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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: 1069689-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jason Pehler Suspected Maltreatment Reported: It was reported a vulnerable adult (VA) was not provided care and services by the facility. Date of Incident(s): Ongoing since December 2021 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 for this investigation was obtained remotely, including documentation from the facility medical records; and through three interviews conducted with the VA’s guardian, VA’s case manager (CM) and a facility supervisor (P1). The VA was not interviewed during the investigation. Facility documentation showed the VA was described as creative, inquisitive, and friendly. The VA was able to eat and walk independently. The VA was diagnosed with Down syndrome, and had a significant history of cavities. The VA was provided 24 hour services by the facility. The VA client specific information showed the G and “caregivers” would continue to ensure and provide the VA’s health and safety as needed. The following information was from interviews with the G, P1 and the CM, and documentation that was provided: · The VA moved out of the facility on/or around October 25, 2022, prior to the investigation. The G removed all of the VA’s file and documentation from the facility, which included the VA’s client specific documentation, medication administration records, and other documentation that was required to remain at the facility. During the investigation, the G provided some of the information this investigator requested from the VA’s file, but it was unable to be determined if the missing documentation was in the VA’s file prior to the file being removed from the facility and/or if the G did not provide the requested information. There was conflicting information related to the circumstances in which the file was removed, however, the G did not request the file from a supervisor, nor contact a supervisor prior to removing the file from the facility. · The G and an administrative staff person (P2) had interpersonal conflicts while the VA lived at the facility that likely contributed to some of the concerns outlined in this report. · The G had multiple concerns regarding the overall care of the VA while s/he was at the facility. The G concerns were with the lack of care, and lack of follow up of with appointments that were supposed to be completed to ensure the VA’s health and safety. 1. In 2019, the VA was seen for a dental appointment at the University of Minnesota and it was recommended the VA have a root canal. After multiple delays, the CM scheduled an appointment with a dental office in October 2022 and the concern regarding the VA’s abscessed tooth was resolved. The G was concerned because the VA was not seen for the root canal and abscessed tooth until October 2022 (approximately three years later). The G explained there was a lack of dental appointments completed and follow up that should have occurred. o The G said between March and August 2022, multiple dental appointments were scheduled to address the root canal/abscessed tooth, however, there was no resolution to the concern until October 2022. o The G said the facility delayed the VA receiving treatment from the dental office on multiple occasions: - On one occasion, a staff person forgot the VA’s identification card and the VA was unable to complete the appointment. - On a second occasion, a staff person did not communicate with the dentist that the VA needed a root canal/abscess tooth and the concern was not addressed. - On a third occasion, the dental office required a payment from the VA to continue care/services, however, a staff person did not contact the G to make the payment while the VA was at the dental office. o The G said an additional delay occurred when s/he was sent a consent form from the dental office, but did not see the form in his/her email. The G requested the facility assist him/her with the process, but the facility was not helpful. Based on documentation and information obtained, between 2019 and 2022, there were multiple circumstances that caused delays in the VA receiving care for the abscessed tooth including the COVID-19 pandemic. All persons involved including: staff persons at the facility, the G, and the dental office, were involved in the circumstances that contributed to the delay in the completion of the VA’s dental treatment. In October 2022, the VA’s dental work was completed and there was no information that the VA sustained any lasting harm as a result. 2. The G said the VA lost 50-60 pounds between December 2021 and September 2022 and that s/he was concerned that the loss of weight was related to the lack of dental services completed. The G said that the VA completed multiple appointments with his/her primary physician between December 2021 and October 2022 and the VA’s primary physician was not concerned about the VA’s weight loss during the appointments. The G added that the VA continued to lose weight after s/he moved out of the facility and was currently below the ideal weight the primary physician had stated. Based on documentation and information obtained, the VA lost weight while at the facility but was seen by his/her primary physician multiple times who had no concerns with the VA’s weight loss at that time. Furthermore, the VA continued to lose weight after leaving the facility and there was no information that the facility or staff persons lack of care caused or contributed to the VA’s loss of weight. 3. The G said the VA had a lack of hygiene supplies while at the facility including toothpaste, shampoo, and other hygiene products. P1 denied that the VA did not have hygiene products available for his/her use. The VA completed tasks hygiene tasks independently. Based on the conflicting information it was it was not determined whether the VA had hygiene products at the facility. 4. The G provided a video of a phone/video chat which showed a staff person interacting with the VA and attempting to problem solve potential food options with the VA and the G. During the interaction, after the VA made a statement, the staff told the VA to not lie. The staff also said there was limited food at the facility, however a supervisor planned to go shopping for food for the facility. During the video, it was discussed that the VA be provided eggs and applesauce and there was an additional statement made about cereal. The G told this investigator that the VA was provided cereal, which the G believed would cause additional issues for the VA due to his/her dental needs. A review of the video showed that interaction occurred while the VA was on the phone with the G and the staff person was speaking over the VA’s shoulder. The VA stated s/he did not want the staff to speak loudly into his/her ear (the staff was positioned behind the VA during the video). During the video, the staff continued to try to meet the needs of the VA and the requests the G made during the video call. It was unknown if the staff was aware s/he was being recorded on video during the interaction, but the staff acknowledged the facility had a lack of food at the moment the video ended, however, said s/he would provide the VA with eggs, applesauce, and/or cereal. Based on documentation and information obtained, the staff telling the VA not to lie was not a therapeutic interaction, but it did not appear to cause the VA emotional distress and/or a change in the VA’s behavior during the interaction. The VA was provided with food as s/he had applesauce and cereal during and/or after the video call. There was no other information that supported ongoing concerns with the staff speaking loudly at the VA. 5. The G was concerned the VA was being provided limited food when s/he was in his/her room for long periods of time. The G said the VA spend up to 22 hours a day in his/her bedroom. The VA had COVID-19 and was isolated in his/her bedroom for a period of time per CDC guidelines. The G believed this caused a behavioral change in the VA and the VA became confused whether it was night or day. The VA struggled to maintain a routine, and the G did not believe the facility was providing required support and services to ensure the VA’s routine when the VA was isolated in his/her room. Staff persons provided verbal prompts, but may or may not have been providing physical assistance or multiple verbal prompts to assist the VA. Based on documentation and information obtained, the VA had a right to refuse any prompt and had access to the facility but chose to remain in his/her bedroom. There was no information provided, aside from the G’s information, that staff persons and/or the facility were not providing care and/or services to the VA or that their interactions were not therapeutic or inconsistent with the VA’s plans. 6. The G assisted the VA move out of the facility and during that time the G was provided multiple medications including levodopa and carbidipoa that were not on the VA’s medication administration record. The G located information within the VA’s documentation which showed the medications were discontinued in May 2022. The G also said the VA did not receive vitamin D for multiple days before s/he was discharged. The P said s/he tried to arrange for the issue with the vitamin D to be resolved, but thought the G was ordering the medication and that the G would get it from the pharmacy. The P said the VA was provided the medications prescribed. Based on documentation and information obtained, when the VA moved out the G was given some medications that had been discontinued. However, there was no information to show that the VA was administered the discontinued medications and if s/he had, whether there was any harm to the VA taking a medication longer than was prescribed. In addition, there was no information provided that the VA’s missed doses of vitamin D harmed the VA in any manner. 7. The G said the VA had appointments for an Ear/Nose/Throat doctor for earwax to be removed and the appointments were recommended every three months. However, the VA did not attend all of the appointments. The appointments were as follows: o September 2021: appointment completed o December 2021: no show for the appointment o May 2022: late cancellation for the appointment o June 2022: appointment completed o September 2022: no show for the appointment o October 2022: appointment was cancelled Based on documentation and information obtained, the VA was to have earwax removed 4 times a year but from September 2021 to October 2022, not all of the VA’s appointment for earwax removal were completed and the VA’s earwax was removed two times. While it would have been reasonable to follow the physicians order for the wax to be removed quarterly, there was no known physical impact or harm to the VA based on the information provided. Conclusion: Although the G had multiple concerns regarding the care and services the VA was provided by the facility, given the following, there was not preponderance of the evidence whether the facility failed to provide the VA with reasonable or necessary care or services: · Multiple circumstances including the COVID-19 pandemic and all persons involved including staff persons, the G, and the dental office contributed to the delays in the VA’s dental care. In October 2022, the VA’s dental work was completed and there was no information that the VA sustained any lasting harm as a result. · Although the VA lost weight while at the facility, the VA saw his/her primary physician multiple times who had no concerns with the VA’s weight loss at that time and the VA continued to lose weight after moving from the facility. In addition, there was no information that the facility or staff persons lack of care caused or contributed to the VA’s loss of weight. · Based on the conflicting information it was it was not determined whether the VA had hygiene products at the facility. · The staff telling the VA not to lie was not a therapeutic interaction, but it did not appear to cause the VA emotional distress and/or a change in the VA’s behavior during the interaction. The VA was provided with food as s/he had applesauce and cereal during and/or after the video call. There was no other information that supported ongoing concerns with the staff speaking loudly at the VA. · There was no information provided, aside from the G’s information, that staff persons and/or the facility were not providing care and/or services to the VA or that their interactions were not therapeutic or inconsistent with the VA’s plans. · There was no information to show that the VA was administered discontinued medications and if s/he had, whether there was any harm to the VA taking a medication longer than was prescribed. In addition, there was no information provided that the VA’s missed doses of vitamin D harmed the VA in any manner. · While it would have been reasonable to follow the physicians order for the wax to be removed quarterly, there was no known physical impact or harm to the VA based on the information provided. 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 Department of Human Services, Office of Inspector General: No further action taken.
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