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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: 1071579-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Alice Percy 651-431-6569 Suspected Maltreatment Reported: Allegation one: It was reported that a vulnerable adult’s (VA1’s) physician prescribed Epsom salt foot soaks for VA1, but the prescription for Epsom salts was not filled for approximately one week. Allegation two: It was reported that a vulnerable adult (VA2) did not receive his/her prescribed Lactulose (stool softener) for three days. Allegation three: It was reported that a vulnerable adult’s (VA3’s) bowel program was not followed, causing him/her to be admitted to the hospital. Date of Incident(s): Ongoing, January 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 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 February 16, 2023; from documentation at the facility and medical records; and through fourteen interviews conducted with two facility administrative staff persons (P1 and P2), five facility staff persons (P3 – P7), the facility’s health care professional (HCP), VA1, VA1’s guardian (G1), VA2’s case manager (CM1), VA2’s guardian (G2), VA3’s case manager (CM2), and VA3’s guardian (G3). VA1’s diagnoses included diabetes mellitus, vitamin D deficiency, pure hypercholesterolemia, hyperlipidemia, bipolar disorder, insomnia, essential hypertension, functional intestinal disorder, and retention of urine. VA1 enjoyed talking about history, going shopping, going for drives, and going to church. According to VA1’s Risk Assessment Detail, VA1 had memory issues and may not accurately recall or report exactly what occurred. According to VA1’s ISSA Assessment Detail, the staff persons were to monitor all of VA1’s prescribed medications. Because of VA1’s amputated leg, VA1 was unable to ambulate independently and used a wheelchair for mobility. VA1 had a history of falling and sometimes chose to sit on the floor. VA1 did not always want to wait for the assistance of a staff person. VA2’s diagnoses included epilepsy, intellectual disabilities, aphasia, atherosclerotic heart disease, conduct disorder, dysphagia, and muscle weakness. VA2 enjoyed being around other people and going on community outings. According to VA2’s Risk Assessment Detail, VA2 was nonverbal, but would yell and scream if someone was abusing him/her. VA2 was unable to report abuse. According to VA2’s ISSA Assessment Detail, VA2 required the assistance of the staff persons to manage his/her medication orders. The staff persons were trained to accompany VA2 to his/her medical appointments and to bring all communications with VA2’s physician back to the facility, document the information, and inform the HCP about the communications or prescriptions. VA2 used a wheelchair for mobility. VA3’s diagnoses included intellectual disabilities, behavior disturbance, hypothyroidism, and hyponatremia. VA3 was unable to communicate verbally, but communicated with signs and pointing. VA3 used a wheelchair for mobility. VA3 enjoyed going on community outings, going on van rides, going out to eat, and talking to his/her family members. According to VA3’s Risk Assessment Detail, VA3 did not understand when someone was being verbally or emotionally abusive to VA3 and would be unable to communicate what occurred. According to VA3’s ISSA Assessment Detail, VA3 did not self-administer medications and required a staff person to administer his/her medications to VA3. A staff person accompanied VA3 to all of his/her medical appointments. Allegation one: It was reported that VA1’s physician prescribed Epsom salt foot soaks for VA1, but the prescription for Epsom salts was not filled for approximately one week. P1 – P7, the HCP, and the facility’s documentation provided the following information: · The HCP stated that VA1 had diabetic neuropathy and did not feel pain in his/her feet. VA1 had a sore on his/her foot that the staff persons routinely cleaned and covered with gauze. A staff person always attended VA1’s medical appointments with VA1 and brought any physician notes back to the facility to be entered into VA1’s file. · On January 18, 2023, VA1’s physician prescribed Epsom salt foot soaks for VA1, but VA1 did not receive them until January 27, 2023. The HCP stated that the physician’s prescription was “a mess” and it was unclear how much of the Epsom salts were to be used for each foot soak. The pharmacy told the staff persons that the prescribed amount of Epsom salts was “excessive” and that VA1’s insurance would “probably not cover” the cost. During the week that the HCP and the pharmacy were trying to “clarify” the prescription, the HCP became ill and was not at the facility for part of the week. On January 27, 2023, VA1 began receiving his/her foot soaks after the physician clarified his/her prescription. · The HCP stated that there were no physical consequences for VA1 not immediately receiving the Epsom salt foot soaks. After the incident, the HCP requested that VA1’s physician provide detailed instructions to the staff persons about any new treatment or prescriptions so that there would be no confusion in the future. The staff persons were retrained on ordering medications and processing new prescriptions. · P1 stated that VA1’s foot did not appear to be irritated or infected even though s/he did not immediately receive his/her Epsom salt foot soaks. P7 stated that even though VA1 did not immediately receive the Epsom salt foot soaks, the staff persons continued to place ointments and bandages on the wounds on VA1’s feet. · After the incident, the staff persons were retrained on the facility’s policies to ensure that all prescriptions were documented and filled promptly. G1 stated that it was concerning that VA1 did not receive all of the recommended foot soaks because it was important to keep VA1’s skin healthy. Conclusion for allegation one: On January 18, 2023, VA1 was prescribed an Epsom salt foot, but VA1 did not receive the Epsom salt foot soaks until January 27, 2023. The HCP stated that the physician’s prescription was unclear and both s/he and the pharmacist worked with the physician to clarify the prescription. The pharmacist was concerned that the original prescription was “excessive” and VA1’s insurance would not pay for the amount of Epsom salts included in the prescription. Once the prescription was changed, VA1 received his/her Epsom salt foot soaks. All additional care to VA1’s feet continued as prescribed during this time period. Given that there were no adverse effects from VA1 missing the Epsom salt foot soaks, that the pharmacist was concerns about the original prescription, and that the HCP was in contact with VA1’s physician during that time as s/he tried to clarify the prescription, there was a preponderance of the evidence that there was not a failure to provide care or services to VA1 which were reasonable and necessary to maintain VA1’s physical health and safety. It was determined that neglect did not occur (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 VA2 did not receive his/her prescribed Lactulose (stool softener) for three days. P1 – P7, the HCP, and the facility’s documentation provided the following information: · Consistent information was provided that on January 20, 2023, the staff persons used the last dose of VA2’s Lactulose. None of the staff persons told the HCP immediately that there was no Lactulose available. P2 stated that the previous week s/he noticed that the bottle of Lactulose was “fairly low,” but there was a second bottle of the medication at the facility. P4 stated that on January 20, 2023, s/he noticed that VA2’s Lactulose was “gone” and P4 was unable to administer the Lactulose to VA2 that evening. P4 left a note for the HCP saying that VA2 needed more Lactulose. P1 stated that VA2 received his/her Lactulose on the morning and afternoon of January 20, 2023, but did not receive his/her evening dose because the staff persons ran out of the medication. The HCP noticed that it was not administered to VA2 over the weekend, but was not able to immediately order the Lactulose because the pharmacy was closed on weekends. The order was placed on January 23, 2023, and VA2 received his/her Lactulose that day. · P4 stated that the Lactulose was a liquid medication, so it was difficult to determine how many doses were left in the bottle. The HCP stated that all of the staff persons were trained to contact the HCP when they noticed that any medication was running low, but that no one contacted the HCP to let him/her know that they were running out of VA2’s Lactulose and that it had to be reordered. After the incident, all of the staff persons were retrained on the need to ensure that all of the residents’ medications were available as prescribed. G2 stated that the staff persons notified G2 when VA2 missed some of his/her Lactulose medication. G2 believed that the staff persons generally took good care of VA2. CM1 stated that s/he had no complaints about the care VA2 received at the facility. When s/he visited VA2, VA2 seemed “happy and in a good mood.” CM1 was told that the staff persons were being retrained on the residents’ health protocols. Conclusion for allegation two: Although VA2 was prescribed three doses of his/her Lactulose medication each day, on January 20, 2023, the staff persons ran out of the medication and VA2 did not receive the Lactulose until the prescription could be filled on January 23, 2023. It was unclear if the staff persons followed the facility’s protocols for reporting that a medication was unavailable. Although VA2 did not receive all of his/her Lactulose medication over the weekend, given that the pharmacy was closed on the weekends so the medication was not able to be refilled, that the prescription was refilled on Monday, and that there was no information was provided that VA2 sustained any injury or adverse effects from missing the medication, there was not a preponderance of the evidence whether there was a failure to provide care or services to VA2 which were reasonable and necessary to maintain VA2’s physical health and 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 VA3’s bowel program was not followed, causing him/her to be admitted to the hospital. P1 – P7, the HCP, and the facility’s documentation provided the following information: · VA3 had a bowel program that the staff persons were to follow when VA3 did not have regular bowel movements. If VA3 did not have a bowel movement for three days, s/he was to get mineral oil. If VA3 did not have a bowel movement for four days, s/he was given a glycerin suppository. If VA3 did not have a bowel movement for five days, s/he was given a Fleet enema. If VA3 did not have a bowel movement for six day, s/he was to be given a tap water enema. · The HCP stated that all of the staff persons received training on VA3’s bowel program prior to the incident. The HCP, P1, and P2 each checked the residents’ MARs to ensure that all medications were administered as prescribed. The HCP stated that in December 2022, s/he noticed that on “some days” VA3’s bowel program was “being missed.” At that time, the HCP talked to the staff persons about the need to follow VA3’s bowel program. The HCP stated that all of the staff persons should check on what other staff persons documented on previous work shifts so as to ensure that they followed VA3’s bowel protocol as necessary. P3 stated that each staff person was trained to check the notes from the staff persons working the previous shifts to determine whether VA3 had a bowel movement. P3 believed that some of the staff persons did not always document when VA3 had a bowel movement. P5 stated that when s/he started working at the facility, s/he was not trained on how to check the documentation to learn when VA3 had his/her last bowel movement or what to do if VA3 did not have a recent bowel movement. · According to facility documentation, on January 22, 2023, VA3 had a bowel movement. On January 23, 2023, VA3 was given a Fleet enema and mineral oil enema. On January 25, 2023, VA3 should have received mineral oil, but s/he did not receive it. On January 26, 2023, VA3 should have received a glycerin suppository, which s/he did not receive. P4 stated that s/he worked on January 26, 2023, and gave VA3 a Fleet enema, which resulted in VA3 having a bowel movement. It was unclear if the staff persons did not document the steps of the bowel program that were taken during this time period or if they failed to follow the steps. · On the morning of January 27, 2023, at 8:30 a.m., VA3 was ill when s/he woke and had black vomit. The staff persons contacted the HCP and told him/her about VA3. At 10 a.m., the staff persons telephoned 9-1-1 because VA3 continued to vomit. The paramedics then transported VA3 to the hospital. The HCP stated that when VA3 was admitted to the hospital, s/he asked the physician what caused VA3’s illness and was told that VA3’s hospitalization was not caused by failing to exactly follow VA3’s bowel protocol. P1 also stated that VA3’s hospitalization was because of a stomach issue. P2 stated that s/he was told by the hospital staff persons that VA3’s medical issue was not caused by a failure to follow VA3’s bowel program. The hospital admitting diagnoses was ischemic bowel disease with a degree of respiratory failure. VA3 had a history of aspiration and developing sepsis extremely quickly. · On February 20, 2023, VA3 returned to the facility on hospice care. On February 21, 2023, VA3 passed away. · Consistent information was provided that if a staff person was uncertain of what to do when caring for a resident, they were able to call on-call supervisors and nursing staff persons. G3 stated that when VA3 vomited on the day s/he went to the hospital, VA3 aspirated some of the vomit. G3 believed the failure to follow VA3’s bowel program contributed to VA3’s hospitalization. CM2 stated that VA3 was discharged from the hospital and went back to the facility on hospice care, where s/he passed away a few days later. CM2 believed VA3’s hospitalization was not connected to the staff persons’ failure to follow VA3’s bowel program. According to the hospital’s Provider’s Notes: · On January 27, 2023, VA3 was admitted to the hospital on January 27, 2023, complaining of abdominal pain. VA3 was diagnosed with aspiration pneumonia of both lungs, hypotension (low blood pressure), acute chronic respiratory failure with hypoxia and hypercapnia, ischemic bowel disease (narrowing or blockage of arteries supplying blood to the intestines), and sepsis, due to unspecified organism. VA3 had “portable venous gas in the left hepatic lobe and air/gas in the perigastric vasculature, distended stomach.” The “distention was associated with coffee ground emesis, hypotension, and tachycardia” (increased heart rate). · On January 31, 2023, it was documented that VA3’s CT scan showed “a lot of stool” and VA3 had no bowel movement since being admitted to the hospital. VA3 was unable to take any medication by mouth, so s/he required regular rectal enemas. · On February 14, 2023, it was documented that VA3 had “acute respiratory failure with hypoxia b2/2 to severe sepsis and aspiration pneumonia with possible necrosis with possible ARDS, POA” as well as a possible fungal infection of the lungs and a “chronic mass-like consolidation in the left upper lobe.” It was determined that palliative care would be initiated. · On February 20, 2023, VA3 was discharged from the hospital to the facility. Facility documentation showed that the HCP and P1 – P7 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VAs’ plans prior to the incidents. Conclusion for allegation three: Between January 22 and 27, 2023, the staff persons did not consistently document whether VA3’s bowel program was followed and it was unclear whether the staff persons failed to follow the bowel program or failed to document the steps they took. However, it was more likely than not that VA3’s bowel program was not consistently followed by the staff persons. On January 27, 2023, when VA3 became ill and vomited, s/he was taken to the hospital, where s/he was diagnosed with aspiration pneumonia, hypotension, acute chronic respiratory failure, ischemic bowel disease, and sepsis. VA3 remained in the hospital until February 20, 2023, when s/he returned to the facility on hospice care. On February 21, 2023, VA3 passed away. VA3 had multiple medical issues that contributed to his/her death and the staff persons ensured that VA3 was taken to the hospital when his/her health condition worsened. Therefore, there was not a preponderance of the evidence whether there was a failure to provide care or services to VA3 which were reasonable and necessary to maintain VA3’s physical health and 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 and determined that the facility’s policies were adequate, but were not followed by the staff persons. All of the staff persons received retraining on following the facility’s protocols and procedures. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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