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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: 1070424-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Sarah Schumacher Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) “overdosed” on insulin on three occasions because an insulin injection pen was “left out” for the VA to obtain and use without staff person supervision. Date of Incident(s): July 14, August 4, and August 13, 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 25, 2022; from documentation at the facility and medical records; and through six interviews conducted with the VA, three facility staff persons (SP1, SP2, and P1), a facility supervisor (P2), and the VA’s guardian (G). A facility staff person (SP3) told this investigator s/he did not wish to participate in an interview because s/he provided information about the incident in facility documentation and would contact this investigator if s/he wanted to report further information. SP3 did not contact this investigator to provide further information however, SP3 provided information to a facility administrator and in facility documentation so that information was included below. The VA’s diagnoses included borderline personality disorder, diabetes, depressions, post-traumatic stress disorder, and schizoaffective disorder. The VA required the supervision of two staff persons at all times. The VA had a history of engaging in “maladaptive behaviors” when s/he “did not get what s/he wanted.” The VA enjoyed playing cards, going out to eat, and watching movies. The VA was prescribed Lantus (an insulin glargine injection pen) 55 units twice daily. The VA was also prescribed NovoLog (fast acting insulin injection pen) given on a sliding scale based on the VA’s blood glucose level three times daily. Both pens contained insulin and were administered by turning a dial to the correct dose, inserting the needle of the pen into the stomach, and then pressing a release on the pen to inject the insulin. To administer either pen to the VA, staff persons took the pen out of a locked box, turned the dial to the correct dose of insulin, and then gave the VA the pen for the VA to inject him/herself (unlicensed staff persons were not authorized to administer injections). Staff persons were to observe the VA injecting the insulin and then take the pen when s/he was completed returning it to the locked box. The VA told this investigator that staff persons “just give me the [insulin] pen” and that s/he “overdosed three times.” Each occasion, the VA took more insulin than prescribed to “overdose.” The VA did not “overdose” more than once on each date of occurrence. The VA stated that one time “they” gave the insulin pen to him/her and “they” left the room so the VA overdosed by dialing the dosage “all the way up.” Then the VA went to “them” to tell “them” to call the ambulance because the VA “just overdosed,” but “they” would not let the VA use the telephone to call 9-1-1 so an unnamed staff person called 9-1-1 “after I fainted.” The VA stated that s/he told staff persons “immediately” but staff persons did not call 9-1-1 because the VA had to “learn a lesson.” The VA did “not want to die” but just “wanted to get out of here” and go to the hospital where s/he could watch television and play cards. The VA did not recall which staff persons were working when s/he “overdosed” on insulin. The VA’s medical records stated that the VA told hospital staff persons that facility staff persons left the insulin pens out on a table so the VA could access the pens to take more insulin than prescribed and also told hospital staff persons that the VA increased the insulin dose on the pen after a staff person gave the pen to the VA. The G stated that the VA was “not always the most accurate reporter” but that “not everything” the VA reported was “false” and it was “difficult to differentiate” what was “false.” The VA told the G that unnamed staff persons left the insulin pen on the table but the facility told the G that staff persons did not leave the insulin pen on the table and that when they gave it to the VA dialed to the correct dose, the VA quickly “dialed it up” and injected him/herself with more insulin than prescribed. The G was concerned that staff persons at the facility were not “qualified” to observe the VA administering his/her insulin. Information from interviews and documentation provided consistent information that on July 14, August 4, and August 13, 2022, while staff persons were assisting the VA with insulin administration, the VA increased the insulin dose on the insulin pen after the staff person gave the pen to the VA and then injected him/herself with a higher amount of insulin than prescribed. There was no information to support that any staff person left either insulin pen out of the lock box for the VA to independently access without staff person supervision. SP1, SP2, SP3, and P1 each provided consistent information (which was supported by facility documentation and P2 who talked with SP1, SP2, and SP3 after each incident) that each time they administered insulin to the VA, they remained with the VA to observe the VA injecting him/herself and they locked up the insulin pens when not in use. There was also no information to support that staff persons prevented the VA from calling 9-1-1 or that staff persons did not call 9-1-1 when they were aware that the VA took more insulin than prescribed. On July 14, 2022, SP1 administered the VA’s insulin. SP1 dialed the insulin pen to the correct dose and gave it to the VA to inject. SP1 did not see the VA increase the insulin dose but shortly after, the VA told SP1, “I’m so sorry I’m going to get you in trouble. I overdosed and need to call the ambulance.” SP1 called 9-1-1 and the VA was transported to the hospital. SP1 denied leaving the VA’s insulin pen out of the locked box when not in use. On August 4, 2022, SP3 administered the VA’s insulin. SP3 dialed the insulin pen to the correct dose and gave it to the VA to inject. SP3 and the other staff person working saw the VA increase the dose and then inject him/herself with the insulin. SP3 called 9-1-1 and the VA was transported to the hospital. At the hospital, the VA’s medical record showed that the VA stated s/he was upset about not going on an outing so s/he increased the dose on the insulin pen when staff persons gave it to him/her so s/he could go to the hospital. When interviewed by the facility administrator, SP3 and the other staff person working stated that the VA’s insulin pen was not left out of the locked box when not in use. On August 13, 2022, SP2 administered the VA’s insulin. P1 was also working and observed SP2 do so. SP2 and P1 provided consistent information that the VA told both that s/he wanted to go to the hospital because they “treated” the VA well and so the VA could watch a movie. SP2 dialed the insulin pen to the correct dose and gave it to the VA to inject. The VA then turned the dial to a higher dose and injected the insulin. SP2 called 9-1-1 and when paramedics came, they told the VA that his/her blood glucose level was not concerning so s/he did not need to go to the hospital. Then the VA told the paramedics that s/he had suicidal ideations so then the VA was transported to the hospital. SP2 denied leaving the insulin pen out of the lock box and P1 stated that s/he did not observe SP2 leave the insulin pen out of the lock box when not in use. The facility’s Internal Review stated that on August 5, 2022, the VA’s team met to discuss a plan to prevent the VA from increasing the insulin dose as s/he was self-administering the injection because non-licensed staff persons were not authorized to administer injection medications. The team decided that the facility would talk to the VA’s medical provider about training staff persons to inject the VA’s insulin rather than the VA doing so. On August 18, 2022, the VA had an appointment with his/her medical provider but the provider declined to “make any changes” to the VA’s insulin administration procedure. On August 31, 2022, the VA had another appointment scheduled with his/her medical provider to obtain orders for another home care agency to go to the facility to train staff persons to do “hand over hand” assist when the VA injected insulin. However, that morning, the VA canceled the appointment. The facility was continuing to search for other agencies to assist with the VA’s insulin injections. Although the VA was able to take more than the prescribed amount of insulin on three occasions, and that the VA told hospital staff persons and the G that staff persons left the insulin pens out so the VA could access them and that staff persons refused to call 9-1-1 or let the VA call 9-1-1, given that the VA’s plans allowed for the VA to self-administer the insulin; that information was consistent that the VA increased the dose of insulin when staff persons gave the VA the insulin pen to self-administer the injection; that SP1, SP2, and SP3 each denied leaving the insulin pen out of the locked box when not in use; and that SP1, SP2, and SP3 each called 9-1-1 when they were aware that the VA took more insulin than prescribed, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. 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 followed but not adequate for the VA because the facility policies did not allow staff persons to administered injectable medications without oversight and training by a physician. The facility continued to search for a licensed medical professional or agency to train staff persons and provide required oversight. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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