MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

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:

802787-DS (Detoxification Center)

Investigator(s):

Lindsay Arth
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
lindsay.arth@state.mn.us

651-431-6537

Suspected Maltreatment Reported:

It was reported that a vulnerable adult (VA) was found deceased at the facility. There were concerns that staff persons did not check on the VA as they were trained to do, that staff persons refused to do rescue breaths, and did not administer Narcan (treatment for suspected opioid overdose).

Date of Incident(s): September 10, 2021 (On August 8, 2022, the Department of Human Services was made aware of additional concerns regarding the incident and the report was assigned for investigation.)

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 two site visits conducted on October 25 and December 28, 2022; from documentation at the facility, law enforcement records, and medical records; and through eight interviews conducted with three facility staff persons (SP1, SP2, and SP3), a supervisory staff person (SP4), a registered nurse (RN1) who was also a supervisory staff person, a registered nurse (RN2), a licensed practical nurse (LPN), and the VA’s family member (FM).

The facility provided detoxification services to clients experiencing intoxication or withdrawal from drugs or alcohol. The facility served up to 22 clients at a time and clients typically shared a bedroom. The Facility Abuse Prevention Plan said that the facility used “surveillance videos” to monitor activity within the unit. Clients were to be “assessed throughout their stay.” This included that staff persons were to monitor the client’s vital signs “carefully” for signs and symptoms of withdrawal. Clients were encouraged to “rest as the effects of the substance subside.” Staff persons were to visually check and document the whereabouts of each client at least once per hour. If a client was at risk of harm to themselves or others, was highly intoxicated, or was “in withdrawal,” staff persons may place a client on 15 minute “visual checks.” Staff persons were “skilled” at identifying withdrawal symptoms and medical emergencies and “taking appropriate action.” An on-call supervisor or psychiatrist was available to staff persons during the evening, late night hours, weekends, and holidays.

The facility had a common area that contained a dining area and a lounge area with couches and chairs. There was also a bedroom area and clients typically shared a bedroom. Within the bedroom area were client bathrooms and an area with a TV and couches/chairs. There was a staff office in the middle of the common area and bedroom area. The office had multiple windows providing sightlines into the facility’s common area and towards the facility bedrooms. There were cameras facing the common area, the bedroom area, and within the staff office. There were no cameras in the client’s bedrooms.

The VA enjoyed spending time with his/her family members, fishing, and outdoor activities. The VA was diagnosed with opioid intoxication and stimulant intoxication.

The FM provided the following information:

· On September 10, 2021, at 3:40 a.m., the VA was admitted to the facility for detoxification of fentanyl (synthetic opioid). At 10:46 a.m., the VA was found deceased at the facility.

· The FM did not see the facility video footage during the time the VA was at the facility but read what was in the video footage via the police report. The FM had multiple concerns with the “room checks,” specifically after the 7 a.m. shift change. This included that there was a “contradiction” of the “room checks” that were documented “versus what the video surveillance showed via police reports.”

· SP1 documented that s/he did “room checks” on the VA at 7:00, 7:30, 8:30, and 9:30 a.m. However, facility video footage showed that SP1 “pass[ed] by” the VA’s bedroom door one time during that time period (The FM did not say what time this was). SP1 also told law enforcement that s/he entered the VA’s bedroom around 9:30 a.m. to “confirm” the VA sleeping. However, the video footage did not show this. SP1 also told law enforcement that around 8:30 a.m., s/he closed the VA’s bedroom door due to “snoring complaints” as the VA was snoring. However, law enforcement told the FM that video footage showed that SP1 “pass[ed]” by the VA’s bedroom door but law enforcement was unable to view if the door was open or closed. (Note: This investigator’s review of the video did not show SP1 or any staff person checking on the VA at 7 or 7:30 a.m. At 8:16 a.m., SP1 walked to the VA’s bedroom door but did not go inside. SP1 then appeared to shut the VA’s bedroom door. At 8:35 a.m., SP1 stood outside the VA’s bedroom door but did not open it or go inside. There were no checks by any staff person on the VA after this, including by SP1 at 9:30 a.m.).

· Additionally, staff persons said that they checked on the VA every 15 minutes while at the facility. However, the video footage only showed staff persons checking on the VA at 6 a.m., before the VA went to bed (Note: This investigator saw that the VA went into his/her bedroom at 6:29 a.m. and did not come out at any point after that).

· The FM also said that it was “alarming” that video footage showed the VA in the bathroom for 40 minutes between 3:51 and 4:33 a.m. (which this investigator also viewed on the video footage) and that no staff persons checked on the VA during that time (Note: This investigator also viewed no staff person going into the bathroom to check on the VA during this time). The FM also had concerns that the VA went into the bathroom a total of three times between 3:51 and 6:19 a.m. (Note: This investigator viewed that the VA went to bathroom three times, including between 3:51 and 4:33 a.m.; between 5:50 and 6:03 a.m.; and from 6:20 to 6:29 a.m.)

· The police report also showed that at some point, another client (C1) who was the VA’s roommate said that the VA was snoring “so loudly” so C1 left the room. The VA was then left in his/her room for three and a half hours without anyone checking on him/her. Later, the VA was found deceased by an unknown client (later determined to be C2). The police report also showed that it took staff persons 12 minutes to “call an ambulance.” (Note: This investigator viewed video footage that showed that at 10:20 a.m., SP1 was notified of the incident by C2. At 10:22 a.m., SP2 was on the phone with 9-1-1 and at 10:28 a.m., law enforcement arrived).

· The FM said that snoring was the “number one sign of respiratory distress.” The VA was snoring “so loud and disturbing people” and the other clients were “complaining” that the VA was snoring for “several hours.” The FM had concerns that the facility was a “medical facility” staffed with “nurses” and other medical staff and that staff persons were “unable to detect [and] determine [that] loud snoring could possibly be [and] probably [was] respiratory distress from probable [opioid] overdose” which the FM said was “very alarming.” The VA was “obviously gurgling” which is what happened during an overdose. The VA’s autopsy showed that the VA’s lungs were “so heavy” and “filled with fluid” which was “very common” with overdoses.

· The FM was also told by law enforcement that there was a “feeble attempt” at “nasal” Narcan (treatment for suspected opioid overdose) due to the VA having “fluids” coming out of his/her mouth and nose. The FM asked law enforcement who attempted the Narcan but “no one really knows.” The FM said that the autopsy showed that Narcan was not administered. The FM said that s/he carried Narcan with him/her

and did so for a “long time.” The FM was “infuriat[ed]” that the VA did not receive Narcan as the VA was “very savable.”

· The FM also had concerns that staff persons, including an RN, “decided” to not give the VA rescue breaths because at some point, the VA had vomited. The FM said that persons who overdosed “vomit[ed]” and that Narcan kits had mouth guards in them for “that reason.” Additionally, the FM was told that staff persons did cardiopulmonary resuscitation (CPR) while the VA was in bed, which was “something a layman knows is useless.” This “wasted much precious time.”

· The FM also had concerns that the VA either got the fentanyl at the facility or “snuck it in” despite staff persons documenting that they “searched” him/her. The VA had been at the facility one prior time (in July 2021) and during that, the VA had a “strip search,” which the VA did not have at the time of his/her admission to the facility immediately prior to the incident.

· The VA came to the facility from a sober living home and the FM thought that the sober living home should have taken the VA to the emergency room, due to the fentanyl, instead of the facility.

· The VA entered the facility with the “most deadl[y] drug in the world in [his/her] system [fentanyl] and [got] zero supervision.” If the VA had “stage four cancer,” s/he would not have “laid in bed” without supervision. The VA had a history of seizures and “withdrawals” and there was “no supervision” of the VA. Staff persons documented a “lot of lies” and the FM believed that the VA “lay in respiratory distress for a few hours while [the] safe and secure facility did nothing.” The facility was a “secure medical facility for detox” and the VA should not have “died” there.

The Rochester Police Department Report Summary provided the following information:

· On September 10, 2021, at approximately 10:23 a.m., law enforcement was notified of a “medical call” of an “unresponsive” client who was not breathing at the facility. An unknown staff person said that the VA was found unresponsive by C2 after C2 was “advised” to check on the VA after the VA received a phone call on the facility phone.

· A law enforcement officer (LEO1) arrived to the facility first (Note: the police report did not say what time LEO1 arrived but LEO1 said that s/he “responded” to the incident at 10:24 a.m. Additionally, video footage showed the first law enforcement officer at the facility at 10:28 a.m.) and said that when s/he arrived, the VA’s bedroom door was closed and when s/he entered, RN1 and SP2 were preforming CPR on the VA (who was on the bed). The VA was on his/her back and was “fully clothed.” The VA had a “dark blood like fluid on [his/her] face and had foam coming from [his/her] mouth.” It was also noted that there was “reddish brown vomit all over [the VA’s] face.” LEO1 checked the VA for a carotid and radial pulse but could not “locate any.” The VA was “warm” to the touch. LEO1 began to cut the VA’s shirt off when the Rochester Fire Department (RFD) arrived. The RFD moved the VA to the floor and began preforming CPR. Additional emergency personnel arrived and began “life-saving efforts as well.” Narcan was “attempted” by law enforcement officers and/or the Mayo Clinic Ambulance but it was not successful due to being unable to administer it due to the amount of stomach contents “clogging” the VA’s nasal passage. The VA was “pronounced” deceased at 10:42 a.m.

· Law enforcement then spoke to staff persons, including SP1. SP1 said that the VA arrived to the facility around 3:40 a.m. from a nearby sober living house. The VA tested positive for fentanyl, Percocet 30 milligrams (mgs), and Tetrahydrocannabinol (THC) while at the sober living house so the VA was brought to the facility.

· SP1 told law enforcement that at some point, s/he was notified by C1 that the VA was “snoring very loud and [C1] could not sleep.” Around 9:30 a.m., SP1 “went in and checked” on the VA. (Note: As previously stated, this investigator’s review of the video showed that at 8:16 a.m., SP1 walked to the VA’s bedroom door but did not go inside. SP1 then appeared to shut the VA’s bedroom door. At 8:35 a.m., SP1 stood outside the VA’s bedroom door but did not open it or go inside. There were no checks by any staff person on the VA after this, including by SP1 at 9:30 a.m.) SP1 “confirmed” that the VA was “sleeping” in his/her bed and was snoring “very loud.” SP1 then moved C1 to another room so that s/he could sleep and the VA remained his/her room so that s/he could “continue to sleep.”

· SP1 said that between 10:15 and 10:30 a.m., the “client phone” rang in the common area and C2 answered the phone. It was the VA’s sober living home looking for the VA. SP1 told C2 to “go wake up” the VA to let him/her know that s/he had a phone call. C2 then went to wake the VA but saw that s/he was not breathing and then C2 told SP1. SP1 then “ran” and checked on the VA and “confirmed” the VA was not breathing (Note: The law enforcement report did not say how SP1 determined that the VA was not breathing). SP1 then told RN1 who went to the VA’s bedroom and began CPR.

· Law enforcement also spoke to C2 who said that the VA had been “snoring so loud all morning.” Around 10:30 a.m., C2 was in the common area when the phone rang. C2 answered it and the person said that they were looking for the VA. C2 had “no clue” who the VA was so C2 told SP1. SP1 told C2 what room the VA was in and to “go and wake [the VA] up.” As C2 “approached” the VA’s room, C2 said that s/he could no longer hear the snoring. C2 then opened the VA’s bedroom door and stood in the doorway and called the VA’s name “multiple times” but the VA “was not responding.” C2 also noticed that the VA’s stomach was “not going up and down as if [the VA] was not breathing.” C2 then told SP1 who then “came over.”

· Law enforcement then spoke to C1. C1 said that at some point, C1 woke up to someone “snoring very loud” and then noticed that s/he had a “new roommate [the VA].” C1 then left the room to sleep on a nearby couch in a sitting area near the bedrooms but the “snoring was still so loud.” Around 9:30 a.m., C1 asked staff persons if s/he could switch rooms and staff persons let C1 do so. C1 did not have any further interactions with the VA.

· Law enforcement then spoke to RN1 who was “visibly upset and crying.” RN1 told law enforcement that the VA was brought to the facility earlier that morning from the sober living home but RN1 “did not know much about [the VA].” At some point, RN1 went to get the VA because the sober living home called and wanted to speak to the VA (Note: All other information showed that C2 went to get the VA to notify him/her of the phone call) and when s/he entered the VA’s room, s/he heard that the VA was “making a snoring noise [Note: RN1 told this investigator that s/he never said that]” and “not breathing.” RN1 and another staff person (who was not identified) began CPR. During CPR, a “liquid and foam” began coming out of the VA’s mouth. The VA did not have this prior to staff persons starting CPR.

· Law enforcement then spoke to SP2 who was “trembling” and “appeared to be bothered by what had just happened.” SP2 said that s/he had “no contact” with the VA prior to preforming CPR on him/her. When SP2 typically arrived to the facility at 8 a.m., s/he wrote down the names of “all” the clients so that s/he could “meet with them and do rounds.” However, on the date of the incident, SP2 began to write down the names but was “interrupted” and told that s/he needed to meet with another client “ASAP.” SP2 then met with that client and spent a “couple hours” in a meeting with him/her.

· SP2 said that s/he had just gotten out of the meeting and returned to the office when s/he saw C2 talking with SP1 and then SP1 “ran off” to the VA’s bedroom. SP2 followed SP1 to the VA’s bedroom and “briefly” saw the VA who was in bed, lying face up, and had a white substance “running” down from the VA’s nostrils. SP2 then ran back to the office to call 9-1-1 and 9-1-1 told SP2 to start CPR. SP2 then got the automated external defibrillator (AED) and when SP2 arrived back to the VA’s room, s/he saw RN1 in the VA’s room. SP1 and RN1 then began chest compressions while the VA was still in his/her bed and during this, a white substance and blood “came out” of the VA (Note: the report did not say where on the VA this was). RN1 and SP2 “opted not to try rescue breaths due to the amount of stuff coming out of [the VA]” but RN1 and SP2 continued chest compressions until law enforcement arrived. SP2 said that it was less than five minutes from the time they found the VA not breathing to when the first officer arrived. SP2 did not use the AED as they did not have time to get it “attached” as the emergency personnel arrived shortly after.

· SP4 told law enforcement that on the date of the incident, s/he was in his/her office when SP1 told him/her that the VA was “found unresponsive” and also that the VA was “dead.” When SP4 entered the VA’s bedroom, staff persons were doing “compressions” on the VA and had “called 9-1-1 at that point.” SP4 said that the clients were either on 15 minute or hourly checks, depending on how the client “present[s] to us.” SP4 said an example would be if a client was suicidal or their vitals were “up,” then they would be on 15 minute checks.

· Law enforcement then reviewed the VA’s “progress reports.” These showed that the VA arrived to the facility from the sober living home that morning at 3:40 a.m. The VA made no suicidal statements. Upon admission, the VA’s pockets were “checked and gone through.”

· At some point, law enforcement went to the sober living home and it was noted that the VA had “cherry berry” flavored ice cream in his/her room, which “appeared to be similar to what [the VA] had vomited up.”

· The staff persons at the sober living home said that on the night of September 9, 2021, they found a needle in the home that was not used. However, they found it “suspicious” so had the VA and other clients do a urinalysis (UA). The VA’s UA came back positive for fentanyl and THC. The VA “admitted” to using both “oxy” 30 mgs and smoking marijuana earlier that evening. The VA “admitted” to bringing the needle to the sober living home and said it was his/hers but that it was not used. The protocol at the sober living home was to take a client to detox unless it was a “really severe situation,” in which case,

9-1-1 would be called. The VA was then taken to the facility for detox. When the VA left to go to the facility, s/he “appeared pretty normal” and was “walking and talking just fine.” The VA and a staff person from the sober living home had a “coherent conversation” on the way to the facility and the VA said that

s/he “wanted to stop using and was struggling with it.” The VA arrived to the facility between 3:15 and 3:30 a.m.

· The FM told law enforcement that “you don’t leave high” from the sober living home at 3 a.m. and then “die” at 9 a.m. at “detox.”

The Autopsy Report said that the VA’s “postmortem toxicology” was “positive for fentanyl.” The VA had pulmonary congestion and “foam” was present in the VA’s trachea and bilateral upper and lower airways. The VA “died as a result of the toxic effects of fentanyl.”

SP3, RN2, and the Session Information completed by SP3 provided the following information:

· On September 10, 2021, around 4 a.m., the VA was “admitted” to the facility because s/he tested positive for fentanyl while at a sober living house. SP3 and RN2 did the VA’s admission. During the admission, the VA told SP3 and RN2 that at some point prior, s/he also took half of a 30 mg Percocet pill along with THC. During the admission, the VA was “really quiet” but “very nice.” RN2 documented that the VA was “very complacent” but was “very out of it” and “obviously intoxicated.” RN2 said that this included that the VA was “tired” which was from the “drugs” the VA used. However, RN2 did not have any concerns with the VA. The VA made no suicidal ideation statements.

· RN2 and SP3 checked the VA’s pockets, had the VA remove his/her shoes and socks, had the VA “lift” his/her shirt, and “pull[ed]” and “shook” the waist band of the VA’s pants. RN2 and SP3 did not find any illegal substances on the VA’s person. RN2 said that during this, the VA was “moving around a lot.” RN2 said that it was “hard to search a person who [was] intoxicated but you do the best you can.” Staff persons were not able to remove client’s clothing or check in their “body parts” and clients had “unfortunately” brought substances into the facility on prior occasions.

· RN2 and SP3 also checked the VA’s vitals. The VA’s blood pressure upon admission was 150/90. The VA’s heartrate was 98 and his/her respirations were 16. The VA’s temperature was 98 degrees Fahrenheit. SP3 said that the VA’s vitals were “a little bit elevated” but not “concerning.” RN2 said that there were no concerns with the VA’s vitals or concerns with the VA not being “alert and oriented.” The VA did not have a UA as the VA previously had one prior to coming in and the VA also “admitt[ed]” to taking the aforementioned substances. The VA did not have any “health complaints.” However, on the Session Information under “special conditions and precautions,” it was noted that the VA had a “history of withdrawal.” [Note: SP4 said that this was due to a seizure the VA reported earlier that year from heroin].

· RN2 said that at some point, the VA’s vitals were checked a second time during his/her shift like what was “usually” done (Note: This investigator did not find any documentation to show this had been done). The VA did not have any respiratory distress or difficulty breathing at any time during RN2’s shift.

· The VA was on 15 minute checks. SP3 said this was due to not knowing the VA’s history. Clients were also put on 15 minute checks if they had a history of withdrawal. Staff persons knew who was on 15-minute checks because their name was on a board in the office written in “red.” When a client was on hourly checks, their name was in “blue.” The staff persons working admission decided what checks each person was on. SP3 and RN2 said that the clients usually remained on 15 minute checks for the day if staff persons did not know the client “too well.” SP3 and RN2 each were not familiar with the VA. SP3 and RN2 each said that the VA would have remained on 15 minute checks throughout the day. When this investigator asked who did the checks, SP3 said that “everyone kind of does them” and RN2 said that staff persons “take turns.” On the night of the incident, SP3 “believed” that s/he did some of the 15 minute checks and RN2 said that s/he also did some. These checks were documented.

· SP3 said that it was “not ideal” to have only two staff persons working during the overnight shift and when this investigator asked if staff persons were able to do 15 minute checks with two staff persons, SP3 said that it depended on “what [was] going on.” SP3 did not “really remember [the] night” of the incident and what else had been happening. RN2 said that it was manageable to do the 15 minute checks with two staff persons working. However, RN2 said that during admissions, there should be two staff persons in the admission room with the client being admitted so during those times, there should “ideally be three staff,” so that the third staff was in the other areas of the facility. RN2 said that between one and seven clients were typically admitted to the facility per shift.

· RN2 said that the checks included that when a client was asleep, staff persons had to “go in” to the client’s bedroom and “watch them breathe.” RN2 said that s/he did this with the VA on the night of the incident and did not have any concerns. SP3 said that s/he typically counted a client’s respirations for a “minute” to “check how they are breathing.” If there were concerns, staff persons were to wake the client and ask them questions. RN2 said that there was nothing on the night of the incident that prevented him/her from checking on the clients as s/he was trained to do and said that it was not “more hectic than usual.” SP3 and RN2 did not have any concerns that staff persons did not do the checks as they were trained to do.

· RN2 and SP3 did not have any concerns with the VA during his/her shift, including during the VA’s admission and after. During RN2’s and SP3’s shift, the VA was walking around, getting a snack, using the bathroom, and going to his/her room to “rest” as the VA said that s/he was “tired.” The VA was able to communicate normally and walk on his/her own and there was no indication that anything was “wrong.” On prior occasions with other clients, RN2 had to send clients to the hospital if their vitals were “abnormal” or if they were “no longer alert or oriented” but did not have to do so with the VA.

· RN2 said that the VA used the bathroom during his/her shift but “came right back out.” SP3 said that at some point, the VA went into the bathroom for a “little bit and came back out.” SP3 and RN2 did not recall the VA being in the bathroom for 40 minutes. If a client was in the bathroom for that long, staff persons were to knock on the door and then “crack open the door” and ask if the client was “okay.” If a client did not respond, then staff persons entered the bathroom. Staff persons would still do the 15 minute checks if a client was in the bathroom. RN2 said that staff persons knew where the clients were in the facility “at all times between the staff that were working.”

· Clients could shut their bedroom doors but would need to leave it “cracked” if there was a concern with a client’s behavior. The VA’s bedroom door was not shut during SP3’s or RN2’s shift.

· Around 6:30 a.m., SP1, SP2, and the LPN arrived to the facility for their shift. At that time, staff persons did a “shift report” together. SP3 and RN2 left the facility around 7 a.m., as their shift had ended. SP3 said that s/he last saw the VA around 6 a.m. when the VA also asked to switch rooms but due to C1 snoring (which SP3 did not allow the VA to do). SP3 did not “remember” if s/he checked on the VA after that. SP3 did not “remember” what the VA was doing when s/he left. RN2 said that the VA was “resting” in his/her room when s/he left.

· RN2 said that C1 did not express any concerns with the VA during his/her shift. RN2 did not have any specific concerns with the incident and said that staff persons did “everything to the best of [their] ability.” However, RN2 said that s/he was “upset” about the incident and did not want it to “happen to anybody.”

· SP3 said that clients could “sneak” things, including drugs, into the facility. SP3 thought that this may have happened with the VA, due to the “fact” that the VA arrived to the facility “fine” and later “was not fine.” SP3 thought that if the VA took something prior to arriving to the facility that would have caused his/her death, then SP3 would have seen concerns with the VA during his/her shift. RN2 said that s/he had seen clients go through withdrawals in “different ways” so each person’s body reacted “different to the drugs.”

· At the time of the incident, staff persons “did not really know much” about fentanyl or “Perc[ocet] 30 [opioid].” However, since the incident, those drugs have become “huge” and staff persons were “more aware of it and the complications someone could have from it.” RN2 said that the VA was the first client that the facility had, who had used fentanyl.

· At some point, staff persons received training on Narcan but SP3 did not recall if it was prior to the incident or after. However, SP3 thought that Narcan was available to staff persons at the time of the incident. RN2 said that Narcan was available to staff persons at the time of the incident. The Narcan was in a locked medicine cabinet at the facility. RN2 said that staff persons could administer it if a client was not responding.

· Staff persons were to call 9-1-1 if a client’s heart rate was “extremely high” or if a client’s withdrawal symptoms were “out of control.” Additionally, if a client has chest pain, then they would seek additional help. Staff persons also called 9-1-1 if a client had “delirium,” tremors, seizures, if they did not respond to “any stimuli,” or if their respirations, heart rate, or blood pressure were “too low.” However, SP3 never saw these symptoms in the VA. However, SP3 had seen it with other clients and had to call 9-1-1 or seek additional help with other clients.

· After the incident, SP3 “learned” that if someone was “snoring really weird or loud” and had been using fentanyl, staff persons were to “always wake people up,” as it could be a sign of respiratory distress. SP3 never heard the VA snoring when s/he was at the facility but later, heard from staff persons that at some point, the VA was snoring and that it was “really loud.”

· RN2 said that the VA fell asleep near the end of RN2’s shift. The VA was not “snoring a whole lot” and it was “brief” and the VA would stop. When this investigator asked RN2 if snoring would be concerning, RN2 said it would be if there was any “gargling or apneic [pause in breathing] episodes,” which the VA did not have. If a client had those concerns, staff persons should wake the client and ask how they were

feeling. It was normal for clients to sleep at the facility because clients sometimes had not “slept for a while” prior to coming to the facility. It was not “unusual” to hear clients snoring.

· Staff persons were trained on CPR but were trained that they “did not have to do the breathing” as a way of “protecting” staff persons from “any type of diseases.” RN2 said that if a client was known to have taken fentanyl, as the VA was, then staff persons were “advised” that they were not “obligated” to do rescue breaths. RN2 said this was because fentanyl was a “danger” to the person giving the rescue breaths, because the person giving the breaths could go into respiratory distress as “drugs stay in a person’s system for a while.” RN2 said that staff persons could do “compression only CPR.”

· There were no other deaths at the facility in the 10 years that SP3 had worked there and SP3 said that the incident “kind of rattled everybody.”

SP1, and the Critical Incident and Drill Form and the Session Information ZV Progress Note both written by SP1 provided the following information:

· On September 10, 2021, at 6:30 a.m., SP1 arrived for his/her shift. Between 6:30 and 7 a.m., there was a “shift report,” where the overnight staff persons talked to the arriving staff. During that time, C1 said that s/he switched rooms because the VA’s “snoring was too loud,” which SP1 said happened at times with clients. Additionally, the overnight staff persons said that the VA went to bed just prior to SP1 arriving for his/her shift.

· Around 8 or 8:30 a.m., SP1 was doing his/her “normal routine checks.” During this, SP1 walked by the VA’s bedroom and saw the VA in his/her bed lying on his/her side and facing his/her bedroom wall. SP1 heard the VA “snoring” and described it as a “regular [really] loud snore.” SP1 also described the snoring as “heavy.” When SP1 heard a client snoring, SP1 let them sleep because SP1 “would not want to be woken,” which SP1 did with the VA. SP1 did not have any concerns with the VA during this time. SP1 continued doing “checks” and then went back to the office. Around this time, it became “super busy” with other clients and taking phone calls.

· Additionally, at some point, other clients began to say that the VA was snoring “too loud” so SP1 shut the VA’s bedroom door but did not shut it “all the way.”

· At 10:20 a.m., C2 answered the facility phone and told SP1 that someone asked for the VA. SP1 told C2 which room the VA was in so that C2 could notify the VA of the call. C2 then came back and told SP1 that the VA was “not breathing.” SP1 “took off running” to the VA’s bedroom and saw that the VA’s “color was off” and that the VA was “definitely cold.” SP1 also called out the VA’s name four times and “shook” the VA but the VA did not respond and was not breathing. SP1 then “ran” and got RN1 so that RN1 could “help to assess” the VA. SP1 told RN1 that s/he was “pretty sure [the VA] [was] dead.” RN1 then ran to the VA’s room with SP1. RN1 told SP1 to “run and grab” SP4 and SP1 did so. SP1 told SP4 that s/he was “pretty sure [the VA] [was] dead.” SP1 and SP4 then ran to the VA’s bedroom and then SP1 ran to the office and called 9-1-1. However, SP1 also said that s/he was “unsure” if s/he made the initial call to 9-1-1 and said that at some point, SP2 also spoke to 9-1-1.

· RN1 and SP2 then began CPR while SP1 remained on the phone with 9-1-1. 9-1-1 asked SP1 if Narcan was administered and SP1 said that it was not but that staff persons were doing CPR. SP1 did not know if staff persons administered Narcan but said that s/he did not administer it. However, the facility had Narcan available in a “red bag.”

· SP1 said that 9-1-1 was called “probably within 10 to 15 minutes” from the time C2 notified him/her that the VA was “not breathing.” When this investigator asked SP1 why 9-1-1 was not called sooner, SP1 said that it was “because we were making sure [the VA] was actually dead.” (Note: video footage showed that staff persons called 9-1-1 within two minutes.)

· Clients were checked on either every 15 minutes or every hour. SP1 thought that the VA was switched from 15 minute checks to hourly checks during the shift change at 6:30 a.m., as the overnight staff persons said that the VA was “fine.” When this investigator asked SP1 who made the decision to switch the VA from 15 minute to hourly checks, SP1 said that “we all do” during the shift change. SP1 said that there was usually a progress note written stating that a person had been switched from 15 minute to hourly checks (Note: SP4 said that there was no progress note for this and a review of the progress notes showed no notation regarding a change in the 15 minute checks.)

· Staff persons took turns checking on the clients and at the time of the incident, the LPN and SP1 were doing the checks. The checks were documented on the computer in the staff office and staff persons knew if another staff person did a check by looking at the document on the computer. SP1 did not know if the VA was checked on between when s/he checked on the VA around 8:30 a.m. to when C2 found the VA “not breathing.” However, SP1 thought that the LPN checked on the VA at 9:30 a.m., as it was just the LPN and SP1 doing the checks that morning.

· At times, it was hard to check on the clients as scheduled due to having a “full house” or “staffing” issues. If a staff person missed a supervision check, staff persons would not leave it blank on the tracking sheet. The next person to do the check would document that the missed one was done even if they “did not see” the client at the scheduled time because “all” staff persons “shared” the supervision checks. However, staff persons were “usually good” at doing the checks when scheduled but may be “five to ten minutes late” on the checks. When this investigator asked SP1 why one staff person was not assigned the checks, SP1 said that it was not assigned because staff persons “get busy.” SP1 did not have any concerns that staff persons did not check on the VA as they were trained to do.

· At no time did SP1 talk to the VA during his/her shift and SP1 only checked on the VA “once” during his/her shift at 8:30 a.m.

· At the time of the incident, staff persons were “just learning” about fentanyl and “perc 30’s.” The facility had a “couple” prior clients who had used fentanyl and “perc 30” but staff persons were “very unaware” of those at the time of the incident. However, following the incident, staff persons did “opioid checks” every four hours which included asking a client how they were doing and checking their vital signs. Staff persons also discussed during shift change about which clients were on fentanyl or heroin or who had “low respiratory rates,” so that staff persons were “very aware of those situations.” The facility also provided annual training on Narcan following the incident.

· SP1 thought that the VA “snuck something” into the facility. SP1 thought his because the VA was “up” and “walking and talking” at the time of admission and there were no concerns at that time.

· During CPR, if staff persons were not comfortable doing rescue breaths, they could do “compression only” CPR.

The LPN provided the following information:

· The LPN did not recall the date of the incident but on that date, at 6:30 a.m., the LPN arrived for his/her scheduled shift. The LPN did not recall who had worked the overnight shift but when the LPN arrived, the overnight staff gave him/her a “report” of how the night went and who the clients were. The LPN did not recall any specific concerns with the VA aside from that the VA had used fentanyl. That day, the LPN worked with SP1, SP2, SP3, SP4, and RN1.

· Around 10 a.m., there was a phone call made to the facility for the VA. C2 then went to notify the VA of the call but then came to the office and said, “I think [the VA’s] dead.” SP1, SP4, and RN1 “immediately” went to the VA’s bedroom. SP2 called 9-1-1 and they told SP2 to start CPR, which SP2 did. The LPN “believe[d]” that 9-1-1 was called right away. The LPN remained in the office to let emergency personnel into the facility.

· The LPN did not have any interactions with the VA during his/her shift. The LPN “did not recall” if the VA was snoring.

· When this investigator asked who did the supervision checks, the LPN said that “all” staff persons did them and that it was “not one person’s responsibility.” If a staff person was busy, another staff person would do them. Staff persons knew if it was done because they documented the checks on a computer and would “usually voice” when it was done. On the date of the incident, the LPN did not do the checks and said that SP1 did them. When this investigator asked the LPN how s/he knew that SP1 did them, the LPN said that SP1 said that s/he was doing them and SP1 had also “signed the computer sheet.”

· During the checks, staff persons were trained to “go around” and “visually” see the client. This included that if a client was in their bedroom, a staff person had to go into their room. Staff persons were to also ensure that a client was breathing. The LPN did this by “watching” the clients or talking to them to get a response. Additionally, a staff person may open a client’s bedroom door and the client “might move” so then staff persons “knew they [were] okay.” If a client was in the bathroom during a supervision check, the staff person doing the check was to knock on the bathroom door and ask if they were okay. If the VA was in the bathroom for 40 minutes, a staff person should have checked on the VA. If a client was not in their bedroom during a supervision check, then staff persons should check the common area. Staff persons could see this area from the office so did not need to go into the common area unless the client was sleeping on the couch. In that case, staff persons would need to check on the client to ensure they were “breathing.”

· Clients were able to shut their bedroom door but if they were suicidal or “higher risk,” then they needed to have their door open. A client could be higher risk if they had withdrawal symptoms or seizures. The LPN was not aware of any reason why the VA would not be able to have his/her door closed.

· Some clients were on 15 minute checks and some were on hourly. The staff person admitting the client decided what type of check they were on. A client was typically monitored for “at least 24 hours” before being moved from 15 minute checks to hourly. If a client’s behaviors “changed to a positive” or if a client did not have “any signs of withdrawal,” then they were moved to hourly checks.

· The LPN said that s/he was trained that “compressions” were the “most important” thing when doing CPR. The LPN was not aware of a staff person refusing to do rescue breaths. There were “masks” available to staff persons if they wanted a barrier to do rescue breaths.

· Client’s vitals were checked upon admission and then “usually once a day” if they had used drugs. If they used alcohol, then the clients were “checked a little more often.” The nursing staff person checked the vitals and it could be done “anytime” during the day. The LPN never checked the VA’s vitals.

· The LPN said that the facility provided training on fentanyl and Narcan but s/he did not know if it was before or after the incident. The LPN did not know if Narcan was available at the time of the indent.

· When a client used fentanyl, staff persons were to watch out for if a person was “unresponsive” or not breathing. The LPN said that from his/her “understanding,” someone displayed symptoms “pretty soon” after using fentanyl.

· Upon admission, staff person’s searched a person’s pockets and ensured nothing was in their socks, but a client could still bring in drugs as the facility “could not do a strip search.” Clients had brought in drugs prior without staff persons knowing.

SP2 and the Session Information ZV Progress Note written by SP2 provided the following information:

· On September 10, 2021, between 10:20 and 10:25 a.m., SP2 was notified that the VA was “non-responsive.” SP2 then went into the VA’s bedroom and observed that the VA’s skin was “leathery” and “kind of blueish-grey.” There were “white bubbles” coming from the VA’s nose and the VA “did not appear to be breathing.” SP1 and the LPN were nearby and “instructed” SP2 to call 9-1-1. The 9-1-1 operator took “basic information” and then “recommended” that staff persons start CPR. SP2 did not recall 9-1-1 advising him/her to do anything else besides CPR, including to administer Narcan.

· SP2 then handed the phone to SP1 and went into the VA’s room to begin CPR. When SP2 arrived, RN1 was in the room and SP2 told RN1 that the 9-1-1 operator advised to begin CPR. SP2 and RN1 “agreed that it may not be safe for [them] to perform the breathing aspect of CPR” for “safety” so SP2 began the “chest compression aspect.” As SP2 did so, s/he observed a “white mucus type substance” or “white foam” coming from the VA’s nose and mouth. Then, a dark purple or black “blood like substance” came from the VA’s mouth. SP4 then told SP2 that s/he could take over the chest compressions if s/he was “exhausted” but SP2 continued the chest compressions until emergency personnel arrived.

· SP2 was not aware of anyone administering Narcan but said that staff persons were able to if needed. SP2 “did not consider it at that time.” SP2 “believe[d]” that staff persons were trained on Narcan at the time of the incident.

· On September 10, 2021, when SP2 first arrived to the facility at 8 a.m., SP2 was told that s/he needed to meet with a different client which s/he did until 10:15 a.m. SP2 normally met with all the clients in the morning, but did not do so on the date of the incident due to meeting the other client.

· Clients were initially on 15 minute checks when they arrived to the facility and then during shift change if they were “doing okay,” they were placed on one hour checks. Any staff person could make the change but staff persons typically spoke to the nursing staff person working the prior shift. There “should be” a

progress note that noted the change, which might include a client’s vitals (Note: SP4 said that there was no progress note for this and a review of the progress notes showed no notation regarding a change in the 15 minute checks.) SP2 “believe[d]” that the VA was initially on 15 minute checks but changed to hourly during the morning shift change around 6:30 or 7 a.m.

· When this investigator asked SP2 who did the checks, SP2 said that it was a “collective exercise” regarding who did the checks. SP2 normally checked the “log” to see who was doing the checks. SP2 “sometimes” did the checks but had “other priorities” in his/her role as a counselor that took “precedence” over the checks. SP2 never checked on the VA on the date of the incident and did not recall who did.

· SP2 said that the “logging of the checks” was at times a “lower priority.” There were times when SP2 had checked on a client and the client had not been “checked for a while,” so SP2 documented the “same representation” for the missed times “under the assumption if they are good now, they were good then.” However, SP2 did not do that with the VA. Additionally, there were times that SP2 and other staff persons might get “pulled away” for a time and “miss a check.” When this occurred, SP2 would document that s/he did a check “even though [SP2 or any other staff person] did not actually do it.” However, SP2 did not know if staff persons had done similar at the time of the incident. When this investigator asked SP2 if s/he could leave a supervision check blank if one was missed, SP2 said that was “not the practice.”

· SP2 was not aware of the VA being in the bathroom for 40 minutes. If a client was in the bathroom for that long, SP2 would “often go in and ask them [if they were] doing okay.”

· When this investigator asked SP2 if s/he had any specific concerns with the incident, SP2 said that following the incident, s/he was “more aware” of “when and how” Narcan could be used. Additionally, SP2 had a “little bit of concern” regarding the checks but SP2 “believed” that staff persons did those. SP2 also had concerns that the VA may have “smuggled” fentanyl into the facility. Staff persons did a “fairly good job” at searching for drugs during admission but at times, things had “gotten missed.”

· SP2 did not hear the VA snore while at the facility but said that it was “hearsay” that the VA had “labored” breathing prior to the incident. SP2 said that in “retrospect,” the “signs [that there were concerns with the VA] were there if someone had realized it.” Following the incident, SP2 realized the “impact of [the VA’s] labored breathing” and said that fentanyl was “very potent” and even a “small amount” could “kill a horse.”

· SP2 said that s/he “did not know” if anyone could have “helped” the VA. Staff persons had a “responsibility” to keep clients safe but the clients, including the VA, had the “responsibility” not to put themselves “in that situation.”

RN1 and the Session Information ZV Progress Note written by RN1 provided the following information:

· On September 10, 2021, at approximately 10:20 a.m., SP1 came to RN1’s office and stated that s/he needed RN1 to “assess” the VA who SP1 did not think was breathing in his/her bed. SP1 also told RN1 that s/he “shook” the VA and was trying to wake him/her by calling his/her name.

· RN1, SP1, and SP2 then went to the VA’s bedroom and RN1 observed the VA lying on his/her back in his/her bed with his/her mouth slightly open. The VA had “dark droplets speckled on the front of [his/her] shirt” that looked like “dark chocolate pudding splatters.” Both of the VA’s eyes were one-fourth open with “only the white’s observable.” The VA’s eyelids appeared to be “enlarged and swollen” and the VA’s skin was “waxy in appearance.” RN1 touched the VA’s arm which was “warm.” RN1 checked for a pulse and did not find one and no breathing was observed. A staff person was then “directed” to call 9-1-1 but RN1 did not recall who the staff person was or who directed the staff person to call 9-1-1. During this time, RN1 “remained with [the VA] and continued to observe.” Within 10 seconds, RN1 saw staff persons on the phone with 9-1-1 who “motioned” to RN1 to start CPR. RN1 then “motioned” for SP2 to “assist” him/her. RN1 then looked at the VA and the VA “suddenly” had “white foam and bubbling from [his/her] nasal passages.” RN1 “directed” SP2 to start chest compressions. During the compressions, the VA had a “large amount of fluids gushing from [his/her] mouth” so RN1 “did not provide mouth to mouth.” RN1 “did not think that anyone” could have done rescue breaths, even with a mask, as the VA had a “large amount of fluids” “overflowing” from his/her mouth.

· RN1 then left the VA’s room to get an AED and “rescue mouth cover” and returned to the room while SP2 continued chest compressions. The VA’s “condition continued to remain unchanged.” RN1 began “preparing placement for AED” when emergency personnel arrived and “immediately took over.” When they arrived, they placed the VA on the floor and began placing the AED on the VA. Their arrival was approximately four minutes after SP1 asked RN1 to “assess” the VA.

· RN1 thought it was a “couple minutes” from when staff persons realized the VA was not breathing to when 9-1-1 was called. RN1 did not think it was 10-15 minutes.

· RN1 had no interactions with the VA prior to the incident.

· At the time of the incident, RN1 did not know “anything about Narcan” and staff persons did not administer Narcan to the VA. Additionally, the VA was the “first person” to come to the facility who had used fentanyl. Around the time of the incident, “someone” at the facility obtained Narcan from a local college but staff persons were not trained on it and there was no “policy” for staff persons to administer it. However, the facility was in the “process” of developing policies and procedures for it. Although the facility had Narcan, RN1 “did not know” if s/he could have administered it because there was “no policy.” However, since the incident, there had been “more of a fentanyl epidemic” in Rochester, Minnesota, so “a lot ha[d] changed since then.” This included that following the incident, RN1 received training that if a client “appear[ed] to be lethargic” or was “not responding,” staff persons administered Narcan as it “would not hurt them.” Following the incident, RN1 also learned that “even a grain of fentanyl could kill you.”

· Clients were to be checked on either every 15 minutes or every hour. The staff person working at the “desk” usually did the checks but there was no assigned staff person and staff persons usually “took turns.” This included nursing staff, counseling staff, or “extra” staff. The VA was initially on 15 minute checks during the overnight but since RN1 was told at some point that the VA was “up and moving” and “talking and doing fine,” the VA was switched to hourly checks by either the night shift or the morning shift. RN1 did not see who was doing the checks on the date of the incident because RN1 was in his/her office. RN1 never did any checks.

· At some point following the incident, RN1 had been told that the VA was snoring, which “everyone” that came to the facility did. Following the incident, RN1 was told that the VA may have fallen asleep from an “overdose” and was “trying to breathe.” The VA was “fine for hours” prior to this so it “did not make any sense” to him/her. Following the incident, persons were trained to wake the clients if they were snoring, even if they became “upset.”

SP4 provided the following information:

· On September 10, 2021, around 10 or 10:30 a.m., SP4 was working in his/her office when SP1 came into his/her office and said that the VA was “dead.” SP4 “immediately” went into the VA’s bedroom where the VA was “unresponsive.” SP4 tried to “rouse” the VA and shake him/her but “nothing was happening.” SP4 did not check for a pulse. During this time, SP1, SP2, and RN1 were also in the room. SP4 thought that SP2 called 9-1-1 and was then directed to start CPR. SP2 handed the phone to another staff person and SP2 began chest compressions. SP4 told SP2 that if s/he became tired while giving CPR that SP4 could take over but SP2 “kept going.” During this, the paramedics arrived.

· 9-1-1 was called within “seconds” of SP4 going into the VA’s bedroom. SP4 denied that it was 10 to 15 minutes.

· SP4 had not had any interactions with the VA prior to SP1 notifying him/her of the incident.

· At some point following the incident, SP4 saw video footage while the VA was at the facility. SP4 said that the documentation for the supervision checks matched what was on the video. SP4 saw that at some point, the VA was in the bathroom for a “longer period than typical” and said it was about 20 minutes. The VA was also on video at times moving around the facility. This included talking to staff persons and making toast. The VA “seemed to be functioning fine.” Prior to the incident, the VA was last checked at 9:30 a.m. by SP1 (Note: As previously stated this investigator’s review of the video did not show SP1 or any staff person checking on the VA at 7 or 7:30 a.m. At 8:16 a.m., SP1 walked to the VA’s bedroom door but did not go inside. SP1 then appeared to shut the VA’s bedroom door. At 8:35 a.m., SP1 stood outside the VA’s bedroom door but did not open it or go inside. There were no checks by any staff person on the VA after this, including by SP1 at 9:30 a.m.)

· The VA was initially on 15-minute checks and then at 7 a.m. the VA moved to hourly checks, which was a nursing staff or “clinical judgement” decision. However, there was usually a progress note for this and there was not one for the VA. SP4 also said that a progress note was “not required” but was “typically done.”

· Staff persons did not administer Narcan as staff persons had not had training on it until after the incident (on November 11, 2021). However, if 9-1-1 had directed staff persons to administer it, then staff persons would have, but they did not “direct” staff persons to do so.

· Staff persons were trained on CPR every year and if there was blood, staff persons were trained to “maybe” not do rescue breaths due to “risk of communicable diseases.” Staff persons were trained via an “independent trainer who references both the American Heart Association and American Safety and Health Institute.” The instructor states that “chest compression only CPR is a choice for a rescuer and due to the nature of our facility and the high risk of communicable diseases, it is not recommended to preform mouth to mouth.” SP4 said that compression only CPR had been shown to be “effective as we attempt to circulate blood to the brain.”

· Snoring of a client could be normal and staff persons heard it “often enough” at the facility.

· SP4 did not have any specific concerns with the incident and said that the VA “seemed like [s/he] was functioning fine” via the video footage.

Law enforcement (via the Rochester Police Department Report Summary) and this investigator reviewed video footage and saw the following (Note: It is noted below any time that a staff person checked on or had interactions with the VA):

· On September 10, 2021, at approximately 3:39 a.m., a staff person from the sober living home brought the VA to the facility. A staff person from the facility opened the door and the VA walked into the facility (Note: There was no video footage from the VA’s admission, because there was not a camera in the admission room).

· At approximately 3:49 a.m., the VA went with a staff person (later determined to be RN2) to the dining area and got a cup of water. At approximately 3:50 a.m., RN2 walked the VA to his/her bedroom. At 3:51 a.m., the VA walked out of his/her bedroom and into a nearby bathroom. The VA did not exit the bathroom until 4:33 a.m. and no staff person checked on the VA during this time (42 minutes). The VA then exited the bathroom and walked to the dining area for a “couple minutes.” RN2 was with the VA while in the dining area and the VA got something out of the refrigerator/freezer. At approximately 4:35 a.m., the VA walked back to his/her bedroom.

· Between 4:35 and 5:50 a.m. (75 minutes), no staff person checked on the VA while s/he was in his/her bedroom (this included no staff person going near or into the VA’s room).

· The VA remained in his/her bedroom until approximately 5:50 a.m. At this time, the VA walked out of his/her bedroom and got a drink of water out of a nearby drinking fountain. The VA then went into the bathroom. During this time, no staff person went into the bathroom to check on the VA. However, SP3 was in the nearby bedroom area.

· At approximately 6:03 a.m., the VA walked out of the bathroom and went to the dining area. It appeared that the VA made toast. At approximately 6:08 a.m., the VA sat down at a nearby table to eat his/her food. No staff person was in view of the camera, although information from staff persons showed that staff persons could see the dining area from the staff office.

· At approximately 6:19 a.m., the VA walked to the bathroom and went inside. At approximately 6:29 a.m., the VA exited the bathroom. The VA had taken off the sweatpants s/he was previously wearing and walked out of the bathroom wearing shorts. The VA was holding his/her sweatpants (Note: the VA likely had on shorts underneath his/her sweatpants as the VA did not appear to enter the bathroom with anything). There were no staff persons in view of the camera during this time. The VA then walked to his/her bedroom and entered (Note: at no point after this did the VA exit his/her bedroom).

· At approximately 6:41 a.m. (12 minutes after the VA entered), C1 (the VA’s roommate) exited their bedroom and went into the lounge area and then returned to the bedroom at 6:43 a.m. C1 then walked out of the bedroom with a blanket and pillow and then lay down on a couch in the common area. The VA’s bedroom door appeared to be open during this time.

· At 7:58 a.m., the LPN walked another client to his/her bedroom, which was near the bathroom, but the LPN did not go near the VA’s bedroom.

· Between 6:29 a.m. when the VA entered his/her bedroom and 8 a.m., no staff person went into or near the VA’s bedroom (91 minutes). At 8:00 and 8:09 a.m., SP2 walked near the VA’s bedroom but did not appear to go inside. The VA’s bedroom door was still open at this time.

· At 8:12 a.m., C1 appeared to look into the VA’s bedroom and then “quickly le[ft]” the area and walked towards the dining area.

· At approximately 8:16 a.m., SP1 “peak[ed]” inside the VA’s bedroom but did not go inside and then SP1 closed the VA’s bedroom door. (Note: It was difficult to see on camera if the VA’s bedroom door was closed all the way or was slightly ajar). At approximately 8:36 a.m., SP1 walked past the VA’s bedroom and appeared to have a pen and paper in his/her hand. SP1 opened another client’s door but did not enter the VA’s bedroom. At 8:46 a.m., SP1 went into another client’s bedroom but did not go into the VA’s bedroom. The VA’s bedroom door remained closed. At 9:41 a.m., a maintenance person began replacing ceiling lightbulbs in the area outside of the bedrooms, including the VA’s. This person did not enter the VA’s bedroom.

· At 10:03 a.m., the LPN entered the room next to the VA’s room but did go inside the VA’s room. At 10:10 a.m., SP1 opened another client’s bedroom door but did not go into the VA’s bedroom. SP1 then sat on a chair in the sitting area outside of the client’s bedrooms and spoke to another client. The VA’s bedroom door was still closed.

· At approximately 10:19 a.m., C2 walked towards the VA’s bedroom but did not appear to go inside. C2 then left the VA’s bedroom area and went to the office where SP1 was. At approximately 10:21 a.m. (two hours and four minutes after SP1 last “peaked” into the VA’s bedroom), SP1 went into the VA’s bedroom and then “quickly” left to get RN1 (who was in his/her office near the common area). At 10:22 a.m., SP1 and RN1 are seen going to the VA’s bedroom and around this time, SP2 was on the phone in the staff office. At 10:25 a.m., SP2 is shown leaving the office and going into the VA’s bedroom while SP1 is now on the phone in the staff office. At approximately 10:28 a.m., a law enforcement officer arrived and other first responders arrived shortly after.

The Session Information CRU Facility and Individual Abuse Prevention Plan dated September 10, 2021, and filled out by SP3 said that the VA was on 15 minute checks due to having a history of withdrawal (Note: There was no information to show that the VA was moved to one hour checks).

The Session Information 11 PM to 7 PM Monitored Behavior Sheet dated September 10, 2021, said that at 3:30 a.m., the VA was admitted to the facility by SP3. At 3:45 a.m., RN2 noted that the VA was in the “dayroom” and “eating [a] meal.” At 4 a.m., RN2 noted that the VA was in the bathroom and in the dayroom. At 4:15, 4:30, 4:45, and 5 a.m., RN2 noted that the VA was in the dayroom and “pacing.” (Note: Video footage showed that at 4:15 and 4:30 a.m., the VA was in the bathroom not the dayroom. From approximately 4:34 to 5:50 a.m., the VA was in his/her bedroom not the dayroom.) At 5:15 and 5:30 a.m., RN2 noted that the VA was in his/her room. At 5:45 and 6 a.m., RN2 noted that the VA was in the dayroom and/or “pacing.” (Note: From approximately 4:34 to 5:50 a.m., the VA was in his/her bedroom not the dayroom.) At 6:15 and 6:30 a.m., RN2 noted that the VA was in the day room and eating a meal. At 6:45 a.m., RN2 noted that the VA was in the dayroom. (Note: At 6:30 a.m., the VA went to his/her bedroom and at no point after, came back out.)

The Session Information 1 Hour Checks for the VA showed that on September 10, 2021, SP1 noted that s/he checked on the VA at 7, 7:30, 8:30, and 9:30 a.m., and that during those times, the VA was in his/her room “sleeping.” (Note: Video footage did not show any staff person, including SP1, checking on the VA at 7, 7:30, or 9:30 a.m.) At 10:20 a.m., it was noted that the VA was “deceased.”

The VA’s Property Receipt for Client dated September 10, 2021, said that the “articles on admit” included a phone and the VA’s wallet. There were no additional things found during a “search.” The Medication Information/Withdrawal said that the VA was due for his/her “8 [hour]” vital check on September 10, 2021, at 11:40 a.m. The VA was due for his/her “48 [hour]” vital check on September 12, 2021, at 3:40 a.m.

The Zumbro Valley Health Center Policy and Procedure revised December 1, 2019, provided the following information:

· The Connections and Referral Unit staff persons were responsible for monitoring the health of all clients on the unit throughout the entirety of their stay.

· Information about a client, including their health, was to be documented on the admission form, admission progress note, and in the admission health screening tool. Due to varying levels of intoxication and behaviors upon admission, this may not be able to be done upon admission. However, staff persons were to “review all information” within 12 hours of admission.

· Within 4 to 12 hours of admission, staff persons were to re-assess each client for health complaints using a 12 hour screening tool.

· All clients were to meet with an RN, LPN, or medication assistant to complete a 48 hour nursing observation if the client had not discharged within 48 hours. Those required to complete the nursing assessment included clients “intoxicated with chemical substances.”

· Staff persons were to monitor clients either hourly or every 15 minutes, depending on the client’s health and behavior status. Clients may start out on 15 minute or hourly observations and be switched during their stay if appropriate. Situations where a client may have a 15 minute observation include but were not limited to known withdrawal, seizure history, active withdrawal, and suicidal ideation.

· If at any point, including upon initiation of services or throughout the entirety of the stay, that a client exhibited “unstable” vital signs, chest pain, difficulty breathing, persistent pain, or persistent vomiting or diarrhea, staff persons were to consult with the on-call physician or nurse practitioner. Staff persons were to take a client to the emergency room if a client had a generalized seizure, was unconscious, had delirium, had a suicidal attempt, or any other conditions warranting transfer as indicated by the on-call physician or nurse practitioner.

Facility documentation showed that RN1, RN2, the LPN, SP1, SP2, SP3, and SP4 received training on CPR, first aid, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. The LPN, RN1, RN2, SP1, SP2, SP3, and SP4 were also trained on emergency procedures such as a client death and the facility abuse prevention plan.

Relevant Rules and/or Statutes:

Minnesota Rules, part 9530.6550, item A, states that the license holder must have written procedures for assessing and monitoring client health including that the procedures must specify those staff members responsible for monitoring client health and provide for hourly observation, and for more frequent observation if the service initiation assessment or follow-up screening indicates a need for intensive physical or behavioral health monitoring.

Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b), clause (3) states that the license holder shall monitor implementation of policies and procedures by program staff.

Minnesota Statutes, section 245A.07, subdivision 3, paragraph (a), clause (3) states in part that the commissioner may impose a fine a licensor holder knowingly gives false or misleading information to the commissioner during an investigation or regarding compliance with applicable laws or rules.

Conclusion:

A. Maltreatment:

Information was consistent that on September 10, 2021, at 3:40 a.m., the VA was admitted to the facility for detoxification of fentanyl (synthetic opioid). Around 10:42 a.m., the VA was “pronounced” deceased.

Regarding the VA being searched when arriving to the facility:

Although the FM said that the VA had a “strip search” done when s/he was a client at the facility in July 2021, staff persons said that they could not “strip search” a client. Information obtained showed that upon the VA’s admission to the facility, staff persons checked the VA’s pockets, clothing, and shoes/shoes but did not find any illegal substances. In addition, it was not known if the VA passed away from the effects of the fentanyl s/he took prior to coming to the facility or if the VA brought something into the facility concealed in a manner that staff persons would not have discovered. Therefore, there was a preponderance of the evidence that there was not an omission by staff persons to supply the VA with care which was reasonable and necessary to maintain the VA’s physical health or safety.

It was determined that neglect did not occur (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.)

Regarding Narcan:

The FM also said that s/he was told by law enforcement that someone made a “feeble” attempt at Narcan but the FM did not know by whom. The FM was “infuriat[ed]” that the VA did not receive Narcan as the VA was “very savable.”

The law enforcement report showed that Narcan was “attempted” by law enforcement and/or the Mayo Clinic Ambulance but it was not successful due to being unable to administer it due to the amount of stomach contents “clogging” the VA’s nasal passage.

Although there was Narcan at the facility, the facility had yet to implement its use according to Minnesota Statutes. In addition, 9-1-1 did not direct staff persons to administer Narcan. Therefore, there was a preponderance of the evidence that there was not a failure or omission to supply the VA with care which was reasonable and necessary to maintain the VA's physical health or safety.

It was determined that neglect did not occur (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.)

Regarding rescue breaths:

The FM also had concerns that staff persons, including an RN, “decided” to not give the VA rescue breaths because at some point, the VA had vomited. The FM said that persons who overdosed “vomit[ed]” and that Narcan kits had mouth guards in them for “that reason.”

SP2 administered CPR on the VA and RN1 was present in the room during that time. RN1 and SP2 each said that they did not provide rescue breaths due to the VA having a “large amount of fluids gushing from [his/her] mouth.” RN1 “did not think that anyone” could have done rescue breaths, even with a mask, as the VA had a “large amount of fluids” “overflowing” from his/her mouth.

Information was consistent from staff persons that they were trained that they “did not have to do the breathing” as a way of “protecting” staff persons from “any type of diseases.” SP4 said that staff persons were trained via an “independent trainer who references both the American Heart Association and American Safety and Health Institute.” The instructor states that “chest compression only CPR is a choice for a rescuer and due to the nature of our facility and the high risk of communicable diseases, it is not recommended to preform mouth to mouth.” SP4 said that compression only CPR had been shown to be “effective as we attempt to circulate blood to the brain.” RN2 said that if a client was known to have taken fentanyl, as the VA was, then staff persons were “advised” that they were not “obligated” to do rescue breaths. RN2 said this was because fentanyl was a “danger” to the person giving the rescue breaths, as the person giving the breaths could go into respiratory distress as “drugs stay in a person’s system for a while.” The LPN said that s/he was trained that “compressions” were the “most important” thing when doing CPR. However, the LPN also said that there were “masks” available to staff persons if they wanted a barrier to do rescue breaths. When this investigator asked SP2 if s/he could have used a barrier for breathing during CPR, SP2 said that it was “probably an option” but was “not considered in the moment.” Given that staff persons administered chest compressions but not rescue breaths, there was not a preponderance of the evidence whether there was an omission by staff persons to supply the VA with care which was reasonable and necessary to maintain the VA’s physical health or safety.

It was not determined whether neglect occurred (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.)

Regarding the supervision checks:

The Facility Abuse Prevention Plan and the Zumbro Valley Health Center Policy and Procedure said that clients were to be “assessed throughout their stay.” This included that staff persons were to monitor the client’s vital signs “carefully” for signs and symptoms of withdrawal. Clients were encouraged to “rest as the effects of the substance subside.” Staff persons were to visually check and document the whereabouts of each client at least once per hour. If a client was at risk of harm to themselves or others, was highly intoxicated, or was “in withdrawal,” staff persons may place a client on 15 minute “visual checks.” Staff persons were “skilled” at identifying withdrawal symptoms and medical emergencies and “taking appropriate action.”

RN2 and the LPN each said that the checks included that when a client was asleep, staff persons had to “go in” to the client’s bedroom and “watch them breathe.” SP3 said that s/he typically counted a client’s respirations for a “minute” to “check how they are breathing.”

There was inconsistent information regarding whether the VA was on 15 minute or hourly checks. SP3 and RN2 each said that the VA was on 15 minute checks and would have remained on 15 minute checks “throughout the day.” SP3 said that although there were no concerns with the VA upon admission, the VA had a history of withdrawal and because of this, when clients had a history of withdrawal, they were put on 15 minute checks. The LPN said that a client was typically monitored for “at least 24 hours” before being moved from 15 minute checks to hourly. SP1, SP4, and RN1 thought that the VA was switched from 15 minute checks to hourly checks during the shift change at 6:30 a.m., as the overnight staff persons said that the VA was “fine.” Additionally, information was consistent that when a client was moved from 15 minute to hourly checks, there was a progress note written for the change. However, there was no progress note to indicate that the VA had been moved to hourly checks.

The Session Information 11 PM to 7 PM Monitored Behavior Sheet dated September 10, 2021, said that at 3:45 a.m., RN2 noted that the VA was in the “dayroom” and “eating [a] meal.” At 4 a.m., RN2 noted that the VA was in the bathroom and in the dayroom. At 4:15, 4:30, 4:45, and 5 a.m., RN2 noted that the VA was in the dayroom and “pacing.” (Note: Video footage showed the VA in the bathroom between 3:51 and 4:33 a.m. and that no staff person checked on the VA during this time). At 5:15 and 5:30 a.m., RN2 noted that the VA was in his/her room. At 5:45 and 6 p.m., RN2 noted that the VA was in the dayroom and/or “pacing.” (Note: From approximately 4:35 to 5:50 a.m., the VA was in his/her bedroom not the dayroom and no staff person checked on the VA during this time. Between 5:50 and 6:03 a.m., the VA walked out of his/her bedroom and into the bathroom and no staff person went into the bathroom to check on the VA.) At 6:15 and 6:30 a.m., RN2 noted that the VA was in the day room and eating a meal (Note: Video footage showed that between 6:19 and 6:29 a.m., the VA went into the bathroom and no staff person checked on the VA during this time). At 6:45 a.m., RN2 noted that the VA was in the dayroom. (Note: At 6:30 a.m., the VA went to his/her bedroom and at no point after, came back out.)

The Session Information 1 Hour Checks for the VA showed that on September 10, 2021, SP1 noted that s/he checked on the VA at 7, 7:30, 8:30, and 9:30 a.m., and that during those times, the VA was in his/her room “sleeping.” However, this investigator’s review of the video did not show SP1 or any staff person checking on the VA at 7 or 7:30 a.m. At 8:16 a.m., SP1 walked to the VA’s bedroom door but did not go inside. SP1 then appeared to shut the VA’s bedroom door. At 8:35 a.m., SP1 stood outside the VA’s bedroom door but did not open it or go inside. There were no checks by any staff person on the VA after this, including by SP1 at 9:30 a.m.

Facility policies and procedures said that clients were to be “assessed throughout their stay,” including that staff persons were to monitor the client’s vital signs “carefully” for signs and symptoms of withdrawal and that staff persons were to visually check and document the whereabouts of each client at least once per hour. SP1 and SP2 provided consistent information that when a supervision check was missed and the tracking sheet had blank or uncompleted documentation, the staff person who next completed a check filled in the missing checks without knowing if the check had been completed or who had completed the check. This was a violation of Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b), clause (3) and Minnesota Statutes, section 245A.07, subdivision 3, paragraph (a), clause (3).

Although there was inconsistent information given as to if the VA was on 15 minute or hourly checks, given that the VA had a history of withdrawal including seizures and was not checked on by multiple staff persons either every 15 minutes or hourly (including approximately two hours between when SP1 last checked on the VA at 8:30 a.m. to when C2 found the VA unresponsive), which were violations of Minnesota Rules, part 9530.6550, item A, and Minnesota Statutes, chapter 245A.04, subdivision 14, paragraph (b), clause (3), there was a preponderance of the evidence that there was a failure to provide reasonable and necessary care to the VA.

It was determined that neglect occurred (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.)

Regarding providing care to the VA when s/he was found unresponsive:

Although there was concern that staff persons took 12 minutes to call 9-1-1, video footage showed that at 10:20 a.m., SP1 was notified of the VA’s unresponsiveness and around 10:22 a.m. (two minutes later), SP2 was on the phone with 9-1-1. Law enforcement records also showed that they were called at approximately 10:23 a.m.

Video footage also showed that at approximately 10:19 a.m., C2 found the VA unresponsive in his/her bedroom. At 10:20 a.m., SP1 was notified by C2 of the incident. SP2 said that s/he started CPR only after being told by 9-1-1 to begin CPR. After being on the phone with 9-1-1, SP2 is not seen going into the VA’s bedroom until 10:25 a.m., which was five minutes after C2 told SP1 that the VA was unresponsive. Additionally, RN1 and SP1 were each in the VA’s bedroom prior to 9-1-1 being called and each did not initiate CPR until being directed to do so by SP2.

Although there was not a delay in calling 9-1-1, staff persons, including a registered nurse, were immediately made aware that the VA was not breathing yet failed to start CPR until five minutes later after being directed to do so by the 9-1-1 operator. Therefore, there was a preponderance of the evidence that there was a failure to supply the VA with the care or services that were both reasonable and necessary, to maintain his/her physical health.

It was determined that neglect occurred (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.)

B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c):

When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors:

(1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care;

(2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and

(3) whether the facility or individual followed professional standards in exercising professional judgment.

Facility documentation showed that RN1, RN2, the LPN, SP1, SP2, SP3, and SP4 received training on CPR, first aid, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. The LPN, RN1, RN2, SP1, SP3, and SP4 were also trained on emergency procedures such as a client death and the facility abuse prevention plan.

Although information was inconsistent regarding whether the VA was on 15 minute or hourly checks, given that staff persons were trained to visually check and document the whereabouts of each client at least once per hour, yet multiple staff persons at all levels of authority failed to check on the VA; that the facility failed to monitor implementation of its policies and procedures when staff persons failed to monitor the VA’s health and hourly supervision; that multiple staff persons said that when a scheduled check was missed, they documented that the missed check was done; and that staff persons, including a registered nurse failed to initial CPR for five minutes after the VA was found unresponsive and not breathing, individual staff persons responsibility was mitigated and the facility was responsible for maltreatment of the VA.

C. Serious Maltreatment:

The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.”

Minnesota Statutes, section 245C.02, subdivision 18, states:

"Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult.

It was determined that the substantiated maltreatment for which the facility was responsible did not meet statutory criteria to be determined as serious. Although the VA was found deceased, it was unknown if the VA’s death was a result of the maltreatment.

Action Taken by Facility:

The facility completed an internal review and determined that policies and procedures were adequate and followed. There was no additional training necessary. The incident was not similar to other incidents.

Action Taken by Department of Human Services, Office of Inspector General:

On March 1, 2023, the license holder was ordered to forfeit a fine of $2000 as a result of the two determinations of substantiated maltreatment for which facility was responsible. The facility was also issued a $200 fine for providing false or misleading information when a supervision check was missed and the tracking sheet had blanks or uncompleted documentation for the checks, the staff person who next completed a check filled in the missing supervision check/s without knowing if the check had been completed or who had completed the check. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal.

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