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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: 1070308-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: Allegation One: It was reported that a vulnerable adult (VA) experienced worsening physical health due to lack of care provided by two staff persons (SP1 and SP2) and the facility, specifically: · SP1 and SP2 do not always bring the VA to the bathroom when needed and that SP1 does not wipe the VA’s buttocks. · SP1 does not allow the VA time to complete his oral hygiene resulting in concerns with his/her oral hygiene. · SP2 failed to dry the VA’s buttocks and skin folds, which led to skin breakdown and SP1 refuses to administer the VA’s powder treatments as ordered. · SP1 used an assistive technology device (reacher) on the VA’s genitals causing the VA’s genitals to bleed. When the VA asked for SP1 to be “gentler,” SP1 told the VA “You are just going to have to deal with it.” · Staff persons do not clip the VA’s fingernails and toenails, do not take the VA to a podiatrist, and that one of the VA’s toenails recently fell off. · Staff persons do not clean the VA’s supra-pubic catheter (a medical device used to drain urine from a person’s body) twice daily and used saline that was not from a pharmacy or medical supply company. · Staff persons do not complete range of motion (ROM) exercises with the VA, which led to the VA having increased contractures and pain in his/her feet, ankles, and knees. · Staff persons did not provide the VA with timely medical attention following a motor vehicle accident in July 2022. Allegation Two: It was reported that SP1 and SP2 failed to plug in the VA’s wheelchair, which led to it not being accessible to the VA and that SP1 and SP2 broke some of the VA’s items, such as adaptive water bottles, and failed to replace them. Allegation Three: It was reported that SP1 makes the VA go to bed at 7:30 PM, which was against the VA’s will and that the VA does not have time to brush his/her teeth, which led to his/her oral hygiene getting worse. Allegation Four: During the investigation, it was reported that another staff person (SP3) drove in an erratic manner when providing transportation services to the VA. Date of Incident(s): Prior to September 15, 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 (1); 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. 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 23, 2022, from documentation at the facility, from the VA’s medical records and through eight interviews conducted with the VA, a community social worker (CSW), SP1, SP2, SP3, a facility management staff person (P1), the VA’s case manager (CM), the facility’s health care professional (FHCP) and the VA’s family member (FM). Although this investigator contacted another facility staff person (P3), P3 did not respond to requests to be interviewed. The facility had a ceiling lift in the VA’s bedroom that was used when staff transferred the VA from one place to another. Some of the VA’s transportation services were provided by an outside entity. The VA resided on the lower level of the facility and there was an elevator to assist persons with moving from one level to another within the facility. The VA’s Support Plan showed that s/he enjoyed spending time with family and attending a day training and habilitation program. The plan further showed that the VA was diagnosed with Multiple Sclerosis, used an electric wheelchair for mobility, and needed assistance with “most activities of daily living.” In addition, the plan stated that the VA “does not like to be rushed” and “prefers that people do not hover over [him/her], although [s/he] requires complete attention when [s/he] so desires.” Facility documentation showed that the VA had a catheter in place for the elimination of urine. Regarding the allegations that the VA experienced worsening physical health due to lack of care provided by SP1, SP2 and the facility: The CSW provided the following information: · In mid-September 2022, the CSW met with the VA for the first time to do an assessment. During the meeting, the VA said that while SP1 cleaned the VA’s genitals recently, SP1 used the reacher that had a “sponge” on the end so hard that the VA bled and that SP1 told the VA that s/he needed to “deal with it” when the VA stated it was painful. The VA told the CSW that s/he did not require medical care as a result of the incident. The CSW described the VA as being “more than competent” to provide information. · The VA also stated that SP1 and SP2 do not always bring the VA to the bathroom when needed and that SP1 “refuses” to wipe the VA’s buttocks after the VA had a bowel movement. The VA did not provide information as to the frequency that this happened. The CSW believed that the VA had the ability to know when s/he needed to have a bowel movement. The VA did not have concerns related to SP2 wiping his/her buttocks, but had concerns that SP2 did not always take the VA to the bathroom when the VA needed to have a bowel movement. · SP2 did not adequately dry the VA’s body after a shower and “refused” to apply a doctor order powder (information from the investigation showed that the VA used an over the counter powder and another powder that was ordered by the VA’s medical doctor) on the VA’s skin. The VA was concerned that s/he might have skin breakdown at some point as a result, but the CSW did not know how often the powder was to be applied. · The VA, who did not have the ability to clip his/her toe or fingernails, stated that no staff persons assisted the VA with clipping his/her finger or toenails and because of that, the VA bit his/her fingernails. The VA also stated that his/her right toenail recently “fell off.” The CSW did not know how often the VA needed assistance with clipping his/her finger or toenails. The VA also stated that s/he had not been taken to a podiatrist, but the CSW did not know how often the VA was supposed to see a podiatrist. · Although staff were supposed to clean the VA’s catheter site (stoma) twice daily, that was “rarely” done and not done at all by SP1, according to the VA. · The VA also told the CSW that getting saline (used to flush the VA’s catheter) was “problematic” at times and because of that, staff made saline at the facility, but the VA did not say who did that. · The VA was concerned that staff did not do range of motion (ROM) exercises with the VA, which led to him/her having increased pain, but the VA did not provide additional information related to that and did not say who was not doing the exercises. · The VA told the CSW that while s/he was being transported by the outside entity on July 26, 2022, the VA was injured in a motor vehicle incident and that no facility staff persons were present at the time of the incident. After the incident, the VA told SP1 that s/he had pain, but medical care was not sought until the next day. The next day, the VA was diagnosed with a broken femur in his/her right leg, which resulted in the VA need to have surgery and be hospitalized. The VA stated that before the incident occurred, the driver of the transportation company placed a seatbelt around the VA’s knees, instead of around his/her waist, and when the driver had to use the brakes, the VA was injured. · The VA also told the CSW that it was an “ongoing” issue that when s/he had a bowel movement, some of his/her bowels got on his/her shower chair and that SP1 refused to clean the shower chair. The VA provided information to this investigator that was mostly consistent with the information that s/he provided to the CSW, but added the following additional information: · When SP2 applied the powder, s/he used a “ton” and “wastes it.” · When SP1 assisted the VA with showering, SP1 said that s/he did not want to “break” his/her back. When the VA was in his/her bedroom and needed assistance, s/he rang a “bell,” but SP1 and SP2 did not respond. When the VA was asked how long s/he needed to wait for assistance from SP and/or SP2, s/he stated that s/he did not remember how long s/he had to wait. The FHCP provided the following information: · Although the VA was able to wash his/her genitals, the FHCP did not have knowledge that SP1 cleaned the VA’s genitals with the reacher and was not aware of a time that the VA had bleeding in his/her genital area or a time that his/her buttocks was not cleaned after having a bowel movement. · Because of the VA’s diagnoses, s/he sometimes felt that s/he needed to use the bathroom for a bowel movement and when staff would take him/her to the bathroom, the VA did not have to go. The FHCP was not aware of a time that the VA needed to wait to be cleaned after having a bowel movement. · The VA was “constantly complaining” about staff, but particularly about SP1 and SP2 because the VA “doesn’t like them.” The VA told the FHCP that SP1 “doesn’t listen” to the VA and that SP2 was “impatient” with the VA, but the FHCP had worked with both SP1 and SP2 and did not have concerns related to how they interacted with the VA. The FHCP further stated that s/he was not aware of a time that the VA needed to wait an extended period of time to use the bathroom. · The VA had a “little” sore on the VA’s stoma (where the catheter attached to the VA’s body), in July or August 2022. Although the VA had a history of picking at it, staff treat it twice daily with “saline” and “peroxide” and it healed “pretty quickly.” The FHCP was not aware of other skin breakdown or a time that a staff person did not administer the VA’s powder treatments as prescribed. · On one occasion, the FHCP was aware of a time that the VA waved his/her hand and said “good enough” in terms of being dried off after a shower. · When requested by the VA, staff trimmed the VA’s fingernails, but because the VA had “poor circulation” in his/her feet, the FHCP was the only staff person that trimmed the VA’s toenails. The FHCP did not remember the specific date, but on one occasion, a portion of one of the VA’s toenails fell off because it got “snagged” on the VA’s sock. When the VA needed podiatry care, the VA was taken to those appointments. · The FHCP provided training to all new staff in terms of cleaning the VA’s stoma site two times daily and s/he was not aware of a time that it was not done. In addition to cleaning the stoma site, staff were trained to flush the VA’s catheter three times daily with saline solution, which typically came from a pharmacy, and the FHCP was not aware of a time that it was not done for the VA. Because the facility sometimes had issues getting saline from the pharmacy, the facility made “homemade saline (a cup of salt and a gallon of water that was then boiled).” · Although the VA did not have a doctor’s order to do ROM exercises, the VA had “pictures” of ROM exercises that s/he did on occasion, but the VA typically had “so much pain” when doing them so staff rarely did them because the VA “screams and cries” when they are done. · When the VA returned to the facility after the travel incident in July 2022, the VA told the FHCP and SP3 that his/her leg “or” knee hurt. As a result, the FHCP assessed the VA. When the FHCP did not see an obvious sign of injury, s/he told the VA to take over the counter pain medications, which helped “initially,” and to tell someone if the pain got worse. When the VA had a “lot of pain” the following morning, the FHCP told SP3 to take the VA for medical care. The VA was taken to a local “Urgency Room” and when an x-ray showed that s/he had a fracture, the VA was transported from that medical office to a local hospital. The VA had surgery and returned to the facility a few days later. · When the FHCP was asked to provide information in terms of how the VA’s condition had changed over the past year, s/he stated that it “definitely declined” and that was due to his/her Multiple Sclerosis diagnoses. P1 said that when the VA complained of pain on the night of the van incident, SP1 offered, two times, to call 911 for the VA, but the VA “declined.” When the VA’s pain increased, SP3 took the VA for medical care, but P1 did not specifically remember when that was. The VA’s case notes, dated July 20, 2022, stated that the VA’s hip (did not say which one) was “hot so [s/he] ask for pain relief. Staff gave [him/her] Acetaminophen. [S/he] took [his/her] meds. All cares done.” The following day, it was documented that staff “place a camphor menthol-methyl external patch on [his/her] upper right thigh area due to complaints of pain and discomfort.” The notes also added that additional pain medication was given that day and that it did “help with the right hip pain.” When the VA complained of right knee and hip pain the following morning, July 22, 2022, the VA was taken for medical care. The MAR showed that the VA took one dose of 325 milligrams (mg) of acetaminophen on July 21, 2022, two doses on July 22, 2022, and one pain patch at 4:32 p.m. on July 21, 2022. The FM said that when s/he talked to the VA on the day of the travel incident, the VA mentioned having pain in his/her leg, but the FM did not think too much about it because the VA had a previous leg injury and “that leg hurts anyways.” The FM also stated that the VA had mentioned that s/he had to wait a “few minutes” for staff to take him/her to the bathroom and that s/he does not “always rely” on what the VA told him/her. The VA’s “Urgency Room” records, dated July 22, 2022, showed that the VA had a “displaced intertrochanteric fracture of the right femur.” The records stated that the VA was transported to the hospital that day. The VA’s hospital records showed that the VA was admitted to the hospital on July 22, 2022, had surgery to repair a “right femur fracture,” and was discharged on July 26, 2022. The VA’s Medication Administration Record (MAR) showed that the VA was prescribed Nystatin Powder (a powder medication used to treat fungal or yeast infections on the skin) twice daily. A review of the MAR showed that it was consistently signed off. The MAR provided also instructions for staff to “cover the stoma site with gauze on shower days.” A review of the MAR from May-September 2022, showed that these care were almost always completed, but there were minimal times that there was no documentation to show that they were completed. Facility documentation showed that the VA saw a podiatrist two times in 2020 to “examine toenails” and to have “toenails trimmed and checked.” Documentation from January 35, 2020, showed that the VA had a foot ulcer that was to be treated with “bacitracin” until healed. When the VA next saw the podiatrist on September 25, 2020, the foot ulcer was not identified as a concern. A review of the VA’s case notes from June through September 2022, did not identify any concerns related to the VA having skin breakdown. The CM stated that s/he did not have information related to the travel incident, but that the VA told him/her that s/he had to wait a “few minutes” for staff to assist her for general requests, but specific information was not provided. In addition, the VA did not bring up concerns related to staff not administering his/her powder treatments, caring for his/her catheter, drying the VA’s buttocks and skin folds, having skin breakdown or that the VA was not assisted with clipping his/her finger or toenails. The VA did not like staff persons that were the opposite gender as the VA. The CM was not aware of a medical order for staff to do ROM exercises, but knew that s/he complained of pain, at times, when the exercises were done. SP1 denied using the reacher on the VA, not administering the VA’s powder treatments, saying that the VA would have to deal with pain, that the VA had skin breakdown, and that s/he refused to assist the VA with wiping his/her buttocks. SP1 and SP2 each said that there were times that the VA would ask to go to the bathroom and the VA might need to wait a few minutes because they were busy with other clients or tasks. SP2 also denied not administering the VA’s powder treatments, not adequately drying the VA after a shower, and did not have knowledge that the VA had skin breakdown. SP3, P1, and P2 denied that the VA’s powder treatments were not administered, that staff did not dry the VA adequately, and that the VA had skin breakdown. Regarding the allegations that SP1 and SP2 failed to plug in the VA’s wheelchair, which led to it not being accessible to the VA and that SP1 and SP2 broke some of the VA’s items, such as adaptive water bottles, and did not replace them: The CSW provided the following additional information: · The VA told the CSW that on an “ongoing” basis, SP1 and SP2 did not plug in the VA’s wheelchair, which led to it not being accessible to the VA. The VA did not have the ability to do that on his/her own. · Although the VA did not provide dates, staff broke some of the VA’s items, such as his/her water bottles, and did not replace them, but the VA did not recall who broke the items. The VA provided similar information to this investigator that was provided to the CSW. The FHCP provided the following additional information: · The VA’s electric wheelchair was supposed to be charged nightly, and aside from one instance when it was not charged and was “dying” the next day, the FHCP was not aware of a time that the VA’s wheelchair was not charged. · Although the FHCP was not aware of a time that a staff person broke the VA’s personal belongings, the FHCP was aware of a time that the VA stated that “staff broke” his/her shaver and when the FHCP investigated, s/he determined that the VA dropped the shaver. The FHCP was not aware of any of the VA’s water bottles being broken by staff. The CM stated that the VA had not brought up concerns related to staff breaking his/her items or not plugging in his/her wheelchair. SP1 and SP2 each denied not plugging in the VA’s wheelchair. P1 said that it “may have” happened that the VA’s wheelchair was not plugged in at night, but that it would be “extremely rare.” The FM said that when s/he had talked to the VA on various occasions, the VA had not mentioned these concerns. Regarding the allegations that SP1 made the VA go to bed at 7:30 p.m., which was against the VA’s will and that the VA does not have time to brush his/her teeth, which led to his/her oral hygiene getting worse: The CSW said that the VA told him/her that SP1 made the VA go to bed at 7:30 PM, and that s/he does “not want” to go to bed that early. As a result of that, the VA, who did not need assistance with teeth brushing, did not always have time to brush his/her teeth, but would need to have items, such as tooth brush and toothpaste, within reach. Although the VA did not identify any specific concerns related to his/her teeth, the VA was “worried” about his/her oral hygiene. The FHCP provided the following additional information: · The VA was able to go to bed “whenever” s/he chose and the FHCP was not aware of a time that the VA was told that s/he needed to go to bed at 7:30 p.m. · Due to issues related of the Covid-19 pandemic, the VA’s insurance, and the closure of the VA’s dental clinic, the VA had not seen a dentist for about one and a half years. However, the FHCP was not aware of dental concerns and the VA had not brought concerns forward that s/he was having oral hygiene issues or that s/he did not receive assistance to brush his/her teeth, when needed. The CM stated that the VA had not brought up concerns to him/her about a staff making him/her go to bed at 7:30 p.m., or concerns related to oral hygiene. A review of the facility’s documentation, related to dental visits, showed that the VA saw a dentist a number of times in 2019 and 2020, but nothing since then. The most recent visit, February 25, 2020, showed that the VA was fitted with a crown and had “slight irritation around the gums” and near where the crown was placed. At the time of the investigation, the facility was working on a plan for the VA to receive dental care. The FM said that when s/he had talked to the VA on various occasions, the VA had not mentioned these concerns. Regarding the allegation that SP3 drove in an erratic manner when providing transportation services to the VA: The CSW stated that the VA told him/her that when SP3 took the VA for medical care the day after the travel incident, SP3 drove like a “bat out of hell,” but the VA did not provided additional information to the CSW. The VA provided similar information to this investigator, but did not identify specific concerns. The CM and the FM each stated that the VA had not brought concerns related to SP3’s driving.
SP3 denied driving in an erratic manner and no staff person provided information that they had any concerns related to SP3’s driving. The facility’s Internal Investigation form provided information that was consistent with the information obtained in this report. The facility’s training records showed that all staff interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to September 23, 2022. Conclusion: Regarding the allegations that the VA experienced worsening physical health due to lack of care provided by two SP1, SP2 and the facility: Although the VA told the CSW and this investigator about a number of concerns the VA had with his/her cares at the facility, information from interviews and documentation showed that SP1, SP2 and the facility were providing reasonable and necessary care to the VA and addressing his/her needs. Given that conflicting information was provided, there was not a preponderance of the evidence whether physical 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult 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). Regarding the allegations that SP1 and SP2 failed to plug in the VA’s wheelchair and broke some of the VA’s adaptive equipment: The VA told the CSW that SP1 and SP2 did not plug in the VA’s wheelchair and broke some of the VA’s items, such as his/her water bottles and did not replace them. The VA provided similar information to this investigator, but did not recall who broke the items. Information from the investigation showed that although the wheelchair may not have been fully charged one time, there was no information provided that staff deliberately failed to plug in the VA’s wheelchair and no information was obtained to show that staff broke the VA’s adaptive equipment. Given that conflicting information was provided, there was not a preponderance of the evidence whether neglect occurred. 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). Regarding the allegations that SP1 made the VA go to bed at 7:30 PM, which was against the VA’s will and that the VA does not have time to brush his/her teeth, which led to his/her oral hygiene getting worse: Although the VA told the HSW and this investigator that SP1 made the VA to go bed at 7:30 p.m. and that his/her oral hygiene worsened, SP1 denied that and information from interviews and documentation did not show that the VA was made to go to bed at that time and that although the VA had not recently seen a dentist, there was no information that his/her oral hygiene had declined. Given that conflicting information was provided, there was not a preponderance of the evidence whether neglect occurred. 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). Regarding the allegation that SP3 drove in an erratic manner when providing transportation services to the VA: Although the VA told the CSW that SP3 drove like a “bat out of hell” and the VA provided similar information to this investigator, there was no information obtained during the investigation that raised concerns related to SP3’s driving habits. Given that conflicting information was provided, there was not a preponderance of the evidence that neglect occurred. 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’s Internal Investigation form stated that although policies and procedures were adequate and followed, additional training was needed because the VA’s “protocol changes frequently.” Action Taken by Department of Human Services, Office of Inspector General: No action taken.
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