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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: 1097945-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady 651-431-6557 Suspected Maltreatment Reported: Allegation one: It was reported that a staff person (SP) did not treat a vulnerable adult (VA1) in a respectful manner including lying about community events being canceled, having VA1 eat frozen food when other consumers received fast food, and having VA1 wait to use the bathroom. Allegation two: It was reported that the SP ignored a vulnerable adult (VA2) when VA2 requested assistance and on one occasion, VA2 tried to get out of bed without assistance from staff persons and broke his/her left hand. Allegation three: It was reported that the SP would leave a vulnerable adult (VA3) in bed for more than 12 hours. VA3 would be incontinent and not changed. VA3 began to develop bed sores. Date of Incident(s): Ongoing, prior to October 10, 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 2, paragraph (b), clause (2); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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 26, 2022; from documentation at the facility; and through interviews conducted with VA1, VA2, five facility staff persons (P1-P4, and the SP), and guardians for VA2 and VA3. Allegation one: It was reported that the SP did not treat VA1 in a respectful manner including lying about community events being canceled, having VA1 eat frozen food when other consumers received fast food, and having VA1 wait to use the bathroom. VA1’s support plans stated: · VA1’s diagnoses included ataxia and muscular dystrophy. VA1 ambulated with the use of a wheelchair. VA1 was able to use his/her feet to propel the wheelchair. VA1 needed assistance from staff person to complete activities of daily living. Staff persons either assisted VA1 or used a mechanical lift for transfers. · VA1 was not subject to guardianship. VA1 enjoyed spending time with his/her family and attending church. VA1 provided the following information in an interview with this investigator and in the facility internal review report: · On July 4, 2022, the SP “lied” to VA1. The SP “promised” VA1 that s/he could go to a parade that day. It rained in the morning and VA1 was told by the SP and another staff person (P5) that the parade was canceled. Later, the SP and P5 took VA1 out to get concessions in the community and VA1 found out that the parade had not been canceled. After the incident, the SP treated VA1 “poorly” and “ignored” VA1. VA1 did not get along with the SP as the SP was “rude and abrupt.” VA1 stayed in his/her bedroom when the SP worked. The SP told VA1 that other staff persons would assist VA1 as the SP was not going to assist VA1. · On one occasion, VA1 had a guest over and when the guest left, VA1 had to use the bathroom “real bad.” At that time, the SP, P2, and P5 were in the garage and P2 told VA1 that P5 wanted to be trained to use the mechanical lift to transfer VA1 onto the toilet. VA1 did not want P5 to transfer VA1 via the lift because it took longer to get VA1 on the toilet using the lift as opposed to a staff person physically assisting VA1 to stand up, turn, and sit on the toilet. · VA1 exercised on the sidewalk outside with his/her wheelchair. One time there was a cable cord over the sidewalk and VA1 could not get over the cord. The SP got out of his/her vehicle and walked past VA1 and into the facility. About 20 minutes later, P2 came outside, saw that VA1 could not get over the cord, and assisted VA1. · VA1 had a birthday party and several of his/her family members were at the facility for a party. VA1 got a fish tank. A couple days later, the SP bought the other consumers fish tanks. The SP did not have parties for VA1, but had parties for the other consumers. · VA1 told this investigator that P2 and the SP bought fast food for the other consumers for lunch, but bought frozen food that had to be made for VA1. In the internal review, VA1 said that it was VA1’s choice to eat food other than fast food when the other consumers had fast food because VA1 did not like fast food. P1 provided the following information in an interview with this investigator and in the facility internal review report: · VA1 was to have a shower every other day at about 6 a.m. If the overnight staff person did not assist VA1 with a shower, the SP, who worked in the morning, did not regularly assist VA1 to shower in the morning. VA1 did not like the SP assisting him/her with a shower so VA1 would ask P1 to assist him/her a shower in the evening. P1 believed that one time, VA1 went for a week without a shower. · The SP and P3 bought birthday and holiday decorations for consumers, but did not buy them for VA1. VA1 had to buy his/her own birthday party supplies and did not get to decorate the facility or dress up for Halloween. · VA1 told P1 about some of the above incidents as described by VA1, but P1 did not have first-hand knowledge of the incidents. · After VA1 purchased a fish tank, the SP purchased fish tanks for other consumers to “spite” P1 and VA1. · P1 had a “close” relationship with VA1 so P1 planned to transfer to a different facility because of their relationship. P1 received training specific to the consumers. P2 provided the following information in an interview with this investigator and in the facility internal review report: · VA1 typically took a shower every other day and was assisted in the morning by the staff person working the overnight shift. P2 was not aware of anytime VA1 went more than a couple days without a shower. VA1 would let staff person know if s/he did not get a shower. · VA1 needed assistance in the bathroom. VA1 would use a grab bar and staff persons would use a gait belt to assist VA1 to stand up and pivot him/her onto the toilet. One day VA1 was upset with P5 wanting to use the mechanical lift to transfer VA1. P2 was outside and P5 came outside and was crying. The SP then went inside and talked to VA1. P2 did not witness what the SP said to VA1. · P2 was not aware of anytime that VA1 did not get meals or holiday parties, the same as other consumers. · The SP and VA1 did not get along. If P2 and the SP were working, VA1 would only ask P2 for assistance and the SP expected P2 to assist VA1. P1 “catered” to VA1 and did not spend time with other consumers. P2 received training specific to the consumers. P3, a supervisory staff person, stated the SP and VA1 did not along. P1 was also “very close” with VA1 and was friends with family members of VA1. P3 was aware of the some of the incidents and concerns regarding the SP and VA1 but did not have first-hand knowledge of the incidents. P3 was not aware of VA1 not taking a shower on a regular basis and believed that if s/he did not shower, VA1 would tell P3. Staff persons were to assist VA1 to stand up and sit on the toilet, but there was also a mechanical lift available to assist VA1 onto the toilet. The facility had decorations for birthdays and holiday, but VA1 had a party with family and 15 to 20 guests, and the family brought their own decorations. (P3 provided this investigator with text messages and social media posts that showed P1 making derogatory comments about the SP.) P4 was aware of the incidents but did not have first-hand knowledge of the incidents. The SP provided the following information in an interview with this investigator and in the facility internal review report: · The SP met with VA1 weekly to work on building a relationship with VA1. The SP did not tell VA1 that s/he would not work with him/her. The SP often worked with P2 and when they worked together, P2 assisted VA1 as VA1 would not ask the SP for assistance. If the SP worked alone, VA1 would not ask the SP for assistance and often remained in his/her bedroom. · On July 4, 2022, the SP planned to take VA1 and another consumer to a parade. The morning of the parade, the SP heard that it was canceled. When the weather improved, the SP and P5 (who at the time of the investigation no longer worked at the facility) took VA1 into the community to concessions and when they arrived, they saw the parade was still going on and they watched the end of it. VA1 did not say anything about being upset until the next day after working with P1. P1 “fueled the fire” of the SP’s and VA1’s relationship. After being with P1, VA1 said that the SP “lied” about the parade. The SP apologized to VA1. · If VA1 needed to use the bathroom, staff persons assisted VA1 to stand up and sit on the toilet. Staff persons could also use a mechanical lift and received training on how to use the lift. On one occasion when P5 was going to assist VA1 in the bathroom, P5 did not feel comfortable lifting VA1 by him/herself and wanted to be shown how the use the mechanical lift again. P5 asked VA1 to use the lift and VA1 asked why and P5 told him/her that s/he did not feel comfortable without using the lift. VA1 got mad at P5 and P5 ran out of the bathroom crying and upset that VA1 yelled at him/her. After, the SP went and talked with VA1 and told VA1 that if staff persons were not comfortable transferring him/her they could use the lift. The SP asked VA1 if s/he could apologize to P5 and VA1 said “that’s fine.” The SP then brought P5 to talk to VA1. The next day after P1 worked with VA1, the incident became “a big deal.” · The SP was not aware of an incident where VA1 was unable to move his/her wheelchair on the sidewalk because there was a cord in the way. If VA1 was stuck, VA1 did not say anything to the SP. The SP denied not assisting VA1 and telling him/her that s/he needed to ask P2 for assistance. VA1 often exercised on the sidewalk and when s/he did, the SP checked on him/her every 20 minutes. · Overnight staff persons typically assisted VA1 with a shower in the morning. If the overnight staff person did not assist VA1 with a shower the SP would assist VA1 if VA1 asked for one. The SP had not given VA1 a shower for a long time. The SP never told VA1 that s/he would not assist him/her with a shower. VA1 showered on a regular basis. · There was an occasion where the SP and P2 went out to get fast food for two of the consumers. P1 and VA1 remained at the facility and they wanted a certain type of food. The only food of that type that the SP was able to get needed to be cooked. VA1 and P1 thought the SP was bringing them back hot food ready to eat. · The facility purchased holiday gifts and decorations for consumers. One day VA1 had a “big” birthday party with family and wanted about 50 hot dogs and hamburgers, buns, and salad. The facility did not have a budget to pay for food for VA1’s family. The facility bought VA1 pizza that was delivered for the party. · The SP stated that s/he received training specific to the consumes. Facility documentation showed that P2 and P3 each received training specific to VA1’s current support plans, but there was no documentation that the SP and P1 each received training specific to VA1’s current support plans. P1, P2, P3, and the SP each received training on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion allegation one: VA1 provided several examples where s/he did not believe that the SP treated him/her in the same manner that s/he treated the other consumers. Information showed that events that VA1 had concerns about happened, but either the SP and/or P2 provided information about them that showed that it was possible that different persons had different perspectives as to what happened. In addition to possible different perspectives, information showed that the SP and VA1 did not work well together, that P1 and VA1 were “close,” and that there was animosity between P1 and the SP. Regarding the SP not assisting VA1 with his/her daily routine, it was unclear whether the SP refused to help, VA1 did not ask the SP for assistance, and/or a combination of both. Regardless, there was no information that VA1 was harmed as a result of the SP’s actions or inactions. Given the above, there was not a preponderance of the evidence whether the SP’s actions would reasonably be expected to cause VA1 emotional distress. It was not determined whether emotional abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening). Allegation two: It was reported that the SP ignored VA2 when VA2 requested assistance and on one occasion, VA2 tried to get out of bed without assistance from staff persons and broke his/her left hand. VA2’s support plans stated: · VA2’s diagnoses included a seizure disorder. At times, VA2 was unsteady on his/her feet and needed assistance from staff persons with walking. Prior the moving to the facility, due to his/her seizure disorder, VA2 had a history of falling. When VA2 was at the facility, a staff person was to be on premises at all times. · VA2 enjoyed video games and going out in the community. VA2 wanted to live in Rochester and was on waiting lists for places to live. VA2 moved to the facility on September 8, 2022. (Information showed that VA2 moved to the facility from a hospital and prior to that lived independently with some in home support so there was not a lot of information about VA2’s history before s/he moved into the facility.) Information from staff persons showed that when VA2 moved to the facility, VA2 initially had a whistle and a call button to alert staff persons. According to the facility internal review report, on September 10, 2022, the SP documented the following in VA2’s progress notes. The SP came in the morning and asked VA2 if s/he was ready to get out of bed and VA2 said no. The SP made breakfast and then heard VA2 blow a whistle to call for assistance and staff persons went back found VA2 on the floor. VA2 was not able to get up so 9-1-1 was called. VA2 complained that his/her left hand hurt, but paramedics refused to transport him/her. VA2 wanted staff persons to wrap his/her hand with duct tape so staff persons called 9-1-1 again and then paramedics transported him/her for medical care. VA2 was diagnosed with a broken finger which was splinted and then VA2 returned to the facility before lunch. VA2 provided the following information in an interview with this investigator and in the facility internal review report. VA2 stated that s/he did not remember the incident where s/he broke his/her hand. Typically staff persons responded when VA2 pushed his/her call button (at the time of the interview VA2 had a call button on a lanyard around his/her neck and another button mounted on his/her bed). VA2 did not like to ask for assistance from staff persons as VA2 lived on his/her own before moving to the facility. The SP took “everything seriously” when assisting VA2. When this investigator asked VA2 who staff persons treated him/her, VA2 replied that there was “nothing to do.” P1 provided the following information in an interview with this investigator and in the facility internal review report: · When VA2 moved to the facility staff persons were not given a lot of direction of how to work with VA2 nor was there much background information on VA2. VA2 was good at notifying staff persons via a whistle or a call button if s/he needed assistance. VA2 did not like to wait for staff persons to respond so if they did not respond in five minutes, VA2 would try to get out of bed by him/herself. VA2 told P1 that s/he did not want to live at the facility and that sometimes VA2 fell on purpose. · On the first or second day VA2 was at the facility, VA2 fell and broke his/her hand. P1 was not working at the time, but VA1 told him/her that the SP, P2, and P3 were each in the garage and did not respond to VA2 blowing a whistle for assistance prior to his/her fall. Recently VA2 moved to a different bedroom and had two different call buttons available for his/her use. P2 provided the following information in an interview with this investigator and in the facility internal review report. The day that VA2 fell and broke his/her hand, P2 was in the garage at shift change with the door cracked. P2 was working with the SP and another staff person and the SP heard a noise and went and found VA2 on the floor. P2 said that s/he also heard VA2 yelling for help. Prior to that, VA2 did not use his/her whistle and P2 did not hear VA2’s alarm go off. P2 said that staff persons would have been able to hear the VA2’s alarm from the garage. The only time staff persons did not immediately respond to VA2’s calls for assistance was if staff persons were helping another consumer. In those cases, P2 told VA2 that s/he would with him/her as soon as possible. P2 said that s/he typically responded to VA2 in a more timely manner than other staff persons including the SP. P3 provided the following information in an interview with this investigator and in the facility internal review report. VA2 did not want to live at the facility. If VA2 wanted assistance, s/he wanted it “right now.” Initially VA2 had a whistle to call for assistance but mucus would build up in it and it would not work. VA2 also had a button s/he could push that would sound an alarm when s/he wanted assistance. The alarm (which was music playing) could be heard throughout the facility including the garage. VA2 did not always call for staff persons when s/he needed assistance. When P3 worked with the SP, the SP responded to VA2 when s/he called for assistance, but if the SP was busy with something else before s/he could assist him/her, s/he did not always tell VA2. P4 did not have first-hand knowledge of any incidents with VA2. The SP provided the following information in an interview with this investigator and in the facility internal review report: · When VA2 moved from the hospital, the facility was told that VA2 was “independent,” but VA2 was not. VA2 fell quite a bit and sometimes refused to eat. At one point, VA2 fell without asking for help or pushing his/her call button and at that point, VA2 was moved to different bedroom. A bed with side rails was obtained for VA2 and a mattress was placed on the floor next to the bed. Several different ways for VA2 to request assistance were tried with VA2 including a whistle and an alarm on his/her bed. When VA2 moved to the new bedroom, VA2 had a call button s/he kept around his/her neck and an alarm attached to his/her bed. VA2 sometimes did not use the call button for assistance or use it several times and got frustrated with it. The SP was told by a staff person that P1 did respond to VA2 when s/he used his/her call button. · When VA2 fell and broke his/her wrist, his/her whistle was full of phlegm and was not working, but the alarm worked. At the time of the fall, the SP, P2, and another staff person were talking at shift change in the garage with the door open to the facility. The SP said that they talked at shift change in the garage because one of the consumers liked to “eavesdrop.” The garage door into the facility was not shut tight. At the time of the fall, VA1 came to the garage and told staff persons that VA2 was yelling for help. When staff persons got to his/her bedroom, VA2 was on the floor. Staff persons could hear VA2’s call button from the garage so the SP did not think VA2 used his/her call button before trying to get out of bed. · The SP never failed to respond to VA2’s requests for assistance. VA2’s guardian (G1) did not have concerns about the care AV2 received at the facility. VA2 broke his/her hand when s/he tried to get up and transfer him/herself without staff person assistance. VA2 had a call light to notify staff persons if s/he needed assistance and VA2 did not use it as s/he should. VA2 then had a whistle to call for staff persons. VA2 still tried to get out of bed and transfer him/herself without assistance. Facility documentation showed that P3 received training specific to VA2’s current support plans, but there was no documentation that the SP, P1, or P2 received training specific to VA2’s current support plans. Conclusion allegation two: VA2 moved to the facility on September 8, 2022. On September 10, 2022, VA2 was found on the floor of his/her bedroom and was subsequently diagnosed with a broken hand. Prior to being found on the floor of his/her bedroom, staff persons including the SP and P2 were in the garage at shift change. The garage door into the facility was not shut tight. The SP said that VA1 came to the door and said that VA2 was yelling and P2 said that staff persons heard a noise and went and found VA2 on the floor (the SP documented that s/he responded when s/he heard the whistle). It was unclear if VA2’s whistle was working, but VA2 did have an alarm s/he could use to request assistance from staff persons that could be heard throughout the facility. Information showed that VA2 did not always request assistance and at times tried to get out of bed on his/her own. Because it was not known whether VA2 called for assistance prior to falling and breaking his/her hand, there was not a preponderance of evidence whether a staff person failed to provide VA2 with reasonable and necessary supervision. In addition, it was reported that the SP ignored VA2 and did not always respond to VA2 when VA2 requested assistance. P2 and P3 each stated that the SP did not necessarily respond as quickly to VA2 as other staff persons, but there was no information that the SP did not respond at all when VA2 requested assistance. Therefore, there was not a preponderance of evidence whether the SP failed to provide VA2 with care and services which were reasonable and necessary to maintain his/her 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). Allegation three: It was reported that the SP would leave VA3 in bed for more than 12 hours. VA3 would be incontinent and not changed. VA3 began to develop bed sores. VA3’s support plans stated: · VA3’s diagnoses included a seizure disorder and depression. (This investigator met VA3, due to VA3’s diagnoses, VA3 was not able to provide information pertinent to the investigation.) · VA3’s food was pureed and VA3 drank thickened liquids. VA3 received hospice care with nursing services coming out twice a week and a hospice aide one time per week. · VA3 ambulated via a wheelchair with assistance from staff persons. VA3 was not able to reposition him/herself in his/her wheelchair or in bed. VA3 was to be repositioned every two hours to ensure that pressures sores did not occur. VA3 wore incontinent briefs, was to be checked for incontinence every two hours, and the brief was to be changed if necessary. VA3 was able to communicate to staff persons if s/he needed to use the bathroom or if his/her brief needed to be changed. · VA3 enjoyed using his/her computer, listening to music, and watching western movies. P1 provided the following information in an interview with this investigator and in the facility internal review report: · VA3 was to be repositioned every two hours while s/he was in bed. P1 did not believe that the morning staff persons repositioned VA3 (the SP typically worked mornings). VA3 was to be repositioned rotating between both sides and his/her back. VA3’s incontinent brief was to be checked every two hours and changed if necessary. The SP and P2 did not always change VA3’s brief in the morning until VA3 was transferred from his/her bed to his/her wheelchair. · VA3 had more than one bed sore on his/her buttocks. Hospice staff persons provided staff persons with patches and creams to treat VA3’s bed sores. · The SP and P2 sometimes waited until 12 or 1 p.m. to get VA3 of bed after VA3 was in bed since 8 p.m. the night before. VA3 recently lost a family member and P1 was told by the SP to leave him/her in bed all day. When in bed all day, VA3 did not get fed properly. The SP and P2 left VA3 in bed all day prior to VA3’s family member passing away. · P1 brought concerns to P3, but no action was taken regarding his/her concerns. P2 provided the following information in an interview with this investigator and in the facility internal review report: · VA3 was to be repositioned and was to have his/her brief checked every two hours. VA3 typically got up between 8:30 and 9:30 a.m. VA3 went to bed between 7 and 8 p.m. · When asked about concerns with VA3 being left in bed for long periods of time and not having his/her brief changed, VA3 said that sometimes evening staff persons put VA3 to bed “a little too early.” In the past there was an overnight staff person who was not changing VA3 as required at night. That staff person no longer worked at the facility. · There were a couple days where VA2 remained in bed all day after a family member passed way. A hospice staff person was told and approved. · VA3 did not currently have issues with bed sores. P3 provided the following information to this investigator and in the facility internal review report: · VA3 typically did not get out of bed until 10 a.m. P3 was aware of at least one occasion that VA3 was left in bed until the afternoon. It was right after VA3’s family member passed away and a hospice staff person was contacted and told that VA3 did not want to get out of bed. The hospice staff person said that it was okay because VA3 was grieving. P3 was not aware of any other concerns that VA3 was being left in bed for long periods of time. VA3 was not aware of anytime that VA3’s brief was not changed in a timely manner. At one point, hospice staff persons did bring some concerns to P3 about VA3’s care, but that staff person who the concerned about no longer worked at the facility. · VA3 occasionally got bed sores because s/he was not able to move himself. On October 27, 2022, a facility health care professional (HCP) assessed VA3’s skin condition and at that time there was a bed sore present, but the bed sore was new. The SP provided the following information in an interview with this investigator and in the facility internal review report: · VA3 was to be repositioned every two hours and have his/her brief checked to see if it needed to be changed. VA3 typically got out of bed at 9 a.m., ate breakfast, and then used his/her computer or watched television. VA3 typically ate lunch around noon. After a family member of VA3’s passed away, VA3 remained in bed for two days. Hospice staff persons were aware and approved. After VA3 was in bed for two days, a hospice staff person visited VA3 and told him/her that s/he needed to get out of bed or s/he would get bed sores. At that time, VA3 did not have any bed sores. VA3 recently had a pressure sore but it healed. Hospice staff persons monitored VA3’s pressures sores. The SP never left VA3 in bed because s/he did not want to get him/her out of bed. The SP “heard” that evening staff persons were putting VA3 to bed at 5 p.m. The SP did not leave VA3 in wet briefs. P4 did not have first-hand knowledge of any incidents with VA3. VA3’s guardian (G2) said that there were concerns in the past brought up by a hospice health care professional about staff persons not changing VA3 often enough when VA3 was incontinent. At that time, there were concerns about bed sores developing. Additional training was provided to staff persons and now the bed sores were healing. G2 stated that at the time of the investigation, a family member of VA3 recently passed away which led to VA3 being depressed. The following was regarding concerns about VA3 purchasing items for the facility: · P1 stated that G2 gave permission for the SP to spend money on anything that VA3 needed. VA3 bought inflatable decorations, a computer, and a computer table. VA3 also bought two fish tanks. One of the tanks was kept in the living room and one was kept in the C’s bedroom. · P2 stated that VA3 bought two fish tanks, one for a common area and one for his/her bedroom. VA3 also rented a dumpster for the facility. VA3 bought on Halloween blow up decoration (it was outside the day of the site visit). · P3 said that VA3 had money for a “spend down” and G2 told P3 and the SP that VA3 could buy items for the facility. VA3 bought pizza, a grill, and some outside Halloween decorations. P3 was aware that VA3 was going to buy a fish tank, but did not realize that the SP purchased two fish tanks with VA3’s money. VA3 also purchased screens for the front and back door because s/he liked to sit outside and staff persons could have the door open for him/her to sit outside. At the time of the investigation, one screen was installed and one was still in the box. · The SP stated G2 told him/her that if something was needed for the facility to have VA3 purchase it. VA3 bought an inflatable decoration for Halloween that was outside in the front of the facility. VA3 bought a grill. G2 and P3 also told the SP that s/he could rent a dumpster for the facility and could purchase outdoor furniture so s/he could sit outside and screens for the doors so VA3 could be outside and the door left open so bugs could not get in. The SP bought two fish tanks, one for VA3 and one for the common area. The SP also bought a fish tank for another consumer with the SP’s own money. The SP said that s/he did not purchase anything for VA3 that was not for VA3 or not approved by G2. · G2 stated that s/he was not concerned about expenditures made with VA3’s funds as VA3 recently had a spend down and s/he authorized some purchases for the facility including a grill. G2 did not authorize VA3 to buy a fish tanks. · The facility determined that the SP ordered a dumpster from the sanitation provider that was at the facility from July 25 through August 8, 2022. The cost of the dumpster was $422.53. · On November 2, 2022, the facility noted that there were four fish tanks at the facility. One was in the living room, one was outside of VA3’s bedroom, one was in VA1’s bedroom, and one was in the C’s bedroom. · The facility reimbursed VA3 for a grill, screens, and a dumpster for a total of $634.63 · It was reasonable with G2’s permission to make some purchases for the facility that would directly benefit VA3. Although some of the purchases made with VA3’s funds were questionable as to VA3’s benefit, given that the purchases were accounted for at the facility and when VA3’s purchases for the facility were reviewed, the facility reimbursed VA3 $634.63, no further action will be taken by the Department of Human Services. Facility documentation showed that P2 and P3 each received training specific to VA3’s current support plans, but there was no documentation that the SP or P1 received training specific to VA3’s current support plans. Conclusion allegation three: VA3 was to be repositioned and have his/her brief checked every two hours. Although it was reported that there were concerns that VA3 was left in bed for long periods of time, information showed that for two days after a family member of VA3’s passed away, VA3 remained in bed. Hospice staff persons were notified. There was also information provided that evening staff persons thought morning staff persons were leaving VA3 in bed during the day and that morning staff persons thought evening staff persons were putting VA3 to bed too early. With the conflicting information it was not determined how long VA3 was in bed on any given day. In addition, VA3 did have issues with bed sores, given that VA3 was not able to reposition him/herself and wore briefs, it was unclear whether they developed from a lack of care by staff persons. At one point, hospice staff persons did have concerns with the care that VA3 received, but the staff person whom the concerns were about no longer worked at the facility. Given the above, there was not a preponderance of the evidence whether there was a failure to provide VA3 with care and services which were reasonable and necessary to obtain or maintain his/her 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 internal reviews for the allegations and determined that their policies and procedures were adequate but not followed. P3 received training on following facility policy and training requirements, VA3 was reimbursed $634.62, and the SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On March 31, 2023, the facility was issued a Correction Order for failure to maintain documentation that all staff persons received training on VA1’s, VA2’s, and VA3’s support plans.
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