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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: 1103760-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: It was reported that the facility failed to manage a vulnerable adult’s medications in a manner adequate to prevent lapses in administration. Date of Incident(s): March 17 through 20, 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 10, 2023; from documentation at the facility, law enforcement records, and medical records; and through interviews conducted with the VA’s guardian (G) who was also the VA’s family member and two facility supervisory staff persons (P1 and P2). At the time of the site visit, the VA declined to be interviewed. The VA’s support plan and support plan addendum provided the following information: · In 2020, the VA moved into the facility seeking supports and services relating to his/her diagnoses, which included mood disorder, anxiety disorder, and schizophrenia. · The VA had 2:1 staffing during daytime hours; and during overnight hours, had one awake staff and one asleep. · “[The VA] has a history of being non-compliant with [his/her] medication. [The VA] has been known to cheek [his/her] medication in the past. [The VA] has therapeutic medication lab levels taken weekly. After medication administration, [the VA] will run to [his/her] room or to the bathroom and spit [his/her] medications out in [his/her] room or the bathroom and flush them down the toilet.” · “Staff remind [the VA] the importance of taking [his/her] medication. [The VA] does sit at the table to receive [his/her] medication. Staff will supervise [the VA] when [s/he] is taking [his/her] medication, offering a full glass of water, having a conversation, or engaging in an activity if [the VA] chooses. [The VA] will talk to [the G] about [his/her] thoughts and feelings as needed.” · “[The VA] has a history of verbal and violent behavior towards others … Staff will supervise [the VA] in the community and at home. Should staff discover or suspect abuse, they will get [the VA] to safety. If [the VA] is verbally aggressive, they will get themselves to safety and will encourage [the VA] to communicate with [the G] and [his/her] therapists about [his/her] thoughts and feelings.” The facility was a single-family home where the VA lived with one other housemate. The facility provided staff persons for care and supervision. The G provided the following information: · The G said that on March 18, 2023, the VA called stating that his/her lithium carbonate (bipolar therapy) 900 milligram (mg) prescription was out of doses, meaning the VA would not receive his/her prescribed dose that evening. · The VA called again on March 19, 2023, stating that his/her lithium carbonate was still not filled or available at the facility. The G hung up with the VA and text messaged the staff working at that time. The staff responded that the VA’s lithium carbonate was out of doses, and that they had called P1 and P2, left voicemail messages, but neither had responded. The G then hung up and called the pharmacy. The pharmacy stated they had not received any calls or requests for refills from the facility. The pharmacy responded by delivering a refilled lithium carbonate 900 mg prescription later that same day, March 19, 2023. · However, that evening, when staff administered the VA’s lithium carbonate, s/he spit it out and declined to take it. · The G and the CM went to the facility on March 20, 2023, around 1 p.m., to check-in with the VA. The G had previously been told by staff and the VA that the VA was not administered his/her lithium carbonate dose on March 18, 2023, and that the VA spit out his/her next dose on March 19, 2023. The staff had described the VA to the G as being “in a flight of thought mood.” Upon arriving, the G also observed the VA to be “very psychotic.” The G repeatedly tried to convince the VA to go to the hospital, and the VA repeatedly declined. The G remained at the facility until 3:30 p.m. and eventually left while the VA remained at the facility. Later that evening, during a phone call with the G, the VA agreed to go to the hospital. However, the staff did not move fast enough. The VA was yelling at the staff, “I need to go.” The G then heard the VA breaking items in the background of the call. The G hung up and called 9-1-1 requesting a response to the facility. · The G explained that the VA did not like taking his/her lithium carbonate because s/he believed they caused him/her to gain weight. · The G said that the VA’s interdisciplinary team (IDT), consisting of the G, the CM, and supervisory staff persons, including P1, met periodically to review the VA’s progress. They had previously updated the VA’s support plan addendum to include direction for staff to follow when administering the VA’s medications. (Facility information showed that this update occurred in January 2023.) Staff were to administer the VA’s medications at the dining room table and then watch him/her to ensure s/he did not spit them out. However, the G did not believe this protocol was consistently implemented. The staff were not good about remaining with the VA at the table. “It is easy to get rid of [the meds] if no one is watching.” Following the incident on March 18 – 20, 2023, the VA’s medication protocol was transferred onto a separate, stand-alone, sheet for staff to follow. The CM said that the VA had a history of “becoming unstable once a year” and during these phases, s/he would decline to take his/her medications or immediately run to his/her bedroom after receiving the medication so that staff did not know if s/he swallowed it or not. “We were never able to prove that [s/he] wasn’t taking [his/her] meds ….” The VA’s IDT had discussed a medication protocol “to help staff monitor [the VA] more closely,” but this protocol was not documented until after the incident on March 18 – 20, 2023. Facility documentation, P1, and P2, provided the following information: · In February 2020, the VA moved into the facility. The VA was under a civil commitment order, which remained in effect throughout the timeframe within this report. · The VA’s Order for Continued Commitment stated, “As part of [his/her] continued commitment, [the VA] shall comply with all after care provisions or other conditions of [his/her] provisional discharge including, but not limited to the following conditions … [The VA] shall take all medication as prescribed … [The VA] shall not engage in behavior which poses a substantial likelihood of physical harm to self or others or demonstrates that [the VA’s] treatment needs cannot be met under these conditions ….” · P1 and P2 each said the VA had a history of declining to take his/her medications. In January 2023, the VA’s IDT had a meeting regarding his/her medications. At that time, the VA’s support plan addendum was updated. Staff were to ask the VA to sit at the dining room table to receive his/her medications, and once they were administered, staff were to keep the VA at the table as long as they could to make it less likely for the VA to spit the medication out. However, according to P1 and P2, the VA typically did not stay at the table for long and typically returned to his/her bedroom shortly after receiving his/her medication. The VA then closed his/her bedroom door, which prevented staff from knowing if the VA spit the medication out or not. P2 said that staff did “their best” to encourage the VA to take his/her medications and to remain at the table after doing so, but the VA might still decline. · On February 16, 2023, changes were made to the VA’s lithium carbonate prescription. The lithium carbonate was changed to dissolvable tablets making it less likely the VA could spit them out or cheek and spit out later. The dosage was also changed from 1200 milligrams (mg) to 900 mg. At that time, the VA was given a 30-day supply of lithium carbonate 900 mg. [Note: This 30-day supply and medication change came from a hospital, not the VA’s primary doctor.] · P1 and P2 each said that the VA’s lithium carbonate prescription was a cycled medication, meaning the pharmacy automatically refilled it without a phone call. On March 3, 2023, the VA’s lithium carbonate prescription was delivered as per this cycle, but it was for 1200 mg. The pharmacy had not received a prescription for the change in dosage to 900 mg that occurred on February 16, 2023. P1 contacted the VA’s primary doctor requesting a changed prescription order be sent to the pharmacy. The facility still had 12 doses of 900 mg remaining from the 30-day supply given by the hospital. · Facility documentation included a prescription order for the VA to take lithium carbonate 900 mg daily, signed by the VA’s doctor on March 15, 2023. This “new” prescription order was faxed to the pharmacy by the clinic. [Note: P1 and P2 each said that in hindsight, looking back at this dosage change, because the VA’s lithium carbonate cycle automatically delivered every 28 days; and the latest refill, albeit the wrong dosage, was delivered March 3, 2023, the pharmacy did not plan or was not scheduled to send another refill for another 28 days. P1 and P2 each said this issue was what contributed to the forthcoming concerns on March 17 – 20, 2023.] · P1 said that on March 17, 2023, it was nearing the end of the day and s/he was headed out to facilitate a staff meeting. “Right before I was about to leave,” around 3 p.m., a staff person told P1 that the VA had one dose of his/her lithium carbonate 900 mg remaining, which was scheduled to be administered that evening at 8 p.m. After this dose, there were none remaining at the facility; a refill was needed. · P1 “wasn’t necessarily concerned” about this. P1 explained that this was not the first time the VA had zero doses remaining. In the past, P1 called the pharmacy and they would deliver a refill “the next day.” In addition, the VA typically took his/her lithium carbonate at 8 p.m. each day so there was time to prepare and ensure the prescription arrived. “I thought no matter what, we are fine.” · P1 said that s/he called the pharmacy around 3 to 3:45 p.m. and left a message on the prescription refill voice-line. P1 said that this was how s/he had previously refilled the VA’s prescriptions. The message included the VA’s name and the prescription needed to be refilled. In the past, the pharmacy did not return the call, but delivered the prescription within 24 hours. · March 17, 2023, was a Friday and P1 did not work Saturday or Sunday. P1 had been previously instructed that unless s/he was on-call, s/he was supposed to turn off his/her work cellphone when not working. P1 was not on-call that weekend and so when s/he left work for the day, s/he turned off his/her work cellphone. P1 explained that there were guidelines on who staff should contact if they needed help on a weekend (e.g., the on-call supervisor). · P1 said that on Monday, March 20, 2023, s/he returned to work and turned his/her work cellphone back on. P1 then discovered a voicemail message from Saturday March 18, 2023, from a staff person stating that the VA’s lithium carbonate 900 mg had not arrived from the pharmacy. Staff were unable to administer the VA’s lithium carbonate 900 mg on Saturday March 18, 2023. [Note: Like P1, P2 also did not work the weekend and was not on-call. P2’s work cellphone was turned off for the weekend and did receive any voicemails from staff until s/he returned to work that Monday.] · P1 checked with staff and learned that the lithium carbonate 900 mg did arrive on Sunday March 19, 2023. However, the VA “refused” to take his/her dose that day. · Facility documentation included the VA’s Medication Administration Record, which showed that staff marked the VA’s lithium carbonate 900 mg as “OH” or “on hold” for March 18, 2023. Staff then marked “M/R” or “missed/refused” for March 19, 2023. · P1 said that the VA was “starting to be more behavioral” over that weekend. Staff had contacted the G to inform him/her of what was going on and the G asked that staff take the VA to a hospital. However, when staff asked the VA to go to the hospital, s/he declined. P1 had previously asked the hospital what staff should do if the VA declined his/her lithium carbonate, and the hospital told P1 that they needed a court order to force the VA to the hospital. “We cannot force [him/her] to go to the hospital until its court ordered.” [Note: The VA had a preexisting Order Authorizing Treatment with Neuroleptic Medications (a.k.a. Jarvis order) for his/her antipsychotic medications. This did not include lithium carbonate.] · Facility documentation included Daily Logs, in which staff documented the VA’s activities during each shift; these included the following information: o March 18, 2023 – The G visited the VA in the morning. Staff brought the VA to Walmart where s/he bought a few items. “[The VA] was pretty upset because [s/he] didn’t have [his/her] phone since it’s getting fixed so that caused some behavior problems where [s/he] was yelling and stuff. Staff did talk to [him/her] and calmed [him/her] down and [s/he] was fine.” o March 19, 2023 – The VA “relaxed” in his/her bedroom most of the day. Staff brought the VA out for lunch. “[The VA’s] behavior was hyper today. [S/he] would talk a lot and jump around at times throughout the day.” o At 5 p.m., staff brought the VA to a gym. o “Around 7 [p.m.] [the VA] asked for [his/her] meds and staff brought it and [the VA] took it then spit it out in the bathroom and flushed it. [The VA] then got mad and was having behavior problems and yelling. [The VA] then threw a water bottle at staff and then smoked in the house and then went outside.” “[Staff] called [the G] to call [the VA] and help us deescalate the situation.” “[The G] gave [the VA] a call and then [the VA] calmed down.” o March 20 – “When staff arrived at 7:30 [a.m.] [the VA] greeted staff … [The VA] seemed very hyped up and staff was told the individual hadn’t taken one of their medications last night … [The VA] was jumping from conversation to conversation and was talking a lot about random topics.” The VA got “upset” at one point and was “yelling” in his/her bedroom. The CM and the G arrived, and met with the VA. The VA called various family members “and seemed to be in a better mood.” The VA was watching television and “making jokes” with staff. o “At 7 p.m. staff asked [the VA] to take [his/her] meds, and [s/he] agreed. Staff gave [the VA] [his/her] meds but [s/he] quickly ran to [his/her] room as staff asked [him/her] politely to sit and chat. Staff went by the bathroom to listen to [the VA] with the suspicion of [the VA] throwing [his/her] meds and staff did hear spitting in [his/her] room. [The VA] then came out [his/her] room with [the G] on the phone calling staff names … Staff tried to calm [the VA] down but only escalated the issue … [The VA] continued to yell at staff very loud and aggressively got closer to staff.” o “Staff asked [the VA] if [s/he] wanted to go to the hospital because [the G] suggested to take [him/her]. [The VA] got more upset and went to [his/her] room with [the G] on the phone. After a while [the VA] came out yelling telling staff to take [him/her] to the hospital. [The VA] then went out for a smoke as staff got the car ready, then continued to yell out loud and cuss staff … Staff made the decision that it’s not safe to take [the VA] and decided to call the police. While staff was on the phone with the police, [the VA] came out and ripped off a wooden stick from a board in the garage and hit the car to break off a chunk then immediately charged at staff with the stick.” o Staff locked the house doors to prevent the VA from entering as his/her roommate had guests over. “[The VA] tried to force [his/her] way in but couldn’t and charged at staff outside again. While staff was still on the phone with police [the VA] went back to go inside again from both doors, after a couple failed attempts [the VA] got the wooden stick again and went to … window to break the glass. [The VA] successfully broke the window and went [through] it … Police came and approached [the VA] to investigate … Shortly the ambulance came and checked on [the VA] and took [him/her] inside the ambulance to take [him/her].” A Sherburne County Sheriff Incident Report stated the following: · On March 20, 2023, at 8:57 p.m., 9-1-1 dispatch received a call for assistance to the facility for “a mental health call.” · A law enforcement officer (LEO) arrived and met the VA, who was “visibly bleeding” from his/her right hand. The VA declined medical attention and instead handed his/her cellphone to the LEO. The G was on the other end. · “[The G] stated that [s/he] has been requesting that the staff take [the VA] to the hospital all day, however, they were taking their sweet time and not doing anything about it. [The G] advised that [the VA] has been acting strange all day and has not been making any sense with anything that [s/he] had been saying. [The G] advised that [s/he] is pretty positive that [the VA] did not take [his/her] evening medication, as [s/he] would've been asleep by [8 p.m.] had [s/he] done so. [The G] stated that [the VA] refused to take [his/her] medication over the weekend, and has been acting off ever since. [The G] was requesting that [the VA] go to the hospital for a mental health evaluation.” · The LEO met with staff persons and the VA, who agreed to go to a hospital. The VA was taken by ambulance without further incident. CentraCare Health Records stated the following: · On March 20, 2023, “[The VA] was admitted to the Emergency Room due to psychosis, disorganization, some agitation and aggression [at the facility] with [him/her] breaking a window both in the home and on a vehicle. [S/he] had also been noncompliant with [his/her] medications again. We found out later that staff had found multiple pills in the air vents in [the VA’s] room.” [Note: On March 30, 2023, while replacing carpet in the VA’s bedroom, staff discovered lithium carbonate 1200 mg (non-dissolvable tablets) and clozapine tablets (antipsychotic, unspecified dosage) hidden in a vent in the VA’s bedroom. The pills appeared to have been spit out. The lithium carbonate tablets were the type and dosage prescribed to the VA prior to February 16, 2023. It was not known when these tablets were placed in the vent, or over what time period.] · “[The VA] has been refusing [his/her] medication for the last several days. [S/he] has been becoming increasingly confused. Today [s/he] was lashing out and punched through a window. [S/he] was bleeding from [his/her] hand. [S/he] arrives unable to provide any coherent history.” · At 10:37 p.m., that same day, the VA’s therapeutic drug levels were tested and showed the following:
· “[The VA] had a long history of noncompliance and fairly abrupt decompensation when off of [his/her] medications.” · A doctor restarted the VA’s medications in the hospital. “[The VA] improved significantly with this and was sleeping better again at night and no longer appeared manic, agitated or psychotic. [The VA] was calm and appropriate.” · The VA was admitted to the hospital’s psychiatric unit for stabilization. · On March 31, 2023, the VA was discharged from the hospital and returned to the facility. “We did put in a unique treatment plan and I discussed this with the Emergency Room staff that if [the VA] refused the [clozapine] or [his/her] medications at home that [s/he] should come into the Emergency Room, get Zyprexa 10 mg [antipsychotic, injection] per the Jarvis order and then immediately go back home with [his/her] staff. I did also discuss this with the patient and [s/he] seems motivated to continue taking [his/her] medications. [S/he] states, ‘I don't want that’ referring to the [clozapine injection].” (Note: The VA had a preexisting Order Authorizing Treatment with Neuroleptic Medications [a.k.a. Jarvis order] for antipsychotics, including Trilafon, Clozaril [clozapine], and Zyprexa. At the time of this investigation, the VA was no longer taking Trilafon or Zyprexa at the facility. Clozapine was included on the VA’s Medication Administration Record and there was no information of a concern that this medication was not being administered as prescribed. However, clozapine was one of the medications found in the VA’s vent on March 30, 2023. Lithium carbonate was not part of the VA’s Jarvis order.) The facility kept Drug Details for the VA’s medications. These were stored in the facility’s electronic database and accessible to staff persons when administering medications. The Drug Details for the VA’s lithium carbonate included the following: · WARNING: It is very important to have the right amount of lithium in your body … There is only a small difference between the correct amount of lithium and too much lithium. Therefore, it is important that your doctor monitor you closely during treatment. Keep all medical and laboratory appointments while you are taking lithium. · HOW TO USE: … This medication must be taken exactly as prescribed. Keep taking lithium even if you feel well. Do not stop taking this drug without consulting your doctor. Some conditions may become worse when this drug is suddenly stopped. Consult your doctor or pharmacist for more details …. · MISSED DOSE: If you miss a dose, take it as soon as you remember unless your next scheduled dose is within 6 hours. In that case, skip the missed dose. Take your next dose at the regular time. Do not double the dose to catch up. Facility documentation included Policy and Procedure on Safe Medication Assistance and Administration, which stated the following: · The manager or other assigned staff/Independent Contractors person will be responsible for checking medication supply routinely to ensure adequate amount for administration. · Some pharmacies may automatically refill prescriptions of persons served. If this is the case, staff/Independent Contractors will contact the pharmacy if a medication or treatment is discontinued. · An individual’s Medication Administration Record must include, “Notation of any occurrence of a dose of medication not being administered or treatment not performed as prescribed, whether by staff/Independent Contractors error, the person’s error, or by the person’s refusal, or of adverse reactions, and when and to whom the report was made.” Facility documentation stated that P1 and P2, and two staff who were working at various points mentioned in this report, received training on the facility’s Policy and Procedure on Safe Medication Assistance and Administration and on the Reporting of Maltreatment of Vulnerable Adults Act. P1 and the two staff also received training on the VA’s support plan and support plan addendum; P2 was not required to receive this training due to his/her position. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.05, subdivision 2, paragraph (b), clause (1), states, in part, if responsibility for medication administration is assigned to the license holder in the support plan or the support plan addendum, the license holder must implement medication administration procedures to ensure a person takes medications and treatments as prescribed. Conclusion: Consistent information was provided that the VA did not receive his/her lithium carbonate dose on March 18, 2023, due to there not being any available at the facility; a refill was needed. The failure to ensure the VA took his/her medications as prescribed was in violation of Minnesota Statutes section 245D.05, subdivision 2, paragraph (b), clause (1). The VA then spit out his/her lithium carbonate tablet on March 19, 2023; and ran to his/her room after receiving his/her dose on March 20, 2023, making it so staff did not know if the VA swallowed the tablet or not. The staff and the VA were in contact with the G during this time. The G requested that staff take the VA to the hospital, but the VA declined. P1 had previously contacted the hospital asking what staff should do in this exact situation; and the hospital told P1, “We cannot force [him/her] to go to the hospital until its court-ordered.” The VA’s lithium carbonate was not court-ordered or part of the VA’s Jarvis order. Information was provided that during March 18 – 20, 2023, the VA became “more behavioral.” Staff contacted the G and told him/her that the VA was in “a flight of thought mood.” Staff documented in the Daily Logs that the VA was “hyped up” and jumping from conversation to conversation. The G visited the VA earlier in the day on March 20, 2023, and repeatedly asked the VA to go to the hospital, but the VA declined each time. The G then left leaving the VA at the facility. Although staff did not follow the correct guidelines regarding who to call for help (e.g., the on-call supervisor) during the weekend of March 18 – 20, 2023, it was not determined if this would have changed the outcome given the VA’s history of declining to take his/her medications. The staff were in contact with the G and information had been provided by the hospital that they could not force the VA to go to the hospital without a court-order. Although the G believed staff were not good about remaining with the VA at the table after administering his/her medications, P1 said that staff did “their best,” the Daily Logs recorded a staff person attempting to chat with the VA at the table, but the VA ran away; and it was also not possible for staff to force the VA to remain at the table. Therefore, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services, which were reasonable and necessary to maintain the VA’s physical or mental health, considering the physical and mental capacity or dysfunction of the VA and which is not the result of an accident or therapeutic conduct. 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 policies and procedures were adequate and followed. Medication Administration Guidance was created to assist staff with the VA’s medication management and compliance. The facility provided training to all staff persons who worked with the VA. Action Taken by Department of Human Services, Office of Inspector General: On June 23, 2023, the facility was issued a Correction Order for the violation outlined in this report.
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