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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: 1073047-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that staff persons did not follow up with medical care and a vulnerable adult (VA) had to have his/her toes amputated. Alleged Licensing Violations: It was alleged that staff persons did not assist the VA with fixing his/her phone and that there was not enough food for the VA at the facility. Date of Incident(s): Prior to December 15, 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 January 11, 2023; from documentation at the facility; and through six interviews conducted with two facility staff persons (P1 and P3), the VA’s case manager (CM), the VA’s family member (FM), the VA’s mental health worker (MH), and the VA. This investigator made attempts by phone and mail to interview another staff person (P2), but attempts were unsuccessful. The VA was diagnosed with type 2 diabetes, major depressive disorder, generalized anxiety disorder, and osteomyelitis (infection in a bone) on the left foot. The VA was not subject to guardianship. The facility was a three-bedroom one level townhome. In the front of the facility was an open concept living room and kitchen area. In the back of the facility were three bedrooms and two bathrooms. The Coordinated Services and Supports Plan indicated that the VA was able to direct his/her own care needs. The Coordinated Service and Support Plan Addendum Summary indicated staff persons tracked, scheduled, and accompanied the VA to all his/her medical appointments. Staff persons documented and implemented all physician ordered cares. Staff persons worked in cooperation with skilled nursing agencies to monitor and treat the VA’s diabetic ulcers. The Intensive Support Self-Management Assessment indicated that the VA had diabetic ulcers on his/her feet and had multiple toes amputated. The Individual Placement Agreement indicated that the VA saw a podiatrist on a regular basis to cut his/her toenails. The VA had up to six hours of unsupervised time at the facility. A skilled nursing facility (not affiliated with this facility) maintained communication around the VA’s diabetes and diabetic ulcers on the VA’s feet. The facility followed recommendations provided by the skilled nursing facility on care for the VA’s feet. The General Event Reports indicated that on December 4, 2022, the VA was admitted to the hospital due to “issues” with his/her left toe. Hospital records indicated that on December 4, 2022, the VA was admitted to the hospital with a diabetic foot ulcer. There was an infected ulceration on the left 3rd digit digital tuft with clinical and radiographic suspicion of underlying osteomyelitis (infection in the bone). Medical records indicated the following: · On September 19, 2022, the VA was seen at urgent care for swelling in his/her right first toe. The VA said s/he thought s/he might have cut some of his/her skin when cutting his/her toenails. There was redness and swelling to the right great toe and foot. Referred to an emergency room (ER). · On September 19-22, 2022, the VA was admitted to the hospital and diagnosed with hyperkalemia (high potassium levels in the blood). The VA reported that s/he was here because of discoloration of his/her right big toe. The VA also reported chronic non-healing right heel ulcer (did not appear infected). Arterial dopplers consistent with peripheral artery disease (PAD). An aortogram (procedure to find areas where blood vessels are narrowing or closing) to the right lower extremity was performed that did not show significant disease. “Conservative management” was recommended. The VA had chronic lower extremity edema. · On October 31, 2022, the VA was seen by his/her primary medical provider for toe pain on his/her right big toe. Diabetes Mellitus foot right heel shallow ulcer was noted, and a foot exam was completed. It was noted that the VA cut his/her toenail too short on the right middle toe and there was dried blood. · The VA was seen on December 1, 2022, at the emergency department for pain, redness, and swelling of the left third toe. The VA had prior history of the first and second toe amputations due to diabetic foot infections. At that time, the toe looked “salvageable,” and antibiotics were prescribed. A referral was placed for podiatry for a recheck in the next week. If the symptoms did not improve or worsened within 48 hours, the VA was to return. · On December 4-9, 2022, the VA was admitted to the hospital for soft tissue infection of the left foot with underlying osteomyelitis of the third toe. Given the extent of the soft tissue infection to the third digit as well as underlying osteomyelitis, surgical intervention was recommended in hopes to obtain surgical cure for infection. The option of third toe versus transmetatarsal amputation (removing all or part of the forefoot) was discussed with surgeons feeling the latter was more functional given prior amputation to the VA’s same foot in the past. The VA was informed and proceeded with left foot transmetatarsal amputation. The VA said staff persons did not check the VA’s feet to see if there were any issues. There was one staff person that checked the VA’s feet once or twice a week. Staff persons did not look out for the VA’s wellbeing and all staff persons did was give the VA his/her medications and tell him/her to check his/her blood sugar. The FM provided the following information: · The VA had some declines in his/her health and had two toes amputated. After about a year of living with family members, the VA moved into the facility in March 2022. The VA was to have skilled nursing care at the facility and regular toe checks and nail trims. The FM found out that this was not being done at the facility. · The VA had a severe toe infection for two weeks that was not noticed because staff persons were not checking the VA’s feet. The VA ended up having to have all his/her toes amputated on one foot. The MH provided the following information: · The MH saw the VA weekly for four hours starting sometime in or after April 2022. Every week, the MH usually worked on getting needed medical appointments set up for the VA and took the VA to medical appointments. Since the VA had previously lived with family members quite a distance away, the MH set up the VA with new medical providers which were closer to the facility which included an eye doctor and a primary doctor. When the VA moved out of the facility in December 2022, the MH told the FM all the upcoming appointments that were scheduled. · The MH did not look at the VA’s feet and had never heard the VA express any concerns about his/her feet. The MH could not remember if s/he had taken the VA to see a medical professional about the VA’s feet but thought at least one provider had looked at his/her feet during an appointment. · Although everyone at the facility was nice to the VA, the MH felt s/he was the only one “giving cares” to the VA. There was a period when there was a change in the supervisory staff persons. After P1 started, the MH felt that P1 was trying to “catch up from behind” but thought things were going to start happening the “way they should be.” P1 provided the following information: · P1 started with the facility in September of 2022. Shortly after P1 found out the FM had expressed some concerns to P2 that were not being resolved. P1 contacted the FM who said the VA’s benefits were about to run out. The following morning, P1 found out that the VA needed to schedule an appointment to see a certain health care provider for some sort of certification. P1 set up the appointment. · When the VA moved into the facility, s/he had to find new medical providers as his/her previous providers were too far away. P1 worked on the process of switching the VA to new providers. · The VA showered him/herself with staff persons cuing the VA as needed so staff persons did not typically see the VA’s feet or check them. The VA was able to cut his/her own fingernails and toenails. · The MH came in weekly to see the VA, but the VA did not have a nurse that came in to check him/her. The MH worker took the VA to “most” of his/her medical appointments. · In the beginning of December 2022, the FM said that the VA needed to go to urgent care to have his/her foot looked at. Several days later the VA was hospitalized and had his/her toes amputated · The facility had one staff person working at all times. P2 was the direct supervisor of the facility and typically made appointments, provided cares, and made sure the programming was completed. P2 worked some evening and some morning hours. P3 provided the following information: · Staff persons administered the VA medications and prompted the VA to check his/her blood sugar. There was an area on the medication administration sheets (MAR) labeled foot check near the bottom. P3 thought that because it was down low on the MARs that many staff persons may have missed this area as it appeared that P3 was the only staff person signing off on the foot check. P3 asked P2 about it on one occasion. P2 said s/he did not know there was a foot check and never got back to P3 about it. · When P3 checked the VA’s feet they were typically very dry and flaky, but the toenails were always nicely trimmed. P3 applied lotion and encouraged the VA to wear socks. At one point, P3 was working two to three days a week at the facility. The VA’s feet/toes never appeared red or swollen. P3 was not working for approximately 10 days before the VA was hospitalized with his/her infection on his/her toe. Medication Administration Records from September 2022-November 2022 did not show any scheduled medication/treatment or foot check for the VA. Information showed that this was added after the VA’s toes were amputated. T-Logs from September-December 2022, provided the following information: · It was noted that P3 checked the VA’s feet on the following days: September 4, 8, 9, 15, 23, and October 7, 2022. P3 also documented the following days but did not specifically mention checking the VA’s feet: September 3 and 28, October 10, 13, 15, 25, 26, and 28, and November 4, 6, 12, 13, 17, 21, 26, and 27, 2022. · The VA was out of the facility with the FM on the following days: November 4-5, 17-20, 23-24, and December 1-3, 2022. The General Events Report Resolution indicated that P2 was the site supervisor at the facility while the VA lived there, and s/he said that the VA received reminders to check his/her blood sugar and to take his/her insulin as needed. Staff persons also reminded the VA to shower and assisted him/her with making meals. P2 was not aware of any cares such as checking the VA’s feet and/or legs. According to the Mayo Clinic, people who have diabetes may develop osteomyelitis in their feet if they have foot ulcers. Surgery was needed to remove areas of the bone that have died. Symptoms of osteomyelitis include, fever, swelling, warmth and redness over the area of infection, pain in the area of infection, and fatigue. At times, osteomyelitis caused no signs and symptoms, or the signs and symptoms were hard to distinguish from other problems. All staff persons interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults Act, and the VA’s plans prior to the incident. Conclusion: The VA said staff persons did not look out for the VA’s wellbeing. There was one staff person who checked the VA’s feet once or twice a week. The FM said the VA moved into the facility in March 2022 and was to have skilled nursing care at the facility and regular toe checks and nail trims. The FM found out that this was not being done at the facility. As a result, the VA had three toes amputated. The MH said s/he brought the VA to many of his/her appointments. The VA never complained of any foot issues to the MH and the MH never looked at the VA’s feet. The Individual Placement Agreement indicated that the VA saw a podiatrist on a regular basis to cut his/her toenails. The facility followed recommendations provided by a skilled nursing facility on care for the VA’s feet. There was nothing in the VA’s plan that indicated that staff persons were to check the VA’s feet. The facility did not have any information on any skilled nursing that came to the facility, and there was no information in the VA’s file that s/he saw a podiatrist while at the facility. P1 and P2 said that staff persons assisted the VA with checking his/her blood sugars and cueing the VA as needed to complete daily cares. Each P1 and P2 were not aware of any orders to check the VA’s feet. P3 checked the VA’s feet on his/her shifts and said s/he documented on the MARs although this investigator could not find the treatment listed on the MARs dated September to November 2022. After the VA had his/her toes amputated, checking the VA’s feet was added to the MAR. The VA was seen by a medical professional on October 31, 2022, and it was noted that a foot exam was completed with no mention of any issues with the VA’s leg foot or toes. The VA was seen on December 1, 2022, at the emergency department for pain, redness, and swelling of the left third toe. The VA was prescribed antibiotics, given a podiatry referral, and returned to the facility. On December 4, 2022, the VA was admitted to the hospital with a diabetic foot ulcer and subsequently had three toes amputated. The VA was out of the facility with the FM on November 4-5, 17-20, 23-24, and December 1-3, 2022. The FM said the facility did not regularly check the VA’s feet or schedule/complete toenail trims resulting in an infection that required amputation of the VA’s toes. However, given that there was no information in the VA’s plan to indicate that staff persons were required to check the VA’s feet regularly; that the VA said that there was a staff person that checked the VA’s feet once or twice a week; that P3 said s/he checked the VA’s feet when s/he was at the facility and did not see any signs of infection and stated that the VA’s toe nails were “nicely trimmed;” that when the VA or staff person noticed any issues with the VA’s feet the VA was seen at the hospital; and that the VA had a history of prior infection and amputation of other toes so it was unknown if any earlier intervention would have changed the outcome, there was not a preponderance of the evidence whether staff persons failed to provide health care which was reasonable and necessary to 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). Alleged Licensing Violation: It was alleged that there was not enough food at the facility for the VA. Minnesota Statutes section 245D.04, subdivision 3, paragraph (b), clause (5) states that a person’s protection related rights include the right to the right to have access to three nutritionally balanced meals and nutritious snacks between meals. The VA said s/he was “alone” at the facility Monday through Friday from 8 a.m. to 2 p.m. Often the VA made him/herself a peanut butter and jelly sandwich for lunch or s/he did not eat. At times staff persons made pancakes or waffles for breakfast but sometimes the VA was “on my own” for breakfast and lunch. Staff persons did not offer a variety of foods and did not let the VA make choices about the food. The FM said that the VA said s/he was not being asked what s/he preferred to eat and said the groceries were “light.” · P1 said that there was always food at the facility. There was a fridge and freezer in the kitchen and an additional freezer with extra food in the garage. · P3 said that the VA played many video games and stayed in his/her bedroom often. Staff persons had to ask the VA to come out and do things. The VA was at the facility without staff persons during the daytime hours while his/her housemates were out of the facility. If P3 was working in the neighboring facility, s/he would come over and ask if the VA wanted lunch. Usually the VA said s/he would make his/her own lunch or s/he said s/he had already had lunch. The VA ate dinners with his/her housemates in the evenings. · T-Logs from September-December 2022 showed a variety of meals were served as breakfasts, lunches, and dinners including mac and cheese, chicken strips, vegetables, French toast sticks, eggs, sloppy joes, hamburgers, beans, tater tots, grilled cheese, tomato soup, stroganoff, pancakes, sandwiches, and meatloaf. This investigator saw a large variety of food in the facility refrigerator, freezer, and cupboards during the site visit on January 11, 2023. Although there were concerns reported about the VA being provided adequate food, given this investigator saw an wide variety of food at the facility, that P1 said that there was food in the fridge and freezer with another freezer of additional food in the garage area, that the VA said that staff persons made dinner and sometimes breakfast for him/her, that the VA was capable of making an easy meal while s/he was at the facility unsupervised, and that the VA had six hours of unsupervised time at the facility, a licensing violation was not determined. Alleged Licensing Violation: It was alleged that staff persons did not assist the VA with fixing his/her phone. Minnesota Statutes section 245D.04, subdivision 3, paragraph (b), clause (1), stated that a person’s protection related rights include the right to have daily, private access to and use of non-coin operated telephone for local calls and long-distance calls made collect or paid for by the person. The VA said that at some point, his/her cell phone quit working. The FM was able to order another phone but no one at the facility assisted the VA with the phone. There was a landline phone at the facility. · The FM said that at some point, the VA’s phone stopped working. The FM ordered a new SIM card and asked staff persons to put the new card in when it arrived. The VA went several weeks without a phone. The facility had a landline, but the VA would not pick it up when it rang so if the VA was at the facility without staff persons, the FM was unable to get a hold of the VA. · The MH said that at some point, the VA was having trouble with his/her phone. The MH tried to assist the VA. The VA ended up getting a new phone, but it was not programmed correctly. The MH tried to fix the phone but was not able to. It concerned the MH and the FM that the VA was not accessible on his/her cell phone. · P1 said that at some point, the VA came to P1 and said that his/her phone charger was not working. P1 gave the VA a phone charger. P1 was not aware of any other time the VA’s phone was not working. The facility had a house phone that the VA could use as needed. Although the FM and MH had concerns that the VA did not have a working cell phone for a period and did not answer the facility landline, given there was a landline in the facility that the VA was aware of, that there were some technical issues that needed to be addressed with the VA’s phone, and that there were staff persons on shift at the facility for morning and evening hours who could assist the VA with calling or answering the phone as needed, a licensing violation was not determined. Action Taken by Facility: The facility completed an internal review and determined that policies were followed but not adequate. The facility felt there should have been more diabetic cares related to the VA specifically checks on his/her feet. All staff persons were retrained on ISP documentation. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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