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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: 1073045-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: Allegation One: It was reported that a vulnerable adult (VA), who required catheter changes monthly, did not consistently have his/her catheter changed over a two-year period. Allegation Two: It was reported that the VA was not consistently taken to a hospital for intravenous (IV) antibiotics after a hospitalization in July 2022. (Although it was reported that the hospitalization occurred in July 2022, information from the investigation showed that the VA was hospitalized in June 2022). Date of Incident(s): Allegation One: Prior to October 14, 2022 Allegation Two: June 2022 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on October 31, 2022; from documentation at the facility and the VA’s medical records; and through seven interviews conducted with the VA, the VA’s family member (FM), the VA’s medical doctor (MD), the facility’s health care professional (HCP), a facility supervisor (P1), and two facility staff persons (P2 and P3). This investigator attempted to contact and interview three previous supervisory/managerial staff persons (P5-P7), but none responded to requests. The VA’s Intensive Self-Management Assessment showed that s/he was a “great communicator” and “excellent about accepting and attending appointments when asked by staff [persons].” The plan further showed that the VA had a catheter that “gets changed monthly (by the MD or other medical personnel at a hospital),” but the VA “does not currently schedule [his/her] own urology appointments.” The VA was diagnosed with diabetes, epilepsy, and hypertension. The VA was not subject to guardianship. The VA’s Individual Placement Agreement showed that the facility’s “role” was to maintain “good monitoring of signs symptoms of illness and nursing or physician consultations as needed. Inquire with [the VA] to reveal possible illness. Staff [persons were] to communicate with nursing should issues arise or illness suspected.” Allegation One: It was reported that the VA, who required catheter changes monthly, did not consistently have his/her catheter changed over a two-year period. The FM stated that on an unknown date in September 2022, personnel from the MD’s office called the FM because the VA was supposed to have his/her catheter replaced monthly but that had not been done consistently for the past two years. The FM also said that the VA was “prone” to getting infections and if the VA did not have adequate care, the VA “will die.” The VA provided limited information to this investigator but stated that s/he thought that his/her catheter was supposed to be replaced every “three or four months.” The facility’s Maltreatment Investigation and the VA’s medical records provided the following information: · When the VA began receiving services at the facility in 2013, the VA had a catheter and “monthly” catheter changes were ordered and done through an ambulatory surgical center at a local hospital. · “After a catheter change was missed in February 2021, the [VA] was admitted to [a] hospital from March 14 to 16, 2021, for an obstructed catheter and urosepsis.” [Urosepsis is an untreated urinary tract infection (UTI) that spreads to the kidneys and can cause sepsis.] The VA was again admitted between March 27 and 31, 2021, for “sepsis.” (Sepsis is an infection in the blood stream.) The “physician noted this catheter may have stayed in too long.” · On June 14, 2022, the VA was again admitted to the hospital “due to severe sepsis secondary to urinary tract infection.” (The records showed that the last time the catheter was changed prior to this hospitalization was on April 15, 2022). While hospitalized, the VA spent time in the intensive care unit (ICU), was treated with various medications, and discharged on June 18, 2022. On June 16, 2022, the physician noted that “due to difficulty contacting the group home, [the VA] went two months before the catheter could be scheduled to be changed. The last catheter change before that was on April 14, 2022.” · Between September 25, 2020, and September 31, 2022, (24 months) 13 catheter changes were completed and 11 were missed. The longest period between catheter changes was 6 months: July 9, 2021, to January 20, 2022. The facility’s review also noted, “The surgeon reported that the [VA] gets frequent episodes of bacteriuria and sometimes becomes septic (an infection in the blood stream) from them when the catheter gets plugged up,” and that “the bladder is usually filled with gravel, sediment and debris and needs to be evacuated. Not having that removed on a regular basis is likely to contribute to obstruction which has been thought to lead to urosepsis for this resident.” · The “conclusion” section of the review stated, “There is evidence that the [facility] neglected to support the [VA’s] health care needs and that it likely contributed to harm to the [VA]. Missed catheter changes likely contributed to hospitalization for a urosepsis diagnoses in March of 2021 and June of 2022.” Also, “over a two-year period, a pattern was found of missing appointments for catheter changes for this individual.” Information from the facility documentation stated that between August 2020 and November 2022 (28 months): · The VA was taken in for catheter changes 15 times: September and November 2020; January, April, June, and July 2021; and January, March, April, July, August, October, and November 2022. On two occasions, the VA was in the hospital and had his/her catheter changed: March 2021 and June 2022. · The VA did not have his/her catheter changed 13 times: August, October, and December 2020; February, May, August, September, October (a note stated that the procedure was rescheduled by the clinic, but the rescheduled date was not identified), November, and December 2021; and February, May, and September 2022. The MD stated that “bacteria” had a tendency to collect, and that monthly catheter replacement was needed. Missing “those deadlines” for catheter changes was “too much.” The MD said that “communication” between his/her clinic and the facility was an “issue.” The HCP, who was employed by the facility, provided the following information: · The VA did not have “nursing” services in his/her “contract,” so the HCP did not provide oversight to the VA’s medical needs. The HCP was not aware of concerns related to timeliness of the VA having his/her catheter replaced monthly. However, the HCP said that the VA’s catheter should have been changed monthly and that site supervisors, program managers, or program directors would have been responsible for monitoring that the catheter changes took place. (Note: P1, P4, P5, P6 and P7 each held one of these positions at various times throughout the two years.) · The VA’s catheter “could get clogged” if not changed regularly and that the VA had infections as a result of it not being changed regularly. · The facility used two different computer software programs to input data related to medical appointments and the facility “intermittently” used the programs during the two-year time period so the records were incomplete. P1-P3 provided similar information to the HCP’s information in terms of care needed and provided for the VA’s catheter. In addition, each said that the VA’s catheter bag was to be emptied and cleaned daily. P1 also stated that although s/he knew that the catheter was to be replaced monthly, s/he did not know how often it was previously replaced and that site supervisors, program managers, and program directors (P1 and P4-P7) would have been responsible for ensuring that the VA attended all medical appointment. In addition, P1 stated that s/he did not see anything “concerning,” but that the facility previously had “staffing issues.” (P1 began in his/her supervisory role in September 2022.) P2 did not know how often the VA’s catheter was to be replaced but stated that s/he did not see “any issues” with it and that s/he did not know who would have had responsibility to take the VA in to have the catheter replaced. P3 was aware that the VA’s catheter was to be replaced monthly, but P3 did not know how often it actually was replaced. Attempts were made to contact P3 for more information, P3 did not respond to the requests. The facility’s training records showed that all staff interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s specific care plans. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.05, subdivision 1, stated that the license holder is responsible for meeting health service needs assigned in the support plan or the support plan addendum, consistent with the person’s health needs. Minnesota Statutes, section 245D.081, stated that the license holder was responsible for program coordination and evaluation, coordination and evaluation of individual service delivery, and program management and oversight. Conclusion for Allegation One: A. Maltreatment: Although the VA was to have his/her catheter replaced monthly, information showed that between August 2020, and November 2022, (28 months) the VA’s catheter was replaced 15 times and not replaced when it should have been 13 times which was a violation of Minnesota Statutes 245D.05. “The longest period between catheter changes was 6 months, between July 9, 2021, and January 20, 2022.” In addition, the VA was hospitalized twice in March 2021, and once in June 2022, each time with diagnoses related to the VA’s catheter not being changed as required (diagnoses included obstructed catheter and urosepsis, sepsis, and severe sepsis secondary to urinary tract infection respectively). Given that the VA relied on staff persons to schedule and take him/her to his/her appointments for catheter changes, that the VA missed 13 catheter changes over two years, that there was one occasion with a six month period between catheter changes, and that the VA was hospitalized three times resulting from catheter related diagnoses, there was a preponderance of the evidence that there was a failure or omission to supply the VA with care and services which were reasonable and necessary to maintain the VA's physical or mental health. It was determined that 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). 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. The HCP stated that s/he was not responsible for oversight of the VA’s medical needs and P1 and the HCP stated that facility supervisors, managers, and directors were responsible. During this two-year period, there were several staff persons with those titles including P1, P4, P5, P6, and P7. Over the course of two years, there were multiple staff persons with varying degrees of authority within the facility involved in the failure to provide necessary care and services to the VA, which was in violation of Minnesota Statute 245D.081 and represented a systemic failure. Therefore, it was determined that individual staff persons’ responsibility was mitigated and the facility was responsible for the 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 was “serious” maltreatment because the VA was hospitalized three times for infections that likely were the result of the VA’s catheter not being replaced in a timely manner and that for a two-year period, 13 of 28 catheter changes were missed. Allegation Two: It was reported that the VA was not consistently taken to a hospital for intravenous (IV) antibiotics after a hospitalization in July 2022. (Although it was reported that the hospitalization occurred in July 2022, information from the investigation showed that the VA was hospitalized in June 2022). The FM stated that after the VA was hospitalized for sepsis (June 14 to 18, 2022), the VA was supposed to go into the hospital three times daily for IV antibiotics. The facility expressed that three times daily might be too difficult to accommodate so it was changed to twice daily. However, the facility did not consistently take the VA to those appointments. The FM did not know the duration of how long the VA was supposed to get the IV antibiotics, whether the VA was harmed, or how many appointments the VA might have missed. The FM also said that the VA was “prone” to getting infections and if the VA did not have adequate care, the VA “will die.” The VA did not remember staff persons taking him/her to get the IV antibiotics. Interviews with the MD, the HCP, P1, P2, and P3, and facility documentation and medical records provided the following information: · On June 14, 2022, the VA was admitted to the hospital for a sepsis infection and a UTI. On June 18, 2022, the VA was discharged to a nursing care facility for short term rehabilitation care with orders to receive cefepime (an antibiotic medication used to treat infections) IV antibiotics at the hospital, twice daily, for five days on an outpatient basis after the VA returned to the facility. · The records indicated that after the VA was discharged from the nursing care facility and returned to the facility, the IV treatments began on July 11, 2022. The records showed that one appointment was missed but was rescheduled the following day. The records did not indicate any apparent harm to the VA. · A review of the VA’s progress notes for the time period that the VA was scheduled to receive the IV medication at the hospital did not specifically mention staff persons taking him/her to those appointments, but some references were made to the VA going to IV appointments on some days. · The facility’s Maltreatment Investigation stated that the “[facility] reported they could not provide daily transportation for IV treatment. The service plan states transportation to and from community outings (recreation/shopping) and medical appointments would be provided. At least one IV treatment was noted as being missed and was rescheduled for the next day.” · The MD stated that although s/he was aware that the VA was to receive IV antibiotics, s/he did not remember specific information related to that or whether the VA missed any of those appointments. · The HCP stated that s/he did not have knowledge of the need for the VA to have IV antibiotics. · P1 stated that s/he did not remember the specific timeframe but stated that s/he took the VA for the IV appointment a number of times. P1 was aware of one time that the VA did not go to the appointment because a former staff person, who was supposed to take the VA to the appointment, “didn’t show up,” but P1 did not believe that the VA was harmed as a result of missing that appointment. · P2 did not have much information related to the VA having the IV antibiotics but remembered that it was to be done in the hospital. · P3 said that s/he took the VA to two or three IV appointments, but P3 was not aware of a time that the VA missed any of those appointments. Conclusion for Allegation Two: Information showed that the VA was to begin receiving an IV antibiotic medication twice daily for five days after s/he returned to the facility from the nursing care facility and that the IV medication was to be administered at the hospital. The VA had his/her first IV treatment on July 11, 2022. Although the FM believed that some of the appointments might have been missed; P1, information from the facility’s internal review, and the VA’s medical records showed that although the VA missed one dose, it was rescheduled the following day. There was no information provided that the VA had ill effects from the rescheduled dose or that the VA missed any other dose. Therefore, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed a maltreatment investigation and determined that policies and procedures were not adequate, were not followed, and that additional training was needed. In addition, the facility implemented a number of corrective actions, some of which included that “the individual must be taken in for catheter changes monthly.” In addition, additional training was provided to all staff persons. Action Taken by Department of Human Services, Office of Inspector General: On March 8, 2023, the license holder was ordered to forfeit a fine of $5000 as a result of the “serious” substantiated maltreatment for which facility was responsible. The Department also placed the facility’s license to provide Home and Community-Based Services - Community Residential Setting (CRS) on conditional status for two years, beginning March 8, 2023, based on the nature, severity and chronicity of this and a previous determination of serious maltreatment, and on the licensing violations outlined in this report. The maltreatment determination, the Order to Forfeit a Fine, and the conditional license are each subject to appeal.
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