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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: 1073635-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady 651-431-6557 Suspected Maltreatment Reported: It was reported that in August 2022, a vulnerable adult (VA) was hospitalized with low blood oxygen levels. After the VA was discharged from the hospital, the facility was given orders regarding checking the VA’s blood oxygen levels. A staff person found the VA’s blood oxygen level to be at or below 70% and did not immediately call 9-1-1 and instead called a family member/guardian of the VA. There were other occasions where the VA’s blood oxygen levels were low and a staff person did not take action. It was also reported that there were concerns that staff persons were not assisting the VA with hygiene tasks and not assisting the VA with using his/her continuous positive airway pressure (CPAP) machine. Date of Incident(s): Multiple, prior to November 14, 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 for this investigation was obtained remotely, including documentation from the facility and medical records; and through interviews conducted with the VA, two facility staff persons (P1 and P2), and a facility health care professional (HCP). This investigator also spoke the VA’s county case manager (CM) and spoke with and met two family members/guardians of the VA (FM1 and FM2). The VA’s support plans stated: · The VA had several diagnoses related to his/her mental health. · The VA was able to shower independently, but needed daily prompts from staff persons. The VA also needed daily prompts to brush his/her teeth and brush his/her hair. The VA often became upset with staff persons when they prompted him/her to complete hygiene tasks. · The VA had a CPAP to use at night, but due to refusing to wear it, it was discontinued. · The VA had a history of incontinence and it was charted on a daily basis. Staff persons were to check the VA’s bedding and clothing on each shift and if there was incontinence, staff persons were to prompt the VA to change his/her clothes, take a shower, and change his/her bedding. The VA was able to choose his/her clothes and dress independently. The VA needed daily prompting from staff persons to change his/her clothes on a daily basis. FM1 stated: · FM1 had several concerns about the care that the VA received at the facility with the main concern being “medical neglect.” · In August 2022, the VA was hospitalized for low blood oxygen levels and after the VA was discharged there were doctor’s orders regarding staff persons checking the VA’s blood oxygen levels. At one point a staff person checked the VA’s blood oxygen levels and were they were found to be below 70 (blood oxygen levels mentioned in this report were a percentage with normal blood oxygen levels being at or close to 100). The staff person did not have access to the doctor’s orders and instead of immediately calling 9-1-1, they called FM1 to see what FM1 wanted the staff person to do. An ambulance was called later and the VA was checked out by paramedics. There were several other times that the VA’s blood oxygen levels were low and staff persons did not do anything. · FM1 was also concerned because the facility was letting the VA go out with soiled clothes, with his/her hair not brushed, and smelling like urine. In addition, the VA also had an order to use a CPAP machine and staff persons were not helping the VA use or clean the machine. Due to the VA “being maltreated,” FM1 was working on arranging for the VA to move to a different facility. FM2 stated that P1 called FM1 because s/he did not know how to access the information regarding what to do when the VA had low blood oxygen levels. FM2 was not sure what date the incident occurred. FM2 was concerned about the facility addressing the VA’s hygiene issues and addressing the VA using a CPAP machine. FM2 planned to move the VA out of the facility so the VA could get adequate care (during the course of the investigation, the VA moved out of the facility). This investigator met and interviewed the VA, but the VA declined to provide information about concerns with his/her blood oxygen levels. The VA stated that s/he did not like living at the facility including that s/he did not like leftovers as they were too old and that the facility kept milk in a refrigerator that the VA did not have access to. The VA stated that one staff person worked at a time and the facility was always short staff persons. The VA stated that s/he enjoyed art work, taking walks, taking showers, and drinking coffee. Regarding concerns about the facility monitoring the VA’s blood oxygen levels. An incident report dated August 17, 2022, stated that while the VA was at a medical appointment with FM1, it was recommended that the VA be brought to urgent care. The VA went to urgent care and then to the emergency room because the VA’s blood oxygen levels were low. The VA’s blood oxygen levels were in the 80s. Hospital records stated that on August 17, 2022, the VA was admitted to the hospital for acute respiratory failure with hypoxia and hypercapnia. At discharge the VA was ordered to have his/her blood oxygen levels checked “three times a day as needed for other (Spot Checks).” If the VA’s blood oxygen levels were below 87 and they did not recover after five minutes of rest, paramedics were to be called. Staff persons were to seek medical attention immediately if the VA’s blood oxygen levels were below 80. Documentation from the facility stated that starting on August 18, 2022, the VA was to have his/her blood oxygen levels checked twice everyday. If the VA’s blood oxygen levels were below 87 and did not recover after five minutes of rest, paramedics were to be called. Staff persons were to seek medical attention immediately if the VA’s blood oxygen levels were below 80. (The facility provided a two week sample of documentation from November 1 through 15, 2022, which showed staff persons regularly tested and documented the VA’s blood oxygen levels twice a day. They were typically taken later morning to early afternoon and then in the evening. Staff persons documented any refusals to be tested by the VA.) The HCP provided the following information in the internal review and in an interview with this investigator. The VA was hospitalized in August 2022 and upon discharge had an order to call 9-1-1 if the VA’s blood oxygen levels were a certain level. The VA’s blood oxygen levels were monitored by staff persons. Staff persons were to take it twice if it was low, but often the VA would refuse to have them tested. The HCP wanted staff persons to call the HCP if the VA’s blood oxygen levels were below 90. The HCP did not recall staff persons calling him/her, but the HCP was off work for an extended period of time. When the HCP returned to work, the VA often refused to meet with the HCP when the HCP came to the facility. The CM provided the following documentation from conversations with FM1 and emails from FM1 and the facility: · On November 14, 2022, FM1 contact the CM about an incident where a staff person called FM2 and asked what to do when the VA’s blood oxygen levels were below 70. FM2 told the staff persons to call an ambulance as the VA was “dying” and “can’t breathe.” FM1 told the CM that they wanted to move the VA immediately as they were scared for the VA’s life. · On November 14, 2022, the HCP sent an email to FM1 saying that s/he reviewed the hospital discharge instructions for the VA’s blood oxygen levels and they stated that staff persons were to call the HCP if the VA’s blood oxygen levels were below 90. The HCP said that s/he forgot to put the actual order in the VA’s file that staff persons could access, but now the issue was corrected. The facility provided two incident reports (September 5 and 21, 2022) relating to the VA’s blood oxygen levels. An incident reported dated September 5, 2022, stated: · At 5 p.m., FM2 dropped the VA off at the facility and let staff persons know that his/her blood oxygen levels had been in the 80s, but that the VA refused to go to the emergency room with FM2. FM2 told staff persons that they should try to get the VA to go and then left. The VA then locked him/herself in the bedroom. The VA yelled to staff persons that no one was going to manipulate him/her into going anywhere and if they tried to enter his/her bedroom s/he would call the police. Staff persons called the on call supervisor and were told to call 9-1-1 so they did. · When paramedics and police arrived they asked the staff persons to remain upstairs while they tried to “reason” with the VA. Paramedics were able to convince the VA to use his/her inhaler and his/her blood oxygen levels went to 94. They stated that the VA did not need to go in to the emergency room but staff persons should continue to monitor her blood oxygen levels. Later that day, FM2 called about the VA and then came and took the VA out to play bingo. An incident report dated September 21, 2022, stated: · At 2:40 p.m., staff persons took the VA’s blood oxygen level and it was 84. The VA then called FM2 to make plans. Staff person tried to have the VA take his/her blood oxygen level again after 10 minutes and the VA refused. FM2 arrived and a staff person told FM2 that the VA’s blood oxygen level was low and refused to be tested again. FM2 was told that an email was sent to FM2 and FM1 asking about at what point they wanted something done about his/her low blood oxygen levels. FM2 did not give staff persons an answer and left with the VA. · A little while after the VA and FM2 left, the VA returned to the facility and went downstairs to his/her bedroom and slammed the door. FM2 then called staff persons and said that s/he tried to get the VA to stop somewhere and test his/her blood oxygen levels, but the VA refused. FM2 said that s/he wanted staff persons to try again and if the VA did not let them, staff person were to call paramedics. Staff persons told the VA that FM1 and FM2 just wanted to make sure s/he was okay and all s/he had to do was stick her finger in the oximeter for a couple seconds and the VA refused. 9-1-1 was then called. · The fire department arrived before paramedics and tried to get the VA to check his/her blood oxygen levels. When paramedics arrived, the VA agreed to let them check and his/her blood oxygen levels were between 96 and 97. Paramedics then left. P1 documented the following on November 9, 2022: · When P1 arrived, the VA was in his/her bedroom sleeping. At 10 a.m., P1 woke the VA up to check his/her blood oxygen levels. The level was “really low” at 78 so P1 contacted FM2 and the HCP to see what to do. The VA initially agreed to go the doctor with P1, but when they were getting ready to leave, the VA became upset and refused to go. P1 again called FM2 and asked what s/he should do and FM2 told P1 to call an ambulance to have them check the VA. P1 called for an ambulance. As soon as the VA heard the ambulance, s/he went down on the floor for about 10 minutes before getting back up. · At that point, the VA told P1 and paramedics that s/he would not submit to a blood oxygen level test until s/he talked to FM2. P1 called FM2 and had the VA talk to FM2. At that point, the VA was worried that police were coming to take him/her in to jail so the VA went and locked him/herself in his/her bedroom. P1 knocked on the VA’s bedroom door and after a while the VA talked to P1. P1 told the VA that there were only paramedics at the home. Eventually, the VA said they could check her blood oxygen levels. The paramedics checked the VA’s blood oxygen levels and they were “normal.” Once the paramedics left, the VA was in a good mood and was joking with P1. About noon the VA left for an activity with FM2. P1 provided the following information in the internal review and in an interview with this investigator: · P1 was aware of several occasions where the VA’s blood oxygen levels were low. On those occasions staff persons were to wait several minutes and try again to see if they came up. Sometimes the VA refused to be rechecked. P1 believed that after the VA’s hospitalization, s/he was working on three occasions when an ambulance was called due to the VA’s blood oxygen levels. On one occasion, P1 was not sure how to access the computer for the order of what do if the VA’s blood oxygen level was low. On that occasion, an ambulance was called. The first time after the VA’s hospitalization, P1 also called FM2 one or two times when the VA’s blood oxygen level was low and FM2 told P1 to check it again. · P1 was aware of one occasion where the VA refused to have his/her blood oxygen levels rechecked and left with FM2 instead of getting rechecked. · Other than the one time P1 could not access the VA’s protocol regarding his/her blood oxygen levels, P1 said that his/her interactions with the VA were consistent with what s/he was supposed to do. P2 provided the following information in the internal review and in an interview with this investigator: · The VA started having issues with his/her blood oxygen levels in December 2021. The VA had an inhaler that was “hit or miss” whether s/he would use it. The VA also began smoking cigarettes more often. The VA did not like to have his/her blood oxygen levels checked. Between December 2021 and through the summer of 2022, the VA started getting more tired and sleeping more. The VA was taken in to the doctor but they did not “come up with anything.” It was recommended that the VA use a CPAP machine, but the VA did not want to use it. During that time the VA’s oxygen levels were in the 90s. · There were no orders regarding what to do regarding the VA’s oxygen levels until s/he was discharged from the hospital in August 2022. P2 believed that after the VA returned from the hospital, that the orders for checking his/her blood oxygen levels were accessible for all staff persons in the VA’s electronic file. There were at least two occasions where the paramedics came to the facility because of the VA’s blood oxygen levels. P2 believed that s/he was working one of the days that the paramedics were called. Regarding concerns that staff persons were not assisting the VA with hygiene tasks and not assisting the VA with using his/her CPAP machine: · The HCP stated that the VA refused to use his/her CPAP machine. Staff persons provided prompts to the VA regarding hygiene routines. At times the VA refused to do hygiene tasks. Staff persons attempted to get the VA to engage in hygiene tasks such as showering and follow it up with a trip out in the community. The HCP was not aware of the VA needing any medical care due to hygiene issues. · P1 stated that the VA often refused to wear his/her CPAP machine. The VA said that it was uncomfortable and P1 told the VA staff persons wanted him/her to wear it so it would help with keeping his/her blood oxygen levels up so staff persons did not have to call an ambulance. P1 asked the VA if s/he would wear it even for a couple hours and the VA would tell P1 that s/he did try it out. · P1 stated that the VA need prompts and reminders to complete hygiene issues and sometimes the VA would refuse to complete hygiene tasks. P1 was able to have the VA shower on most occasions when asked. When the VA did not want to shower, P1 would have the VA call FM2 and FM2 would be able to get the VA to shower. The VA brushed his/her teeth every day. · P2 stated that when it was recommended that the VA should use a CPAP machine, the machine was kept in the VA’s bedroom. Staff persons encouraged the VA to use it. Staff persons told the VA that it was uncomfortable, but it would help him/her sleep better. A few times the VA did use the CPAP machine and said that s/he slept good, but other times when staff persons talked to him/her about the CPAP machine, the VA locked staff persons out of his/her bedroom. · P2 stated the VA did not always want to complete daily hygiene tasks. Staff persons prompted the VA to compete hygiene tasks, but if s/he did not want to, additional prompting might cause the VA to get upset. At some point, FM2 told the VA that s/he would not take the VA out if s/he did not take a shower and sometimes that would work to get the VA to shower. Staff persons also tried a reward system for the VA, which worked for a little while. Sometimes the VA was incontinent and would not change his/her clothes. P2 told the VA that s/he had a nice smile and that it was important to keep his/her teeth cleaned. · The CM provided a copy of an email dated November 10, 2022, that stated an administrative staff person (P3) told FM1 that the HCP was going to provide additional training on the VA’s CPAP machine and staff persons were to document attempts in regard to the VA wearing his/her CPAP machine. Staff persons were also going to receive training on cleaning the machine. (The facility did not provide documentation of this training or documentation when staff persons attempted to have the VA wear his/her CPAP machine.) · The facility provided a two week sample of documentation from November 1 through 15, 2022, which showed staff persons regularly documented twice a day whether the VA completed hygiene tasks and documented once a day whether the VA showered. Facility documentation showed that P1 and P2 each received training on the Reporting of Maltreatment of Vulnerable Adults Act and training specific to the VA, but that training specific to the VA did not include additional training on using, cleaning, and documenting the use of the VAs’ CPAP machine as reference in email to FM1 on November 10, 2022. Relevant Statue: Minnesota Statutes, section 245D.09, subdivision 4a, paragraph (e) stated that staff persons were to review and receive instruction on the safe and correct operation of medical equipment used by a consumer. Conclusion: Regarding concerns about staff persons were not assisting the VA with hygiene tasks and not assisting the VA with using his/her CPAP machine. Although there were concerns about whether staff persons were to ensure that the VA completed hygiene tasks and wear his/her CPAP machine, information showed that the VA often refused to participate in cares or wear his/her CPAP machine. Staff persons stated that they did prompt the VA to complete hygiene tasks and use his/her CPAP machine. However, it was not determined whether staff persons consistently took all actions they could to encourage the VA to complete hygiene tasks or wear his/her CPAP machine. Therefore, there was not a preponderance of the evidence whether there was failure to provide the VA with care or services which were reasonable and necessary to obtain or maintain the VA’s physical or mental health or safety. Regarding concerns about the facility monitoring the VA’s blood oxygen levels. After a hospitalization in August 2022, staff persons were to regularly check the VA’s blood oxygen levels. If the VA’s blood oxygen levels were below 87 and did not recover after five minutes of rest, paramedics were to be called. Staff persons were to seek medical attention immediately if the VA’s blood oxygen levels were below 80. Documentation and information from staff persons showed that the VA was not always cooperative with having his/her blood oxygen levels tested. On one occasion when the VA’s blood oxygen level was low, P1 called FM2 because s/he could not access the information on the computer regarding the VA’s blood oxygen levels and after talking with FM2, called 9-1-1. When paramedics arrived tested the VA’s blood oxygen level it was in a safe range and they did not transport the VA for medical care. On other occasions where paramedics were called for low blood oxygen levels, the VA was assessed by paramedics and there were not any occasions where the VA needed to be transported for medical care. Although it was concerning that on one occasion, P1 was not able to access the protocol to follow when the VA’s blood oxygen levels were low, P1 took action by calling FM1 and then calling 9-1-1. Paramedics arrived and assessed the VA determining that VA did not need further medical care. In addition, although FM1 stated that on several occasions the VA’s blood oxygen levels were low and staff persons did not take any action, documentation showed on several occasions when the VA’s blood oxygen levels were low, staff persons called 9-1-1. There was no information that after the VA’s hospitalization in August 2022, that the VA had to be taken for medical attention regarding his/her blood oxygen levels. Given the above, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services, including medical care, which was reasonable and necessary to obtain or maintain the VA’s physical or mental health or safety. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an internal review report and determined that their policies and procedures were adequate and followed. Action Taken by Department of Human Services, Office of Inspector General: On March 22, 2023, the facility was issued a Correction Order for the violation outlined in this report.
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