as the VA had missed “so many appointments.” The MD’s office also told the P that the VA missed appointments on February 15 (Note: Information from medical records showed that it was on February 14, 2022) and May 20, 2022. · The P talked to the MD and “sent a letter” to try to get the VA back into the MD’s office. The P told the MD that they would ensure the VA “did not miss appointments” as the VA needed to see the MD. However, that was “denied.” The P then tried to get the VA into other psychiatrists but there were no openings. · The VA was “dependent” on staff persons to “do [his/her] cares,” including appointments. Staff persons needed to tell the VA of appointments prior and assist the VA with getting ready. Staff persons also had to transport the VA. The VA had “never” refused appointments. However, the VA may want to go home when s/he was at an appointment but if staff persons told the VA that s/he needed to “wait” to see the doctor, the VA was “okay.” The D provided the following information: · Staff persons from the VA’s day program had a “really hard time” working with the facility due to “lack of communication.” · The VA was an accurate reporter of information. However, the VA may have some difficultly recalling “specific details” about past events. · At some point, SP2 asked the D to coordinate Metro Mobility (shared ride transportation service) from the VA’s day program to an appointment (The D did not know what the appointment was for). The D told SP2 that they would not be able to do that. · Staff persons should schedule the VA’s appointments but the VA should also be “looped” in and get an email confirmation. Staff persons should also provide transportation to the VA. The D was not aware of the VA refusing to attend medical appointments. The VA attended some appointments while the VA lived at the facility but not to the “frequency” it was happening after the VA moved out. The D was not aware of the VA missing appointments until the P told him/her that the VA was no longer able to see the MD because the VA missed “so many.” SP1 and the Internal Review completed by SP1 provided the following information: · SP2 worked with the VA to assist and “manage” the VA’s medical appointments. This included providing transportation to the VA and scheduling appointments. SP1 thought that SP2 had a “planner” to keep track of these appointments. · SP1 spoke to both SP2 and SP3 who said that the VA missed “several appointments” due to COVID-19, because the VA was “exhausted” and refused to attend, due to the weather, and because the VA had a “paid internship.” However, when these things occurred, staff persons cancelled and “rescheduled” those appointments. SP1 did not know if any of those appointments were with the MD. Additionally, SP2 met with the VA’s new placement and provided them “all” of the VA’s appointments and spent an “hour” doing so. SP1 was not aware of SP2 “dropping that ball” regarding scheduling, re-scheduling, or attending the VA’s medical appointments. · The VA also had a history of refusing to go to medical appointments. However, it was SP2’s “role” to follow up with the VA’s medical providers if the VA refused to go. Additionally, prior to the VA living at the facility, the VA had a “not great track record” of “consistently” attending medical appointments. SP2 provided the following information: · SP2 “escorted” the VA to his/her doctors’ appointments and provided transportation. The VA or SP2 set up the VA’s appointments and the SP2 typically documented on his/her calendar when the VA had a scheduled appointment. At times, SP2 received phone call reminders from the VA’s medical providers when the VA had an appointment. Additionally, the VA’s doctors would email the VA of when the appointments were and then the VA would tell SP2 so they would be on the “same page.” The VA was “pretty good” about knowing when s/he had appointments and would tell SP2. · The VA did not typically refuse to go to appointments but there were times when the VA may not feel well, including due to seizures, and the VA would let staff persons know that s/he was not going to attend that day. When that occurred, the appointment would be rescheduled. · SP2 was not aware of the VA missing any appointments with the MD. SP3 provided the following information: · SP2 was responsible to ensure that the VA’s medical appointments were “set up” and would then transport the VA. The VA was “definitely” good about communicating when s/he had an upcoming appointment and would tell staff persons “several times.” If the VA told other staff persons about upcoming appointments, those staff persons would call SP2 and tell him/her. · SP3 was not aware of the VA missing any medical appointments. However, there were times when the VA was not feeling well, had seizures, or “did not want to go to appointments.” If a client could not attend an appointment, staff persons would call and reschedule. The Policy and Procedure Manual said that individuals served at the facility had the right to adequate medical care. The facility assisted clients with scheduling medical appointments and provided transportation to those appointments. Facility documentation showed that SP1, SP2, and SP3 received training on facility policies and procedures including health service coordination and care and the Reporting of Maltreatment of Vulnerable Adult’s Act. Relevant Rules and Statutes: Minnesota Statutes, section 245D.05, subdivision 1, state that when the facility was responsible for meeting the residents’ health service needs, they were to assist with or coordinate medical and other health service appointments. Conclusion: Information was consistent that the VA relied on staff persons at the facility to schedule appointments and to get transportation to those appointments. If the VA could not attend an appointment, staff persons were to reschedule. Although SP1 said that the VA had a history of refusing medical appointments, the VA’s plans said that the VA was “not resistant” to care and the CM, the P, the D, and SP2 each said that the VA did not have a history of refusing to attend medical appointments. The VA had seen the MD since at least September 29, 2020, with no noted prior issues attending those appointments. Although the facility was not aware of the VA missing any scheduled appointments with the MD, documentation from the MD showed that the VA missed or had a “late cancel” for three appointments. The MD noted that the “first” “late cancel” appointment was on February 14, 2022, with a subsequent missed appointment on March 2, 2022 (Note: The CM noted in the Chronology Item Summary that SP1 was aware of this scheduled appointment.) Additionally, the P said that while the facility gave him/her a list of some medical appointments when the VA moved to the P’s, the facility did not tell the P about a scheduled appointment with the MD on June 8, 2022, which caused the VA to miss it. On June 9, 2022, the MD sent the VA a letter stating that because the VA had been unable to adhere to the MD’s “attendance policy,” the VA was no longer able to schedule appointments with the MD or “any other psychiatrist with the Allina Mental Health clinics.” The P wrote a letter to try to get the VA back to see the MD but was “denied.” The P then tried to get the VA into other psychiatrists but there were no openings. The CM said that the facility “neglected” the VA’s medical needs which caused the VA “further harm” due to the increased pseudo seizures. Additionally, the CM said that the VA began to have “more violent” pseudo seizures lasting 30 minutes each, including some that required hospitalizations. The VA’s pseudo seizures were “getting more out of hand.” A doctor at the hospital noted that the VA was “under treated.” Although the VA used MyChart to get appointment reminders and then typically told staff persons of these appointments (which SP2 and SP3 each said that the VA did), information showed that the facility staff persons were responsible for scheduling the VA’s medical appointments and ensuring that the VA attended the appointments. Not ensuring that all of the VA’s required medical appointments were attended was a violation of Minnesota Statutes, section 245D.05, subdivision 1 and of the facility’s policies and procedures. While it was very concerning that the VA missed or had a “late cancel” for three appointments with the MD which caused the MD to stop seeing the VA as a patient, SP1, SP2, and SP3 each said that at times, the VA had cancelled appointments due to seizures, not feeling well, COVID-19, the weather, or a paid internship with his/her day program. SP1, SP2, and SP3 each said that when that occurred, the VA’s appointments would be rescheduled. On February 14, 2022, the VA was a “late cancel” but no information was given as to why. Additionally, although it was concerning that the VA “failed” to attend an appointment on March 2, 2022, which SP1 was aware of, information showed that the VA saw the MD a week later and there was no information that there was any harm at that time due to the missed appointment on March 2, 2022, and the MD said that the VA’s seizures had decreased “considerably” over the last week. Additionally, while it was concerning that the P was not aware of an appointment on June 8, 2022, SP1 said that all known appointments were given to the P and there was nothing to show who scheduled the appointment on June 8, 2022, or who was aware of that appointment. Therefore, given the aforementioned, there was not a preponderance of the evidence as to whether there was a failure to provide the VA with care or services which were reasonable and necessary to maintain the VA’s physical or mental 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed. SP2 and SP3 were “counseled and understand the importance of documenting the precise reason” why appointments were missed and/or rescheduled. Additionally, there was to be a “record” of “refusals and adjustments made with appointment making and keeping.” Action Taken by Department of Human Services, Office of Inspector General: On October 7, 2022, the facility was issued a Correction Order for the violation outlined in this report and for failing to ensure that the designated manager provided program management and oversight of the services provided by the license holder.
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