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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: 1071449-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was allowed to take ecstasy (stimulate/psychedelic) intravenously. As a result, the VA passed out and medical care was not sought for the VA in a timely manner. Date of Incident(s): Ongoing, prior to August 12, 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 September 7, 2022; from documentation at the facility and medical records; and through interviews conducted with the VA, two facility staff persons, and the VA’s guardian. The VA’s diagnoses included a traumatic brain injury. The VA’s support plans stated: · The VA was hearing impaired, but was able to communicate via text message. · The VA was able to be in the community without staff person supervision for up to 12 hours. The VA had a cell phone and was able to utilize public transportation. · The VA had a history of constipation and refused to take a regular medication for constipation, but would ask for over the counter medications if s/he was constipated. · The VA enjoyed working and raising chickens at the facility. A health care professional (HCP) provided the following information. On August 12, 2022, the VA arrived for an appointment and reported to be in “serious pain all over,” had not eaten or slept in a week, and had bowel incontinence. The VA deteriorated at the medical appointment and the VA was transported to the hospital. Hospital medical records stated: · On August 12, 2022, at about 3:50 p.m., the VA presented at the emergency room with complaints of muscle pain, decreased oral intake, and “feeling hot.” The VA’s symptoms reportedly started on August 8, 2022. The VA stated that his/her back muscles hurt, but denied any body tenderness. The VA stated that the pain happened when it was hot outside. The VA believed that s/he was dehydrated. The VA stated that s/he had decreased food and fluid intake because “it hurt to chew.” The VA stated that his/her lips were sore, but the VA did not have throat pain or areas of tenderness. The VA said that s/he had some lightheadedness when s/he stood up, but denied passing out. The VA was constipated for three days, but had a bowel movement in the waiting room. The VA reported that it hurt when s/he urinated. The VA stated that s/he did “shoot up” ecstasy five days ago, prior to the onset of the symptoms. · The VA was evaluated and given intravenous fluids and was ready for discharge at 11:47 p.m. There was not transportation available for the VA at the time so the VA remained overnight and returned to the facility the following morning. An administrative staff person (P1) completed an internal review report which included interviews with five staff persons (P2-P6). The internal review report stated: · The VA went to work on August 8 and 9, 2022. After work, the VA spent time with his/her family in the community. Upon returning to the facility on August 8 and 9, 2022, the VA was observed to be within “baseline.” The VA interacted with staff persons and spent time with his/her chickens in back yard. · On August 10, 2022, in the morning the VA shared with P2 that s/he fainted, but did not fall down. When asked if s/he was okay to go to work, the VA answered, “Yes.” The VA was asked if s/he wanted to see a physician and the VA replied, “No.” P2 talked to P1 and it was decided to make an appointment for the VA (the appointment was made for August 12, 2022). Later that day, the VA’s work contacted staff persons and asked where the VA was as s/he was not at work. P1 called the VA and the VA said that s/he was waiting for public transportation to return to the facility. P1 decided to go pick the VA up and at that time, the VA said s/he spent with family members. · P1 asked the VA about the fainting and the VA told P1, “Yesterday too hot.” The VA was helping a family member and the family told the VA that s/he had a “blackout” so the VA returned to the facility. P1 asked the VA if s/he wanted to seek medical care and the VA responded, “No, I’m okay. I’m not sick. Just need water, it’s hot today.” Upon returning to the facility, the VA cleaned his/her bedroom and took a shower. · On August 10, 2022, in the evening, staff persons did not notice anything out of the ordinary with the VA. The VA was in and out of the facility and took care of his/her chickens. The VA told P3 that s/he had some diarrhea and P3 gave the some over the counter medication and later the VA told P3 that s/he was dong okay. · On August 11, 2022, the VA was within “baseline”. The VA did not eat at mealtimes, but was observed to be drinking fluids, water, and pop throughout the day. The VA visited with his/her chickens, played video games, talked to persons on the phone, listened to music, and socialized with staff persons. The VA was reminded of his/her appointment the next day. The VA slept well. · On August 12, 2022, the VA was doing “okay” and met with his/her interdisciplinary team. The VA was hesitant to go to his/her medical appointment, but his/her guardian (G) encouraged him/her to go. The VA was asked if s/he did any drugs during the week and the VA said, “No.” Later that morning, prior to the appointment, the VA told P4 that s/he had ecstasy with him/her, but threw it away when s/he cleaned his/her bedroom. · P5 took the VA to the medical appointment but P5 was not allowed to go in. P5 did not know what the VA told the physician, but the VA “was not [him/herself]” after s/he saw the physician. P5 was told that they were sending the VA to the hospital. Later that evening, the G said that at the emergency room they gave the VA fluids and did lab work, but did not test for drugs. The VA stated that s/he did consume drugs but it was not medically confirmed. The VA was medically cleared to come home but could not be transported home until morning. The VA returned to the facility that morning. The investigator met and the VA and then the VA and this investigator communicated via text message. The VA stated that s/he stayed out in the sun too much and became dehydrated. Documentation obtained from the facility and information obtained from interviews with P1, P2, and the G was consistent with the information in the internal review report. In addition, the G stated that s/he did not have concerns about the care that the VA received at the facility. Facility documentation showed that P1 and P2 each received training on the Reporting of Maltreatment of Vulnerable Adult Act. Facility documentation also showed that P1 developed the VA’s program plans and P2 received training specific to the VA. Conclusion: On August 10, 2022, the VA told P2 that s/he fainted. The VA did not want to seek medical treatment at that time, but an appointment was made for the VA on August 12, 2022. On August 12, 2022, prior to the appointment, the VA stated that s/he used ecstasy earlier in the week. At the appointment, the VA told the HCP that s/he was in “serious pain all over,” had not eaten or slept in a week, and had bowel incontinence. The VA deteriorated at the medical appointment and the VA was transported to the hospital. At the hospital, the VA was evaluated and treated for dehydration and cleared to be discharged that night. Information showed that prior to August 10, 2022, when the VA said that s/he fainted, there were no concerns noted with the VA. Also on August 10, 2022, the VA reported that s/he had diarrhea so the VA took an over the counter medication and after, did not indicate any further concerns. On August 11, 2022, there were no concerns noted with the VA. On August 12, 2022, prior to his/her medical appointment, the VA first told staff persons about his/her drug use that week. Given that staff persons were monitoring the VA the two days prior to his/her appointment, that prior to the appointment there were no noted concerns to the extent of what the VA reported to the HCP, and that the VA was only treated for dehydration at the hospital, there was not a preponderance of the evidence whether the facility failed to seek medical care for the VA in a timely manner. 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 their policies and procedures were adequate and followed. The facility planned to provide follow up training with staff persons including training on recognizing the signs and symptoms of drug and alcohol use. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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