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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: 1073045-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) presented at an emergency room with pain in his/her legs. At that time, healthcare professionals discovered maggots in wounds on the VA’s legs. The VA had been relying on facility staff persons to meet all of his/her medical needs. Date of Incident(s): Ongoing prior to July 25, 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 15, 2022; from documentation at the facility and medical records; and through interviews conducted with the VA’s family members (FM1 and FM2), the VA’s case manager (CM), and a facility supervisory staff person (P). Information was also obtained from an emergency room healthcare professional (HCP), who had provided care to the VA. (Note: This investigator reached out to the VA. The VA declined to be interviewed at that time, but asked that this investigator contact FM1 and FM2 regarding the allegations.) The VA’s support plan and support plan addendum provided the following information: · In 2000, the VA moved into the facility seeking supports and services relating to his/her diagnoses, which included cerebral palsy. · The VA moved around independently using an electric wheelchair. · The VA relied on the facility to ensure all of his/her “health and safety needs” were met. · “[The VA] is a strong verbal communicator and will tell staff when [s/he] needs assistance in relation to [his/her] chronic medical diagnoses. [The VA] is aware of [his/her] diagnoses and knows what [s/he] needs to stay healthy in each area.” · Regarding preventive (medical) screenings, “[The VA] is independent in this area. [The VA] can plan [his/her] own preventative screenings and get to them without staff assistance.” · Regarding medical appointments, “[The VA] is independent in this area. [The VA] schedules [his/her] own medical/dental appointments, schedules [his/her] own rides to go to them, and will give staff the dates of [his/her] next appointments so they are aware of when [s/he] will be gone.” The VA also had a history of attending his/her appointments without a staff person present. · Regarding medication administration, “[The VA] is very knowledgeable about [his/her] medications and knows exactly what [s/he] takes and when. [The VA] is a strong verbal communicator and will ask staff for [his/her] meds at the designated medication times.” The VA’s medications were stored in a locked cabinet that only staff had access to. “Notification will be made to [the VA's] physician and [interdisciplinary team] after (3) three or more missed/refused/overdoses of a prescribed medication within a 7 day period ….” · Regarding bathing, “[The VA] is a strong verbal communicator and can tell staff when [s/he] wants to bathe or wash [his/her] hair. Staff assist [the VA] into [his/her] shower chair via [a mechanical lift].” The VA also relied on staff assistance for changing his/her clothes. · The VA was not subject to guardianship. At the outset of this investigation, the following information was provided: · Medical records stated that on July 25, 2022, “[The VA] presented to [the emergency room] from [the facility] with increased pain to bilateral lower extremities with associated redness. In the emergency room, dressings were removed from [the VA’s] lower extremities and maggots were found [under the dressings on the VA’s] right lower extremity … [The VA] was admitted to hospitalist medicine from [the emergency room] for ongoing evaluation and treatment. When [the HCP] saw [the VA], [the VA] continued to appear uncomfortable. [The VA] reported ongoing pain to bilateral lower extremities.” · The VA provided information that prior to July 25, 2022, s/he had asked unidentified staff person(s) three to four times to go to the emergency room, but each time the staff declined the VA’s request. · The VA also provided information that as of July 25, 2022, s/he had not been bathed at the facility for “close to a month.” The VA stated that whenever s/he asked to bathe, unidentified staff person(s) told him/her to wait. The VA also stated that unidentified staff person(s) were verbally abusive towards him/her; and that the facility was “very unsanitary.” This investigator reviewed the VA’s medical records and the facility’s documentation, and determined the following timeline leading up to July 25, 2022: · In May and June 2022, the VA attended multiple medical appointments regarding ongoing issues with his/her legs; this included diagnoses for “bilateral leg edema stasis dermatitis of both legs, open wounds of legs.” · On May 9, 2022, a doctor prescribed the following treatment plan for the VA’s legs: o Apply mupirocin (dermatological, antibacterial) to the open area on the VA’s leg and apply Telfa (wound dressing) to protect the area; o Apply triamcinolone (corticosteroid) to the pink, swollen areas on the VA’s legs; and o Use chlorhexidine (antiseptic) on the VA’s legs when showering. · On May 12 and 20, 2022, a registered nurse completed wound assessments of the VA’s legs, and provided the facility with care instructions, including that Telfa (wound dressing) should be changed daily. · Around mid-May 2022, the facility posted the following instructions for staff: The VA’s Topical Medication Routine for Legs 1. In the morning ask the VA if s/he would like to take a shower. Please chart accordingly. If the VA refuses you will also need to include that s/he refused a shower in your daily note. 2. If the VA showers s/he will need help with his/her medicated cleanser for his/her legs. First rinse the legs with water, then use a small amount of the antiseptic, use on his/her legs gently creating a lather. After that you will rinse his/her legs and then rinse one more time. This can be used once a day. 3. After the VA’s legs are dry, you can apply a thin layer of mupirocin ointment on each wound or sore. This can be used once a day. 4. After the mupirocin ointment has been on the VA’s legs for a couple hours, the VA can then use the triamcinolone. This should help with redness and swelling. You only need to use a thin layer of this medication. This is the one in the jar and it looks like petroleum jelly. This can be used once a day. · The VA’s Medication Administration Records (MARs) for May 1 through July 25, 2022, provided the following information. (Note: The VA was hospitalized for some of the days within this timeframe.): o On May 10, 2022, the VA was prescribed mupirocin ointment to be applied once daily to the “open areas” on his/her legs. According to the MARs, this was not completed on any of the days between May 10 and July 25, 2022. Instead, the MARs were marked 52 times during this timeframe as “M/R,” or “Missed/Refused;” and the remaining 11 days during this timeframe had no documentation to state whether the ointment was applied or not. There was also no documentation or information provided that a pattern of the VA refusing to take his/her medication(s) or treatment(s) was reported to the provider or a nurse. This was in violation of Minnesota Statutes 245D.11 subdivision 2, clause (3), which states that the license holder must implement policies and procedures that promote health and welfare by ensuring safe medication assistance and administration according to the requirements in sections 245D.05, subdivisions 1a, 2, and 5, and 245D.051. o Also on May 10, 2022, the VA was prescribed triamcinolone cream to be applied once daily to the “rash on [the VA’s] lower extremities.” According to the MARs, this was not completed on any of the days between May 10 and July 25, 2022. Instead, the MARs were marked 52 times during this timeframe as “M/R;” and the remaining 11 days had no documentation. o Note: There was similar “M/R” documentation for the VA’s blood sugar test, which was supposed to be checked once daily, but was recorded as “M/R” 69 times between May 1 and July 25, 2022. The VA’s loperamide (anti-diarrheal) 2 milligrams (mg), which was supposed to be administered twice daily, had no documentation to state whether it was administered or not, 121 times between May 1 and July 25, 2022. The VA’s omeprazole (treatment for gastroesophageal reflux disease) 20 mg and the VA’s vitamin C 250 mg, which were each supposed to be administered once daily, had no documentation to state whether they were administered or not, 83 times each between May 1 and July 25, 2022. o Also on the MARs for May through July 2022, there was a section labeled, “MAR Review-Weekly.” Instructions stated that a supervisor (i.e. the P and another supervisory staff person) would review the MAR each week using the MAR Review Checklist. § For May 2022-the MAR was reviewed on May 5, 8, 12, 19, and 23, 2022; § For June 2022-the MAR was reviewed on June 3 and 12, 2022; and § For July 2022-the MAR was not reviewed any of the days. o This investigator reviewed the MAR Review Checklist, which stated, “Initialing the MAR for this review indicates that items on the checklist were reviewed and actions were taken to make necessary corrections … Missed, Refused, On-Hold, LOA entries are explained in the comments box [on each MAR]. [Note: The MARs for May through July 2022, had zero comments in the comment boxes, despite there being 482 times, as described above, with “M/R” or no documentation – This was in violation of Minnesota Statutes 245D.11 subdivision 2, clause (3), which states that the license holder must implement policies and procedures that promote health and welfare by ensuring safe medication assistance and administration according to the requirements in sections 245D.05, subdivisions 1a, 2, and 5, and 245D.051.] · Between June 1 and July 31, 2022, multiple staff persons documented in the facility’s daily notes regarding the VA, and almost every day, there was something documented, similar to, the VA’s legs being “very painful … complained about [his/her] legs … [The VA’s] legs still [leak] water and is very painful … [The VA] cry from pain in [his/her] legs,” etc. · In addition, in the daily notes, there was documentation of the VA “refusing” to elevate his/her legs and “refusing” to get out of his/her wheelchair. Twice, in the daily notes, June 2 and 22, 2022, staff documented that the VA took a shower. However, there was no other documentation stating whether the VA took a shower, whether staff asked if the VA would like to take a shower, and/or whether the VA “refused” to take a shower. – This was inconsistent with the VA’s, aforementioned instructions for applying medications to his/her legs, titled, Topical Medication Routine for Legs, and the failure to ensure this documentation was maintained was in violation of Minnesota Statutes section 245D.05, subdivision 1, paragraph (b), clause (2), which states that if responsibility for meeting the person's health service needs has been assigned to the license holder in the coordinated service and support plan or the coordinated service and support plan addendum, the license holder must maintain documentation on how the person's health needs will be met, including a description of the procedures the license holder will follow in order to monitor health conditions according to written instructions from a licensed health professional. · On July 7, 2022, the VA was admitted to a hospital for kidney stones. During that time, healthcare professionals discovered that there was “chronic severe venous stasis changes bilateral lower extremities with scaling and keratosis which was severe, patient has redness, almost cellulitis of the groin area in the lower belly.” The VA had “moisture associated skin maceration located on buttocks [and] bilateral heels with skin breakdown.” Once admitted to the hospital, healthcare professionals used cleansing and drying; medicated powders, and wound dressings for the VA’s legs, which were elevated; and healthcare professionals repositioned the VA every two hours. On July 14, 2022, the VA was discharged back to the facility. (Note: This investigator reviewed the VA’s medical records relating to this stay, including discharge plan, and did not see any discharge planning specific to the VA’s skin care.) · On July 25, 2022, the VA presented at the emergency room “with a new wound to [his/her] right leg … [The VA] does have cellulitis. [The VA] also has maggots in the creases.” The VA was diagnosed with cellulitis of right leg and infestation of maggots. “[Emergency Medical Services] share [the VA] has had a wound on [his/her] posterior right lower leg and heel/ankle for many months. Staff at [the facility] have recently noted worsening of the wound with increased redness and pain. The wound is now odorous and staff believe there are maggots coming from the wound.” (Note: This investigator spoke with the HCP, who saw the VA when s/he arrived at the emergency room on July 25, 2022. The HCP’s opinion was that the presence to maggots in a person’s wounds “Doesn’t happen quickly … Usually, if you know, [maggots] are found on trash or carcass, but when talking about a human being, I mean even if [staff] were checking on [the VA] once a day, every other day, that shouldn’t happen.” · This investigator also reviewed the facility’s Health Care Reports for June 1 through July 31, 2022; this included the VA’s health history and what had been documented by staff during this time period. The information included “no data” for infection tracking and “no data” for skin/wound tracking. FM1 and FM2 each said that they were aware the VA had a history of “refusing” showers. FM1 and FM2 asked the facility more than once to send a nurse to help out; however, they “didn’t send anyone.” The facility mainly hired staff persons who were not the same gender as the VA, and the VA declined to accept help with showers for privacy reasons. The facility also provided the VA with an “old, old bed” to sleep on, and the VA was scared to sleep on it; and so, instead for almost two years the VA slept in his/her wheelchair. FM1 and FM2 repeatedly asked the facility to get the VA a different bed, but they did not. Following one of the VA’s previous hospital admissions, an unknown healthcare professional told FM1 and FM2 that had the VA not gone to the emergency room when s/he did, s/he would have most likely died at the facility based on his/her condition when s/he had arrived at the emergency room. In addition, following the VA’s admission to the hospital on July 25, 2022, when maggots were found in the VA’s wounds, the HCP told FM1 and FM2, “Do not send [the VA] back there (to the facility). Do not go back to that house.” For the facility’s Internal Review, seven direct care staff persons were interviewed, and each provided information that the VA “refused” cares for his/her legs. The VA scheduled his/her own medical appointments and then routinely did not inform staff of the appointments or cancel them for unknown reasons. The VA did not want staff to communicate with his/her doctors. At various points, medicated-creams, -ointments, and -washes were prescribed for the VA’s legs, and the VA declined to use them stating that they made his/her legs “hurt” and/or “itchy.” Information was also provided that the VA “refused” to sleep in his/her bed, choosing instead to sleep in his/her wheelchair; that the VA “refused” to shower; and that the VA “refused” staff helping him/her with his/her clothing. The VA “always kept [his/her] legs and feet covered with [his/her] robe.” The P provided the following additional information: · The P was first made aware of concerns with the VA’s legs around mid-May 2022. At that time, the P asked to look at the VA’s legs, and the VA immediately responded in a defensive manner; however, eventually allowed the P to look. The P described the VA’s legs as “red … swollen … [with] skin flaking off … leaking a little bit.” The P contacted a nurse who advised that the VA be seen by a doctor. (Note: The VA was seen at a clinic on May 9, 2022, as stated above.) · Also in response to the VA’s leg concerns, the P instructed staff to visually check the VA’s legs every day; however, according to the P, “most times” the VA would be “offended” if asked by staff and/or “refused” to show his/her legs to staff. · According to the P, the VA had a history of going to the doctor or being hospitalized, and during that time, his/her legs would improve. However, when the VA was discharged back to the facility, s/he would refuse all cares from staff persons, which would then lead back to an increase in concerns for his/her legs; and s/he would return to the hospital, and so on. This happened at least three times that the P was aware of. · The most recent incident, at the time of this investigation was in July 2022. The VA was discharged from the hospital on July 14, 2022, and at that time, the VA’s legs “looked so good.” They were not red or swollen; they “looked healthy.” Then, on July 25, 2022, the P was informed by staff that there were maggots on the VA’s legs. The P said that s/he had worked direct care with the VA on July 23 and 24, 2022. At that time, the P asked if the VA wanted to take a shower, and the VA declined. The P asked if the VA wanted his/her legs washed, and the VA said that s/he would wait until the next shift’s staff person arrived. The P added that it was common for the VA to want certain staff to complete certain cares for him/her. The VA had never wanted the P to help him/her with changing clothes or showering, and so the P was not concerned when the VA said that s/he would wait until the next staff arrived. The P did not check or verify if the VA actually received a shower from the next shift staff person. · The P said that the VA’s showers and refusals for cares were not documented by staff “as well as it should have been.” The facility’s policies and procedures provided the following information: · “It is the policy of Mary T. Inc. to meet the health service needs of each person being served as defined and assigned in each person’s [support plan and support plan addendum] … the program will maintain documentation on how the person’s health needs will be met. The record will include a description of the procedures to follow in order to … Monitor health conditions according to written instructions from a licensed health professional.” · In the event of a medication/treatment event, including a missed or refused medication/treatment, staff persons were to complete a General Event Report (GER). [Note: There were no GERs completed for the 482 times, as documented above, where the VA’s medications/treatments were missed or refused. – This was in violation of Minnesota Statutes 245D.11 subdivision 2, clause (3), which states that the license holder must implement policies and procedures that promote health and welfare by ensuring safe medication assistance and administration according to the requirements in sections 245D.05, subdivisions 1a, 2, and 5, and 245D.051.] · When assigned responsibility for medication administration … the program must ensure that the information maintained in the MAR is … regularly reviewed to identify medication administration errors … Based on the review, the program must develop and implement a plan to correct patterns of medication administration errors when identified … The program must report (a person’s refusal or failure to take or receive medication or treatment as prescribed) to … the person’s case manager.” [Note: There was no information that the 482 times, as documented above, where the VA’s medications/treatments were missed or refused were communicated to the CM. – This was in violation of Minnesota Statutes section 245D.05, subdivision 4, paragraph (b), clause (2), which states that when assigned responsibility for medication administration, the license holder report a person's refusal or failure to take or receive medication or treatment as prescribed to the person's legal representative and case manager as they occur or as otherwise directed in the coordinated service and support plan or the coordinated service and support plan addendum.] · “Wounds are to be reported immediately to the program nurse when assigned, or program supervisor. These staff members will help determine when medical care is needed and will monitor and ensure there is documentation until the wound resolves.” [Note: There was no information that the VA’s wounds as documented above were reported to a nurse or program supervisor, and/or that the VA’s wounds were monitored until resolved.] · “Dressings over closed wounds should generally be removed or changed if they are wet or if the individual has signs or symptoms suggestive of infection, for example, fever or unusual wound pain. Follow care instructions and consult a medical provider or nurse with questions.” [Note: There was no information that the VA’s wound dressings were changed as required or that anyone contacted a medical provider or nurse with questions about this.] · “Daily documentation will occur from staff until the wound is resolved.” [Note: There was no wound documentation completed by staff until the VA’s wound was resolved.] · Regarding when to seek medical care or advice for a wound, “If the wound worsens; or does not improve within 7 days of providing care … If there is evidence of infection.” [Note: There was no information that anyone sought medical care for the VA’s wounds, which were present for more than 7 days and had evidence of infection.] This investigator reviewed training records for nine staff person, including the P. All records showed that staff persons received training on the facility’s medication administration policies and on the Reporting of Maltreatment of Vulnerable Adults Act. Some staff also received training on Documenting, Observing, and Reporting; First Aid; and/or Medication Management. [Note: None of the records reviewed showed training specific to the VA’s support plan and/or support plan addendum. – This was in violation of Minnesota Statutes section 245D.095, subdivision 5, paragraph (a), clause (2), which states that the license holder must maintain documentation of staff qualifications, orientation, training, and performance evaluations as required under section 245D.09, subdivisions 3 to 5, including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor.] Conclusion: A. Maltreatment: Between May 1 and July 25, 2022, multiple staff persons repeatedly documented the VA’s refused/missed medications and treatments; however, there was no information that anyone reported these incidents as required in the facility’s policies and procedures. In addition, at least seven times, a supervisory staff person reviewed the VA’s MAR, specifically looking for missed/refused medications or treatments; however, there was no information that concerns were noticed or followed up on. There was also no information that at any point the facility developed and/or implemented a plan to correct the patterns of medication administration errors for the VA. These were in violation of Minnesota Statutes section 245D.05 and 245D.11 as outlined in the above Summary of Findings section. Although the VA was not subject to guardianship and, as stated in his/her support plan and support plan addendum, was “a strong verbal communicator” and able to self-advocate, the plans also stated that the facility was responsible for ensuring all of the VA’s “health and safety needs” were met, and this was not done in a manner necessary to prevent the VA’s wounds from reaching a level that included the infestation of maggots. Therefore, there was a preponderance of the evidence that there was a failure to supply the VA with care and services, which were reasonable and necessary to maintain the VA's health, considering the physical and mental capacity or dysfunction of the VA. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The facility provided training to staff persons on the facility’s medication administration policies and on the Reporting of Maltreatment of Vulnerable Adults Act. Some staff also received training on Documenting, Observing, and Reporting; First Aid; and/or Medication Management. The facility failed to document for nine staff persons training specific to the VA’s support plan and/or support plan addendum which was a violation as outlined above in the Summary of Findings section. Although staff person were trained on policies and procedures, multiple times the facility’s policies and procedures were not followed, and this went unnoticed and uncorrected for at least three months in May through July 2022. Given that there were multiple staff persons with varying degrees of authority within the facility involved in the failure to provide necessary care and services to the VA, and that the facility failed to maintain compliance with Minnesota Statutes section 245D.05 and 245D.11 regarding the VA’s care and 245D.095 regarding staff persons training, individual staff persons responsibility was mitigated and it was determined that the facility was responsible for the maltreatment of the VA. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated maltreatment for which the facility was responsible was “serious” maltreatment. After almost three month of neglect for the VA’s health care needs, the VA developed an infestation of maggots in his/her leg wounds, which required hospitalization. Action Taken by Facility: The facility completed an internal review, and determined that policies and procedures were adequate, but not followed. The facility provided additional training to staff persons regarding follow-up and communication with healthcare providers. Action Taken by Department of Human Services, Office of Inspector General: On November 9, 2022, the license holder was ordered to forfeit a fine of $5000 as a result of the “serious” substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal.
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