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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: 1115738-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady 651-431-6557 Suspected Maltreatment Reported: It was reported that there were multiple concerns about how staff persons interacted with a vulnerable adult (VA), how staff persons failed to provide care to the VA, and how staff persons spent the VA’s money. Date of Incident(s): Ongoing, prior to January 6, 2023 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), clauses (1) and (2); and subdivision 9, paragraph (b), clause (1); 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: · Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. · 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. In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. 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 February 1, 2023; from documentation at the facility and through interviews conducted with the VA, five facility staff persons (P1-P5), a facility health care professional (HCP), and three family members (FM1, FM2, and FM3) of the VA. Two additional staff persons (P6 and P7) did not respond to this investigator’s request for an interview. The facility was a single level wheelchair accessible home. The facility had an open common area with a living room, dining room, and kitchen. The VA’s bedroom was at the end of the hallway off the common area. The VA’s support plans stated: · The VA’s diagnoses included a mild intellectual disability, cerebral palsy, quadriplegia, depression, and insomnia. · The VA had a history of aspiration pneumonia. The VA ate via a feeding tube and was not able to have anything orally. · The VA ambulated with the use of an electric wheelchair. The VA preferred to have staff persons move him/her around in the wheelchair. The VA had a goal to use his/her wheelchair independently. Staff persons used a mechanical lift (Hoyer) to transfer the VA. · The VA had a limited understanding of his/her finances so the facility was responsible for managing the VA’s finances. · The VA had a history of refusing to allow staff persons to give him/her shower, to brush his/her teeth, to reposition him/her, and to change his/her incontinent brief. The VA had a history of manipulating staff persons to assist with tasks that s/he was able to do independently. · The VA had a history of refusing to take his/her medications and attending medical appointment. · The VA had history of false reporting symptoms to staff persons and family members to seek medical attention. The VA often reported false information regarding staff persons in an attempt to move in with family members. · The VA’s interests included spending time with family members, listening to audio books, and going shopping. FM1, FM2, and FM3, who was also the VA’s guardian, had multiple concerns about the care that the VA received at the facility. IN addition to talking with FM1, FM2, and FM3, this investigator interviewed the VA. At times, the VA’s speech was difficult to understand, and the VA was either not asked or did not provide information pertinent to every concern expressed by family members. The following were the concerns by family members and/or the VA followed by the information obtained about each concern. FM1, FM2, and/or FM3 stated that the VA was prescribed Hizentra once a week to build immunity. (According to the Food and Drug Administration [fda.gov], Hizentra was an immune globulin liquid used to boost immunity and was administrated via a subcutaneous infusion.) The VA’s dosage was ordered to be increased, but the facility did not immediately increase it. Information from interviews with staff persons, from the facility internal review report, and documentation from the facility stated: · The VA’s Medication Records dated December 2022 and January 2023, showed that the VA received several medications including Hizentra. Up until January 19, 2023, the VA was prescribed Hizentra 6 grams (30 milliliters) that was to be administered one time each week by a facility health care professional. Beginning on January 19, 2023, it was increased to 8 grams (40 milliliters). · The HCP stated and/or documented that on December 14, 2022, a physician wanted to increase the VA’s dose of Hizentra. The HCP called the clinic as the HCP’s understanding was that they were planning on decreasing the medication. The HCP was told that FM2 called and said that the VA was sick more lately and that FM2 wanted it increased. The HCP told the clinic that the VA recently had Covid, but did not have any other illnesses. The clinic was going to talk to the physician and get back to the HCP. At that time, the HCP ordered the next month’s supply of Hizentra which was a 6 grams dose. The clinic called back and told the HCP that the physician still wanted to increase the dosage, but that it was not urgent so the HCP could use up the Hizentra on hand and the next time it was ordered, s/he could order the new dose of 8 grams. FM1, FM2, and/or FM3 stated that three or four weeks prior to January 9, 2023, a dermatologist ordered a lotion to put on the VA’s skin as the VA had itchy skin. At the time of the investigation, the new medication had not been administered to the VA. The VA stated that s/he itched but lotion was not put on his/her skin and that seeing the dermatologist did not help. Information from interviews with staff persons, from the facility internal review report, and documentation from the facility stated: · A Medical Referral stated that on December 7, 2022, the VA was prescribed Sorna (over the counter anti-itch lotion) as needed for itching one time per day. The VA’s Medication Records dated December 2022 and January 2023, stated that the Sarna was to be applied as needed (it was documented as given one time). · The HCP stated and/or documented that on December 22, 2022, a dermatology clinic called the HCP as the clinic had been getting calls from the VA’s family members saying that the VA was not getting the medications that were ordered by the dermatologist. The HCP told the clinic that that Sarna had not been requested to be given by the VA. · Staff persons stated that they applied the Sarna if the VA requested it. The VA did not request Sarna very often. The Sarna was available at the facility. · P4 stated that the VA would call family members and tell them s/he was itchy, but not tell staff persons. Family members would then call staff persons and say that staff persons were withholding the Sarna from the VA. FM1, FM2, and/or FM3 stated that the VA had a sore on his/her backside and saw a wound care clinic for treatment. Family members and the VA had concerns that P5 and P7 did not reposition the VA at during the night. The VA had an air mattress on his/her bed and the VA told family members that at times it was not plugged in. The VA told this investigator that the air mattress was turned on all the time. Information from interviews with staff persons, from the facility internal review report, and documentation from the facility stated: · Staff persons stated that the VA did have issues with a bed sore and needed to be repositioned. Staff persons generally repositioned the VA every two hours as required, but P5, who worked overnights, said that s/he repositioned the VA every two and half to three hours. P2 stated that staff persons regularly repositioned the VA, but sometimes the VA refused to let staff persons repositioned him/her. P4 said that the VA did not like to have to be moved from his/her wheelchair to the bed when s/he needed to be repositioned. P4 said that some concerns about P7 repositioning the VA during overnights were brought to P4 and P4 addressed the concerns with P7. · A review of the VA’s progress notes dated from December 1, 2022, through February 15, 2023, showed that the VA was regularly repositioned. · Staff persons stated that occasionally the VA’s air mattress became unplugged by accident. The VA would tell staff persons if it was not working. P4 stated that s/he switched the plug to a different outlet and since then had not had many problems. P5 stated that s/he arrived at work one night and air mattress was not inflated but was told that earlier told the power went out. · The HCP said that a couple years prior when the VA moved to the facility, the VA had white spot over a bony area on his/her right buttocks. The spot would sometimes open up, then staff person kept the VA from sitting on it, and it would then heal. At the time of the investigation, the VA and the VA’s family did want the VA to lay down as much and wanted him/her to spend more time in the wheelchair. The wheelchair tilted, but the VA still sat on his/her buttocks. At the time of the investigation, the VA’s sore was open and was being followed regularly by a wound care nurse. · Facility health records for the VA stated that on January 16, 2023, the VA was seen for a pressure ulcer. Bandages were to be changed at home and the VA was to be repositioned every two hours. After, the VA was seen by a wound care clinic approximately once every two weeks. As of February 22, 2023, they were still ordering two week checks of the VA’s sore. · On January 18, 2023, the HCP spoke with the clinic regarding the VA’s dressing changes for his/her pressure sore and that the HCP trained P2 how to change the dressing in case the HCP was not available to change the dressing. · The VA’s progress notes showed that starting on January 20, 2023, staff persons documented that on several days a health care professional came and completed wound care. FM1, FM2, and/or FM3 stated that there were concerns about the VA’s hygiene as the VA often had a dirty face and oily hair. FM1 brought this concern to several different staff persons and nothing was addressed. Information from interviews with staff persons, from the facility internal review report, and documentation from the facility stated: · Staff persons did not have concerns about the VA’s hygiene. It depended on the VA’s mood whether the VA would cooperate with his/her daily cares. The VA was regularly showered. · P4 stated that the VA typically showered three times a week and if the VA refused, the VA received a bed bath. The VA clinched his/her teeth which made it almost impossible for staff persons to brush his/her teeth. Sometimes, the VA tried to hit staff persons when they were dressing the VA. Staff persons did their best to complete the VA’s cares, but the VA made it “very difficult almost all of the time.” · The VA’s progress notes dated between December 1, 2022, and February 15, 2023, showed that on several occasions, staff persons documented that the VA was uncooperative, refusing care, swearing at staff persons, and/or threatening to get staff persons fired. Staff persons heard the VA on the phone telling family members things that were not true about staff persons’ actions with the VA. FM1, FM2, and/or FM3 stated that the VA was left in his/her bedroom and staff persons did not come and assist the VA when the VA called for assistance. The VA was supposed to be checked on every two hours during the overnight, but staff persons frequently did not. P4 ignored the VA if s/he called for assistance. P2 and P6 put the VA in his/her bedroom and turn up the volume on the television so they could not hear the VA calling for assistance. The VA told this investigator that staff persons responded when the VA yelled for assistance, but then the staff persons yelled at the VA. Information from interviews with staff persons, from the facility internal review report, and documentation from the facility stated: · Staff persons stated that they did not leave the VA alone in his/her bedroom and were not aware of other staff person leaving the VA in his/her bedroom. The VA was generally in the common area. If the VA was in his/her bedroom by him/herself, the VA was usually on the phone with family members as the VA liked to talk to them in his/her bedroom. Staff persons waited for the VA to be done on the phone and then moved the VA a common area. Sometimes when the VA called for assistance, but staff persons were busy with other tasks or other consumers and could not immediately respond to the VA. P3 stated that sometimes the VA talked “mean” to the other consumers and threatened them and one time to intervene, P2 moved the VA to his/her bedroom for five minutes and then brought him/her back out to the common area. · The VA’s progress notes dated from December 1, 2022, through February 15, 2023, showed that the VA was regularly moved between the common area and his/her bedroom as well as from his/her wheelchair to bed. The VA talked to his/her family members on the phone daily. FM1 stated that on an unknown date before Christmas, the VA told FM1 that s/he had mark on his/her face and a staff person (name not given) told the VA that it looked like the VA had been “hit.” The VA told this investigator that P2 and P4 told the VA that s/he had a mark on his/her face, but the VA did not know how s/he received it. Information from interviews with staff persons, from the facility internal review report, and documentation from the facility stated: · P2 was aware of the mark on the VA’s face. P2 asked the VA how s/he received it and the VA said that staff persons accidentally hit his/her face with the Hoyer lift. The VA did not seem upset. · P3 was aware of a small mark on the VA’s chin around Christmas time, but did not know how it happened. P3 was not aware of any staff persons telling the VA that it looked like a staff person hit him/her. · P4 did not know how the VA got a mark on his/her face, but it could have been from the Hoyer lift or a bedrail on the VA’s bed. · P1 and P5 were each not aware of a mark on the VA’s face. · There was no documentation at the facility regarding the mark on the VA’s face. FM1 stated that on January 5, 2023, the VA told FM1 that P1 told the VA that s/he was going to put the VA outside in a snowbank. P2 then went outside and took some snow and put snow on the back the VA’s neck and then P1 took some snow and put it down the front of the VA’s shirt. P3 witnessed the incident. Staff persons also called the VA names and “picked on” the VA. The VA told this investigator that P2 put snow on his/her neck and P1 put snow down the front of his/her shirt. Information from interviews with staff persons, from the facility internal review report, and documentation from the facility stated: · P3 stated that there was an incident where P2 and another staff person (P3 did not recall the name of the staff persons) threatened to put the VA outside in joking manner. P2 and the VA were both laughing. P2 also placed a small amount of snow on the back of the VA’s neck. The VA was smiling and joking with P2. P3 was not aware of any other incidents. P3 was not aware of any staff persons calling the VA names. P3 did not call the VA names. · P2 said that one time s/he overheard a staff person say “jokingly” that they were going to take the VA outside and make “snow [VA’s name].” The VA was joking along with staff persons. One time, P2 entered the facility and kicked his/her shoes off and some snow hit the VA in the leg. P2 never put snow on the VA. P2 never saw or heard a staff person calling the VA names or being mean to the VA. · P4 stated that there was a “joke” about putting the VA outside and making “snow [the VA’s name].” No staff person put snow down the VA’s shirt nor did staff persons bring the VA outside. P4 never saw a staff person be mean to the VA or call the VA names. One time, P4 was told that P3 told the VA that the VA was being a “pest” and “annoying” P3. · P1 stated that s/he was not aware of any incident where staff persons threatened to put the VA outside or put snow down the VA’s shirt. P1 did not threatened the VA. · P5 was not aware of an incident where staff persons threatened to put the VA outside or put snow on the VA. One time, P5 asked the VA if s/he wanted to go out and play outside in the cold and the VA laughed at P5. The VA then asked P5 if s/he wanted to go outside and P5 told the VA no. FM1 and/or the VA stated that P4 bought a candle for FM1 as a Christmas gift with the VA’s money. The VA was upset as s/he did not ask P4 to buy the candle and was not involved in the purchase. FM1 told P4 to return it and get the money back, but P4 said that s/he would not return it. FM1 eventually took the candle back and got a gift card which s/he gave to the VA. The VA told FM1 that P4 was buying briefs with the VA’s money. The facility was supposed to provide the VA with briefs, but instead the VA had to pay for the items. Information from interviews with staff persons, from the facility internal review report, and documentation from the facility stated: · P4 stated that s/he took the VA shopping for gifts and when they returned, P4 realized that the VA spent less money on FM1 than other persons. Later when P4 was shopping by him/herself, s/he called the facility to talk to the VA, but staff persons did not answer the phone. P4 then bought a candle for FM1 with the VA’s money, but FM1 did not want to candle. P4 did not immediately return the candle and then P4 had turned in the final reports for month and the receipt was not at the facility. A receipt showed that on December 2, 2022, the VA purchased a candle ($7.44) and a plug-in totaling $14.30. (The VA was reimbursed for the cost of the candle.) · Prior to moving into the facility, the VA lived in a facility where the VA’s briefs were paid for and provided. After the VA moved, there were communication issues between the physicians, pharmacists, and the insurance company regarding the VA’s briefs because the VA’s family members changed a password in a health care portal so staff persons could no longer communicate with health care providers via the portal. As a result, after the VA moved to the facility, the VA purchased his/her briefs for a brief period of time. P4 stated that the VA no longer purchased his/her own briefs. Attempts to interview P6 and P7 were unsuccessful. This investigator scheduled a time to interview P6, but P6 did not answer the phone at the scheduled time and did not respond to a voicemail to contact this investigator. This investigator attempted to contact P7 and left two voicemails, but P7 did not return the calls. Facility documentation showed that P1-P7 each received training specific to the VA and P1-P7 and the HCP each received training on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Regarding neglect of the VA: The VA was prescribed Hizentra once a week to build immunity. The VA’s family members had concerns because the VA’s dosage was ordered to be increased, but the facility did not immediately increase it. Information showed that Hizentra was increased from 6 grams to 8 grams. However, the HCP said that the increase was after s/he ordered a supply of 6 grams and the physician told the HCP that s/he could use up the 6 grams supply before switching to 8 grams.
The VA’s family members had concerns because a dermatologist ordered a lotion to put on the VA’s skin as the VA had itchy skin that at the time of the investigation, the new medication had not been administered to the VA. Information showed that the lotion, Sarna, was prescribed as needed. Information from staff persons showed that Sarna was at the facility and the VA did not request the Sarna. Documentation showed it was given one time. Given the above regarding the VA’s medication, there was a preponderance of the evidence that the facility did not fail to administer the VA’s medications in accordance with prescribed orders. FM1, FM2, and/or FM3 stated that the VA had a sore on his/her backside and had concerns that not all staff persons reposition the VA at during the night. There were also concerns that the VA’s air mattress was not always plugged in. The HCP stated that the VA had ongoing issues with a sore on his/her buttocks. At the time of the investigation, the VA had sore on his/her buttocks that as being monitored and followed by a wound care clinic. P4 said that some concerns about P7 repositioning the VA during overnights were brought to P4, but P4 addressed the concerns with P7. Otherwise, staff persons stated that they were aware of the sore and regularly repositioned the VA. Staff persons also said that the VA’s air mattress occasionally became accidentally unplugged, but the VA told staff persons if it was not working. FM1, FM2, and/or FM3 stated that there were concerns about the VA’s hygiene as the VA often had a dirty face and oily hair. Staff persons did not have concerns about the VA’s hygiene and said that it depended on the VA’s mood whether the VA would cooperate with his/her daily cares (which was supported by information in the VA’s support plans). The VA was regularly showered, but P4 stated if the VA refused the VA could be given a bed bath. Given that the VA did have a bed sore and that family members had concerns about the VA’s hygiene, it was not determined whether staff persons always repositioned the VA and completed daily cares as required. However, because it was a likely a combination of more than one factor that led to the bed sores and hygiene issues, there was not a preponderance of the evidence whether there was a failure by staff persons to provide the VA with care and services which were 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. Regarding abuse of the VA: The VA told FM1 that s/he had mark on his/her face and a staff person (name not given) said that it looked like the VA had been “hit.” Some staff persons were aware of the mark, but other than speculating that it might have come from the VA hitting his/her head on bed rails or the Hoyer lift, staff persons and the VA did not know how the VA received the mark. There was no information that it required any first aid. Because the VA did not say a staff person hit him/her causing the mark, there was a preponderance of the evidence that the mark was not caused by staff persons other than by accidental means. The VA told FM1 and this investigator that P1 told the VA that s/he was going to put the VA outside in a snowbank and then P1 and P2 put snow down on the VA’s neck and down the front of the VA’s shirt which was witnessed by P3. Staff persons stated that they were aware of incidents where staff persons were joking with the VA about taking the VA outside in the snow and the VA was laughing with staff persons, but no staff person said that the VA ever went outside. P3 said that P2 placed a small amount of snow on the back of the VA’s neck, but the VA was smiling and joking with P2. P2 denied putting snow on the VA. P1 denied knowing about the incident. No other staff persons were aware of anyone putting snow on the VA. FM1 stated that staff persons called the VA names and “picked on” the VA. The VA told this investigator that staff persons yelled at the VA. There was no information from staff persons that they witnessed a staff person being mean to the VA. FM1, FM2, and/or FM3 stated that the VA was left in his/her bedroom and staff persons did not come and assist the VA when the VA called for assistance. P2 and P6 put the VA in his/her bedroom and turn up the volume on the television so they could not hear the VA calling for assistance. Staff persons stated that they did not leave the VA alone in his/her bedroom. The VA was generally in the common area. If the VA was in his/her bedroom by him/herself, the VA was usually on the phone with family members. Sometimes when the VA called for assistance, staff persons were busy with other tasks or other consumers and could not immediately respond to the VA. P3 stated that one time when the VA was being “mean” to the other consumers, P2 moved the VA to his/her bedroom for five minutes and then brought him/her back out in the common area. Given the above, there was not a preponderance of the evidence whether a staff person engaged in non-therapeutic conduct which would reasonably be expected to cause physical pain or injury or emotional distress to the VA. It was not determined whether 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: Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult and/or 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). Regarding financial abuse of the VA: P4 bought a gift for FM1 with the VA’s money. The VA was not with P4 when P4 bought the gift. FM1 did not want the gift. P4 did not return the gift. FM1 returned the gift and got a gift card for the VA. The facility also reimbursed the VA for the cost of the gift. For a period of time after moving to the facility, the VA purchased his/her own incontinent briefs. P4 stated that there was delay in getting insurance to pay for the briefs as there were communication issues between the facility, the physician, the pharmacist, and the insurance company. Because the VA was not missing any money from the purchase of the gift for FM1 and the briefs were purchased with the VA’s money for his/her own use, there was a preponderance of the evidence that a staff person did not willfully use, withhold or dispose of funds or property of the VA. It was determined that financial exploitation did not occur (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). Action Taken by Facility: The facility completed an internal review and determined that their policies were adequate and followed. The facility was going to have staff persons increase documentation of the VA’s cares and repositioning. The VA was reimbursed for the cost of the candle.
Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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