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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: 1070240-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) fell down the stairs hitting his/her head. There were concerns that a staff person (SP) was not near the VA or using the VA’s transfer belt at the time of the fall. The VA started to convulse and vomit later in the evening but was not taken to the hospital. On April 3, 2023, the VA was taken to the hospital after s/he did not seem like him/herself and was diagnosed with a brain bleed. There were additional concerns that the SP did not follow the VA’s dysphagia diet. Date of Incident(s): March 27, 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 April 12, 2023; from documentation at the facility, law enforcement records, medical records; and through seven interviews conducted with two facility staff persons (SP, P), the VA’s case manager (CM), two hospice medical professionals (MP1, MP2), and the VA’s guardians (G1 G2, and G3). The VA was nonverbal and unable to provide any information about the incident. The facility was a three-level home with an attached garage. The entry from the garage was through a door that had one step up to the main level of the home. Approximately 2 feet to the left of the entry door were six carpeted steps going down to the basement. The basement had a painted/finished concrete floor. There was one small thin black mat in front of the entry door. Straight ahead of the entry way was a large open kitchen and dining area with a dining table. The upper level contained the individual’s bedrooms, a bathroom, and a living area. The VA was diagnosed with developmental disabilities, anxiety disorder, dysphagia (difficulty swallowing), and history of aspiration (when food or liquid goes into the lungs) pneumonia. The VA enjoyed watching movies and listening to music. The Coordinated Services and Supports Plan indicated that the VA was currently on hospice and the facility provided cares based on guardian preference. The VA’s My Plan (SP-A) provided the following information: · The VA was at risk for falling. When the VA had “high energy” s/he was able to walk on his/her own. If the VA walked on uneven terrain, staff persons offered the VA a hand to keep his/her balance. Staff persons reminded the VA to go slow and use the railings in the facility. · The VA easily choked and needed support to eat more slowly. The VA was on hospice and ate and drank based off of his/her plans including pureed foods and thickened liquids. Staff persons fed the VA and thickened his/her liquids to prevent choking and aspiration. The SP, the P, and Incident Report provide the following consistent information: · The P said that the VA had weakness on his/her left side and had “good days and bad days” with walking. The VA had a history of falls and many times s/he was able catch him/herself before s/he fell to the ground. Staff persons assisted the VA with walking in parking lots on unsteady ground by offering the VA the staff person’s arm to hold. The VA had a transfer belt that could be used as needed if the VA was “really” unsteady. The transfer belt was “mostly” used if the VA was out in the community. Staff persons did not assist the VA on the stairs in the facility unless s/he appeared very unsteady. · In October of 2022, the VA had aspiration issues and numerous cases of aspiration pneumonia that damaged his/her lungs. The VA was in the hospital and not showing signs of improvement, so s/he was placed on hospice. With the VA being on hospice all preventative care was eliminated and staff persons and hospice staff persons just kept the VA comfortable. The VA’s team had a meeting in October 2022, at which time it was made clear that when there was an emergency 9-1-1 was not called and guardian approval would be needed. · On March 27, 2023, the SP worked the evening shift at the facility. The SP took the individuals at the facility including the VA out to do some shopping. The VA bought some snacks that s/he enjoyed and was excited about it. At approximately 7 p.m., when they returned, the VA got out of the vehicle and went into the facility with the other individuals. The SP got out of the vehicle to assist the VA, but by the time the SP came around the car, the VA was already going inside. · As the SP was walking into the facility, the other individuals said the VA fell down the basement stairs. When the SP came through the door and looked, the VA was conscious and lying at the bottom of the stairs. The SP went to the VA and asked him/her if s/he hurt anywhere. The VA pointed to the back of his/her head and to his/her right knee. · The SP called the VA’s hospice number and MP1 from hospice was sent to the facility. At that time, the SP also called the P. The SP assisted the VA up the stairs and to the dining table as the VA had not eaten dinner yet. The P called G1 and G2 to inform them about the fall. · MP1 arrived from hospice and noticed a bump on the back of the VA’s head and the SP asked if the VA might have a concussion. MP1 said s/he did not think so as the VA was responsive, his/her vitals were normal, and s/he did not display any other symptoms. MP1 said it was possible the VA could have a mild concussion and the SP was to watch for any changes. MP1 spoke with G1 and G2 about the VA’s fall and condition and then left the facility. · Shortly after, at approximately 8:15 p.m., the VA ate all his/her dinner and had his/her medications. At 9 p.m., the VA went from the dining room chair down to his/her knees and then to the floor. The VA appeared to be having seizure like convulsions and his/her eyes were rolled back into his/her head. After approximately five minutes, the VA started vomiting. The SP supported the VA ‘s head and made sure the VA was on his/her side. The VA was unresponsive, so the SP called the P and MP1 on a three-way call. · The P called G1 and G2 to let them know of the changes and asked if the P should call 9-1-1 or wait for MP1 to arrive. G1 and G2 said to wait for MP1. · The P arrived at the facility and assisted the SP to clean up the VA and get him/her into bed. MP1 arrived at the facility sometime later and assessed the VA while the SP was completing an incident report. · The P was at the facility on March 29, 2023, and the VA seemed very tired. The P called G1 and G2 to let them know and also a staff person from hospice (possibly MP2) came out and updated G1 and G2 as well. On March 31, 2023, G1 and G2 picked up the VA for the weekend. When the VA returned on April 2, 2023, G1 and G2 said the VA fell while at their home. On April 3, 2023, G1 and G2 called and said to call an ambulance to get the VA checked out at the hospital. The VA went to the hospital and was admitted. · The VA was on a dysphagia six diet which consisted of all food being mushed with a fork to apple sauce consistency and should be fed to the VA by staff persons. At some point, the VA also started on thickened liquids. The SP said that on one occasion, a hospice worker came in while the SP was feeding the VA. The previous staff person had made beef stew in the crock pot and the SP put some in a bowel. The hospice worker noted that the food looked chunky, but s/he did not watch the SP feed the VA. The food was soft, and the SP mashed it with a fork before feeding it to the VA. MP1 provided the following information: · MP1 was on call on the evening of the incident and had seen the VA on other occasions but did not regularly work with the VA. The SP called and said the VA had a fall with a head strike. When MP1 arrived, the VA was sitting at a table and was able to move all his/her appendages and his/her pupils were responding. When asked if anything hurt, the VA touched a spot on his/her head. There was a small hematoma on the back of the VA’s head, but the VA seemed to be at his/her baseline. · MP1 called G2 and was “brutally honest” with him/her and explained if G1 and G2 did not want to send the VA in for an evaluation, multiple things could happen. G1 said that s/he wanted to “wait and see” what happened. Since staff persons had already given the VA something for pain, MP1 advised staff persons to use an ice pack on the hematoma and check on the VA every hour during the night. MP1 left the facility. · Later that evening the SP called MP1 again and reported that the VA was having seizure activity and was vomiting. When MP1 arrived at the facility, the VA appeared to be at baseline and was “excited” and moved around when s/he saw MP1. When asked if s/he was in pain, the VA did not indicate anything. MP1 spoke with G2 again explaining the consequences (more seizures, more falls, death) of not having the VA evaluated and G2 indicated that s/he did not want the VA to be evaluated at the hospital. MP1 noticed the VA “twitching” when the bright light turned on and thought maybe s/he might be twitching from pain versus a seizure. The VA had dysphagia issues and it was not uncommon for him/her to vomit. MP1 ordered lorazepam for possible seizures but s/he did not witness any seizure activity while at the facility. MP2 provided the following information: · MP2 saw the VA twice a week following his/her hospice enrollment. On the day of the fall MP2 saw the VA in the morning before the VA’s fall and the VA seemed to be at his/her baseline. Two or three days following the VA’s fall, MP2 saw the VA at the facility. The VA had blood shot eyes and complained of head pain and pain in the elbow area. MP2 updated G1 on the VA’s change in condition. The VA went to G1 and G2’s home the next day to stay the weekend. On Monday when the VA returned to the facility, G1 and G2 wanted the facility to bring the VA to the hospital to be evaluated. Until G1 and G2 saw more decline in the VA’s condition, they did not want to VA to go to the hospital. · The VA had times when s/he was more unsteady and staff persons were to have hands on the VA when the VA was not in the facility. MP2 ordered a transfer belt that staff persons were to use when the VA was outside of the facility. When the VA was at home, s/he used the railing when going up and down the stairs and walked independently. · MP2 said that when a person is on hospice, they are provided comfort measures and do not typically go to the hospital unless the family want them to. Hospice handles the individuals’ symptoms from home. Since hospice had the ability to handle the seizures with lorazepam, G1 and G2 did not want the VA to be evaluated at the hospital until they saw more of a decline which occurred three to four days later. · MP2 did not have any concerns with staff persons following the VA’s diet. The VA ate fast so staff persons fed the VA to slow him/her down and made sure the VA stayed upright for 45 minutes to an hour after s/he ate to make sure the VA did not aspirate. G1 and G2 provided the following information: · The VA did not have a normal gait and his/her foot drug on the ground when s/he walked. Staff persons held the VA’s arm or used a transfer belt when needed. · On the day of the incident, G1 and G2 were informed that the VA had fallen and talked with MP1. MP1 took the VA’s vitals and said s/he was “fine.” G1 called the facility “every day” to get an update on the VA’s condition and the facility kept telling G1 that the VA was “fine.” · On March 31, 2023, G1 and G2 picked up the VA from the facility. The VA’s eyes were bloodshot and kept rolling back into his/her head. G1 and G2 brought the VA to their home where the VA slept a lot. G1 and G2 decided to bring the VA back early on April 2, 2023, and had a hospice staff person meet them at the facility to evaluate the VA. The hospice staff person took the VA’s vitals and recommended more lorazepam and morphine for comfort. · On April 3, 2023, G1 and G2 decided that an ambulance should be called for the VA, and s/he was taken to the hospital. · On one occasion, G1 was told by a hospice staff person that they saw the VA’s plate of food that the SP was preparing, and the food was not cut up according to the VA’s pureed diet. The hospice staff person mentioned it to the SP, but the SP did not do anything about it. The Residential Communication Form filled out by MP1 indicated that on March 27, 2023, the VA fell down six steps and struck his/her head. There was a golf ball sized hematoma on the back on the VA’s head and Tylenol was given for a headache. The VA was alert and at baseline. The right pupil was slow to react, and the left pupil was large but reactive. Staff [person] Notes provided the following information: · On March 21, 2023, the VA has an episode of vomiting and coughing up phlegm while eating. On March 22, 2023, the VA’s diet was changed to a pureed diet with honey thickened liquids. The VA’s oxygen was also low and oxygen was ordered. · On March 23, 2023, the VA was weaned off oxygen and it was ordered as needed for comfort. · On March 25, 2023, the VA slept until 1 p.m. · On March 28, 2023, hourly overnight checks were completed with the VA responding throughout the night. · On March 29, 2023, the VA slept until 12:30 p.m. · On March 30, 2023, the VA slept until 10 a.m. The VA needed assistance to get up, bathed, and dressed. When walking down the stairs, the VA attempted to grab the railing with his/her right hand, but his/her arm just dropped to his/her side. The VA’s eyes were bloodshot. MP2 was called to check the VA over. MP2 talked with G1 to inform him/her of the weakness the VA was having. · On April 2, 2023, MP2 came to check on the VA per G1’s request. The VA had been at G1 and G2’s house over the weekend and was doing worse. G1 reported the VA had slept all weekend. The VA was not able to focus on anything and his/her eyes rolled into the back of his/her head. · On April 3, 2023, the VA was very unsteady, his/her eyes were bloodshot and not focusing. G1 and G2 were called, and they instructed staff persons to call 9-1-1. The VA was taken to the medical center. Hospice information indicated that hospice should be called for any change in condition, especially a decline, temperature, nausea, vomiting, any time there was a fall, and prior to transport to hospital, or calling 911. If the VA was in full code, staff persons started CPR, called 9-1-1, then called hospice. Hospital records showed the VA was admitted to the hospital on April 3, 2023, for a fall/weakness and diagnosed with an intercranial bleed, hyponatremia (low sodium in the blood), pneumonia of the right lower lobe, and constipation. The VA was prescribed Keppra (antiseizure medication) for any seizure activity and sodium chloride and urea powder for hyponatremia. Sodium levels gradually improved, and the VA was discharged on April 9, 2023. It was noted that should the VA’s hyponatremia recur, G1 and G2 did not wish to hospitalize the VA. All staff persons interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults Act, the VA’s plans, and the VA’s hospice care plan. Conclusion: Regarding the VA’s fall: Information was consistent that on the day of the incident, the SP arrived back to the facility from an outing with the VA and other individuals that lived at the facility. The VA and other individuals entered the facility before the SP. As the SP came into the facility, the individuals said that the VA fell down the stairs and the SP found the VA at the bottom of the basement stairs which were directly to the left of the garage door. The VA was later diagnosed with a brain bleed. The VA’s plan indicated that the VA was at risk for falling but when s/he had “high energy” s/he was able to walk on his/her own. If the VA walked on uneven terrain, staff persons offered the VA a hand to keep his/her balance. Staff persons reminded the VA to go slow and use the railings in the facility. The P said staff persons assisted the VA if s/he was unsteady by using a transfer belt or by offering the staff person’s arm. Staff persons did not typically assist the VA on the stairs at the facility. The VA had a history of falls but many times was able to catch him/herself before s/he fell to the ground. MP2 said that the VA had a transfer belt that staff persons used when the VA was out in the community. When the VA was more unsteady, staff persons were to have hands on the VA when s/he was out of the facility. The SP said s/he returned home with the VA and parked the vehicle in the garage. The VA got out of the vehicle quickly and entered the house before the SP could get out of the vehicle and to the VA. Although the VA had a fall that caused serious injury, given that the VA got out of the vehicle quickly and entered the facility before the SP could get to him/her, that the VA’s plan did not indicate that staff persons had to use a transfer belt or have hands on the VA at all times, and that staff persons indicated that the VA did not require much assistance when inside the facility unless s/he was unsteady, there was not a preponderance of the evidence whether staff persons failed to provide care which was reasonable and necessary to maintain the VA’s physical health. Regarding the VA’s medical care: Information was consistent that on the evening of the incident, MP1, G1 and G2 were all contacted about the VA’s fall and again after the VA vomited and had what appeared to be seizure activity. MP1 came to the facility on both occasions to assess the VA and also spoke with G1 and G2 who decided not to have the VA evaluated at the hospital. G1 and G2 remained in contact with MP1, MP2, and other facility staff persons thought out the following week and received updates on the VA’s condition which appeared to worsen as the week progressed. The VA went to G1 and G2’s home that weekend, where the VA’s condition continued to worsen. The VA arrived back at the facility on Sunday, April 2, 2023, following the fall and was again evaluated by MP1 or MP2. On Monday April 3, 2023, G1 and G2 relayed to the facility that they wished to have the VA evaluated at the hospital and the facility called 9-1-1. The VA was transported to the hospital and admitted. The VA was diagnosed with an intercranial bleed, hyponatremia (low sodium in the blood), pneumonia of the right lower lobe, and constipation. The VA was on hospice care during which s/he was provided comfort measures and would not typically go to the hospital unless the family wished. Given the VA was on hospice during which s/he received only comfort measures as directed by his/her family, that staff persons contacted both hospice staff persons and G1 and G2 after the incident, and many additional times during the following week, and that when G1 and G2 indicated that they wanted the VA evaluated, the facility called 9-1-1, 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. Regarding the VA’s diet: G1 said that s/he was told that on one occasion when the SP worked, the VA’s food was not cut up according to the VA’s pureed diet. MP2 did not have any concerns with staff persons following the VA’s diet. The VA ate fast so staff persons fed the VA to slow him/her down and made sure the VA stayed upright for 45 minutes to an hour after s/he ate to make sure the VA did not aspirate. The SP said the VA was on a dysphagia diet which included all food should be mushed with a fork to apple sauce consistency and should be fed to the VA by staff persons. At some point, the VA also started on thickened liquids. On one occasion, a hospice worker came in while the SP was feeding the VA. The previous staff person had made beef stew in the crock pot and the SP put some in a bowel. The hospice worker noted that the food looked chunky, but s/he did not watch the SP feed the VA. The SP stated that the food was soft, and the SP mashed the food with a fork before feeding it to the VA. Although it was reported that the SP did not follow the VA’s diet, given the SP indicated that although the food may have looked chunky on the plate, s/he mashed the food as it was soft from being in the crockpot, and that MP2 had no concerns with any staff persons following the VA’s diet, 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). Action Taken by Facility: The facility completed an internal review and determined and determined that policies and procedures were adequate and followed. The facility changed the VA’s staff ratio to one to one if s/he was out in the community. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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