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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: 1070857-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: Allegation One: It was reported that a staff person (SP1) called a vulnerable adult (VA1) a “faggot” and withheld food and showers from VA1 and two other vulnerable adults (VA2 and VA3), that a staff person (SP2) told VA1 that his/her “demons” would drag him/her to hell, and that another staff person (SP3) withheld food and showers from VA2 and VA3. Allegation Two: It was reported that VA1 overdosed on insulin and Tylenol, that staff were responsible for multiple medication errors and inaccurately reported when the VAs refused medications. Date of Incident(s): Prior to April 21, 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 2, paragraph (b), clause (2); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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 May 19, 2022, from documentation at the facility, from the VAs’ medical records, and through ten interviews conducted with SP1, SP2, VA1’s case managers (CM1 and CM2), a facility management staff person (P1), a facility management staff person (P2) with medical health care experience, a facility health care professional (HCP), VA2 and VA3. Although this investigator contacted VA1, VA1 chose to not provide information in an interview, but did provide written information. Although this investigator talked to SP3 on the phone, SP3 ended the discussion and did not return further calls to continue the interview. VA1’s Annual Plan showed that s/he had six hours of alone time in the community, enjoyed going to church, and accessing the community. Although the plan noted that VA1 may “urinate” on him/herself and “not change” his/her clothing, there was not documentation to show that the VA needed assistance when s/he took a bath or showered. VA1’s Self-Management Assessment showed that some of his/her diagnoses included diabetes, asthma, sleep apnea and cerebral palsy. VA1 was “able to administer [his/her] own insulin and check [his/her] own blood glucose when provided the equipment and staff cues.” In addition, the plan stated that VA1 could be “non-compliant” with “medical treatments/medications” and that staff would notify a supervisor for “medication refusals.” VA1’s Individual Abuse Prevention Plan showed that staff provided assistance to him/her related to showering and dressing. VA1 had a history of having “suicidal thoughts” and staff would assist VA1 if s/he had suicidal thoughts by checking on VA1 every 15 minutes when s/he verbalized “suicidal thoughts.” VA2’s Emergency Data Form showed that s/he had cerebral palsy and “requires assistance” with activities of daily living. VA2 used an electric wheelchair for mobility and needed “physical assistance” with eating and “requires support” when s/he bathed or showered, but the support to be provided was not outlined. VA2 had eight hours of alone time in the community and enjoyed being able to be independent in the community. VA3’s Emergency Data Form showed that some of his/her diagnoses included depression, “anxiety disorder,” and epilepsy. VA3’s Annual Plan showed that s/he was diagnosed with a traumatic brain injury (TBI), used an electric wheelchair for mobility and enjoyed “Halloween.” Allegation One: It was reported that a SP1 called VA1 a “faggot” and withheld food and showers from VA1 and VA2 and VA3, that SP2 told VA1 that his/her “demons” would drag him/her to hell, and that SP3 withheld food and showers from VA2 and VA3. It was reported that a staff person (SP1) called a vulnerable adult (VA1) a “faggot” and withheld food and showers from VA1 and two other vulnerable adults (VA2 and VA3), that a staff person (SP2) told VA1 that his/her “demons” would drag him/her to hell, and that another staff person (SP3) withheld food and showers from VA2 and VA3. CM2 said that when s/he talked to VA1 on May 4, 2022, VA1 stated that SP1 called VA1 a “faggot,” but VA1 did not provide more information. VA1 also said that SP1 and SP3 occasionally “withheld” second helpings of food from VA2 and that there were instances when VA3 asked for assistance with showering. VA1 further told CM2 that SP3 made a statement a “few months ago” that VA1 would be “dragged to hell” due to his/her “demons.” VA1 also told CM2 that when VA2 drank alcohol in the community, SP1 was “short” with him/her, but additional information was not provided. VA1’s written documentation showed that s/he was “yelled” at for “strange reasons,” such as using the “front bathroom” by an unnamed staff person and that staff person got “dangerously close to putting” his/her hands on VA1 and “choking” VA1. VA2 stated that there were a few incidents “awhile” ago in which s/he returned to the facility after dinner and the staff person on duty did not “bother” to feed VA2, but VA2 did not remember the name(s) of that staff person. VA2 also stated that s/he did not hear a staff person call a VA a faggot. VA2 stated that although some staff “ignore” him/her, VA2 did not need “a lot of help” when s/he bathed or showered. Although VA3 did not have concerns that staff withheld food, s/he stated that when s/he asked SP1 for assistance with showering, it happened on more than one occasion that SP1 refused to provide assistance with showering. VA3 also stated that s/he did not hear a staff person call a VA a faggot, but VA1 told VA3 that s/he “didn’t get along” with SP1 even though specific information was not provided. P1 provided the following information: · On April 26, 2022, VA1 told P1 that a staff person called VA1 a “faggot,” but VA1 did not provide the name of that staff person. VA1 also stated that SP2 told VA1, “I hope the demons you’re fighting drag you to hell.” · VA1 also said that staff withheld food and showers from VA1, but VA1 did not provide more information. P2 provided the following information: · On a weekly basis, the facility spent approximately $225.00 on groceries. Prior to grocery shopping, VA1 and his/her housemates had the opportunity to plan meals and snacks. Although VA1 told P2 that there was not enough food at the facility at times or that the food did not meet his/her nutritional guidelines, P2 was aware that there were times that VA1 ate snacks “through the night” or was “chugging” juice from a bottle. P2 was not aware of a time that the facility did not have an adequate supply of food. · Although VA1 was able to be independent when s/he bathed, s/he needed some assistance with showering and dressing, but that there were times that VA1 refused to comply. When that happened, staff were trained to approach VA1 at a later time to see if s/he would be accepting to take a shower at that time. · P2 was aware of the concern from VA1 that SP1 called VA1 a derogatory name, but P2 did not hear SP1 say that and did not think that SP1 would say something like that based on P2’s observations. · When P2 was asked what discussion s/he had with VA1 in terms of a staff person allegedly telling VA1 that his/her demons would drag him/her to hell, P2 stated that it was VA1’s family members that had made those comments to VA1 and not a staff person. · P2 was not aware of a time that any of the staff withheld food or showers from the VAs and also that staff were not told that they needed to document when they performed daily cares on the VAs, but that some notes could be written in the VAs daily log notes. SP1 provided the following information: · SP1 denied calling VA1 a “faggot,” did not have knowledge that another staff person called VA1 that name and did not choke or attempt to choke VA1. In addition, SP1 did not have knowledge about a staff person saying anything to the VAs about demons and dragging them to hell. · VA1 typically showered independently, but may need some assistance with dressing. However, “most of the time,” VA1 refused to shower. When that happened, staff asked VA1 if s/he showered and if VA1 said no, staff documented the occurrence. SP1 denied that s/he refused to provide assistance to VA3 with showering. · The VAs always had access to food and SP1 denied that s/he or anyone withheld food from the VAs. SP2 denied withholding food or showers from the VAs or making inappropriate statements to the VAs. The facility’s Investigation Summary Report and Summary provided information that was similar to the information provided in the investigation, but the following information was added: · The facility determined that the allegation that staff withheld food was “false” because “visits to the program on 3-25-22 and 4-4-22 determined that adequate food was available.” · The allegation that staff withheld showers was “inconclusive” because VA1 had a history of refusing showers.
· In regard to the allegation that staff made inappropriate comments to VA1, the facility determined it was “likely false” because “those interviewed report never hearing that term (faggot) used at any location” and because VA1 “did not report any of these concerns to anyone on the management team.” Conclusion for Allegation One: According to CM2, SP1 called VA1 a “faggot,” occasionally “withheld” second helpings of food and did not provide assistance to VA3 with showering. VA3 told this investigator that although s/he did not have concerns related to food, SP1 refused to provide assistance with showering on more than one occasion, but SP1 denied that and said that VA1 refused to shower “most of the time.” In addition, VA1, who did not provide information to this investigator, told P1 that a staff person called VA1 a “faggot,” but the staff person’s name was not provided, that SP2, who did not provide information to this investigator, told VA1, “I hope the demons you’re fighting drag you to hell,” but P2 believed that VA1’s family members made that comment to VA1. In addition, SP2 denied withholding food or showers from the VAs and VA2 said that s/he did not need “a lot of help” when s/he took a bath or showered. SP3 did not provide information for the investigation. For the aforementioned reasons, there was not a preponderance of the evidence whether emotional abuse or neglect occurred. Although VA1 documented that an unmade staff person choked or attempted to choke him/her, further information was not able to be obtained from VA1 and SP1 and SP2 denied the allegation. It was not determined whether emotional abuse or neglect occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening or 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: It was reported that VA1 overdosed on insulin and Tylenol, that staff were responsible for multiple medication errors and inaccurately reported when the VAs refused medications. The facility had a Medication & Emergency Medical Authorization form, dated February 24, 2022, for VA1 that stated that staff persons administered medications to VA1. Although VA1 did not provide information to this investigator, s/he provided written information that there were “repeated” medication errors and “inaccurately reporting” when medication errors occur, but specific information, including the staff persons names, was not included. CM1 provided the following information: · While VA1 was hospitalized (around mid-May 2022), VA1 called CM1 and told him/her that s/he took too much insulin and Tylenol, but VA1 did not say how much. CM1 obtained VA1’s medical records and noted that instead of taking 15 units of insulin, VA1 took 200 units and also took five or six Tylenol at the same time. · CM1 was under the impression that VA1 was able to “self-medicate,” but that staff were to provide visual oversight, but CM1 acknowledged that s/he had just recently started working with VA1. · CM1 “believed” that VA1 had a history of taking too much medication. P1 also said that s/he was not aware of any medication errors or times that staff inaccurately reported medication errors. VA1’s medication administration record (MAR) showed that s/he received 15 units of insulin at bed time and that the “pen” (used to administer the insulin) was to be discarded 28 days after “first use.” VA1’s hospital records, dated April 21, 2022, stated that VA1 took 200 units of insulin and “half a bottle of acetaminophen” in an “attempt to harm” him/herself. Another part of the records showed that VA1 took five to six Tylenol. VA1 was monitored in the intensive care unit (ICU) for 24 hours, then moved to a different floor and monitored for reasons associated with mental health, and discharged on May 19, 2022, according to a hospital employee. This investigator asked the facility to provide documentation related to medication errors for the past year. The facility provided documentation that showed that two medication errors occurred during that time period, that the VAs were not harmed as a result of the errors, and that “staff involved will be retrained and counseled per policy.” P2 provided the following additional information: · P2 was not aware of any medication errors, but stated that VA1 had “concerns” related to his/her medications and believed that staff were not always giving VA1 the correct medications, even though staff verbally reminded VA1 of his/her medication orders and what they were administering to VA1. P2 did not have any knowledge that staff were incorrectly documenting on medication errors. · In the days leading up to when VA1 overdosed on insulin and Tylenol, VA1 was “fine” and “no one mentioned anything out of the ordinary.” In addition, VA1 participated in activities as “normal.” · When VA1 took his/her insulin, staff persons took the insulin, which was stored in an unlocked refrigerator in the kitchen, and were supposed to put 15 units of insulin in the insulin pen. Once that was done, VA1 could inject the medication by him/herself, or have staff do it. After VA1 received the insulin, the pen and insulin were to be returned to the refrigerator. According to P3, VA1 had not previously gone into the refrigerator and taken insulin without staff persons’ knowledge. · When VA1 was hospitalized, VA1 told P3 that when VA1 was in the community on unsupervised time, VA1 purchased the Tylenol, but VA1 did not say when that happened or how many s/he took. SP1 provided the following additional information: · When SP1 was asked to provide information related to how VA1 typically got his/her insulin, SP1 stated that the insulin pen came from the pharmacy with 100 units of insulin in each pen, that VA1 “sets” the “dial” to 15 units and then does the injection him/herself. · At about 9 p.m. on the night of the incident, SP1 administered VA1’s medication to him/her and when SP1 asked VA1 if s/he took the insulin, VA1 said “yes,” but SP1 did not see VA1 do the injection or dial up the medication. SP1 described the day as being “normal.” A short time later, VA2’s family member called the facility, talked to SP1 and asked to talk VA1. SP1 gave the phone to VA1 and after VA1 talked for three to four minutes, VA1 brought the phone back to SP1 and went outside to smoke. A few minutes later, persons from “Minneapolis Crisis Prevention” came to the facility and stated that they received a phone call from the clients’ family member. When they asked SP1 where VA1 was, SP1 said that VA1 was outside smoking. SP1 went to the office so they could have “privacy” with VA1. After three to four minutes, they told SP1 that VA1 took 200 units of insulin and that they wanted to check VA1’s bedroom. SP1 went with them and they found two “empty” insulin pens so 911 was called. SP1 did not know how VA1 obtained the insulin pens that were later found in his/her bedroom. · SP1 did not have knowledge that VA1 took Tylenol that night. P1 and P3 were not aware of medication errors and did not have concerns that staff were inaccurately reporting on medication errors. Furthermore, facility documentation showed that there were two medication errors in the past year, that the VAs were not harmed as a result of the errors and that additional training was provided. The facility’s Investigation Summary Report and Summary provided information that was similar to the information provided in the investigation, but the following information was added: · The facility determined that there were three medication errors related to VA1 within the past year. Of those, VA1 refused to take his/her medications on two occasions and there was one time when the medication(s) was not available. In addition, the facility did not have information that staff did not document medication errors. · When P2 was interviewed as part of the facility’s internal investigation, s/he stated that the insulin was previously stored in a refrigerator in the office, but the “refrigerator apparently broke” and that “it should have been kept locked where [the VA] would not have access to it.” In addition, P2 stated that his/her understanding was that staff were to prepare the insulin, give it to VA1 for self-administration, and then return the medication to the refrigerator. P2 also stated that “staff don’t report things when they break.” The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VAs specific care plans prior to April 21, 2022. Conclusion for Allegation Two: Although originally reported that medication errors existed and that staff inaccurately reported on those errors, P1 and P3 were not aware of medication errors and did not have concerns that staff were inaccurately reporting on medication errors. Although facility documentation showed that staff persons were to administer insulin to VA1, SP1 and CM1 understood that VA1 was able to self-medicate his/her insulin. P2 understood that after staff placed 15 units of insulin in the pen, VA1 was able to do the injection by him/herself or ask staff for assistance. In the days leading up to the April 21, 2022, incident, P2 described VA1 as being “fine” and participating in activities as “normal” and SP1 said that VA1 was “normal” on the day of the incident. On the day of the incident, VA1 took 200 units of insulin, instead of 15 units, which was supposed to be locked according to the Investigation Summary Report and Summary. When VA1 was hospitalized, s/he told hospital personnel that s/he also ingested Tylenol, but the exact amount was not determined. VA1 told P3 that s/he purchased the Tylenol when VA1 had alone time in the community. Although the insulin should have been locked in the refrigerator, there was no indication that the VA was suicidal at the time and no information presented that the VA had a history of taking too much insulin. Given the aforementioned, there was not a preponderance of the evidence whether neglect occurred. It was not determined whether neglect did not occur (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’s internal review determined that policies and procedures were adequate, but not followed because the VA’s insulin “was not properly secured” and “improperly stored when it was kept in the refrigerator at [his/her] home and was not locked.” The facility purchased a small refrigerator with a lock on it and provided additional training related to “expectations for documenting and implementing programs for the individuals as well as medication documentation.” Action Taken by Department of Human Services, Office of Inspector General: No action taken at this time.
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