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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: 801558-RMI (Residential Treatment and Services for Adults with Mental Illness) Investigator(s): Deb Neubauer-Hoffman Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had ongoing ingestion of inedible objects despite 1:1 supervision at the facility and increased supervision during transportation. Date of Incident(s): February to August 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 September 15, 2022; from documentation at the facility; and through seven interviews conducted with five facility staff persons (P1-P5), a facility health care professional (HCP1), and a guardian (G). Attempts were made to interview another facility health care professional (HCP2) who declined to be interviewed. This investigator briefly met the VA with the investigator remaining in the staff person office behind Plexiglass. The VA was not interviewed due to concerns for the VA’s safety if the VA were to take an item to ingest during the interview. It was noted that the VA was wearing a tear-proof gown. The VA was admitted to the facility on February 28, 2022. The VA’s diagnoses included borderline personality disorder, oppositional defiant disorder, major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder. The VA’s history included ingestion of foreign bodies. The VA enjoyed writing, playing cards, coloring, doing crafts, and listening to music. Facility documentation showed that the VA had a long-standing history of “disruptive and self-injurious behaviors.” Prior to his/her admission to the facility, the VA resided at Anoka Metro Regional Treatment Center (AMRTC) due to “unmanageable self-harm” primarily by means of swallowing inedible items and requiring medical intervention on multiple occasions. While at AMRTC, the VA had a 4:1 staff ratio at all times and was able to acquire items to ingest while staff persons were present at his/her side. It was determined that the staffing ratio or proximity to the VA at all times did not impact his/her ability to swallow inedible items. On the contrary, staff person proximity to the VA added exposure to items s/he could swallow (face masks, name badges, keys, eyeglasses, etc.). Information also showed that the VA’s history included a plethora of psychotropic medications and electro convulsive therapy, neither of which were thought be effective in managing his/her self-harm behaviors. The VA’s initial Psychiatric Assessment dated March 2, 2022, provided a review of his/her history and an order for “1:1 observation at all times. May use camera when in room. When on unit, may have one barrier but view must be unobstructed at all times. When showering, staff [persons] must stay outside shower and interact verbally every one minute. Prior to showering, staff [persons] must search shower room and remove all items in shower. Patient may be given shampoo/body soap in paper cup. . .. Patient will utilize edible spoons to eat. [The VA] will turn in all items from meals/snacks afterwards. [The VA] may be given a washcloth for dental hygiene but should turn this back in when completed.” Given the VA’s level of “dysregulation and agitation when restrained, and [his/her] history of trauma, staff [persons] should weigh the risks of going hands on to the behaviors we may be attempting to cease. It is recommended that hands-on intervention may be limited to absolutely only when necessary.” The VA’s Support Plan showed that over time, various interventions were attempted to address the VA’s incidents of foreign body ingestion. Interventions included check-ins twice per day, prompting or engaging in relaxation techniques, suggesting coping skills, offering to engage with him/her (examples included playing basketball, writing poems, talking with staff persons, etc.), providing verbal praise, or offering him/her an alternative item (such as hard candy). When the VA was escalating or at a higher risk of engaging in unsafe behavior, staff persons were to present a supportive approach that was “calm and neutral” by telling the VA that s/he had a choice to make. Staff persons were to establish and maintain clear limits and expectations, validate the VA’s concerns and emotions, and not engage in physical touch unless it was deemed necessary to maintain safety or for a medical reason. The focus of this investigation was from the VA’s admission on February 28, 2022, through September 6, 2022. It should be noted that prior to the completion of this investigation, the facility continued to report incidents of foreign body ingestion as well as medical intervention required. Those additional reports were assessed but not included in this report. An additional maltreatment investigation was opened that included other incidents but that investigation was still pending at the time this report was concluded.
Information from the Mayo Clinic and the facility, including Internal Reviews and/or Incident Reports provided the following information: · On March 1, 2022, the VA resided on Willow unit. That morning, the VA met two staff persons (HCP1 and an unidentified HCP) at the medication window. Following the meeting, the VA went to his/her room and began punching walls and banging his/her head. Staff persons offered verbal support and redirection. The VA returned to the medication window to meet with the same two HCPs and HCP1 observed broken skin on the VA’s knuckles. HCP1 put on exam gloves and tended to the VA’s knuckles. After HCP1 removed the exam gloves, the VA quickly reached through the medication window, took the gloves, and ran to his/her room. An incident command system (ICS, the system the facility uses to notify other staff persons that more support was needed where the incident was occurring) was implemented and additional staff persons arrived. Verbal prompts and attempts to redirect the VA were unsuccessful and manual restraint was authorized. While in manual restraint, the VA successfully swallowed one exam glove and assaulted staff persons by biting, spitting, kicking, hitting and scratching. An intermuscular medication was administered and the VA was placed in a restraint chair. The VA’s primary medical provider came to the unit and determined additional medical attention outside of the facility was not indicated. · Later that same evening, the VA was observed via camera in his/her room. The VA had a blanket over his/her head and was on the bed, rocking back and forth. The VA came out, asked for water, and was given water in a paper container. The VA went back to his/her room and was again observed rocking back and forth and “acting strange.” A staff person (P9) asked the VA what was going on but the intercom did not seem to be working. Two unidentified staff persons and two health care professionals went to the VA’s room where s/he told them s/he swallowed the elastic from his/her underwear. The VA said s/he removed the elastic when s/he was in the shower earlier that day and did this while keeping verbal communication with the staff persons present. The VA requested and was given anxiety medication. A physician was contacted and no medical intervention was advised. · Facility information showed that following the incident, the VA’s psychiatric provider stated that “the risk of respiratory distress, staff [person] injury, or patient injury is high during [the VA’s] episodes of restraints and don’t appear to be less risky than [his/her] swallowing a pair of elastic from [his/her] underwear. I ask that we use judgement when going hands on if [s/he] is attempting to swallow or is engaging in low-risk self-harm because we have to keep in mind the risk when implementing emergency procedures.”
· The VA was transferred to Tamarack unit on March 15, 2022, and previous 1:1 staffing was increased to 2:1 with the use of a camera when the VA was in his/her room. · On March 16, 2022, on the Tamarack unit, the VA told an unidentified staff person that s/he had pain in his/her throat. When the VA went to his/her room, s/he was observed making him/herself gag and having emesis. The VA picked up a piece of what was believed to be a plastic spoon and re-swallowed it. It was unknown when or where the VA obtained the plastic spoon. Health care professionals (HCPs) assessed the VA and obtained orders for an as needed (PRN) medication. After the assessment by the facility HCPs, the VA was on the unit with a peer. The peer had a plastic bag that s/he threw in the garbage. The VA “grabbed” the plastic bag and put a piece of it in his/her mouth. Verbal prompts to stop this behavior were unsuccessful and the VA grabbed another piece and put it in his/her mouth. When the VA attempted to grab a third piece of the plastic bag out of the garbage, a staff person stepped in front of the garbage can and the VA went to his/her room. The VA was transferred to a local hospital for evaluation and was then transferred to Mercy Hospital for removal of the ingested items. While the VA was at Mercy Hospital, s/he swallowed intravenous (IV) tubing following the operation for removal of the initial items. In addition, while at the hospital the VA was in four-point restraints and “got loose” two times. The VA was discharged back to the facility on March 17, 2022. After this incident, edible silverware was implemented on Tamarack, the unit garbage can was moved inside the unit station, and after the VA’s food arrived from the kitchen it was moved onto paper products. · On March 20, 2022, on the Tamarack unit, the VA reported that s/he swallowed two safety pens. (This type of pen was allowed on the unit within the possession of the other residents on the unit.) The VA denied swallowing difficulty or discomfort but was transported to a local hospital for evaluation. No treatment was provided, and the VA was transported back to the facility where s/he obtained a key from the van transport area and attempted to swallow it. The VA stated, “I want to kill myself.” Staff persons were able to retrieve the key from the VA’s mouth. · On March 23, 2022, a medical assessment was needed and prior to the assessment, the Tamarack/Willow exam room was checked for items the VA could possibly swallow and questionable items were removed. The VA was in a “good mood” and at the end of the exam, requested to wash his/her hands and did so at the sink in the exam room. One unidentified staff person was behind the VA, another staff person (P6) stood directly to the VA’s right, and a medical doctor (MD1) was behind P6. The VA dried his/her hands and threw the paper towels in the garbage can with his/her right hand while reaching with his/her left hand to grab nitrile gloves from a box on the counter in front of him/her and “quickly put them in [his/her] mouth.” Staff persons held the VA’s arms and wrists, and s/he did not resist as s/he gagged until s/he swallowed the gloves. Poison control was contacted and confirmed the glove should pass naturally. Staff persons remained present to monitor the VA and did not document any distressing symptoms. The VA remained on 2:1 observation without barrier while out of his/her room and the use of a camera with one-minute checks while in his/her room. · On March 24, 2022, on the VA moved to the Willow unit and his/her supervision changed from 2:1 to 1:1, and that staff person was responsible for maintaining visual contact at all times either while on the unit or via camera from the staff office Facility information showed at this time the VA was the only resident on the Willow unit. The transfer to Willow unit was due to an increase in aggression as well as attempts to assault other residents on Tamarack unit. Residing on the Willow unit was believed to present less risk to others.) That same day the VA was observed sitting on his/her toilet with a blanket over his/her head. The VA then reported s/he ingested approximately one third of his/her flat sheet that s/he tore into strips. Facility medical personnel were contacted and an x-ray was completed showing a foreign body in the colon as well as extreme constipation. The VA was offered Miralax to aid with constipation. The VA was also provided tear-proof bedding. · On March 25, 2022, on the Willow unit, the VA broke a phone receiver against a wall on the unit. Staff persons entered the unit to secure the broken pieces of the phone. The VA “quickly” put a small piece of the phone in his/her mouth and took a drink of water. The VA was manually restrained and transitioned into a restraint chair. HCPs were contacted for assessment of the VA and it was documented that s/he was not in respiratory distress. The VA’s primary physician was also informed about the incident and an x-ray was completed with a plan for a follow-up x-ray in two days. On March 27, 2023, health care notes documented a curved piece of black plastic in the VA’s stool, likely the piece of phone, as well as multiple pieces of long thin fabric. (Following this incident, phones that did not have receivers were ordered for the unit.) · On March 31, 2022, on the Willow unit, the VA said that s/he spilled food on him/herself and needed the garbage can (kept inside the unit station). While an unidentified staff person held the garbage can out for the VA to throw items away, the VA grabbed a fork or spoon and swallowed it. An email was sent to staff persons to refrain from allowing the VA access to the garbage can. The VA was transported to Mercy Hospital via a state vehicle for removal of the swallowed item via endoscopy. · On either April 4 or 5, 2022, (documentation showed a conflict regarding the date of occurrence) on the Willow unit, the VA stated that s/he pulled out a one-inch screw from a metal plate on the wall (such as a light switch). Facility information showed that although the VA’s 1:1 order allowed a barrier with unobstructed view, there were times the VA was talking to staff persons and his/her hands were not visible, such as when the VA was standing at the nursing window and his/her hands were below the window. After the VA said s/he had the screw s/he was encouraged to make a safe choice and give the screw to a staff person; however, the VA proceeded to ingest the screw. Nursing staff persons were informed about the incident and the VA continued to be observed. An on-call physician as contacted and an x-ray was ordered and completed on April 6, 2022. · On April 5, 2022, on the Willow unit, the VA had “several coins” and was asked to make a safe choice and hand them over to a staff person. The VA refused and ingested “one quarter,” stating s/he ingested five total; however, only one was in the presence of a staff person. The HCPs were notified as well as the VA’s primary physician and Miralax was provided to assist in moving the coins along the VA’s gastrointestinal tract. An order for Lactulose was also provided if the Miralax was ineffective. An x-ray was completed on April 6, 2022. (Facility information showed that there was no specific plan to restrict the VA’s access to his/her money because prior to this date, the VA did not demonstrate a risk to him/herself with having access to his/her money.) · On April 27, 2022, the VA’s 1:1 staffing expired due to the VA “residing on a sterile unit (Willow)” meaning there were no other residents. · On April 30, 2022, on the Willow unit during medication pass, the VA obtained a plastic knife and swallowed it. The VA was taken to a local hospital and transferred to Abbott Northwestern Hospital for removal of foreign object via endoscopy. Following the incident, staff persons were told to only remove the small “block” from the medication pass window, take garbage items from the VA and dispose of them in the office, and do not hold the garbage can up to the door. When asked about ingesting the knife, the VA said, “I am an opportunist. I saw it, so I swallowed it.” The VA was transferred to Tamarack on May 4, 2022, and 1:1 staffing was resumed. · On May 5, 2022, the VA moved to the Tamarack unit in order to accommodate additional patient acuity needs within the facility that required the use of Willow unit. · On May 13, 2022, the VA was on the Tamarack unit when a staff person (P7) returned from the canteen and began to pass out items purchased by the patients. P7 handed the VA all his/her snacks inside the shopping bag and when s/he realized what s/he had done, prompted the VA to return the bag and items. The VA ignored the prompts and went to his/her bedroom. When staff persons entered the VA’s room, s/he was observed swallowing the plastic shopping bag. The VA was manually restrained, and staff persons were able to get the VA to spit out the plastic bag. · On May 18, 2022, the VA’s psychiatric provider (MD2) discontinued his/her 1:1 observation. MD2 documented that “there does not appear to be much benefit to [1:1 observation]. [The VA] generally completes acts of aggression or self-harm in the presence of staff [persons] therefore there doesn't appear to be benefit to monitor [the VA] in [his/her] room as this can be significantly intrusive. We discussed the ability to have [the VA’s] room pulled up on the monitoring system but that it will not be continuously monitored. [The VA] will continue to have limited items of personal effects and this portion of previous 1:1 order will remain unchanged. The unit is quite sterile in nature and efforts have been made to mitigate risks of self-harm including edible silverware and limiting what is given/how things are given during meal times. Garbage is handed in after meals/snacks. There are limited objects in the unit milieu that may be used to harm self or others. [The VA] will remain on level A care rounds which are 15 minutes. This is evaluated ongoing and increased observation can always be re-implemented if needed.” (One-to-one observation was restarted after August 1, 2022.) · On May 19, 2022, the VA approached the Tamarack staff person office door, presumably to make a request. When staff persons opened the “half door,” the VA reached into the office and obtained a garbage bag, left the area, ripped the bag, and began ingesting pieces of it. Contents of the garbage bag were unknown and it was necessary to manually restrain the VA to obtain the bag in order to prevent ingestion of any potentially dangerous objects. An unidentified HCP contacted a facility physician who said no additional intervention was needed. · On May 22, 2022, on the Tamarack unit, the VA reported that s/he swallowed a piece of plastic from a phone, approximately the size of a quarter. The VA went to the hospital emergency room and x-rays were completed. No foreign bodies were seen and no medical treatment was needed. · On July 17, 2022, the VA swallowed two AAA batteries from his/her radio and a broken comb. Prior to the ingestion of the batteries, a staff person asked the VA to turn in the radio because the VA voiced wanting to swallow the batteries. However, during that interaction the VA assaulted the staff person and swallowed the batteries. (At that time the VA was allowed various items after displaying a period of safe behaviors and choices.) On July 18, 2022, an x-ray showed one battery in the rectal area and one in the mid-ascending colon. The VA was taken to an emergency room. Abdominal surgery was required due to the VA’s inability to remain safe and calm during the endoscopy procedure. Four pieces of a plastic comb as well as 15-20 pieces of cardboard (from milk cartons) were removed. It was decided the batteries would pass naturally. The VA returned to the facility on July 21, 2022. · On July 23, 2022, the VA was seen “going through a roll of toilet paper in order to have the cardboard tube” that the VA would likely swallow. The VA was then required to request toilet paper rather than being able to have access to a whole roll. However, the VA reported to unidentified staff persons that s/he swallowed two toilet paper rolls, two paper plates, four staples, and a small notepad cardboard. The VA was taken to a local hospital and kept overnight for observation. · On July 24, 2022, “all belongings” were removed from the VA’s room and placed in locked storage. (The VA was allowed to have family photos, a mattress, a pillow, a tear-proof blanket, a “coping device” provided by occupational therapy, and the clothes s/he was wearing.) · On July 25, 2022, the VA returned to the hospital for ongoing abdominal pain. An x-ray also showed one AA battery. While at the hospital s/he continued to engage in self-harm behaviors including tying his/her IV line in knots, putting the IV line in his/her mouth, inserting a finger into an abdominal wound, and banging his/her head while in the bathroom. The VA also engaged in physically assaultive behaviors towards staff persons. A colonoscopy was completed for removal of foreign objects. No further surgical procedures were needed. The VA returned to the facility on July 29, 2022. · On July 31, 2022, unidentified staff persons assisted the VA in obtaining items out of the “controlled contraband bin,” as well as two towels, a washcloth, and a change of clothing. The VA was in the shower an extended period of time and reported to staff persons that s/he swallowed half of a washcloth and part of his/her sweatpants. The VA provided the remaining items to staff person. The VA went to a local hospital where labs were drawn, along with CT scans and x-rays. No further treatment was provided, and the VA was discharged that same day. (Information showed that at this time the VA’s hygiene items were given in paper cups, s/he used edible silverware, and used tear-proof blankets and pillows. At the time of the incident, washcloths were allowed.) · On August 1, the VA obtained a “flex pen” and a towel from a resident on the unit. The VA swallowed the flex pen and tore up the towel, swallowing some pieces and tying some pieces around his/her neck. Staff persons were able to work with the VA and s/he removed it. That same day the VA was also observed with a “piece of wood” from the white board next to the unit entrance and had it up his/her sleeve before bringing it to a staff person. (The VA’s 1:1 supervision was reinstated.) After ingesting the pen and pieces of towel, an unidentified HCP notified a facility physician and an x-ray was completed, lactulose was administered, and a repeat x-ray was completed the next day. · On August 3, 2022, the VA obtained a staff person’s safety glasses, broke them, and ingested some pieces. Due to a history of becoming combative with staff persons, there were concerns about being able to transport the VA safely in a state vehicle. It was determined the safest option was to transport the VA via ambulance. Once at the hospital, the VA underwent an upper gastrointestinal (GI) endoscopy and one pen and one eye glass frame were removed. The VA was discharged back to the facility that same day. (As of this date, each time the VA was transported via ambulance, one facility staff person accompanied him/her in the ambulance and another staff person followed in a facility vehicle, that way there were two staff persons supervising the VA once s/he arrived at the hospital. While at the hospital, facility staff persons maintained supervision of the VA. Upon discharge, the VA was transported back to the facility via the facility’s vehicle given that a return transport via ambulance was not medically necessary.) · On August 4, 2022, the VA was observed to “quickly and suddenly” take the glasses off of a resident’s face and then ran to his/her room. Staff persons ran to the VA’s room; however, s/he already broke and ingested each bow of the glasses. The VA was transported to the hospital via ambulance. An upper GI endoscopy removed two parts of an eye glass frame. The VA was discharged back to the facility that same day. · On August 7, 2022, the VA reported that s/he obtained a clip from an ice pack from his/her most recent hospital visit and “placed it between his/her buttocks, concealing and smuggling it” into the facility. The VA later ingested the clip and told an unidentified health care professional about it several hours later. The VA was transported to the hospital via ambulance for further assessment and treatment. An upper GI endoscopy resulted in the removal of a 10-centimeter-long plastic clip. · In the early morning hours of August 8, 2022, the VA returned from the hospital via the facility vehicle. Although during the ride back to the facility the VA wore wrist “cuffs” that were secured at his/her waist and “leg shackles,” the VA stated s/he obtained plastic parts of the vehicle’s air vent, concealed them on him/herself and later broke them into multiple pieces and swallowed them. (Documentation stated that when staff persons heard a “crack” at the back of the vehicle, they turned a light on for the rest of the ride.) After swallowing pieces of the vent, the VA was transported back to the hospital via ambulance and an upper GI endoscopy removed “plastic pieces with sharp edges.” · On the evening of August 8, 2022, the VA returned to the facility from the hospital and was uncooperative when staff persons attempted to obtain socks on the VA’s feet. (At this time the VA was only allowed tear-proof clothing and it was evident something was hidden in his/her socks.) An incident command system (ICS), (a request for multiple staff persons to be present) was implemented; however, prior to that occurring, the VA obtained some type of “plastic” from his/her sock and ingested it. The VA was transported via ambulance to the hospital for the third time in 24 hours for further assessment. The VA was intubated and a computerized tomography (CT) scan showed no obvious foreign body. The VA stayed in the emergency room for observation before being discharged to the facility in the early morning hours of August 9, 2022. (Hospital notes stated that at this time, the ethics committee and the chair of the hospital’s psychiatry department determined the hospital would continue to treat the VA when s/he arrived at the emergency room.) · On August 9, 2022, the VA reported that “yesterday” s/he took a hard piece of plastic from the facility’s vehicle vent and kept in his/her “stomach fold” and then hid it in his/her genital area. The VA said s/he later rinsed it off and swallowed it. A camera in the VA’s room was reviewed to determine if s/he swallowed the item in his/her room during the time frame s/he specified; however, the camera footage was not conclusive. The VA was sent to the hospital via ambulance. Although a CT scan showed no foreign body, just prior to discharge, the VA grabbed and swallowed a “metal bar from a surgical mask.” An upper GI endoscopy resulted in the removal of “a metal piece with a sharp end” from the VA’s stomach. During the transport back to the facility, the VA wore hand cuffs secured at his/her waist and leg restraints. · On August 16, 2022, the VA swallowed pieces of his/her “croc” shoe. Prior to this discovery, HCP1 observed the VA “doing something suspicious” and approached the VA in his/her room. The VA asked for and was given a drinking cup. The VA “demanded” that the light in the room remain off. HCP1 inquired further and eventually the VA forfeited his/her croc shoes that were torn apart and s/he said that s/he swallowed pieces of the shoes. The VA’s physician was contacted and the 1:1 supervision continued with a barrier and staff persons utilized a camera when the VA was in his/her room. The physician contacted an unidentified gastrointestinal provider and it was felt the pieces would pass naturally. · On August 18, 2022, the VA took a staff person’s (P3’s) face mask, ran to his/her room and said s/he swallowed the metal nose piece. An x-ray showed pieces of the shoe previously ingested and showed the nose piece was too far into the gastrointestinal tract for removal. The VA was remained in the intensive care unit and monitored. It was believed the item would pass naturally. · The VA remained hospitalized, and on August 20, 2022, s/he “chewed off” a “monitor electrode.” A chest x-ray showed the electrode was impacted in the VA’s upper esophagus as well as a piece of foam (likely pieces of the shoe ingested on August 16, 2022.) The face mask piece ingested on August 18, 2022, was still visible but not amenable to GI retrieval. The electrode was “pushed into the stomach” and the goal was to get it out through the colon or rectum; however, the foam (Croc shoe) previously ingested needed to be removed. · On August 22, 2022, the VA remained in the hospital. The metal nose piece the VA ingested on August 18, 2022, was “progressing” through the VA’s gastrointestinal tract with no signs of perforation. · On August 25, 2022, the VA was discharged from the hospital and returned to the facility. Upon discharge, the VA wore hand cuffs attached to his/her waist and leg restraints during transport. · On August 27, 2022, the VA was observed pacing the unit before entering a peer’s room who was out of the room taking a shower. Staff persons responded from the office when the VA was observed with a peer’s eyeglasses in his/her hands. The VA twisted the glasses until the hinge came apart and s/he swallowed the hinge. The VA was manually restrained while s/he still had the glasses in his/her hands. The VA was transported via ambulance to the hospital. An endoscopy removed the piece of eyeglass frame. · On August 28, 2022, in the late afternoon the VA said that s/he ingested pieces of hard plastic from a vent in the facility van. The VA said s/he obtained the pieces while being transported back to the facility that day in the early morning hours. The VA gave staff persons the remaining pieces. Staff persons also searched the VA’s room for additional pieces. The VA was transported to the hospital via ambulance and an endoscopy removed seven pieces of plastic. · On August 30, 2022, the VA reported that s/he “swallowed an entire deck of cards while in the shower.” The VA was observed vomiting some playing cards and some additional cards were observed falling out of his/her bed covers when his/her room was checked. Observation of the VA continued and it was determined no medical care was needed. (P4 later verified that s/he left a deck of cards on the table after playing with the VA.) · On August 31, 2022, the VA resided on the Tamarack unit. While being monitored via cameras, the VA was observed ripping and tearing apart the Velcro fabric of his/her tear-proof gown. Staff persons requested the VA switch to a new gown, but the VA refused and started swallowing the pieces s/he already ripped off. Staff persons entered the VA’s room and manually restrained him/her, removed the ruined gown, and left a new tear-proof gown in the VA’s room. The VA reported abdominal discomfort; however, s/he was observed walking about normally and did not appear to be in any distress. · On September 6, 2022, the VA reported swallowing pieces of a Styrofoam cup. When an ICS was called, the VA took his/her medications and threw the cup on the floor. No further intervention was needed. None of the staff persons interviewed expressed concern that the VA was being maltreated or neglected and those interviews with this investigator provided the following information: P1, a supervisory staff person, stated the following: · Ambulance services were utilized to transport the VA to outside medical facilities; however, “they don’t transport back” so the facility was responsible for the return transportation. Initially a “caged” van was used for this transportation and the VA was seated in the rear of the vehicle, facing the front. Two staff persons, including a driver, sat in the front of the van with the “cage” located behind the front seats. (This investigator observed the van that showed a solid barrier between the single bench located at the back of the van and the two front seats. Plexiglass was located behind each front seat and a metal “cage,” approximately 18 inches by 18 inches was located between the Plexiglass panels of the two front seats to allow conversation with anyone in the back of the van.) Staff persons supervised the VA by turning around or using the mirrors in the vehicle as well as attempting to have conversation. Regardless of the restraints and supervision, without the staff persons knowledge, the VA obtained pieces of the air vents and swallowed them on three separate occasions. (Photographs of the van show four vents were located on the ceiling, two above the rear seat where the VA sat and two near the front of the van, directly behind the barrier behind the two front seats. At the time the photographs were taken, three of the ceiling vents were removed/missing.) · Following the VA’s removal of the van vents, a “transport” van was used when returning the VA to the facility. On those occasions, a driver sat in front and three additional staff persons sat in the back of the van with the VA. (The “transport” van was not available on the day this investigator was at the facility. P1 stated that the configuration of the van was similar to a small school bus with all seats facing forward.)
· While on the unit, the VA received “continuous observation.” If staff persons were not on the unit, they maintained that observation from inside the office by viewing onto the unit through Plexiglass. When the VA was in his/her room, staff persons used a camera for supervision. · One-to-one supervision did not completely remove the VA’s ability to swallow items, but it assisted with notifying staff persons when s/he was attempting to swallow items and allowed for multiple staff persons to respond when necessary. · P1 had never seen an individual “as motivated or driven” to obtain and ingest items as the VA and stated that the VA’s “brain thinks quicker than ours for removing [items] and keeping them on [his/her] person.” P1 believed that when the VA was in that mindset, “there is no way to stop [him/her].”
P3 was working with the VA on August 18, 2022. P3 and the VA were outside in the courtyard so P3 was able to take off his/her face mask that s/he then wrapped around his/her wrist. P3 and the VA typically met for about 35 minutes and on this day, there was “nothing out of the ordinary” about the VA. P3 generally had his/her fingernails decorated and the VA frequently asked to see P3’s nails on prior occasions so when the VA asked to see them on this day, P3 held out his/her hands and the VA “reached over and snatched” P3’s mask off of his/her wrist, breaking the elastic. The VA ran into the building while P3 and another unidentified staff person followed right behind the VA. The VA did not respond to requests to return the mask. Although P3 did not see the VA ingest anything, s/he was told the VA swallowed the metal nosepiece from the mask. HCP1 provided history background information regarding a “plethora” of medications that were tried without success in lessening the VA’s foreign body ingestion. HCP1 said that to “intervene and go hands on” each time the VA obtained something to swallow was a “safety concern” for the VA as well as staff persons and seemed to “amplified the behavior;” however, every situation was different. P4 said that for a period of time s/he worked with the VA daily and was aware of his/her history. The VA enjoyed many activities, including shooting baskets, listening to music, and playing cards. On one occasion (determined to be August 30, 2022), the VA and P4 played cards for approximately 45 minutes. P4 said that s/he did not “think of cards as ingestible” so when they were done, P4 “accidentally left” the deck of cards on the table. The VA must have taken the cards because someone later told P4 that the VA took the cards into the shower and swallowed them. P5 said that s/he was present in the van on one occasion when the VA obtained a ceiling vent when s/he was transported back to the facility from the hospital. P5 was aware that staff persons were supposed to have “eyes on [the VA] 100%,” so that the VA was seen “in any position.” However, on this occasion, despite a “side light” being on at the back the “caged” van, it was during “overnight” hours and P5 was only able to see “some of the [VA’s] movement.” The VA was wearing handcuffs and leg restraints when P5 saw movement of the VA’s hands and heard a loud noise. The driver of the van (P8) said that s/he thought the VA hit something. Because the van was close to the facility, and they “would not be able to do anything” unless they called law enforcement, they believed it was “safe enough” to keep driving to the facility. P5 later heard that the VA broke a vent. The VA’s guardian (G) said there was “absolutely nothing” that worked with the VA in the past including trials of over 37 medications, 16 sessions of electroconvulsive therapy, and several years of hospitalization. The VA’s self-harm over the years included climbing on furniture and jumping on his/her head, attempting to strangle him/herself, jumping off a roof, and swallowing harmful items/objects. The G believed the VA’s “fixation” was not on swallowing but was on “self-harm” and the swallowing was just “one tiny aspect of wanting to die.” The G expressed concern that the VA was successful at the facility in engaging in “life threatening behaviors” and that it was “highly likely” that the VA will successfully “commit suicide” or die as a result of the multiple medical procedures required to address the items the VA swallowed. The facility attempted to support the VA in multiple ways, including, but not limited to: · Psychiatric interventions including: medication management, observation levels, and medical consultation. · The VA resided on an acute crisis unit (either Willow or Tamarack). These units were the most secure psychiatric units within the facility. During the course of this investigation, when the VA resided on the Tamarack unit, two other residents lived on that unit with the VA. The primary focus on Willow and Tamarack units was on mental health stabilization, medication adherence, and the assessment and management of risk to and from self and others. · From March 15-24, 2022, staff persons were on the unit at all times (per the VA’s observation orders.) Despite staff person presence, the VA continued to be able to acquire items to ingest while staff persons were present at his/her side, thus the staffing ratio or proximity to the VA at all times was not determined to impact the VA’s ability to swallow foreign objects. · Support and behavioral plans were reviewed at weekly clinical review meetings that included facility staff persons, HCPs, supervisor, and other providers and/or treatment team members. The team discussed what was working/not working and updates were made as needed.
· The VA received individual therapy twice per week. · The VA received dialectical behavioral therapy weekly. · There were internal and external consultations, reviews of the VA’s pattern of swallowing, and staff persons were trained regarding patients who engaged in foreign body ingestion. · The VA was offered the opportunity to talk to a “preferred” staff person and/or to take a PRN medication. · Coping skills for the VA included listening to music, journaling, watching TV/movies, crafting, and playing games. These options were somewhat effective; however, the VA struggled when the activity ended. · Groups and individual sessions were scheduled throughout the day to assist with boredom and to keep the VA busy with healthy distractions. · The VA’s clothing bin was kept in the office due to swallowing concerns. The VA was given tear-proof clothing and bedding. · Hygiene products were provided in paper cups to assist with consuming items that caused a swallowing concern. · When meals arrived on the unit, the VA’s food and drink (as well as other residents on the Tamarack unit) were moved to paper plates/bowls/cups and edible silverware was provided. · Staff persons were trained to be mindful of the placement/monitoring of objects near the unit station door to prevent opportunities for the VA to impulsively swallowing items.
· The VA was limited to items in his/her room and on her body to deter maladaptive behaviors. · During transport in a facility vehicle, the VA wore a combination of restraints (wrist cuffs and/or wrist cuffs attached to his/her waist, and leg restraints).
· The VA was provided hard candy in exchange for handing over inedible objects. · The VA read affirmations to him/herself. · Sensory items were used to de-escalate. · Art therapy was introduced. The facility trained all staff persons on client specific information, the facility’s policy and procedures, and Reporting of Maltreatment of Vulnerable Adults. Conclusion: Between March and August 2022, the VA engaged in numerous incidents of ingesting inedible objects that required medical intervention despite 1:1 supervision. Specifically, during that period of time, the VA had 11 upper endoscopies, one abdominal surgery, and one colonoscopy to remove items swallowed such as plastic silverware, pieces of eyeglasses, plastic from vehicle vents, a comb, etc. During the course of the investigation, the VA’s self-harm continued despite the facility taking multiple steps to ensure the VA’s safety, while also trying to provide the VA services which were least restrictive and person-centered. The VA stated that s/he was an “opportunist” and said that s/he wanted to “kill him/herself.” Although the VA was able to obtain and ingest multiple items, the facility took ongoing steps to ensure the VA’s safety such as, but not limited to: 1:1 observation, alterations to the environment (living on a unit by him/herself or on a unit with two others, edible silverware, food served in paper containers, etc.), weekly clinical meetings with the VA’s treatment team, as well as providing and seeking immediate medical care when the items ingested warranted outside medical treatment. Based on the above information, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. 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: Given the history of similar events with the VA, the facility’s internal reviews determined that policies and procedures were in place but were not always followed or were not always adequate. In those circumstances, additional adaptations were made to the VA’s plans, staff persons were retrained, and/or physical accommodations were made to lessen the VA’s ability to swallow harmful objects. In December 2022, the facility implemented a Foreign Body Ingestion Policy that outlined the consistent assessment and management of patients with an identified vulnerability for foreign body ingestion, and a Foreign Body Ingestion Toolkit that listed options to consider for risk mitigation. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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