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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: 1081068-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: It was reported that short staffing at the facility led to vulnerable adults (VA1 and VA3) being left in bed for long periods of time. It was further reported that the short staffing led to another vulnerable adult (VA2) being left unsupervised, which resulted in several falls and a visit to an emergency room. Date of Incident(s): Ongoing between December 23 and 25, 2022; and other dates unknown
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 December 29, 2022; from documentation at the facility and law enforcement records; and through nine interviews conducted with VA2’s guardian (G2) who was also VA2’s family member, VA2’s case manager (CM), VA3, VA3’s in-home wound care nurses (N1 and N2), facility staff persons (P1, P2, and P3), and a supervisory staff person (P4). [Note: At the time of the site visit, this investigator met VA1 and VA3, and on a later date, VA2. VA1 and VA2 did not provide information for this investigation due to their limited communication skills. VA3 provided some information, which was included in this report. VA1’s guardian (G1) was contacted but did not provide additional information; and a staff person (P5) did not respond to this investigator’s phone calls and mail.] The facility was a single-family, one-story home. VA1-VA3 lived together with another housemate (H). [Note: There was no information the H was involved in or impacted by the allegations herein. At the time of the site visit, this investigator asked to interview the H and the H declined.] VA1’s support plans provided the following information: · In February 2019, VA1 moved into the facility seeking supports and services relating to his/her diagnoses, which included traumatic brain injury and spinal cord injury-incomplete paraplegia. · VA1 required two staff persons to transfer into and out of his/her bed, wheelchair, etc., using a manual lift. VA1 moved around using an electric wheelchair. VA1 preferred to “rise” each day around 9 a.m., and go to bed around 8 or 9 p.m. · “[VA1] requires a 24-hour plan of care for [his/her] health and safety as [s/he] is limited in [his/her] abilities to manage [his/her activities of daily living] independently since [his/her] brain injury … Staff are expected to be with [VA1] at all times due to [him/her] being limited with [his/her] expressive communication as [s/he] is primarily non-verbal.” · “[VA1] is ok [sic] to have alone time in [his/her] bedroom while [s/he] is laying down for a nap or watching [his/her] TV. Staff is to complete safety checks every hour … [and] brief checks every 2 hours.” VA2’s support plans provided the following information: · In July 2022, VA2 moved into the facility and his/her diagnoses included dementia. · “[VA2] requires 24-hour awake staffing support to assist with managing [his/her] health and safety. [VA2] has a history of drop seizures that have resulted in fractures and concussions … [VA2] requires physical assistance from 1 staff for all transfers due to unsteadiness and 2 previous broken hips from falls. Due to [VA2’s] dementia and unsteadiness, [s/he] may try to transfer by [him/herself]. Staff should be in visual and hearing range so they can assist [VA2] as needed. Staff should physically assist when standing, ambulating, or transferring … When [VA2] is in bed, [s/he] uses a bed alarm to alert staff [s/he] is transferring. If [VA2] is sleeping, [s/he] should be checked every 2 hours.” · “[VA2] is not an accurate reporter and has a diagnosis of dementia. [VA2] would not be able to direct [his/her] care or express [his/her] symptoms accurately.” VA3’s support plans provided the following information: · In January 2022, VA3 moved into the facility. His/her diagnoses included multiple sclerosis. · “[VA3] is being admitted with a large pressure sore on [his/her] upper buttock and 2 open pressure wounds on [his/her] back. [VA3] currently has a doctor’s order limiting [his/her] time in the wheelchair. [VA3] will require hourly repositioning to alleviate the pressure on [his/her] back and buttocks. Team has requested a new evaluation of wheelchair limitations and expressed concern regarding the amount of time in bed.” · “[VA3] requires support staff to physically assist with all [his/her] instrumental activities of daily living due to [his/her] multiple sclerosis diagnosis and interference of symptoms. [VA3] cannot walk at all and is dependent on [his/her] wheelchair.” VA3 required two staff persons to transfer into and out of his/her bed, wheelchair, etc., using a manual lift. VA3 moved around using an electric wheelchair. VA3 preferred to get out of bed each day around 9 a.m. · “[VA3] can be in [his/her] room alone. Staff will provide safety checks every hour while awake and every 2 hours while [VA3] is asleep.” · “[VA3] has issues with [his/her] memory and cognition and reports attention and concentration concerns” Regarding VA1 and VA3 during December 23 through 25, 2022: P1-P4, law enforcement records, and this investigator’s observations at the time of the site visit provided the following information: · P1 said that on December 23, 2022, s/he was scheduled to start work at 11 p.m.; however, came in early for undisclosed reasons and started around 9 or 10 p.m. P1 was the sole staff person working. His/her shift was set to end at 7 a.m., the next morning, December 24, 2022. However, when the next morning arrived, no other staff came to relieve P1. P1 called the facility’s supervisory staff person (P7) and an administrative staff person (P4), but no one answered. By 9 a.m., P1 had been the sole staff at the facility with VA1-VA3 for around 12 hours; and without being able to get ahold of anyone to relieve him/her, P1 called the sheriff’s office. · A Sherburne County Sheriff’s Office report stated that on December 24, 2022, at 9:12 a.m., dispatch received a call from P1. A law enforcement officer (LEO1) responded to the facility where P1 was the sole staff person. P1 told LEO1, “There was supposed to be two employees on site at all times, as there are two patients that are bed bound or wheelchair bound and required two people to take care of them.” P1 showed LEO1 the facility’s staff schedule, which showed that there was no one scheduled to relieve P1. · The facility’s staff schedule included the following:
· LEO1 helped P1 by calling the various facility supervisors until someone answered. · P4 said that around 11 a.m., on December 24, 2022, s/he received a call from LEO1 regarding the facility’s staffing. LEO1 was at the facility with P1. P4 was not previously aware of a concern with staffing and was also not previously aware of P6’s employment resignation the day prior. P4 told LEO1 that s/he would find someone to relieve P1. Upon hanging up, P4 called P7. P7 agreed to relieve P1 and address the upcoming open shifts. When this call ended, P4 believed the facility’s staffing situation was handled. · A Sherburne County Sheriff’s Office report stated that at 6:10 p.m., dispatch received a second call from P1. P1’s relief (P7) never showed up leaving him/her as the sole staff person for over 20 hours. A law enforcement officer (LEO2) assisted P1 by calling the various facility supervisors and speaking with P4. P4 told LEO2 that s/he would figure out what happened and get someone there to relieve P1. · Upon hanging up with LEO2, P4 called P7 again. During this conversation, P7 “quit” his/her employment while on the phone with P4. Upon hanging up with P7, P4 sent a companywide email asking for volunteers to work the available shifts at the facility. Several staff persons, including P3, responded. · Around 9:30 p.m., two staff persons arrived at the facility in relief of P1. At this point, P1 had been the sole staff person since 9 or 10 p.m., the day prior (24 hours). P1 said that s/he had been able to administer medications to the housemates, ensure meals were served, reposition as needed, and check/change briefs as needed. However, P1 had not been able to transfer VA1 or VA3 out of bed. · P4 said that following the short staffing incident on December 23-24, 2022, the facility had at least two staff persons working 24/7 at the facility. · On December 29, 2022, at 3 p.m., this investigator and a law enforcement officer (LEO3) arrived at the facility without notice (unannounced). Upon entering, this investigator observed four staff persons, including P3 and P5, present with the H, VA1, and VA3. The facility, including bed- and bathrooms, appeared clean and without odor. VA1 and VA3 were in their respective beds, and both appeared to be without obvious hygiene or health concerns. VA1’s and VA3’s communication styles were difficult to understand. VA1 did not appear to answer questions consistently. VA3 said that s/he was “having a blast” at the facility. VA3 could not recall any times when staffing impacted his/her ability to get help when needed. · P2-P4 each stated that they were aware of the short staffing incident on December 23-24, 2022, but other than these dates, they were not aware of any other times the facility lacked staffing. P2-P4 were not aware of any injuries to the housemates because of staying in bed for longer than usual. · P2 added, “We’re always staffed. It’s just unfortunate that happened” on December 23-24, 2022. · The facility’s staff schedule showed that prior to December 23, 2023, most every shift was filled, making it so that there was at least two staff persons during most hours of the day. Regarding VA1 and VA3 during December 2022 through February 2023: P1 said that VA1 and VA3 required assistance to transfer out of, or back into, their respective bed or wheelchair. However, P1 “never” saw VA1 or VA3 out of bed. VA3 moved into the facility with one pressure sore; however, “Now has three … None of them are improving.” The facility’s Resident Notes included the following: · For December 10, 2022, through February 23, 2023, staff documented that they repositioned VA1 and VA3 hourly or every two hours, provided “bed baths” and “brief changes,” conversed or watched movies with, assisted with meals, and administered medications. However, there was nothing documented about VA3 leaving his/her bed at any point during this timeframe. [Note: This investigator’s and LEO3’s unannounced site visit was on December 29, 2022, at 3 p.m. and VA3 was in bed.] · Regarding VA1, staff documented that they transferred VA1 out of bed and into his/her wheelchair one time (December 20, 2022) between December 10 and 29, 2022. Then between December 29, 2022, and February 23, 2023, staff documented that they transferred VA1 into his/her wheelchair at least once every day. [Note: This investigator’s and LEO3’s unannounced site visit was on December 29, 2022, at 3 p.m. and VA1 was in bed.] P2 provided the following information: · Staff “usually” transferred VA1 into his/her wheelchair by 10 a.m., each day. VA1 then typically was transferred back to bed around 2 p.m., each day. Staff would then change VA1’s brief if needed, and s/he would be transferred back into his/her wheelchair at some point later in the day. · “[VA3] stays in bed by doctor’s order because [s/he] has sores on [his/her] bottom. [VA3] cannot sit up for too long for [his/her] medical condition.” P2 said that staff repositioned VA3 every two hours. [Note: VA3’s support plan stated, “[VA3] currently has a doctor’s order limiting [his/her] time in the wheelchair.” This investigator requested a copy of VA3’s doctor’s order from the facility; however, the facility was unable to locate it.] P3 said that to his/her knowledge, VA1 was transferred into his/her wheelchair every day using the manual lift. P3 did not know how VA3 got out of bed, whether by a manual lift or other means. [Note: P3 was working temporarily at the facility to fill open shifts. At the time of this investigator’s interview with P3, s/he had worked one shift.] N1 and N2 provided in-home wound cares to VA3. VA3 had a pressure wound on his/her coccyx, and if VA3 were to sit in a wheelchair, s/he would be sitting directly on his/her wound. N1 and N2 each confirmed that VA3 was “bed bound.” N2 said that VA3’s wounds were “improving.” N2 did not have specific concerns with VA3’s overall care at the facility. N1 had concerns with the facility’s communication, but nothing specific to this investigation. This investigator requested VA3’s medical records through his/her primary physician/clinic, including any documentation regarding the length of time VA3 should remain in bed verses in his/her wheelchair. The clinic responded, “Records have been checked and there is nothing documented on the information you are requesting.” Regarding VA2’s supervision requirements and history of falls: G2 provided the following information: · VA2’s cares were “very high,” and his/her dementia was “getting worse.” · VA2 had a history of falls, and his/her dementia might be playing a role with his/her falls. · On December 24, 2022, G2 was visiting the facility when s/he saw VA2 attempt to stand without assistance and then fall to the floor. G2 was concerned that staff were not present, in the same room, to assist with VA2’s transfer. G2 said that staff were supposed to assist with all VA2’s transfers. [Note: P1 recorded this incident in VA2’s Resident Notes. “[VA2] had a little bit of a fall when using the bathroom and [hit his/her] arm, but [s/he] stated [s/he] was okay and that nothing hurt.” P1 did not document where s/he was during the incident and/or any other involvement by P1 during this incident.] · On December 26, 2022, G2 received a call from an unidentified staff person that VA2 had “slurred speech.” The staff person planned to monitor and transfer VA2 into his/her bed. About 20 minutes later, G2 received a second phone call. VA2 had rolled out of bed and hit his/her head on a dresser. VA2 was bleeding and the staff person called 9-1-1. · G2 was concerned that VA2’s slurred speech, on December 26, 2022, might have been related to an unwitnessed fall or seizure. · VA2 had a history of seizures. If staff believed a seizure was coming, they were supposed to monitor VA2 and make sure s/he stayed safe. G2 was concerned that staff were not present, in the same room, to know what exactly happened to cause VA2’s slurred speech. · G2 also received inconsistent information from the facility regarding whether VA2 fell out of bed on December 26, 2022, or whether s/he fell out of his/her wheelchair. G2 did not receive an incident report from the facility regarding this incident. A Sherburne County Sheriff’s Office report stated that on December 26, 2022, at 9 p.m., P5 called 9-1-1 because VA2 fell and hit his/her head. According to P5’s statement to LEO3, s/he came upon VA2 lying in bed with blood on his/her face. At that time, P5 observed VA2 to be “acting jittery, screaming, and [his/her] speech was slurred.” P5 believed VA2 might have tried to get out of bed and fell striking his/her nightstand. P5 called 9-1-1. VA2 was admitted to a hospital for continued evaluation and remained hospitalized at the time of this investigation. [Note: There was no documentation at the facility regarding this incident. This was not documented in the Resident Notes, and the facility could not locate any other documentation, including an incident report. Failure to maintain information about and report incidents to the person's legal representative or designated emergency contact and case manager within 24 hours of an incident occurring while services are being provided, was in violation of Minnesota Statutes section 245D.06, subdivision 1, paragraph (b).] P2 and P4 each said that VA2 did not have 1:1 staffing and instead had shared staffing with VA1 and VA3. Staff were not required to always remain within the same room as VA2. VA2 typically got up independently each morning and moved around the house independently. The CM said that staff were not required to watch VA2 24/7. When VA2 initially moved in, July 2022, s/he was able to bear weight, but needed assistance to transfer. Staff were told to stand outside the bathroom door and when they determined VA2 was done using the toilet, they entered the bathroom to assist with transferring. By the time of this investigation, December 2022, VA2 was requiring more and more assistance. At the same time, VA2’s dementia was “progressing at a rapid rate,” which had been leading to “a lot of behaviors,” including VA2 trying to be independent with transfers and at times unbuckling his/her own seatbelt in a moving vehicle. A review of the facility’s Resident Notes, for December 11, 2022, through February 23, 2023, showed: · Staff documented that VA2 moved around the facility in his/her wheelchair and appeared independent with transferring into and out of his/her wheelchair. · Staff documented three falls and one seizure on December 19, 2022; staff called 9-1-1 more than once on this day for VA2. VA2 was taken to the emergency room and released the same day. No injuries were noted. · On December 21, 2022, staff documented that VA2’s neurologist was contacted; VA2’s medications were adjusted; and a follow-up neurology appointment was scheduled. · On December 24, 2022, VA2 fell without injury. Note: No criminal charges were pursued by LEO1-LEO3 related to VA1-VA3 and the aforementioned information. Facility documentation stated that P1-P7 received training on the Reporting of Maltreatment of Vulnerable Adults Act. P1, P6, and P7 also received training on VA1’s-VA3’s support plans and support plan addendums; P4 was not required to receive this training based on his/her role. The facility did not have documentation that P2 and P3 received training on VA1’s-VA3’s support plans and support plan addendums. This was in violation of Minnesota Statutes section 245D.09, subdivision 5, paragraph (a), clause (2), which states that the license holder must maintain a personnel record of each employee to document and verify staff qualifications, orientation, training, and performance evaluations as required under section 245D.09, subdivisions 3 to 5, including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a), states the license holder must provide services in response to the person's identified needs, interests, preferences, and desired outcomes as specified in the coordinated service and support plan and the coordinated service and support plan addendum, and in compliance with the requirements of this chapter. License holders providing intensive support services must also provide outcome-based services according to the requirements in section 245D.071.
Conclusion: A. Maltreatment: Regarding VA1: Concern was raised regarding VA1’s care at the facility. The facility’s Resident Notes provided information that staff repositioned VA1 hourly or every two hours, provided “bed baths” and “brief changes,” conversed or watched movies with, assisted with meals, and administered medications. VA1 had a wheelchair and required assistance from a manual lift/two staff persons to transfer out of bed. Although P2 and P3 each said that VA1 was transferred out of bed every day; P1 said that s/he never saw VA1 out of bed and the facility’s Resident Notes supported P1’s account. In addition, P3 was working his/her first shift at the facility when s/he interviewed with this investigator and so it would be difficult for P3 to know exactly what VA1’s time out of bed entailed prior to P3’s employment at the facility. In addition, the facility’s staff schedule showed that there was only one staff person (P1) working for approximately 24 hours on December 23 and 24, 2022, which would have made it impossible for VA1 to be transferred out of bed during that timeframe. After this investigator’s and LEO3’s site visit, the Resident Notes began showing VA1 being transferred out of bed every day, but there was no such documentation prior to the site visit date. Although the exact impact on VA1 was unknown given his/her limited communication skills, it was reasonable to expect that being left in bed or being left without adequate engagement would be considered by a reasonable person to be disparaging, derogatory, and humiliating. Therefore, there was a preponderance of the evidence that VA1 was subjected to conduct, which was not an accident or therapeutic conduct, and could reasonably be expected to produce emotional distress. It was determined that 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). In addition, given VA1’s reliance on staff persons for most activities of daily living, including the act of getting out of bed, and that this was not consistently provided, there was a preponderance of the evidence that there was a lack of services and supports provided to VA1, which were reasonable and necessary to maintain his/her mental health considering the physical and mental capacity or dysfunction of VA1. It was determined that 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 VA2: Concern was raised regarding VA2’s history of falls and with the level of supervision provided to VA2. P2, P4, and the CM each stated that staff were not required to watch VA2 24/7. VA2 was independent at getting up each morning and moving around the facility. In addition, VA2’s dementia was progressing, which led to an increase in his/her attempts to transfer independently. VA2’s support plan stated, “Staff should be in visual and hearing range so they can assist [VA2] as needed.” However, VA2 did not have 1:1 staffing. VA2 shared staffing with VA1 and VA3; and as such, it was reasonable to expect that staff might have a difficult time always remaining within visual and hearing range of VA2 given that VA1 and VA3 also needed help. In addition, there were timeframes, as noted in this investigation, where there was only one staff person at the facility with VA1-VA3, which would ultimately make it impossible for this sole staff person to always remain within visual and hearing range of VA2. The failure to provide services in response to VA2's identified needs was in violation of Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a). Although there was a failure to provide staff within “visual and hearing range” of VA2 at all times, it was unknown if this change would have prevented VA2’s falls. VA2 still might fall even with staff in visual and hearing range. Therefore, there was not a preponderance of the evidence whether there was a failure to supply VA2 with care or services, which were reasonable and necessary to maintain VA2’s 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 VA3: Concern was raised regarding VA3’s care at the facility. P1 said that s/he “never” saw VA3 out of bed. VA3 moved into the facility with one pressure sore; however, “Now has three … None of them are improving.” The facility’s Resident Notes, for December 10, 2022, through February 23, 2023, provided information that staff repositioned VA3 hourly or every two hours, provided “bed baths” and “brief changes,” conversed or watched movies with, assisted with meals, and administered medications. However, there was nothing documented about VA3 leaving his/her bed at any point during this timeframe. P2, N1, and N2 provided consistent information that VA3 was “bed bound” due to a wound on his/her coccyx. N2 said that VA3’s wounds were “improving.” VA3’s support plans stated, “[VA3] is being admitted with a large pressure sore on [his/her] upper buttock and 2 open pressure wounds on [his/her] back. [VA3] currently has a doctor’s order limiting [his/her] time in the wheelchair. [VA3] will require hourly repositioning to alleviate the pressure on [his/her] back and buttocks. Team has requested a new evaluation of wheelchair limitations and expressed concern regarding the amount of time in bed.” Although it was commonly believed VA3 had a doctor’s order stating that s/he was bed bound and/or restricting the amount of time spent in his/her wheelchair, a doctor’s order was not located by the facility or through the VA3’s primary physician/clinic. There was also nothing in VA3’s support plans that stated s/he was bed bound. Instead, there was information about “limiting” VA3’s time in the wheelchair; and that VA3 required assistance from two staff persons to get out of bed and preferred to get out of bed each day around 9 a.m. There was nothing in the facility’s documentation or VA3’s support plans about being restricted from ever getting out of bed. VA3’s support plan also included that his/her interdisciplinary team requested an evaluation of VA3’s wheelchair “limitations” and “expressed concern regarding the amount of time in bed;” however, this also did not state anything about being bed bound or restricted from ever getting out of bed. It was reasonable to expect that being left in bed would be considered by a reasonable person to be disparaging, derogatory, and humiliating; and therefore, there was a preponderance of the evidence that VA3 was subjected to conduct, which was not an accident or therapeutic conduct, and could reasonably be expected to produce emotional distress. It was determined that 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). In addition, given VA3’s reliance on staff persons for most activities of daily living, including the act of getting out of bed, and that this was not consistently provided, there was a preponderance of the evidence that there was a lack of services and supports provided to VA3, which were reasonable and necessary to maintain his/her mental health considering the physical and mental capacity or dysfunction of VA3. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. Given that the facility was responsible for hiring and training staff persons and ensuring required staffing that met the individuals’ needs was maintained, but that this was not done consistently, the individual staff persons’ responsibilities were mitigated. The facility was responsible for emotional abuse and neglect of the VA1 and VA3. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated emotional abuse and neglect for which the facility was responsible did not meet statutory criteria to be determined as serious because there was no information that VA1 and/or VA3 sustained a serious injury which reasonably required the care of a physician whether or not the care of a physician was sought. The substantiated emotional abuse and neglect of VA1 and VA3 was also considered a single incident for each because the incidents met two definitions of maltreatment. Action Taken by Facility: The facility completed an internal review, and determined that during the time of the incident, on December 24, 2022, the facility was single-staffed when it should have been double-staffed. The facility had since hired additional supervisory- and direct care-staff persons. The facility had not been single staffed on any shifts since December 24, 2022. Action Taken by Department of Human Services, Office of Inspector General: On May 24, 2023, the license holder was ordered to forfeit a fine of $2,000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal.
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