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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: 1111823-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady 651-431-6557 Suspected Maltreatment Reported: It was reported that there were multiple concerns about the care that was provided to a vulnerable adult (VA) including issues related to personal hygiene, food and fluid intake, supervision, use of adaptive equipment, privacy, and pain medications being available. Several concerns involved a supervisory staff person (SP). Date of Incident(s): Ongoing, prior to October 27, 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 October 27, 2022; from documentation at the facility and medical records; and through interviews conducted with five facility staff persons, the VA’s case manager, and a family member/guardian of the VA. This investigator met the VA, but due the VA’s diagnoses, the VA was not able to provide information pertinent to the investigation. On October 27, 2022, this investigator and two Minnesota Department of Human Services (DHS) Licensors from Home and Community-Based Services conducted an unannounced site visit to the facility regarding the maltreatment concerns with the VA and a licensing review regarding concerns related to consumer care. REM Minnesota Community Services, Inc. (REM) took over the facility from another provider in July 2021. The facility was a two-story home with a finished basement. The main level included a living room in the front of the home and a family room at the back of the home. There was also a kitchen and dining area. There were no bedrooms on the main level. The lower level had a common area and the VA’s bedroom. The second story had three other consumers’ bedrooms. There was a stair lift chair between the main and lower levels. The VA’s program plans stated: · The VA’s diagnoses included a profound intellectual disability and seizure disorder. The VA was not able to communicate verbally. · The VA was able to walk short distances with staff person assistance using a gait belt. If the VA was not able to walk, staff persons were to transfer the VA into a wheelchair. The VA had a chair lift to go from the lower level of the house to the main floor if s/he was unsteady. · The VA had a seizure watch which the VA was willing to wear. When the VA woke up in the morning staff persons were to make sure the watch was charged and put it on the VA. The VA was unable to communicate if s/he was having a seizure. Staff person were to observe the VA for the following symptoms related to seizure activity including a blank stare, unresponsiveness, drooling, mouth chewing, cyanosis, and convulsions. When the VA had a seizure, staff persons were to make sure s/he was safe and follow his/her seizure protocol which included documenting the seizure. · In the VA’s bedroom, the VA had an alarm mat with a sensor in it to alert staff persons if s/he got out of bed or if s/he rolled out of bed. The mat was kept under the VA’s bed and staff persons were to pull it out from under the bed when the VA was in bed. · The VA was authorized to have 14 hours of one to one staff person support each day. · The VA enjoyed listening to music and watching movies, especially musicals. The VA also enjoyed being outside and sitting in the sun. A Nutritional Assessment dated October 20, 2022, stated: · The VA weighed 127 pounds with a goal body weight of 130 to 140 pounds. The VA lost 20 pounds prior to placement of a G-tube (which was in August 2021). · The VA was to have a liquid supplement up to four times a day via G-tube. If the VA ate a full meal, the liquid supplement could be held. The G-tube was to be flushed with 30 milliliters (ml) water before and after each feeding. In addition, the VA was to receive 200 ml of water through the G-tube four times a day. While using the G-tube, the VA’s head was to be elevated 45 degrees and was to remain elevated for 30 minutes after s/he was done. On the day of the site visit, the VA’s alarm mat was under the VA’s bed. There was a sign on a wall next to the bed that stated that staff persons were to move the mat from under the bed to floor alongside his/her bed. The mat needed to be in proper position to alert staff persons to any falls, seizures, or if the VA tried to get out of bed on his/her own. The sign also said that the VA had instances where s/he rolled him/herself out of the bed and was not discovered for several hours. A staff person (P1) provided the following information in the facility internal review and to DHS: · P1 typically worked overnights. P1 stated that the VA received fluids via his/her G-tube four times a day. The VA was also able to have fluids via mouth. The VA typically received food via G-tube in the morning but if needed could be fed via his/her G-tube three more times during the day. There used to be documentation kept in a food log of when the VA ate food each day, but that was no longer kept (P1 said that after the site visit by DHS, a food log was in place again). P1 believed that the SP only fed the VA via G-tube twice a day and only flushed the G-tube twice a day. P1 believed that the VA was not getting enough food and water, but did not have “proof.” It was hard to get an accurate weight on the VA, but P1 believed that the VA lost 20 pounds in the last year. · P1 did not believe that the VA’s seizure watch was being utilized due to either the VA not wearing it or if s/he was wearing it and if it was charged, staff persons did not know to access the phone connected to it. Since REM took over the facility, the VA only had two known seizures. P1 did not believe that the alarm mat by the VA’s bed was being used and staff persons were not trained how to use the mat. After DHS was at the facility, there was a mat schedule put in place for the mat. The SP told P1 that the watch would not detect the type of seizures of the VA typically had, but P1 believed that it did. The SP did not use the VA’s seizure watch or alarm pad. · The VA required one to one care from a staff person and two staff persons were always supposed to be in the facility. P1 was aware of one staff person who was told when the VA was downstairs and the staff persons were on the main level, they could use a “baby monitor” and did not have to check on the VA. · The VA wore incontinence briefs. At times, P1 marked the VA’s brief when s/he left in the morning and when P1 came back at the evening, the same brief was on the VA. The SP left the VA in his/her bed in the basement without supervision and did not change the VA’s brief during the day. One time, P1 arrived for a night shift and found the VA on the floor and the VA’s brief was soaked. P1 assisted the VA back into bed and the VA fell out of bed again. P1 then made the VA comfortable on the floor and s/he slept on the floor. P1 found the VA on the floor the next couple days (October 6 and 7, 2022). The two nights s/he found the VA on the floor, it was one of either two staff persons (P6 and P7) working before P1. When P1 found the VA on the floor, the VA was not hurt but was uncomfortable and soaking wet and cold. The following weekend, P1 did not think staff persons spent time with the VA and s/he was in the basement all day. With the VA fell out of bed, P1 saw quarter size bruises on the VA’s knees but otherwise s/he did not have other injuries. P1 reported to the SP that staff persons were not changing the VA’s brief or getting the VA out of bed. · On the occasion P1 found the VA on the floor and had the VA sleep on the floor, P1 went to get a Tylenol for the VA because the VA was uncomfortable and P1 wanted to give the VA an as needed (PRN) pain medication. Tylenol was the only PRN pain medication on the standing order list, but the facility only had liquid Tylenol and it was the wrong strength. P1 called the SP (it was a Friday morning) about the Tylenol as the SP was responsible for ensuring that PRN medications were at the facility. When P1 arrived Friday night there was still no Tylenol at the facility so the following day, P1 called an administrative staff person (P12) and P12 arranged to have Tylenol delivered to the facility. · The VA was diagnosed with shingles. (A Medical Referral dated October 12, 2022, stated that the VA was diagnosed with shingles on the left side of his/her face.) When the VA arrived back to the facility from being diagnosed with shingles, the VA was prescribed medications for the shingles that made him/her drowsy. P1 believed that the VA should have been immediately taken downstairs after returning from the appointment as after the VA took his/her new medications, the VA would be unsteady, and it would not be safe to take him/her downstairs. P1 left after the VA returned from the appointment and when s/he arrived back six hours later, the VA was still in living room where s/he was when P1 left. At that time, the VA’s brief were soaked through to the point of falling apart. The first night after the appointment, the VA slept on the living room floor, then a bed was brought up to the family room for the VA to sleep. The bed was not safe as it was too high off the floor and the VA had no privacy because s/he was in the family room (at the back of the facility). According to charting that day, the VA only received two G-tube feedings and the VA was fed laying down instead of at a 45 degree angle. There were no issues with aspiration during that time. · P1 was concerned that the VA’s ears were not being cleaned as required. Prior to REM taking over the facility, the VA went every three to five months to have his/her ears cleaned. · The SP did not bathe the VA or brush the VA’s teeth. Staff persons’ training on the VA was not up to date. A staff person (P2) provided the following information in the facility internal review and to DHS: · P2 typically worked overnights. The VA was supposed to get fluids four times a day via his/her G-tube, plus whatever s/he drank by mouth. The was able to eat food orally, but if s/he refused to eat, s/he was to be fed via his/her G-tube. The VA was able to be fed up to four times a day via his/her G-tube. · The VA had a seizure watch and the watch needed to be charged daily because s/he wore it 24 hours a day unless s/he was in the shower. P2 believed that the watch tracked all types of seizures. P2 stated that s/he “doesn’t believe the watch is charged.” The SP and P12 reported that it was charged, but P2 said that “it has not been charged a single time.” P2 believed that the watch was not tight enough on the VA’s wrist to work correctly. The watch worked in conjunction with a phone, but staff persons were not able to get utilize it because they did not have the code. · P2 stated that the VA had been left in soiled briefs for a long period of time. P2 could tell because s/he could “smell the urine” when s/he arrived and the VA was “cold,” and his/her pants and shirt were “completely wet.” On October 26, 2022, a staff person (P11) called P2 because P11 found the VA on the floor when s/he went to assist the VA into bed. P2 went to the facility and when s/he arrived 15 minutes later, the VA was still on the floor. P11 and P2 assisted the VA into bed and at that time P2 noticed that the VA’s pants were soaked and it looked like they had been that way for longer than 15 minutes. P2 brought his/her concerns about the VA to the SP and P12, but they did not “listen” to P2. · When P2 arrived for overnights, the VA was usually in bed, but staff persons did not have the alarm mat in place as the alarm mat was still not being pulled out when the VA was in bed. · On October 12, 2022, P2 arrived at the facility and took the VA to an appointment where the VA was diagnosed with shingles. P2 stated that the VA was prescribed a PRN for Artificial Tears at his/her shingles appointment (there was no documentation of this on the Medical Referral dated October 12, 2022), but there was no Artificial Tears at the facility. Also at that time, the VA was in pain and there had been no Tylenol or Ibuprofen in the facility for “two/several months.” After the appointment, P2 and the VA returned and talked to the SP and it was decided that the VA would be safest in his/her bedroom. P2 then stated that because of the VA’s medications for shingles, it was unsafe to transfer the VA to his/her wheelchair and to go downstairs so the VA had to sleep on the floor that night in the living room. Other consumers had to step around the VA. P2 worked that night with the VA when the VA slept on the floor. When P2 came back to work the following night, there was a bed set up for the VA on the main floor in the family room. P2 thought that the bed was too high for the VA, and it did not have bed rails. The VA also had no privacy in the family room. · P2 was not sure that the VA was getting his/her liquids and proper nutrition as there was no documentation about the VA’s care. Prior to being diagnosed with shingles, the VA had been left in the basement for hours and days. P2 was concerned that some medications that were not supposed to be given through the G-tube were crushed and given through G-tube. The SP did not know how to package medication correctly and P2 believed that the VA was not getting the correct medications on the correct days. Staff persons called P2 with questions instead of the SP because the SP “doesn’t know anything” and told staff persons to call P2. · P2 had concerns that the VA’s ears were not being cleaned every four months as required and did not believe s/he had them cleaned since REM took over. P2 could see wax in the VA’s ear. · The VA did not get showered very often if P2 was not working. P2 stated that s/he knew “for a fact” that the VA was not “showered for weeks.” · P2 stated that the SP “makes me sign papers without reading them” and P2 believed that the staff persons were not properly trained to work with the VA because the VA’s needs changed daily. A staff person (P3) provided the following information in the facility internal review and to DHS: · The VA received fluids through his/her G-tube four times a day. When using the VA’s G-tube, the VA was to have his/her upper body at a 45 degree angle and remain in that position for 30 minutes after s/he ate. If the VA refused to eat regular food, s/he could be fed via his/her G-tube. P3 was concerned that some staff persons did not try to have the VA eat food orally before feeding him/her via his/her G-tube. One time when P3 first started working at the facility, P3 worked with a staff person (P6) and P3 did not think that P6 gave the VA any fluids through his/her G-tube. · P3 was concerned that some staff persons left the VA in bed and did not check on him/her on regular basis. The VA was to be repositioned every two hours when the VA was in bed. On two occasions in the afternoon, P3 found the VA in a soiled brief. At times when “regular” staff persons worked, when P3 arrived in the morning, the alarm mat was next to the bed, but sometimes when float staff persons worked, it was under the bed. A couple months prior to the investigation, there was a time that the facility was out of Tylenol. · A staff person was supposed to be with the VA at all times. If the VA was in bed a staff person was to be in the basement. The facility did not always have two staff persons working at a time because they did not have enough staff persons to work. At times staff persons had to go back and forth between the basement and upstairs and in those cases the VA had an auditory monitor so staff persons could hear the VA if they were on the main level. If P3 worked alone s/he tried to have the VA be on the main floor instead of in the basement. At the time of the investigation, the facility had two staff persons scheduled to work. · The VA had a seizure watch, but P3 did not know if the VA’s seizure watch worked and did not think that the phone line associated with the watch was activated. · P3 did not think the VA was getting his/her teeth brushed regularly. · P3 said that s/he was adequately trained to work with the VA, but did not think P6 was adequately trained. A staff person (P4) provided the following information in the facility internal review and to DHS: · P4 worked at the facility about once a week. The VA received fluids through his/her G-tube four times a day. If the VA refused to eat, the VA was to be fed through his/her G-tube. The VA’s head was to be elevated with using the G-tube. · P4 checked the VA’s brief every two hours. P4 was not aware of the VA being in a soiled brief for a long period of time. · If two staff persons were working, one was with the VA. If P4 worked alone and the VA was downstairs, there was a monitor in the VA’s bedroom and P4 would check on him/her as often as s/he could. P4 pulled out the alarm mat if the VA was in bed. P4 was not aware of anytime that the mat was not beside the VA’s bed. P4 would be able to hear the alarm mat through the monitor. P4 was not aware of the VA falling out of bed. The VA wore his/her seizure watch but P4 was not sure if it detected small seizures. · P4 never had issues with PRN medications not being available at the facility. · P4 was “trained well” regarding the VA. P4 did not have concerns about other staff persons and how they worked with the VA. The facility’s internal review included the following information from seven additional staff persons (P5-P11): · P5 stated that s/he did not regularly work at the facility. The VA received fluids four times a day via his/her G-tube and if the VA refused to eat, the VA was fed via his/her G-tube. P5 was not aware of the VA being left in soiled briefs for long periods of time. When P5 worked with the VA, P5 was typically with the VA and if the VA was in his/her bedroom, P5 checked on the VA at least every two hours. P5 was never aware of the VA falling out of bed and the alarm mat was always on when P5 worked. When P5 worked, PRN medications were available. It was difficult to shower and dress the VA unless two staff persons were working. P5 believed that s/he was “adequately” trained to work at the facility. · P6 stated that s/he worked sporadically at the facility. The VA received fluids via his/her G-tube three or four times a day. When the VA ate, the VA would also drink juice. If the VA refused to eat, the VA was fed via his/her G-tube. P6 was not aware of the VA being left in soiled briefs for long periods of time. The VA was typically on the main floor with P6 when P6 worked, but if the VA was downstairs, P6 checked on him/her every 30 to 60 minutes. P6 was never aware of the VA falling out of bed and the alarm mat was always on when P6 worked. The VA always wore his/her seizure watch, but P6 never saw the VA have a seizure. When P6 worked, PRN medications were available. P6 was “well trained” to work at the facility and when P6 worked with the VA, P6 provided the VA with his/her required cares. · P7 stated that s/he did not work at the facility very often. When P7 did work, s/he asked questions to make sure s/he knew what to do. P7 was not aware how often the VA received fluids, but was aware that if the VA refused to eat, the VA was fed via his/her G-tube. P7 was not aware of the VA being left in soiled briefs for long periods of time. P7 was not aware of the alarm mat having to be used if the VA was in bed and was not aware of the VA’s seizure watch. The VA never fell when P7 was at the facility. PRN medications were always available when P7 worked. Because of the VA’s medical issues, it was difficult for P7 to keep up on training when not working regularly with the VA. · P8 stated that the last time s/he worked with the VA, the VA received fluids four times a day via his/her G-tube. If the VA refused to eat, the VA was fed via his/her G-tube. P8 was not aware of the VA being left in a soiled brief. At times the VA could go a long time without urinating so when the VA went, the VA’s brief would be soaked. If the VA was in bed, P8 checked on him/her about every 20 minutes. When P8 worked, P8 used the alarm mat and the VA wore his/her seizure watch. PRN medications were always available when P8 worked. P8 received training to work at the facility, but thought everyone could “always” use more training. · P9 stated that s/he used to work sporadically at the facility, but had not worked there for a long time. The VA received fluids four times a day and if the VA refused to eat, the VA was fed via his/her G-tube. The VA wore his/her seizure watch. P9 was aware of the alarm mat, but was not sure if s/he used it last time s/he worked since it had been a while since s/he last worked. · P10 occasionally worked at the facility. The VA received fluids via G-tube and orally throughout the day. If the VA refused to eat, the VA was fed via his/her G-tube. When P10 worked at the facility there were always two staff persons working and one was with the VA. P10 was not aware of the VA being left in a soiled brief. When the VA was in bed, the VA’s alarm mat was beside his/her bed. P10 did not have any concerns regarding PRN medication availability at the facility. P6 also did not have any concerns about his/her training. · P11 occasionally worked at the facility. The VA received fluids via G-tube four times a day. If the VA refused to eat, the VA was fed via his/her G-tube. P11 was not aware of the VA being left in a soiled brief. The VA wore a seizure watch. If the VA was downstairs, P11 checked on the VA every 30 to 60 minutes. The VA’s alarm mat was next to the bed if the VA was in bed. P11 was not aware of the VA falling out of bed. PRN medications were available at the facility. P11 was trained to work with the VA. It was difficult to work at facility if there was only one staff person working. In the internal review, P12 provided the following information: · In July 2021, when REM took over the facility, the VA was living in a transitional care unit (TCU). At the TCU the VA refused to eat and lost 20 pounds. Hospice was considered at that time, but the VA’s family member/guardian (FM) and the VA’s case manager (CM) did not want hospice so the VA received a G-tube and was discharged back to the facility. · On October 8, 2022, P12 received a text from P1 that there was no Tylenol at the facility, other than liquid for children, so P12 arranged for a staff person to deliver some within a couple hours. P1 told P12 that s/he contacted the SP, but did not receive a response. · When the VA was diagnosed with shingles, one of the medications made him/her lethargic so due to concerns about getting the VA to the basement, the VA stayed upstairs for a few nights. Once the VA was able to go downstairs, s/he went back to his/her bedroom. While in the family room the VA had a bed but there were concerns that it was too high so the mattress was moved to the floor. If the VA needed privacy the other consumers were asked to leave the area. · P12 said that the SP talked to the seizure watch company and they said that the watch would not detect the small type of seizures that the VA typically had. The SP told P12 that the VA had a seizure mat but staff persons were not always pulling the mat out from under the bed at night. The SP provided the following information provided the following information in the facility internal review and to DHS: · The VA received fluids four times a day through his/her G-tube. The VA was offered food to eat and if s/he did not want to eat, the VA was fed via his/her G-tube. The VA’s head was to be elevated at 45 degrees when receiving food or water and the VA was to remain in that position for 30 minutes after s/he was done. · If the VA was downstairs in bed, the alarm mat was pulled out beside his/her bed. If staff persons were not downstairs, there was a monitor so they could hear the VA. If the VA was sleeping staff persons were to check on him/her every 30 minutes. If the VA was not sleeping, the SP was not sure how often staff persons were expected to check on him/her. During the day staff persons might check on the VA every hour or couple hours. The VA’s brief was to be checked every couple hours. The SP was not aware of staff persons not supervising the VA as required. · In January or February 2022, the SP set up the seizure watch for the VA and did not know it was not working until “recently." At times, the SP found the watch in drawers or in the staff person office. At the time of the investigation, the SP said that the watch was working. The watch had to shake to sound an alarm, so it did not detect small seizures. · After the VA was diagnosed with shingles, due to the VA being lethargic, it was not safe to take the VA downstairs so a bed was set up in the family room. When the VA needed privacy, the other consumers were asked to go into the living room or somewhere else in the facility. Staff persons had concerns about the height of the bed that was used for the VA, so the mattress was placed on the floor. The CM and FM were notified about the VA being in the living room. (The CM stated that s/he was aware that the VA slept in the living room after the shingles diagnoses.) · On October 7, 2022, P1 called the SP about there not being Tylenol at the facility, but the SP forgot about the Tylenol until P12 called the SP the next day and told him/her that a staff person brought Tylenol to the facility. · The SP was not aware of the VA being left in bed or in his/her wheelchair too long. · P1 and P2 brought concerns to the SP about float staff persons not taking care of the VA. All staff persons, including floats and fill in staff persons, who worked with the VA were trained to work with the VA. The SP did train the float staff persons or had long term staff persons train the float staff persons. With the different staff persons who worked at the facility, the SP was able to look at documentation to ensure that all staff persons were doing what they were supposed to be doing. · Due to staffing shortages, there was more often one staff person working at a time as opposed to more than one staff person working at a time. The SP was aware that the VA had funding available for one to one staffing. The SP said that the facility provided care to the VA that they were supposed to provide. A Medical Referral dated November 10, 2022, showed that the VA had an impaction in his/her right ear and the ear was cleaned out. The VA’s progress notes between August 14 and November 14, 2022, supported staff persons descriptions of the VA being found on the floor on occasions, having a soaked brief, and the VA’s time spent in the living room after the shingles diagnoses. The VA’s Medication Administration Records for September and October 2022, included the following: · In September 2022, the longest the VA went without a shower was four days where s/he was either sleeping or refused. In October 2022, the longest the VA went without a shower was 10 days. · In September 2022, there were two days where documentation indicated that the VA did not get his/her teeth brushed. Otherwise, the VA got his/her teeth brushed at least once a day. In October 2022, the VA did not have his/her teeth brushed for more than half the days with various reasons documented why s/he did not. · In September and October 2022, there was not always completed documentation of the VA’s daily fluid intake. · On October 10, 2022, the facility began documenting seizure alarm mat positioning and there were two days in October where it was not documented as positioned. The VA’s family member/guardian (FM) stated that REM took over the facility from the former provider in July 2021. The former providers had protocols for everything, but REM did not continue those protocols. The FM was concerned about what s/he had been told about the VA’s care. The FM was concerned about staff person training and whether the VA’s staffing was consistent with what s/he was supposed to receive. Facility documentation showed that some staff persons received training on some parts of the VA’s care plan including the G-tube, but there was no documentation that all the staff persons received training on the VA’s program plans. According to the internal review, the facility took the following action regarding the allegations: · The facility was going to work with the seizure monitoring company to ensure that the VA’s watch was working correctly. · The VA’s seizure protocol was being revised and sent to the VA’s physician for approval. · The VA’s Health Needs Record was be revised to include all medical/adaptive equipment used by the VA. · The alarm mat was to be kept out at all times except when staff persons were transferring the VA in and out of bed. · The VA’s program plans were revised to reflect any changes and staff persons were to be retrained on any changes. · Staff persons were also retrained on documenting fluid and food intake, medications, treatments, and shift notes. · A new supervisory staff person was assigned to oversee the facility. DHS licensing reviewed all the changes made by the facility in response to licensing concerns regarding consumer care and accepted the facility’s action taken and did not take any corrective action. Conclusion: There were multiple concerns reported regarding the VA's care including sitting in soaked briefs, not using the VA's bedside alarm mat and seizure watch, not giving the VA the required feedings and liquids via his/her G-tube each day, not having PRN meds available for the VA, not bathing the VA or brushing the VA's teeth, and not having privacy on the main floor. Interviews with 12 staff persons by this investigator and/or the facility, and documentation at the facility showed that there were occasional failures to follow the VA's plans or complete the VA’s cares. However, there was no information there was harm to the VA. In addition, staff persons stated that they at least had some training regarding taking care of the VA. Furthermore, after DHS conducted a licensing and maltreatment investigation, the facility took corrective action to address the concerns regarding the VA. Therefore, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services which were reasonable and necessary to obtain or maintain the VA’s physical or mental health or safety. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were adequate but not followed. In addition to the action taken listed above in the report, the SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: Regarding the allegation of maltreatment, no further action was taken. In addition, as stated above, DHS licensing reviewed changes made by the facility in response to licensing concerns regarding client care and accepted the facility’s action taken and did not take any corrective action.
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