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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: 1069211-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Tessa Ripka Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was left lying on the bathroom floor for an extended period while not feeling well. The VA became unresponsive and was hospitalized. Date of Incident(s): October 4, 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 October 20, 2022; from documentation at the facility; and through seven interviews conducted with three facility staff persons (P1, P2, P3), the VA’s case manager (CM), the VA’s guardians (G1, G2), and the VA. The VA was diagnosed with epilepsy and a nonverbal learning disorder. The VA enjoyed drawing and participating in Special Olympics. The facility was a single story home with a main kitchen, living room, and dining room area. To the left of the main area was the VA’s bedroom which was located in a mother-in-law type suite that had a separate small kitchen, living area, and bathroom. The Coordinated Services and Supports Plan indicated that the VA had severe migraines that could cause hemiparesis (weakness on one side of the body) and seizures. The Individual Abuse Prevention Plan indicated that the VA had three hours of unsupervised time in the community and at the facility. The Intensive Services Assessment indicated that the VA experienced mega migraines that caused hemi paralysis. The VA felt when a migraine was coming on and asked for his/her migraine medication. If the VA informed staff persons that s/he was “feeling funny,” staff followed the VA’s seizure or migraine protocol as directed. Staff persons contacted the facility medical professional and administered medications as directed in the protocol. In the past the VA experienced migraines that displayed stroke like symptoms such as drooping in the face, slurred speech, and slow movements. If the VA displayed these symptoms, staff persons called 911. The VA could experience balance issues when s/he had a migraine headache. The VA had a walker to utilize when s/he felt his/her balance was compromised. The Outpatient Individual Migraine Protocol indicated that at the first sign of a headache the VA was given rizatriptan (used to treat migraines) 10 milligrams (mg) and prochlorperazine (used to treat severe nausea and vomiting) 10mg. If the migraine continued the dose could be repeated after one hour. If there was sleepiness, despite the early treatment staff persons could try a half tablet of the rizatriptan at the start of the headache and repeat the other half after 30 minutes. Staff persons could add 1000 mg Tylenol to the first rizatriptan to make it work better. If the VA was unable to lie down s/he may continue the 10 mg of rizatriptan because sleep was the best cure for his/her migraines. Staff person could try gabapentin (can be used to control migraines) 100 mg for a persistent/severe headache or hemiplegic migraine. This could be repeated every four hours as needed. The medication caused sleepiness. Staff persons were to use an ice pack on the VA’s head and encourage him/her to rest. If symptoms continued or worsened after two hours, staff person administered a methylprednisolone (steroid used to treat migraines)dose pack for the next six days. If symptoms persisted or worsened, staff persons called the neurology clinic for further recommendations. If the VA exhibited symptoms of weakness, difficulty getting words out, or slurred speech that did not resolve after treatment, staff persons called 911. The VA said that on the day of the incident, the VA was on the floor and first responders came and got the VA up and took him/her to the hospital. The VA said s/he was “kind of out of it” and did not remember if s/he laid down on the floor or fell. At one point, the VA tried to get water or go to the bathroom and the next thing s/he knew, s/he was on the floor. The VA was not sure how long s/he was on the floor or if s/he could get up on his/her own. P1-P3 provided the following information: · On October 2, 2022, the VA went to the ER for a migraine headache. The VA was given some diluadid (pain reliever), tramadol (pain reliever), and Tylenol and returned home that day. On October 3, 2022, around midday, P3 went to the facility to check on the VA. The VA was tired and in bed but was able to have a simple conversation with P3 but was not as talkative as usual. P3 had seen the VA with a migraine before and this was not out of the ordinary. · P3 noticed that part of the VA’s migraine headache protocol had been completed as s/he had been given the first dose of medications on October 2, 2022. Since a significant amount of time had passed since the first dose, P3 called the VA’s neurologist to see if they should start over from the beginning of the protocol or start with the methylprednisolone six-day dose pack. The VA’s neurologist called back and said they were not familiar with the protocol so P3 sent them a copy but did not hear back. · On October 4, 2022, at approximately 8 a.m., P1 arrived at the facility. The overnight staff persons said the VA was doing well. The VA had gotten up, had breakfast and medications, and chatted with the staff person and his/her housemate before returning to his/her bedroom. · P1 went to check on the VA and the VA came out of his/her bedroom for a while to talk with P1 and then went back to his/her bedroom. P3 called to check on the VA and P1 told P3 that the VA had been up that morning, had breakfast, and gotten his/her medications. P1 told P3 that the VA seemed quiet but was up and moving around. P3 called P2 and asked him/her to go to the facility and assess the VA. · Later on P1 started preparing lunch and assisting the VA’s housemate with getting ready for work when P2 arrived to the facility around 10 a.m. When P2 checked on the VA, P2 found the VA lying on his/her bathroom floor. · P2 asked the VA how s/he was and the VA just mumbled. P2 took the VA’s vitals and everything was within normal range. When asked if the VA was going to get up and eat the VA said “Yes.” · P2 told P1 to make sure the VA got up and had something to eat and drink and then left the facility after approximately 15-20 minutes. P1 then offered the VA an ice pack for his/her head and finished preparing lunch. · When P1 checked on the VA again, s/he was in his/her bed resting. A while later when P1 checked the VA was heading to the bathroom. P1 came back to give the VA his/her medications and lunch and found the VA in his/her bed. The VA ate all of his/her lunch while in bed. · P3 called P1 again at approximately 12:30 p.m., and P1 said the VA had been up, had lunch, and drank some Gatorade water. The VA then laid back down in bed. · P1 came back to get the VA’s lunch dishes and the VA was still in his/her bed. When P1 went back to check on the VA around 2:15 p.m., the VA was on the floor in the bathroom again. · At approximately 3 p.m., P3 arrived at the facility to check on the VA and found the VA lying on the bathroom floor. The VA was unable to answer P3’s questions and was not opening his/her eyes so P3 called paramedics. P3 and paramedics continued to try to get the VA to get into a sitting position and eventually were able to put the VA on a gurney and transport him/her to the hospital. The Internal Review of An Alleged Maltreatment Report indicated that the VA was admitted to the hospital on October 4, 2022, for the intractable headache unspecified (headache that does not go away), chronicity pattern (long term), unspecified headache type, fever unspecified, acute right-sided weakness, and leukocytosis (high white blood cell count) unspecified. The VA completed a CTA (computed tomography angiography) of his/her neck/head area, a MRI (magnetic resonance imaging) of his/her brain, and chest x-rays all with no acute abnormalities. There were no signs of stroke, large vessel occlusion (ischemic stroke), pneumonia, or reported seizures. An empiric (broad spectrum) antibiotic for possible meningitis was recommended and the VA was discharged on October 10, 2022. Daily Log Notes provided the follow information: · On October 2, 2022, at approximately 9 a.m., an overnight staff person checked on the VA and s/he was not responding. The staff person called the facility on-call medical professional. The VA refused to talk with him/her as well so the staff person called 911 and the VA was taken to the hospital. · At approximately 2:40 p.m., the VA returned to the facility even though s/he told staff persons s/he did not want to return home. The VA was offered a shower but declined and went to sleep instead. After a couple hours, the VA woke up and was still not feeling well. The staff person called G1 and G1 said to give the VA the rizatriptan and prochlorperazine. The staff person gave the VA one of each medication and the VA slept the rest of the day. · When the overnight staff person arrived, the VA was in his/her bedroom relaxing. The overnight staff person checked the VA at 10:10 p.m., 12:10 a.m., and 5 a.m., and the VA said s/he was “ok.” The VA’s vitals were taken at 5:30 a.m. and were within normal limits. An as needed medication was administered at 6 a.m. (determined to be gabapentin) and the VA drank 4 ounces of water and ate scrambled eggs and went to his/her bedroom to rest. · Later in the day on October 3, 2022, staff persons administered evening medications to the VA and the VA ate dinner. The VA slept through the night and was given his/her morning medications and breakfast on October 4, 2022. · On October 4, 2022, P1 arrived and the VA was in bed relaxing. The VA had his/her breakfast and medications and talked with P1 before going back to his/her bedroom. P2 arrived before lunch and found the VA on his/her bathroom floor. P1 went and got the VA an ice pack for his/her head and the VA returned to his/her bed. The VA had lunch and took his/her 12 p.m., medications. P1 checked on the VA later in the day and saw the VA was on the bathroom floor again. P1 alerted P3 who came to the facility and the paramedics were called. G1 said the VA had a long history of migraines and seizures including seizures that could turn into migraine headaches. Many times the VA’s migraines resulted in hemiparesis (inability to move one side of the body). The VA had three of these headaches in the last few years resulting in hospitalizations and changes in mobility, speech, and cognition. It took a period of time and therapy for the VA to get back to his/her baseline. G1 was concerned that P2 let the VA lie on the floor and did not call for more assistance. Medication administration records indicated that on October 2, 2022, the VA was given rizatriptan 10 mg and prochlorperazine. On October 3, 2022, the VA was given gabapentin 100 mg. Times the medications were give was not noted on the information received by this investigator. Medical records showed the VA was seen at the ER on October 2, 2022, and was diagnosed with acute nonintractable (controlled by medications) headache, unspecified headache type. The VA was give acetaminophen, ketorolac (pain reliever), and ondansetron (prevents nausea). All staff persons interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults Act, the VA’s plans, and facility policies prior to the incident. Conclusion: Information was consistent that on October 2, 2022, the VA was seen at the ER for a migraine headache. When s/he returned to the facility s/he was given rizatriptan 10 mg and prochlorperazine 10 mg per G1. On October 3, 2022, the VA appeared tired but ate and drank as usual. The remainder of the VA’s migraine protocol was not followed but staff persons gave the VA gabapentin 100 mg on October 3, 2022. On October 4, 2022, the VA had breakfast, medications and chatted with staff persons. At approximately 10 a.m., P2 found the VA on the floor in his/her bathroom. P2 checked the VA’s vitals and they were normal. When asked, the VA, said s/he would get up. Later the VA got up and returned to bed where P1 gave the VA an ice pack. Around 12 p.m., the VA ate lunch and had his/her noon medications while in bed. At approximately 2 p.m., the VA was again lying on the bathroom floor but this time would not respond to staff person questions. P3 called paramedics and the VA was taken to the hospital. While the VA’s migraine protocol was not fully implemented, and the VA lay on the bathroom floor multiple times during the day, given the VA used the bathroom independently; that the VA moved from his/her bedroom to his/her bathroom, ate, drank, and talked with staff persons throughout the day; that the VA continued to respond to staff persons questions while s/he was in the bathroom; and that when the VA failed to respond to staff persons, emergency responders were contacted; there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services that were reasonable and necessary to maintain his/her physical health or safety or if earlier intervention would have changed the outcome. 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 were adequate but not followed when staff persons did not follow the VA’s migraine protocol or sign off on medication administration sheets correctly. Staff persons were retrained on the VA’s protocols and plan, and medication administration. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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