|
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: 1081784-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Kimberly Huettl Anderson 651-431-6553 Suspected Maltreatment Reported: Allegation One: It was reported that a vulnerable adult (VA) was left in bed for an extended period of time which caused a blister on his/her left heel. Allegation Two: It was reported that the VA did not receive a “stress dosing” of prednisone medication as requested by his/her guardian (G1). Date of Incident(s): between December 8 and 23, 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 December 12, 2022; from documentation at the facility and medical records; and through seven interviews conducted with the VA’s guardians (G1 and G2), the VA’s case manager (CM), and facility supervisory and administrative staff persons (P1, P2, P3, and P4). Several attempts were made via telephone and US mail to contact and interview two additional staff persons (P5 and P6) but neither responded to the requests. Attempts were made to obtain follow up information from P1, but P1 did not respond. The VA’s Admission and Data Form stated that the VA was diagnosed with an unspecified disorder of the pituitary gland resulting in a brain injury with major neurocognitive disorder, atopic dermatitis, blindness, and physical difficulties. The VA had a good sense of humor and enjoyed outings with his/her family that included restaurants and parks. Allegation One: It was reported that the VA was left in bed for an extended period of time which caused a blister on his/her left heel. The VA’s Individual Care Plan stated when the VA’s pituitary gland was dysfunctional, the VA’s mental alertness was affected. When staff persons observed a decrease in the VA’s mental activity, staff persons were to check his/her vital signs. The VA’s Intensive Support Self-Management Assessment stated that the VA used a hospital bed, EZ lift, wheelchair, and Hoyer lift to assist with transferring and repositioning. The VA allowed staff persons to reposition him/her while in bed and was able to verbally direct staff persons on where the VA wanted to be. The VA’s Individual Abuse Prevention Plan stated that the VA was at risk of developing pressure sores due being to being unable to get up independently and not being able to get out of his/her wheelchair. Staff persons were to assist the VA with transferring from one location to another and to check his/her body for any type of sores. If a staff person noticed any skin breakdown on the VA, they were to document it and seek medical attention if needed. The facility’s Internal Review stated that between December 7 and 8, 2022, the VA had been in bed for multiple hours. G1 stated that on December 7, 2022, the VA was transferred to his/her bed at approximately 8 p.m. On December 8, 2022, at approximately 4:30 p.m., G1 arrived at the facility and noticed that the VA was still in bed. Later that evening, G1 saw a blister on the VA’s left heel. G1 stated that the blister on the VA’s left foot occurred as a result of being in bed for more than sixteen hours because P1 told G1 that there was no sign of a blister on the VA’s heel when the VA went to bed on December 7, 2022. On December 10, 2022, G1 took the VA to a local medical center to have the VA’s heel looked at. The VA was diagnosed with cellulitis in his/her left heel. G1 was concerned that s/he was not notified by any staff persons when the VA did not want to get out of bed on December 8, 2022. G1 stated that “all” staff persons at the facility were aware that G1 was to be contacted anytime that the VA did not want to get out of bed. Information from P1, P2, and P3, and facility documentation, provided the following information: · On December 8, 2022, P5 and P6 were working with the VA. P1 was also at the facility in the morning. According to P1, on December 8, 2022, the VA appeared to be “sick” and wanted to sleep. P1 checked the VA’s vital signs which were within normal limits. P1, P5, and P6 attempted to wake the VA up several times throughout the day, but the VA was “weak” and continued to sleep. P1 contacted G1 who came to visit the VA that afternoon. · When G1 arrived at the facility around 4 p.m., P5 and P6 were able to wake the VA and transfer him/her out of bed. · P1, P2, and P3 each stated that the VA’s plans did not specify how long the VA could stay in bed and that it was not noted that staff persons were to contact G1 if the VA spent an extended period of time in bed. · P1 did not think the sore on the VA’s left heel occurred because s/he had been in bed for an extended period of time. P1 stated that the VA liked to rub his/her feet on the mattress and couch when the VA was in bed or sitting in the living room. In addition, the VA was able to tell staff persons whether s/he wanted to stay in bed or move to the living room. · The VA’s daily notes showed that the sore on the VA’s left heel was first noticed during the evening shift on December 7, 2022, before the VA was transferred into bed. The VA’s daily notes stated that on December 8, 2022, the VA had a late start to his/her day and that the VA appeared to be lethargic and “extremely” tired. P5 and P6 each tried to get the VA out of bed on multiple occasions, but the VA refused. The VA was repositioned throughout the morning. · The VA’s After Visit Summary from an urgent care facility stated that on December 10, 2022, the VA was seen for “skin problems.” The VA was diagnosed with non-healing ulcer of left foot with limited breakdown of skin. The VA was prescribed an antibiotic and an Bactroban ointment. The facility’s personnel files showed that P1, P2, P3, P4, P5, and P6 were each trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults prior to the incident. Conclusion Allegation One: Although G1 was concerned that on December 7 and 8, 2022, the VA was left in bed for over sixteen hours and developed a sore on his/her left heel as a result of staying in bed for the extended period of time, the VA’s daily notes showed that the sore was present on December 7, 2022, prior to being transferred into bed. Information was consistent that the VA appeared to be lethargic and “extremely” tired on December 8, 2022, that the VA’s vitals were checked and appeared to be within normal ranges, and that G1 was notified in the afternoon. Given that the daily notes stated that P5 and P6 attempted to get the VA out of bed on multiple occasions, but the VA refused; and that the sore on the VA’s left heel was present before spending sixteen hours in bed, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services that were reasonable and necessary to obtain and maintain his/her physical health. 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). Allegation Two: It was reported that the VA did not receive a “stress dosing” of prednisone medication as requested by G1. The VA’s Intensive Support Self-Management Assessment stated that the VA required total assistance with medication administration. The VA’s Coordinated Support and Services Plan Addendum stated that staff persons were to administer all medications and treatments as prescribed by a licensed medical professional. Information obtained showed that there were interpersonal conflicts between G1 and the facility. According to G1, one of the VA’s medical professionals prescribed a “stress dosing” of prednisone for the VA to be administered whenever the VA was showing signs of lethargy and confusion and G1 thought it was necessary. G1 was able to evoke the order of “stress dosing” every five weeks. The “stress dosing” order stated that the VA was to receive 7.5 milligrams (mg) of prednisone the first day, 15 mg of prednisone the second day, and 15 mg of prednisone the third day. G1 stated that between December 7 and December 15, 2022, the VA had been lethargic and did not want to get out of bed. On December 9, 2022, G1 told P1 to start “stress dosing” the VA with prednisone. On December 15, 2022, G1 reviewed the VA’s medications and asked an unknown staff person why the “stress dosing” of prednisone was not being administered. That staff person told G1 that s/he was not able to administer medication that was not on the VA’s Medication Administration Record. When G1 spoke to P1, P1 said that P2 “ordered” P1 to not administer the “stress dosing.” Next, G1 spoke to P2 who told G1 that the facility was not allowed to administer medication without a doctor’s order. G1 emailed the doctor’s order and recent Medication Administration Records to P2 but did not hear anything further. Email communication between G1 and P1 stated that on December 9, 2022, G1 sent an email to P1 stating that due to the VA’s lethargy on December 8 and 9, 2022, and per G1’s and P1’s conversation, G1 wanted P1 to begin a stress dosing of prednisone per the order from the VA’s doctor. P2 and P4 told G1 that the facility was not allowed to administer medication without a doctor’s order and that there was no order in the VA’s files. No further email communication between the facility and G1 was provided to this investigator. Information from P1, P2, P3, and P4, and facility documentation, provided the following information: · The VA’s Medication Administration Record dated December 2022 stated that beginning October 14, 2016, the VA was prescribed 2.5 mg and 5 mg of prednisone each to take once per day. Beginning September 16, 2022, in addition to the daily dose, “per legal guardian,” the VA could be administered as needed 7.5 mg of prednisone for three days. The prescription began September 16, 2022. The VA’s Medication Administration Records from January 2021 through December 2021 did not list prednisone stress dosing as a possible PRN. The VA’s Medication Administration Records dated January 2022 through December 2022 listed prednisone stress dosing as an as needed (PRN) medication. · The VA’s daily notes dated December 9, 2022, stated that VA went out to eat with G1. The VA’s daily notes dated December 15, 2022, stated that G1 asked an unknown staff person how many milligrams of prednisone that the VA was receiving. The staff person explained to G1 that the VA was receiving the dosage listed on the VA’s Medication Administration Record. (Note: On December 9, 2022, there was no documentation regarding G1 requesting stress dosing.) · On December 9, 2022, G1 told P1 to administer a stress dosing of prednisone, P1 stated that P2 told him/her that there was not a prescription for stress dosing and that s/he was not allowed to administer the stress dosing because P2 was not aware that G1 was able to evoke stress dosing for the VA. P2 told G1 that the facility’s policy did not allow them to administer medication to the VA without a doctor’s order. P2 told this investigator that s/he did not remember telling P1 that s/he could not to administer the stress dose of prednisone until a prescription was received from the VA’s doctor. P2 stated that s/he was not familiar with the VA’s Medication Administration Records or that the “stress dosing” PRN was on the Medication Administration Record. According to P2, P3 was responsible for reviewing the VA’s medical information and that at the time of the incident, P3 was on a leave of absence from the facility. (There was no information provided that at any time a staff person reviewed the VA’s Medication Administration Record to verify whether it was listed as a PRN.) · P3 spoke to G1 and G2 on a regular basis regarding the VA’s care. P3 was on a personal leave of absence from the facility at the time of the incident. The order for the VA’s stress dosing was listed on the VA’s Medication Administration Record, but P3 was not aware of the order until s/he spoke to G1 on December 29, 2022. On December 16, 2022, the VA’s medical professional sent P3 an email regarding stress dosing but P3 did not understand the doctor’s order and thought it was “odd” because it mentioned an injectable medication and not prednisone. On December 23, 2022, P3 sent a letter to the VA’s medical professional questioning the information s/he received on December 16, 2022. P3 did not receive information back from the medical professional but G1 told P3 that the order s/he received was incorrect. P3 did not receive a new order for stress dosing. · In January 2023, P3 reviewed the VA’s medications in December 2022 and stated that the VA did not receive a stress dosing of prednisone at all during December 2022 based on the medication counts and documentation on the VA’s Medication Administration Record. (However, G1 told this investigator that s/he started the “stress dosing” on December 16, 2022, and that after the VA received the first “stress dose” the VA “sounded excellent” on the phone.) The VA’s T-Logs, P1, P2, and P3 each stated that the VA continued to be lethargic through the month of December 2022, but was “medically” fine. · According to P4, it was common for G1 to ask staff persons at the facility to administer medications or care to the VA that was not authorized by a physician or in the VA’s plans. When G1 asked P1 to administer the stress dosing of prednisone, P1 talked to P2 and P4 about G1’s request. P4 told G1 that the facility was not able to administer medication to the VA without a doctor’s order. Typically, P3 spoke to G1 about the VA’s medications, but at the time of the incident, P3 was on a leave of absence so P4 spoke to G1. P4 was not aware that that the “stress dosing” of prednisone was on the VA’s Medication Administration Records or that G1 was able to evoke a stress dosing of prednisone for the VA and told P1 that s/he could not administer the prednisone without an order. Relevant Rules and/or Statutes Minnesota Statutes, section 245D.05, subdivision 2, paragraph (b), clause (1) stated that if the license holder was responsible for medication administration, the license hold must implement medication administration procedures to ensure that a person takes medications and treatments as prescribed. Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a) stated that the license holder must provide services in response to the identified needs, interests, preferences, and desired outcomes as specified in the individual’s support plan and support plan addendum, and in compliance with the requirements of this chapter. Minnesota Statutes, section 245D.081, subdivision 2 stated the license holder must ensure that the coordination and evaluation of the individual service delivery be coordinated by a designated staff person. Conclusion: Information was consistent that on December 9, 2022, G1 ordered staff persons at the facility to administer a stress dosing of prednisone to the VA when the VA was showing signs of being lethargic and not wanting to get out of bed. P1, P2, and P4 were not aware that G1 had the ability to evoke the stress dosing of prednisone and each failed to review the VA’s Medication Administration Record which showed that G1 could do so and that it was written on the VA’s Medication Administration Record as a PRN beginning January 2022, almost one year prior. As a result, the VA did not receive the stress dosing of prednisone as requested by G1. This was a violation of Minnesota Statutes, 245D.05, subdivision 2, paragraph (b), clause (1); Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a); and Minnesota Statutes, section 245D.081, subdivision 2. Although the VA’s Medication Administration Record clearly stated that G1 had the ability to order the stress dosing of prednisone, given that the VA was also prescribed prednisone once daily and received those doses as prescribed; and that the VA’s T-Logs, P1, P2, and P3 each stated that the VA continued to be lethargic after the “stress dosing” was administered, but was “medically” fine, there was not a preponderance of the evidence whether there was a failure to provide the VA with health care that was reasonable and necessary to obtain and maintain the VA’s physical health. 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: Allegation One: The facility completed an internal review and determined that their policies and procedures were followed and adequate. Allegation Two: The facility completed an internal review and determined that their policies and procedures were not followed regarding the medication administration and that the VA’s Medication Administration Record was not followed. All staff persons working with the VA were trained on the process for stress dosing the VA with prednisone. Action Taken by Department of Human Services, Office of Inspector General: On March 31, 2023, the facility was issued a correction order for the violations outlined in this report.
|
