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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: 1072710-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman/Thomas Nixon Thomas.c.nixon@state.mn.us Suspected Maltreatment Reported: It was reported that a 9-1-1 call was made and upon arrival, first responders found a vulnerable adult (VA) breathing, but unresponsive. The VA was wearing clothing and sitting on a chair both of which contained urine and fecal matter. The VA was transported by ambulance to an emergency room and then transferred to a different hospital. Date of Incident(s): October 8, 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 the site visit conducted on October 21, 2022; from documentation at the facility and from medical records; and through eight interviews conducted with the VA, two supervisory staff persons (P1 and P2), two staff persons (P3 and P4), a facility health care professional (HCP), the VA’s case manager (CM), and an emergency medical technician (EMT). The facility was a split level home where the VA lived with other residents and staff persons provided 24 hour care that included awake overnight staffing. The VA’s bedroom was located on the upper level of the facility and connected to his/her own personal bathroom with shower. The upper level also included a common area, kitchen, bathroom, and another bedroom. The facility had video cameras positions in the hallways and outside of the house. The VA’s support plans and Discharge Summary stated: · The VA lived at the facility for four to five years. The VA prided himself/herself on being as independent as possible, liked to go on walks around town especially to the lake and library, watch scary movies, and had a very large book collection. · The VA was diagnosed with bipolar affective disorder. On October 6, 2022, the VA was diagnosed with Type 2 diabetes without complication. The VA’s Intensive Support Self-Management Assessment including his/her Individual Abuse Prevention Plan stated that the VA administered his/her own medication with supervision, needed no assistance with using the toilet, and there were no concerns regarding the VA’s mobility or communication. On September 28, 2022, the VA was hospitalized for vomiting and struggling to stand independently. On September 29, 2022, the VA was discharged back to the facility. On October 4, 2022, the VA was in the emergency room for weakness, inability to stand, and frequent urination. The VA was released the same day. The EMT stated that on October 8, 2022, the EMT responded to a call that the VA was unresponsive. When the EMT arrived, a staff person told the EMT that the VA had been unresponsive for about one hour. When the EMT went into the VA’s bedroom, the VA was in a chair with his/her eyes open and s/he some blood on his/her chin. The VA was sitting in a recliner and in feces and urine. The EMT stated that the VA appeared to be sitting in urine soaked clothes and feces for 24 to 48 hours due to the dried fecal matter and high ammonia smell. (P1 said that prior to the site visit, s/he removed the urine and feces saturated chair from the VA’s bedroom.) Medical records showed that on October 8, 2022, the VA was initially transported to a local emergency room (ER). Records for the ER were requested multiple times but were not received at the time of this report. Subsequently the VA was transported via ambulance to a hospital in another city. The hospital records stated that while the VA was in the ER, s/he was intubated and met sepsis guidelines. The VA then had a CT scan and went into cardiac arrest in the machine. The cardiac arrest was due to respiratory arrest likely due to a “vent malfunction.” Once stable, the VA was transported to the hospital. (There was no information regarding the VA’s physical condition upon arrival.) The VA provided the following information: · The VA was primarily independent with cares until s/he initially required hospitalization on September 28, 2022, for vomiting and struggling to stand independently. · After September 28, 2022, the VA required assistance with transferring from bed, changing his/her clothes, and accessing the bathroom. At this time, the VA also started to use adult briefs and bed pads and required staff person assistance to change them. The VA was regularly checked on by staff persons. Staff persons asked the VA if s/he needed assistance or changing and if needed s/he allowed staff persons to do so. The VA denied declining assistance if/when s/he needed help. The VA believed that s/he was having health changes and that s/he at times s/he “started going to the bathroom and couldn’t make it to the toilet” in time. · On October 8, 2022, the VA was unable to move and was sitting in a chair that was saturated in urine and feces. The VA said that s/he was “panicked.” The VA believed that the staff persons did all that they were able to given the situation to assist him/her, but stated that it would have been helpful if an ambulance was called sooner. P1-P4 and the HCP provided the following information: · The VA did not have a history of needing overnight staffing assistance and it was typical that staff persons did not see the VA. During the overnight, the VA typically slept well and woke up in the morning for his/her medications. · The VA was independent with cares and mobility prior to vomiting and a health decline that lead to the hospitalization on September 28, 2022. · On September 29, 2022, the VA was discharged from the hospital. The VA returned to the facility and staff persons were updated verbally by the HCP that the VA had fatigue, weakness, a reduced appetite, and walking instability. Staff persons were told that the VA was incontinent and used adult briefs and now needed increased assistance from staff persons with cares. · On October 4, 2022, the VA went by ambulance to the emergency room for weakness, inability to stand, and frequent urination, and was met by the HCP. The HCP expressed concerns to medical staff persons about having the VA return to the program given his/her issues with mobility, weakness, and decreased independence. Medical staff persons directed to the HCP that the VA should be seen by his/her primary care physician because the emergency room could not tend to the VA’s health concerns. The VA and the HCP returned to the program. · October 6, 2022, the HCP took the VA to his/her regular clinic by to be assessed for the VA’s issues with mobility, weakness, and decreased independence. The physician completed lab work on the VA at the clinic. The HCP requested that the physician admit the VA to the hospital but based on the VA’s test results the physician denied the HCP’s request. · P2 stated that s/he reviewed the facility’s cameras and consulted with staff persons about the events for the period leading up to when emergency services arrived. P2 determined that on October 7, 2022, the day prior to the incident, the VA was assisted with brief changes at approximately 8:50 a.m., 12:05 p.m., and 3:22 p.m. At about 7:40 p.m., P5 went into the VA’s bedroom and asked the VA if s/he wanted his/her brief changed and the VA said s/he was “fine.” · P4 stated that on October 7, 2022, s/he arrived around 11:10 p.m. At that time a staff person (P5) was working. P4 did not recall what P5 said to P4 at that time, but P4 did not note anything unusual during overnight shift regarding the VA’s behaviors or needs. The VA’s door was closed as was normal for the VA. During the overnight shifts, P4 did not enter the VA’s bedroom unless asked by the VA. · On October 8, 2022, P3 arrived at 7 a.m. and P4 told P3 that the VA did not come out of his/her room or need assistance during overnight shift. P3 then prepared medications. After P3 went to the VA’s bedroom and knocked on the VA’s door three to four times. When there was no response, P3 went into the VA’s bedroom. · At 8:10 a.m., when P3 entered the VA’s bedroom, the VA was sitting in a recliner. P3 saw that the VA’s eyes were open, s/he was breathing, and s/he was moving “a bit.” P3 attempted to rouse the VA verbally three to four times but the VA did not respond. P3 then tapped the VA’s hand and rubbed his/her forearm still with no response from the VA. P3 phoned P1 who instructed P3 to test the VA’s blood sugar levels. P3 did so and recalled that the VA’s blood sugar was 325. (The HCP stated that 324 was an elevated blood sugar level, particularly for diabetic who had not eaten recently.) P3 called P1 again, relayed the result, and was instructed by P1 to call 9-1-1. P3 did so and observed as emergency responders arrived and tended to the VA. · P3 stated that s/he did not notice any smell of urine and/or feces in the VA’s room when s/he went into the room. · The HCP said that when the VA was at the hospital, the VA was diagnosed with acute encephalopathy, which the HCP believed caused the VA to be unconscious. According to the National Institute of Neurological Disorders and Stroke, Encephalopathy is “is a term for any diffuse disease of the brain that alters brain function or structure… The hallmark of encephalopathy is an altered mental state. Depending on the type and severity of encephalopathy, common neurological symptoms are progressive loss of memory and cognitive ability, subtle personality changes, inability to concentrate, lethargy, and progressive loss of consciousness. Other neurological symptoms may include myoclonus (involuntary twitching of a muscle or group of muscles), nystagmus (rapid, involuntary eye movement), tremor, muscle atrophy and weakness, dementia, seizures, and loss of ability to swallow or speak.” Facility documentation showed that the staff persons interviewed for this investigation were trained on the VA’s support plans and on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: On October 8, 2022, the VA was found unresponsive in his/her recliner and 9-1-1 was called. The EMT who arrived was concerned because the VA was sitting in a chair in urine and fecal matter. The EMT believed that the VA had been sitting in urine and fecal matter for 24 to 48 hours. Information showed that recently, prior to October 8, 2022, the VA had a decline in physical health, including the onset of frequent incontinence and decreased independence, resulting in an increased need for staffing assistance to get his/her needs met. On October 7, 2022, the VA was last asked by P5 at 7:40 p.m. if assistance was needed for changing his/her brief and the VA declined. The VA was not observed by staff person during the overnight shift as s/he did not request help and nothing unusual occurred during this time. The following morning on October 8, 2022, at 8:10 a.m., P3 entered the VA’s room after not getting a response from knocking on the VA’s door. When the VA did not respond to P3, P3 called P1 and then 9-1-1. P3 later said that s/he did not notice the smell of urine or feces and at that moment, it was reasonable for P3 to prioritize the VA’s non-responsiveness as opposed to addressing the VA’s personal care needs. Although it was likely that the VA’s brief was not changed at any point after October 7, 2022, at 3:22 p.m., the VA declined a brief change at 7:40 p.m. and then did not further request assistance throughout the night. In addition, there was no information that staff persons had to check on the VA throughout the night and the VA generally slept through the night. Given this, in combination with the P3’s immediate response and care of the VA when P3 found the VA unresponsive, and the facility’s continued contact with medical professionals to address the changes in the VA’s health status, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services which was reasonable and necessary to maintain his/her physical 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 were followed. The facility determined that there was not a need for additional training or corrective action. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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