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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: 1078462- Intensive Residential Treatment Services/Residential Crisis Stabilization Investigator(s): Scott Broady Suspected Maltreatment Reported: A vulnerable adult (VA) was found deceased at the facility on July 4, 2022. It was reported that prior to the VA’s death, the VA was not regularly taking his/her prescribed medications and had talked about suicide, but it was unclear what actions the facility took in regard to those concerns. Date of Incident(s): July 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 July 21, 2022; from documentation at the facility, law enforcement records, and medical examiner records; and through interviews conducted with five facility staff persons (P1-P5), four facility health care professionals (HCP1 – HCP4), the VA’s case manager (CM), and a family member (FM) of the VA. The facility provided intensive residential treatment and crisis stabilization services to adults who have been diagnosed as having a serious mental illness. Length of stay in the crisis stabilization program ranged from one to ten days and in the intensive residential treatment program up to 90 days with reauthorization for individuals requiring longer lengths of stay. The facility’s Program Abuse Prevention Plan stated that the facility had a secure entry. Staff persons were to check the whereabouts of residents every four hours. Residents were to let staff persons know if they were leaving, where they could be reached, and when they planned to return. Information from staff persons and documentation showed that the VA moved to the facility on June 10, 2022. Prior to being at the facility the VA was in a hospital due to an overdose in May 2022. The VA’s diagnoses included major depressive disorder, panic disorder, and suicidal ideation. The VA was under a court order to be at the facility. The VA’s Treatment/Care Plan stated: · The VA’s “recovery vision” was to not be on any psychiatric medications and to be stable and healthy. The VA was to establish therapeutic routines within the program. · The VA stated that in the last three months, s/he felt like that s/he should cut down or stop drinking and using drugs. The VA stated that s/he did have a possible “substance abuse” problem. · The VA stated that s/he had a suicide attempt within the three months prior to admission, but did not have thoughts of suicide within the month prior to moving to the facility. · On June 10, 2022, the VA did not have any pass privileges and the criteria to obtain pass privileges included taking all medications as prescribed and regularly attending all group therapy (group) sessions. On June 11, 2022, the facility allowed the VA to go to the FM’s home to get his/her belongings. HCP1 provided the following information: · HCP1 never met the VA, but based on documentation s/he read at the facility, s/he had concerns about the facility addressing the VA’s needs prior to his/her death. The VA was not taking his/her prescribed medication on a regular basis and the facility did not address the issue such as notifying the VA’s psychiatrist that s/he was not taking his/her medications. The VA also had a history of suicidal attempts and talked about suicide while at the facility, but HCP1 was concerned about what action the facility took. · In addition, the day prior to the VA’s death, the VA was out on pass but did not return at the time s/he was scheduled to return. If residents returned late from pass, staff persons were to ask to search the resident’s bedroom. Staff persons did not have to do a body search. A law enforcement report stated: · On July 4, 2022, at about 12:34 p.m., a law enforcement officer (LEO) responded to a report at the facility that the VA was not breathing and cold to the touch. When the LEO arrived, the VA was lying on his/her right side in bed. The VA was cold to the touch, and rigor mortis and rigidity had set in. The LEO pronounced the VA deceased at 12:39 p.m. There was no trauma and nothing suspicious in the VA’s bedroom. · The LEO talked to P1 who said that the last time the VA was seen alive was about 4 a.m. when the VA spoke with P2. At 8 a.m., P3 checked on the VA and documented that the VA was asleep. At 12:34 p.m., P1 went to check on the VA and found the VA to be unresponsive and cold to the touch. · The medical examiner arrived and processed the scene and took custody of the VA. After the VA was moved out of bed, the medical examiner found the VA’s cell phone with a visible text message between the VA and another person that mentioned “getting high” the night before. Apparently the VA was out of the facility the prior evening and returned at about 11 p.m. A report from the medical examiner stated that fentanyl (28 milligrams/milliliter) was found in the VA’s blood. There was no significant trauma noted and an autopsy was not performed at the request of the VA’s family. The VA was 25 years old at the time of his/her death. Information from the FM, P1-P5, HCP2-HCP4, and documentation at the facility showed the following regarding the VA 24 hours prior to the VA’s death: · P1 stated that on July 3, 2022, s/he worked during the day and saw the VA and at that time, P1 did not have any concerns about the VA. · The FM stated that on July 3, 2022, the VA was at the FM’s home. The FM said that the VA arrived about 3 p.m. and left about 7 p.m., but the FM heard that the VA did not return to the facility until 11 p.m. The FM did not know where the VA was during that time. While at the FM’s home, the VA was “very happy” and talked about plans that s/he had. The FM stated that s/he was not contacted about the VA’s death until 4:30 p.m. on July 4, 2022. The FM did not have any other concerns about the facility. · On July 3, 2022, a staff person (P6) documented in the VA’s Progress Notes that the VA was seen at 7 p.m. but did not engage with staff persons. The VA was not seen in the building between 7 and 10:30 p.m., so there was no prompting for medications. This investigator contacted and talked with P6, but P6 declined to be interviewed. · HCP2 worked the evening of July 3, 2022, until 11 or 11:30 p.m. HCP2 twice looked for the VA to administer his/her medications, but the VA was not in the facility. (The log where the VA would have signed in and out did not have any information pertaining to the VA coming or going.) P2 stated that on July 3, 2022, at 11 p.m., when P2 arrived for the overnight shift, the VA was not in the facility. P2 stated that at some point, the VA returned but P2 did not know at what time. P3 stated that on July 3, 2022, P3 saw the VA at 11 p.m. sitting in common area watching television with another resident. · P2 stated that during the overnight shift, P2 first saw the VA at 4 a.m. during a room check. P2 knocked on the door and found the VA to be awake. The VA was sitting at the desk with his/her phone. P2 then left the bedroom. P2 did not notice anything out of the ordinary with the VA. P2 believed that P4 talked to the VA earlier than 4 a.m. · P4 stated and documented that the VA came down from his/her bedroom about 2:15 a.m. on July 4, 2022. The VA told P4 that s/he was not able to sleep. P4 asked the VA if s/he could not sleep because s/he was not taking his/her medications, but the VA said s/he wanted to sleep “naturally” without any medications. P4 and the SP then talked about other things. At that time, the VA was wearing a crochet hat and his/her face appeared to be sweaty. P4 asked about the VA sweating and the VA said that s/he just wanted to go to sleep. The VA then also spent time on his/her phone and listened to music and returned to his/her room around 3:45 a.m. Other than wearing the hat and sweating, P4 did not notice anything out of the ordinary with the VA. · P3 stated that at 8 a.m. when s/he checked on him/her in his bedroom. At that time, the VA was laying on his/her side facing away from the door with his/her head covered up. · P1 stated that the morning of July 4, 2022, s/he started at 9 a.m. At about 12 noon, P1 went to do a routine check on the VA and found the VA not breathing, unresponsive, and “stiff.” The VA was purple and cold to the touch. HCP2 was with P1 and due to the VA’s stiffness, HCP2 was not able to move the VA’s shoulder to check for a carotid pulse. · HCP2 stated that s/he was working when P1 found the VA. HCP2 ran to the VA’s bedroom and tried to wake up the VA and turn him/her over onto his/her back and start cardiopulmonary resuscitation (CPR). HCP2 was having difficulty trying to get a carotid pulse from the VA so HCP2 asked P1 to assist him/her with turning the VA onto his/her back. Due the VA’s size, HCP2 was not able to turn the VA over by him/herself. After the VA was turned on his/her back, HCP2 administrated Narcan (treatment for suspected overdose) in both nostrils. At that point, HCP2 did not know how long the VA was unresponsive. After the medical examiner arrived, the medical examiner stated that s/he thought the VA had been deceased for about six hours. · Checks were to be done every four hours on the VA during the overnight shift. Documentation regarding the VA between June 10 and July 3, 2022, included the following: · The VA’s medication record stated that the VA was prescribed melatonin (hormone that plays a role in sleep) 3 milligrams (mg) once a day and mirtazapine (anti-depressant) 45 mg once a day. Both medications were scheduled to be given at 8 p.m. The VA was also prescribed vitamin D2 once a week. Between June 10 and July 4, 2022, it was documented that the VA took melatonin six times and mirtazapine four times. · There was daily documentation about the VA. There was no mention of drug use or suicidal ideation other than what was mentioned below. Documentation showed that staff persons regularly encouraged the VA to attend groups and to take his/her medications. · A Clinical Consultation dated June 14, 2022, and completed by P5, stated that the VA did not want to die but did not want to suffer and wanted to live a healthier life. The VA had been attending some groups. The VA wanted to look for work and maintain contact with friends and family members. The VA said that s/he had a good rapport with a therapist (the VA’s therapist and psychiatrist worked out of the same clinic) who worked with the VA for six years. The VA was experiencing symptoms of depression which was low engagement with peers and staff persons. The VA was concerned as s/he had a hearing coming up regarding whether the VA should receive court ordered electroconvulsive therapy (ECT). · A Clinical Consultation dated June 28, 2022, and completed by P5, stated that the VA was not attending any programming despite multiple prompting from staff persons. The VA was motivated to find work, but the VA wanted to work a full time overnight job which would not be conducive to him/her receiving treatment at the facility. The VA stated that s/he met with his/her psychiatrist to discuss his/her medications needs. · On June 28, 2022, the VA signed a release of information allowing the facility to communicate with his/her psychiatrist’s clinic. · A Progress Note dated June 29, 2022, completed by P5, stated that the P5 and the CM discussed the VA’s low group attendance. A discussion also took place about how at this point, a full time overnight job was not a suitable option at this point of his/her treatment in the program. The VA agreed to that in 30 days they would meet about employment again contingent on the VA being compliant with participation in the program. · A Client Contact note dated June 30, 2022, stated that the VA talked to two staff persons about “right to die” and “assisted suicide” and organizations that assisted with those things. The VA “assured” the staff persons that s/he was felt safe and that s/he just watched a documentary on the subject. · A Progress Note dated July 1, 2022, completed by HCP3 stated that the VA requested Ativan which s/he brought from home. HCP3 told the VA that the facility did not have an order to administer it and that the facility needed a current order. HCP3, along with the VA, left a voice mail at the psychiatrist’s clinic for a current order. · A Clinical Consultation dated July 1, 2022, and completed by P5 (later than the one above) stated that the VA was having a panic attack and requested transportation to the emergency room. P5 began to drive the VA to the hospital and while driving discussed strategies to manage anxiety attacks. During the drive, the VA made statements like, “I think I am going to die.” Before arriving at the hospital, the VA said that felt better and did not want to the hospital. The VA was calmer and P5 and the VA returned to the facility. P1-5 and HCP2-HCP4 provided the following information regarding the VA’s medications: · The VA regularly refused to take his/her medications. Refusals were documented and discussed at shift change and meetings. The VA did not want to take his/her medications because they were prescribed while s/he was in the hospital prior to coming to the facility as opposed from his/her own psychiatrist. · P5 stated that the week prior to July 1, 2022, the VA missed an appointment with his/her psychiatrist. The VA was told that s/he would have to reschedule the appointment. The appointment was a virtual appointment that the VA could attend via his/her cell phone. The VA did not want any staff person attending his/her appointments. · HCP3 stated that on July 1, 2022, HCP3 left a message with on the after-hours nurse line at the VA’s psychiatrist office for a call back. On July 6, 2022, the call was returned saying that the VA had to sign a release of information before they could discuss the VA’s medications. HCP3 did not know if anyone attempted to contact the VA’s psychiatrist prior to July 1, 2022. · Beside the information from HCP3 and P5 there was no other information regarding the VA arranging or staff persons assisting the VA to arrange an appointment with his psychiatrist. HCP4, a supervisory staff person, said any staff person could contact the VA’s psychiatrist. P1-5 and HCP2-HCP4 provided the following information regarding passes to leave the facility: · Resident were supposed to obtain passes, which were approved by their counselors, and sign in and out with where they are going, when leaving the facility. Residents did not always sign in and out. Residents were also supposed to return to the facility by 11 p.m. If residents were carrying bags from shopping when they returned, staff persons could ask to see what was in the bags, but were not able to search residents. · When a resident returned, if staff persons suspected drug or alcohol use, staff persons were to have the resident due a urinalysis (UA). P1, P3, and P4 each believed that if a resident arrived back later than they scheduled time or returned after 11 p.m., staff persons were to complete a UA, but other persons interviewed stated they would do a UA if they suspected drug or alcohol use. P1-5 and HCP2-HCP4 provided the following information regarding whether the VA engaged in suicidal ideation and/or drug use: · Most staff persons were aware of the VA’s history of drug use and suicidal ideation. · No staff persons were aware of the VA using drugs or alcohol while s/he was the facility. · P4 stated that s/he believed the VA talked about suicide with a couple staff persons the week prior to his/her death, but no other staff persons interviewed were aware of the VA engaging in suicidal ideation while s/he was at the facility. P5, who was the primary staff person for the VA, provided the following additional information: · P5 stated that the VA did not initially attend many therapy groups, but in the week and a half prior to his/her death, the VA said that s/he wanted to get a job and after P5 talked to him/her about that, the VA was more engaged in groups. · P5 believed that “for the most part” the facility provided the VA with the services required. P5 was a part time staff person and P5 believed that the VA would have benefited more from a full time staff person being assigned as his/her primary counselor. HCP4, who had supervisory responsibilities, stated that s/he believed that the facility provided the VA with the care they were supposed to provide to the VA. The CM stated that s/he did not have concerns about the care the facility provided the VA other than whether or not they checked on the VA in a timely manner. Facility documentation showed that staff persons interviewed received training on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: On July 4, 2022, at about noon, the VA was discovered unresponsive in bed. 9-1-1 was called. At that point, HCP2 administrated Narcan in both nostrils, but HCP2 did not know how long the VA was unresponsive. After the medical examiner arrived, the medical examiner stated that s/he thought the VA had been deceased for about six hours. A report from the medical examiner stated that fentanyl (28 mg/ml) was found in the VA’s blood. Although the VA had a history of suicide attempts, it was not determined whether the VA’s death was from suicide or an accidental drug overdose. Regarding the VA 24 hours prior to his/her death: On July 3, 2022, the VA left the facility to visit the FM. The FM said that the VA was at the FM’s home from about 3 to 7 p.m. It was unclear what time the VA returned to the facility (the log where the VA would have signed in and out did not have any information pertaining to the VA coming or going). P3 saw the VA around 11 p.m., sitting in a common area, but around that same time, HCP2 twice looked for the VA to administer the VA his/her medications, but the VA was not in the facility. In addition, P2 said that at 11 p.m., the VA was not in the facility. P4 said that the VA was awake between 2:15 and 3:45 a.m. and during that time, P4 and the VA were interacting. Other than the VA sweating, P4 did not notice anything else out of the ordinary with the VA. P2 said that s/he saw the VA at 4 a.m. during a room check and at that time found the VA to be awake and sitting in his bedroom looking at his/her phone. P3 saw the VA in bed at 8 a.m. when s/he checked on him/her in his bedroom and believed that s/he was sleep. P1 found the VA about noon deceased in bed. Although it was unknown exactly what time the VA returned to the facility, it was unclear whether the circumstances would have resulted in staff persons conducting a UA or whether the VA had ingested any drugs at that time. During the overnight, staff persons did regular checks with two staff persons seeing the VA awake and other than P4 noting that the VA was sweating, there were no other concerns noted. Therefore, there was not a preponderance of the evidence whether there was a failure to provide the VA with supervision which was reasonable and necessary to obtain or maintain his/her physical or mental health or safety. Regarding concerns about the facility not addressing the VA not taking his/her medications and not addressing his/her suicidal ideation:
Information showed that the VA regularly refused to take his/her medications and all staff persons were aware of his/her refusals. P5 documented that on June 28, 2022, the VA stated that s/he met with his/her psychiatrist to discuss his/her medications (it was also documented that the VA signed a release that day giving the facility permission to contact his/her psychiatrist office), but in an interview P5 stated that s/he thought the VA missed an appointment with his/her psychiatrist that week. On July 1, 2022, HCP3 left a message at the VA’s psychiatrist office. It would have been reasonable for the facility to contact or work with the VA to ensure the VA contacted his/her psychiatrist. However, the VA had a right to refuse his/her medications and it was not determined whether taking different medications would have changed the outcome.
Information showed that despite regular encouragement from staff persons, the VA did not regularly attend groups at the facility. However, information showed that the VA did not regularly talk about suicidal ideation while at the facility and the one time anything about suicide was documented, it was when the VA talked to two staff persons about “right to die” and assisted suicide” organizations that the VA had just watched a documentary on the subject. At that time, the VA assured the staff persons that s/he was safe. Therefore, there was not a preponderance of the evidence whether there was a failure to provide the VA with care and services which were reasonable and necessary to obtain or maintain his/her physical or mental health or safety. 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. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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