|
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: 801558-RMI (Residential Treatment and Services for Adults with Mental Illness) Investigator(s): Jason Pehler Suspected Maltreatment Reported: It was reported a vulnerable adult (VA) swallowed multiple non-edible items while at the facility and it resulted in a bowel obstruction on June 13, 2022. Date of Incident(s): Multiple incidents occurred including June 4, and June 10, 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 May 18, 2022; from documentation at the facility; and through eight interviews conducted with the VA, a facility staff persons (P1), a facility supervisor (P2), a facility social worker (SW), two health care professionals (HCP1-2), a medical doctor of psychiatry (MDP), and the VA’s case manager (CM). Facility documentation showed the VA was diagnosed with neurocognitive disorder, bipolar disorder, attention deficit hyperactivity disorder, stimulant use disorder, opioid use disorder, and antisocial personality disorder. The VA was admitted into the facility in November 2020, and had an “extensive history” of self-injurious behaviors (SIB). The SIB, specifically swallowing objects, predated the VA’s admittance into the facility and the VA engaged in the SIB to “get to, or away from things” and/or “to get something that [s/he] wants.” The SIB had required multiple surgeries, including a significant surgery in May 2021. The VA’s history included SIB of swallowing items including (but not limited to) pencils, plastic silverware, razor blades, crayons, a potato chip bag, and socks. The VA described the behavior as “intentional” and “gets me what I want.” The VA was aware of what items would pass through his/her digestive tract, and those which would not. The VA’s Individual Abuse Prevention Plan stated the VA’s “access to and use of items will be continually assessed and limited as needed for safety.” The VA had a nursing care plan due to a laparotomy procedure (a surgical incision to the abdomen) on May 4, 2022. The VA had been transferred to a unit with one other person due to his/her on-going behavior. The VA was not subject to guardianship, however had a conservator regarding decision making of medications. The VA’s Person-Centered Master Treatment Plan showed the VA had extensive history of difficulty managing stress and disappointment, and engaging in self-injurious behaviors (SIB) when s/he was unable to cope. The SIB led to medical intervention and potentially serious complications. During the course of the investigation the following information was obtained within interviews and documentation: · The VA had a history of substance use, and had previously attempted to get transferred to a different unit and/or hospital in an attempt to obtain caffeine or prescription medications. The VA was transferred to different units within the facility due to the SIB. · Facility staff persons completed fifteen minute routine monitoring wellness checks on the VA. During the wellness checks staff persons entered the unit, and attempted to have visual and audio contact with the VA. A review of documentation showed the monitoring wellness checks were completed every fifteen minutes between May 4, and 10, 2022. · Facility staff persons monitored items given to the VA to ensure safety, and the VA had a one on one meeting weekly with a staff person to discuss his/her progress. The VA met with nursing and psychiatry on a monthly basis to assess the VA’s thoughts of self-harm. The following was information from the VA’s progress notes, Incident Reports, and an Internal Review (IR): · On May 3, 2022, while on the Juniper unit, the VA swallowed three pencils, a plastic knife, a toothbrush, and a razor blade from an eye liner sharpener. The VA’s vital signs were assessed, and a medical provider from the facility was contacted. The VA was transferred to an emergency medical facility, and the VA had surgery. It was noted staff should continue to encourage the VA to use coping skills and talk with staff persons, and if the SIB continued a “high level care unit” would be recommended. · The VA did not follow his/her post operation recommendations, and on May 21, 2022, engaged in “strenuous” activity, manipulating his/her incision, and neglecting his/her hygiene. · On May 22, 2022, after being moved to the Tamarack unit, the VA ingested pieces of a DVD/CD that s/he had broken. The VA was assessed by nursing and a medical provider from the facility was contacted. The VA was transported for further evaluation at a medical facility, and an endoscopy procedure was completed. It was noted the VA was struggling with SIB and staff persons would continue to utilize his/her support plans which were in place. · On May 25, 2022, the VA informed staff persons that s/he ingested two juice packets, Velcro, and a safety pen. A medical provider from the facility was notified and the VA was transported to a medical facility. The items were removed via an upper gastrointestinal endoscopy, and the VA returned to the facility. It was noted the VA would be supported by staff persons as s/he continued to struggle with SIB. · On May 31, 2022, the VA had a medical appointment (off site) and was provided a face mask. The VA removed two small metals pieces from the nose of the mask and ingested the items. A medical provider from the facility was notified and the VA was transported to a medical facility. The VA’s bedroom was “searched and emptied” by staff persons. The medical facility completed an endoscopy procedure. A treatment team including the unit director, psychiatric provider, social worker, psychologist, and nursing decided the VA would be best supported if placed on an “individual hold” where s/he was unable to leave the controlled unit until the VA “could demonstrate a significant period of safe behavior.” During that time, the VA was offered treatment groups on an individual basis within the unit. As well as, the ability to provide a list of items s/he may want from the facility store and/or vending. The “individual hold” would be evaluated weekly. · On June 1, 2022, the VA discussed the urge to ingest items, and was provided positive feedback for making safe choices. The VA also said that ingesting items resulted in hospital visits which were a “spiritual experience” and the VA “sees angels and feels what it feels like to be in Heaven.” · On June 4, 2022, the VA informed staff persons that s/he had swallowed plastic (granola/chip wrapper), cardboard (toilet paper roll), and tape. The VA said it was “plastic cardboard, tape, stuff I’ve been collecting.” The VA had taped items together in an attempt to lengthen the items (approximately eight inches) to ensure the items would not pass naturally. The VA expressed concerns of “abdominal pain and discomfort,” but did not require a surgical intervention. The VA was assessed and a medical provider at the facility determined the items could pass naturally. · On June 6, 2022, the VA completed a one on one meeting with a social worker at the facility and discussed the VA’s behaviors and treatment plan. The VA was unsure why s/he engaged in swallowing inedible items and was encouraged to talk with staff persons if s/he had an urge to engage in SIB. · On June 7, 2022, the facility was informed the VA was “cheeking” his/her medications and the VA said s/he had cheeked the medications for two days due to concerns of the medication being “sedating.” The VA discussed starting ECT and a decrease in medication due to how the medication made him/her feel. · On June 8, 2022, the VA passed the objects that were ingested on June 4, 2022. · On June 8, 2022, the VA said s/he had swallowed a “chip bag over the weekend.” · On June 9, 2022, the VA said s/he had passed some tape wrapped mattress tags. · On June 10, 2022, the VA swallowed a part of a milk carton, which was rolled into a long thin piece, and a soft plastic condiment packet from his/her food tray. The VA was assessed by nursing and a medical provider was contacted, and it was determined the VA could pass the items. The VA had abdominal discomfort and the facility nursing team monitored the VA. The information was reviewed with the VA and the VA agreed with the plan. A bowel assessment and vital checks were completed every four hours. · On June 12, 2022, the VA had abdominal discomfort and several episodes of vomiting and diarrhea. An abdominal assessment was completed and there were no areas that were firm and/or identified. A medical provider from the facility was contacted and a nursing plan was developed to complete vitals checks every four hours. During a second bowel assessment on June 12, 2022, an area was “slightly firm” and coincided with the area the VA said was causing discomfort. · On June 12 and 13, 2022, the VA vomited and had diarrhea. The VA was provided magnesium citrate, Tylenol, and Ibuprofen: however, the VA denied any “relief” occurred, and the inedible object had not passed. On June 13, 2022, the VA was found on his/her bedroom floor and said s/he was “ill” and “needed to go to the doctor.” The VA was assessed by a medical provider at the facility and the VA was transported to a medical facility for imaging. A computed tomography (CT) scan was completed and a milk carton appear to be in the VA’s stomach, as well as “multiple radio opaque items” in the VA’s colon. The CT scan also showed a thickening of the bowel wall and a small bowel obstruction. The VA was diagnosed with a small bowel obstruction due to swallowing items on June 4 and 10, 2022. The VA required surgery, which occurred on June 15, 2022. · On June 19, 2022, the VA returned to the facility after surgery. The VA informed the facility s/he had not been on any psychotropic medications for a week. The facility limited the VA’s belongings: “no electronics of any type, staff [persons] were to check [the VA’s] room and remove anything [s/he] could swallow, [s/he] was only allowed clothing that was on his/her person, no spare clothing in his/her room, bedding should be tear proof, if possible and drinks in Styrofoam cups.” · On June 22, 2022, Electroconvulsive therapy (ECT) was initiated and a “high level review” of the on-going SIB was completed by the facility. The VA’s treatment team would continue to meet with the VA and support him/her with managing SIB. The VA provided the following information: · The VA “learned bad things” while at the facility and s/he would “manipulate” situations. The VA said s/he had three surgeries due to making “bad decisions.” · The VA swallowed a razor blade, some pencils, and a milk carton. · It was “stressful” living at the facility and “the walls” were “coming in” on the VA, which lead him/her to swallow the objects to get a “break” from the facility. · The VA was supervised and provided care while at the facility, but would hide items in his/her bedroom and ingest them while staff persons were not observing him/her. · The facility used specialized “silverware” which were biodegradable and breakdown “naturally.” · The milk carton caused the bowl obstruction. · The VA was speaking with “somebody” from the facility regarding the SIB. · The VA felt like there was a lack of interaction with staff persons at the facility, and the VA sat in the common area “all day.” P1- P2, SW, HCP1-HCP2, and the MDP provided consistent information: · The VA created dangerous situations as s/he engaged in SIB. Recently the VA’s SIB increased in “severity” and the VA would inform staff persons and/or nursing after s/he engaged in SIB. After facility personnel were made aware of each incident, nursing completed a check of the VA’s vitals and assessed the VA prior to contacting a medical provider from the facility. The medical provider provided direction to nursing personnel and contacted a gastrointestinal specialist as needed. There were times an x-ray was completed on-site by a third party using a portable machine, or the VA was transported to a medical facility. The medical provider was typically informed of the incident within five minutes, but the process of evaluation and final decision varied depending on the situation. There were instances a medical facility was unable to provide the required care immediately if there was not a bed available, and/or a different medical facility may be contacted. A staff person remained with the VA while a decision was made regarding the care of the VA. · The facility attempted to support the VA in multiple ways, including, but not limited to: o The VA’s behavior was being reviewed in a weekly clinical review meeting which included facility staff persons, nursing staff persons, supervisors, and other providers and/or treatment team members at the facility. They assessed the VA’s safety, discussed the VA’s treatment plan interventions, and completed an examination of recent incidents. Based on the information obtained, it was concluded the VA hid items in his/her bedroom and engaged in the SIB behavior while in his/her bedroom. However, there was no other trend that had been discovered. It was believed the VA used the SIB as a way to control his/her environment and seek medications. o The facility attempted to maintain the VA’s rights and “empower” the VA without taking items away. The facility wanted to provide the VA with a “quality of life” and not “sterilize” his/her environment completely. The facility tried to remove the items that were dangerous or potentially harmful, but was unable to prevent the SIB. o The SW completed meetings with the VA on a weekly basis, and some weeks would meet with the VA multiple times a day. The SW discussed multiple topics with the VA including the VA’s SIB. o Due to surgeries related to the SIB the VA had a decreased physical well-being for a period of time, but s/he had returned to normal everyday activities. o None of the persons interviewed expressed concern the VA was being neglected or maltreated. · The following are some the additional steps the facility took over the past year to prevent or assist the VA with the concern of SIB, and ensure the VA’s safety: o In 2021, the facility had a medical provider (from outside the facility) complete a presentation regarding SIB (swallowing). o The facility continuously assessed and attempted to limit items which could cause significant harm. o Prior to and during this investigation the VA’s psychiatrist worked with the VA in changing and adjusting his/her medications, and the VA had restarted ECT treatment. o The facility completed searches of the VA’s bedroom if there was suspicion the VA had potentially harmful objects, and/or after each SIB incident. o The VA was transferred to multiple units, including a more restrictive unit, in an attempt to better provide services to the VA. § On December 14, 2021, the VA was transferred to the Pine Unit. The VA engaged in SIB shortly thereafter, due to persons of the opposite sex being on the unit. § Between December 26, 2021, and May 3, 2022, the VA resided on the Willow Unit, and then the Juniper Unit. However, after additional SIB the VA was hospitalized and required surgery. § Upon return to the facility on May 11, 2022, the VA was transferred to Tamarack West. The VA did not follow post-surgery instructions and after multiple SIB between May 11, and 31, 2022, the VA was placed on an “individual hold.” The individual hold prevented the VA from leaving the controlled environment of Tamarack West. The VA was offered meetings/programming/groups from a facility social worker, behavior analysts, and/or offered facility treatment (such as substance abuse treatment) within the Tamarack unit. § Within the Tamarack Unit the VA had a higher staffing ratio and fifteen minute wellness checks completed by staff persons.
o While on the Tamarack Unit the facility modified the VA’s access to food, had food delivered into the unit, and removed the plastic wrappers prior to the VA obtaining the food. The VA was also provided with biodegradable cutlery for meals, had increased staff person observation while s/he ate meals/snacks, and the remaining items were dumped in a garbage can in the staff person control unit area. Garbage cans had been removed from the unit. The VA was provided with one clothing outfit at a time, but was able to request new clothing from the staff person unit control area. Shampoo and soap were provided to the VA in a small paper portion cup.
o The progress notes showed the VA was observed and in contact often with psychiatry, nursing, and medical professionals, as well as facility direct care staff persons. In addition, the VA was offered meetings, individual groups, and interactions to best meet his/her needs. The VA had limited access to items and the VA was transferred to a different unit, but was not required to be “continuously monitored.” The CM said the facility took steps to ensure the VA’s safety including, but not limited to, using biodegradable cutlery, changing the VA’s medications, ECT, and transferring the VA to a different unit. The CM believed the facility had done “everything reasonably” to ensure the VA’s safety, and did not believe there was any maltreatment or abuse within the services the VA was receiving. During the investigation, on July 31, 2022, and August 9, 2022, the VA engaged in an additional SIB. The VA swallowed portions of his/her eyeglasses and required an emergency endoscopic intervention. On August 9, 2022, the VA informed nursing staff persons that s/he had engaged in SIB and swallowed a portion of a zipper from his/her clothing. The VA was transported to a medical facility due to the SIB and returned to the facility after the item was deemed “passable.” The facility was in the process of developing a new Foreign Body Ingestion Policy, with the purpose of minimizing the adverse outcomes of foreign body ingestion. The facility trained all staff persons on client specific information, the facility’s policy and procedures, and Reporting of Maltreatment of Vulnerable Adults. Conclusion: It was reported that the VA engaged in multiple SIB incidents within a few months and on at least one incident had caused bodily harm to him/herself which required surgery. The VA had an extensive history of SIB behaviors, specifically swallowing non-edible objects. During the course of the investigation the VA’s SIB continued, and had at least two other instances of SIB. Based on the information obtained, the facility took multiple steps to both ensure the VA’s safety, while also trying to provide the VA services which were least restrictive and person centered. The VA said s/he would “manipulate” situations to give him/herself a “break” from being at the facility, but added that engaging in SIB was a “bad decision.” The VA said s/he hid items in his/her bedroom and engaged in the SIB while staff persons were not observing him/her. The VA said there was a lack of attention from staff persons; however, this was inconsistent with interviews and documented observations. Although the VA was able to obtain and ingest multiple items, the facility progressively took steps to ensure the VA’s safety such as, but not limited to: increased observation, environment alterations, medication/treatment adjustments, and methods of food provision. Additionally, the facility held weekly clinical meetings with the VA’s treatment team to discuss recent incidents and intervention plans, and provided and/or sought immediate medical care for the VA after each incident of SIB. Based on the above information, 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: There was a history of similar events, but there was no additional staff training completed at this time. The facility determined that the policies and procedures that were in place to prevent abuse were adequate and followed. However, the facility also determined the policies and procedures were not adequate, and further action was required to protect the health and safety of the VA. The facility was developing a procedure related to the process of evaluating the risk of foreign body ingestion. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
