|
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: 1071916-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Henne 651-431-3444 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had a lapse in dental appointments between March 2, 2020, and January 4, 2023, and was then recommended to have all of his/her teeth pulled. Date of Incident(s): Between March 2, 2020 and January 4, 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 March 15, 2023; from documentation at the facility and medical records; and through seven interviews conducted with three supervisory staff persons (P1, P2, and P3), one administrative staff person (P4), one facility health care professional (HCP), the VA’s guardian (G), and the VA’s dentist (D) at Apple Tree Dental (ATD). This investigator met the VA, but s/he was unable to provide information due to his/her diagnoses. The VA’s file stated the VA enjoyed a variety of activities including shopping, short vacations, movies, and coloring. The VA was diagnosed with TBI (traumatic brain injury) with “behavior excess,” physical and cognitive limitations, left hemiparesis, ataxia, and sleep apnea. The VA’s Intensive Support Service Assessment, dated March 17, 2022, stated that the VA did not always remember when his/her medical and dental appointments were, and staff would make appointments for the VA and transport the VA to and from appointments. The VA’s Health Needs Record, dated September 25, 2021, stated, “[The facility was] responsible for meeting the health needs for the person as assigned in the Coordinated Services and Support Plan or the Coordinated Service and Support Plan Addendum.” The facility was assigned in the Coordinate Service and Support Plan or the Coordinated Service and Support Plan Addendum to assist with or coordinate medical, dental, or other health service appointments. P4 said that the VA had not been to a dentist in “quite a while.” It was not determined if the VA had a dental appointment since March 2, 2020, until January 2023, when the D said the VA had to have all of his/her teeth “pulled.” An Incident Report and ATD records provided consistent information that the VA attended a dental appointment on January 4, 2023, due to a cracked tooth. It was then recommended that the VA have “all” of his/her teeth “pulled” and an appointment for oral surgery was scheduled for April 2023. The Incident Report also stated that after a record review, it appeared that the VA had not been seen by a dentist since March 2, 2020. At that time, the VA was referred for IV sedation for deep cleaning and additional dental work. According to facility job descriptions: · The program supervisor (PS) oversaw clients’ health care including monitoring the health of the clients, and when applicable, scheduled or assisting in scheduling health care appointments, and assisting with communication and overseeing follow through of orders. (Note: During the timeframe of the incident, the facility had six PSs.) · The program director (PD) was responsible for managing the services and the operation of health care including overseeing coordination of health care appointments and monitoring individual attendance. (Note: During the timeframe of the incident, the facility had four PDs and during some portions there was no PD, so the duties were covered by an area director.) · The nurse/health care professional was responsible for conducting quality assurance checks on health care records. From March 2020 through January 2023, there were six program supervisors and four program directors as well as another facility staff person who filled in when there were lapses in program directors. P1 and the Health Needs Record written by P1 provided the following information: · P1 was the PD from October 2020 until February 2022. The VA did not see a dentist in 2020 due to the COVID-19 pandemic and waiting approval for more dental work in 2021. · At some point, towards the end of the time P1 was the PD, and on an unknown date, ATD told P1 that the VA needed tooth extractions and needed to be “put to sleep” (sedated) for them. The VA had an appointment with ATD, but then ATD changed some appointments and then the anesthesiologist “left,” so the VA was not able to have the procedure and put on a waiting list. Then ATD then said they were no longer going to do sedation services at the location the VA went to, so the VA had to go to another ATD location father away and required the G to fill out paperwork for the VA. The G filled it out and sent it in, but then the dental clinic “claimed” they did not get it, so the G sent it again. After that the clinic said they needed “stuff from us” so that was sent and then it was in “limbo” because a new PD took over at that point. P1 explained the process to the new PD so that person could “follow up.” The G said that every six months s/he asked staff persons at the facility where the VA was at with his/her dental appointments and that the facility “dropped the ball clearly.” The G completed all of the paperwork that was needed for ATD except for the healthcare summary piece that the supervisory staff at the time, who the G could not remember, needed to complete. The G wanted the VA to have a dental cleaning every six months and believed the VA’s last appointment prior to January 2023, was September 3, 2021, but the G was not sure. Emails dated June 18 through July 26, 2021, sent between the G, ATD, and P1 provided the following information:
· On June 18, 2021, ATD emailed the G the documents that needed to be completed by the G for the VA. · On June 22, 2021, the G asked P1 to review the VA’s health history forms and to fill out the parts the G did not complete. · On July 13, 2021, at 1:20 p.m., ATD emailed the G and said that they did not get the fully completed health history and that the facility was only able to complete a portion and was going to forward the form to the G to complete fully. At 1:24 p.m., the G emailed P1 and ATD and said, s/he did what s/he could do and P1 was supposed to finish the rest and send it in when s/he returned from vacation. At 3:17 p.m., the G emailed P1 and ATD and asked if a dental appointment was made for the VA. · On July 25, 2021, the G emailed P1 and included two other facility persons (P5 and P6). The email stated, “Since [P1’s] email is not working – I am sending this out again to see where you guys are at with getting [the VA’s] dental appointment scheduled. [P1], you shared you’d get this squared away [once] you returned from vacation. Please update asap – we are going on 6 weeks now.” · On July 26, 2021, P1 emailed the G and said the VA had an appointment set up for September 3, 2021, at 10 a.m. and, “Sorry about the delay.” P2 said that s/he was the PS from August 2021 to February 2022 and became the PD in the summer of 2022. P2 did not think the VA went to the dentist during “COVID” and when P2 “took over” in 2021, at some point, P1 told P2 that the VA needed teeth pulled. During the time, P2 was the PS, the VA told him/her two or three times that his/her teeth hurt. P2 and P1 were already trying to get the VA into a dentist to get his/her “teeth worked on” but the VA required sedation and the dental office did not have an anesthesiologist, so they were waiting for the dental office to get one. P1 worked with a dental office and the G to get the VA an appointment. In the meantime, staff persons offered the VA pain management options such as Tylenol or ibuprofen. There was a “lot” of “back and forth” with P1, the G, and the dental office trying to get paperwork completed and submitted. The dental office “kept saying” they were not getting the paperwork back from the G, the G “kept sending it” and said that s/he sent it. P2 did not have a lot of “play in it” because P1 was doing a “lot” of the PS responsibilities for P2 at that time because P2 was working a lot of direct care shifts because the facility was short staffed. The VA had a prescription toothpaste that was used twice a day and an electric toothbrush. The VA sometimes used mouthwash and did not floss. The VA “should” have gone to the dentist every six months. P3 provided the following information: · P3 became the PS September 2022. When P3 started, s/he knew the VA had a “lot of missing teeth” and used medicated toothpaste. At that time, P3 was not aware of any current dental appointments scheduled and did not know anything about the VA’s dental history. P3 did not know how often the VA went to the dentist but said that the PD or PS made the appointments. · On an unidentified date, “maybe” January 2023, the VA was eating lunch and a tooth “fell out.” P3 called P2 and told him/her, the VA’s tooth “fell out.” P3 called ATD that same day and got the VA an appointment. At that appointment, the dentist determined that the VA needed to have his/her teeth pulled.
· The VA “love[d]” getting his/her teeth brushed and had not complained of any tooth pain to P3 prior to the day the tooth fell out. Staff persons brushed the VA’s teeth for him/her using the medicated toothpaste twice a day, once in the morning and then before s/he went to bed. Sometimes the VA refused to let staff persons brush his/her teeth and kept his/her mouth closed to prevent brushing. When that happened, P3 tried again at a later time. However, the VA refused “not even once a month.” Staff persons did not floss the VA’s teeth because there were “not enough teeth” to floss between. The VA had “over half” of his/her teeth missing, but P3 did not know the history as to why. (Note: The VA’s Medication Administration Record showed that between September 1, and December 31, 2022, the VA was administered a prescription toothpaste, sodium fluoride dental cream, twice a day with the exception of November 18, 2022, at 2:05 p.m. when the VA “refused.”) The HCP said that the VA should have yearly dental visits. (Note: According to the local dental office’s records from March 2, 2020, the VA next recommended cleaning was six months.) About three to four months prior to March 15, 2023, the VA told the HCP that his/her tooth hurt while the VA was eating. The HCP could not remember who s/he talked to, but was told that staff persons were “working” on getting the VA to the dentist, but they were having a difficult time getting an appointment made. At that time, P3 was responsible for making the VA’s dental appointments. The HCP visited the facility a few times a month to review “med check offs” and saw that “daily living skills” such as tooth brushing was completed for the VA. Dental records/notes from a local dentist office and ATD, emails between ATD and this investigator, and the VA’s facility file provided the following information and timeline: · According to the local dental office’s records, the VA was seen on March 2, 2020. The VA was unable to move into the dental chair, so they cleaned his/her teeth while standing. The VA was also unable to swallow water due to aspiration risk. Due to the aforementioned concerns, the dentist was going to look into finding a specialist that was able to sedate the VA for all dental work at one appointment. Once a location was found, the local dental office would contact the facility. Dental notes stated the VA’s oral hygiene was “poor” and there was decay and plaque on the VA’s gingival margins. The facility staff person who accompanied the VA to the appointment was a “new staff” and was “concerned” about the “shape” the VA’s teeth were in. The next recommended visit for the VA was six months. · On September 10, 2020, the VA did not show for his/her appointment. The local dental office left a message with the facility to reschedule. (Note: The facility’s progress notes for September 10, 2020, did not provide any information as to the VA missing/having a dental appointment.) · On September 16, 2020, the local dental office called the facility and spoke to a staff person and let him/her know ATD does IV sedation once a month and that the VA would get “better care” doing that because the VA cannot swallow water or sit back. The staff person said, “Thank you, I will give them a call.” · According to ATD chart notes, on October 1, 2020, ATD was to contact the facility to get copies of X-rays sent to ATD. On October 5, 2020, at 3:40 p.m., ATD confirmed an upcoming appointment with a facility staff person. The facility staff person stated they would bring the needed paperwork to the appointment. On October 6, 2020, ATD called the facility to inquire about getting X-ray copies, but the staff person who answered had nothing to do with appointments and gave ATD a number for the resident director. ATD called the resident director, but there was no answer and was unable to leave a voice message. According to an email with ATD and this investigator, on October 7, 2020, an appointment was canceled due to not having the paperwork completed. · On October 28, 2020, the VA had an appointment scheduled, but was cancelled by the facility without a 24-hour notice and no reason was given as to why it was cancelled. (Note: A facility progress note from this date did not provide any information regarding a dental appointment for the VA.) ATD left a voice message for a supervisory staff person (P7) that an appointment for November 3, 2020, needed to be rescheduled because the provider was out that day. On October 29, 2020, a staff person at the facility called ATD to reschedule the appointment and asked if they received the paperwork that was needed. ATD said it looked like they did not so the staff person said s/he would fax them to ATD. (Note: During November 2020, there was a PS staff change and according to ATD notes from November 25, 2020, the new staff person was not aware of an appointment or paperwork. ATD confirmed the appointment and faxed paperwork to the facility that needed to be signed.) · On November 30, 2020, the VA missed an appointment because the VA was ill. On December 10, 2020, ATD left a voice message for the facility to reschedule the appointment that was missed in November. On May 5, 2021, the VA missed his/her appointment due to not having paperwork completed. On June 18, 2021, ATD talked to P1 regarding the paperwork that needed to be completed. ATD emailed the G the documents that needed to be completed. · On July 26, 2021, ATD notes stated ATD talked to a staff person at the facility and scheduled an IV sedation consult for September 3, 2021. ATD also explained that it was only a consult and that they may have a pause in their program due to the nurse who provided the sedation services left the clinic. The facility was “ok” with that and “just wanted to get the process started.” · According to ATD notes, on August 11, 2021, ATD cancelled a sedation consult for an appointment that was scheduled for September 3, 2021, because the dentist moved and there was no longer sedation services at the scheduled location. ATD emailed the G and said that they would give him/her a call once the sedation program was “back up and running” or that they could provide a referral to have the VA seen at another ATD location instead. The G told ATD s/he was “fine holding off” until a new doctor was hired and s/he added P1 to the communication and to let “us” know when the appointment can be rescheduled. On September 3, 2021, forms were faxed to the facility and all paperwork was received. · On October 19, 2021, ATD notes showed that a staff person from the facility inquired about “where things stood.” ATD let the staff person know that they were still trying to find a doctor who did sedation dentistry and that they would “keep them in the know.” · On December 14, 2021, ATD notes stated to keep the VA on the “list” for “when/if” sedation resumes. · On January 10, 2022, ATD notes showed that a staff person from the facility called and asked about getting the VA in for sedation. The staff person was informed that there was still no timeline as to when sedation would resume and that another ATD location might be an option. The ATD staff person also left an internal note for one of the dentists at ATD to look at the VA’s information to see if s/he was a “good candidate” to be seen at the other ATD location. The dentist replied to contact the “caregiver” and offer to schedule the VA at the other ATD location. The dentist stated that s/he could not find a form that was needed for the VA and asked the ATD staff person to request it and have it filled out prior to the appointment. · According to ATD notes, on January 28, 2022, at 9:05 a.m., ATD called the facility and asked about information of past dental history. The staff person at the facility who answered did not know that information but said s/he would reach out to supervisor. ATD told the staff person that they would reach out to the G to see if s/he had any information and have the G fill out some paperwork that was still needed and then call back to get the VA scheduled for the IV sedation consult at the other ATD location that did sedation services. ATD called back to schedule the appointments, but the staff person stated they would need to talk to their “boss” to get the appointment scheduled since it was a farther distance away/outside of the Rochester area and that s/he would call ATD back. At 9:07 a.m., ATD called the G and asked about past dental history. The G states facility should have the information and ATD said the staff person s/he just spoke to sounded newer and did not have “much information.” The G stated that before coming to ATD the VA had been to a local dental clinic. ATD staff told the G that due to that location not doing IV sedation, the VA still did not have an appointment. The G asked ATD to email the forms that were needed, and the G would reach out to the facility for records of dental visits. At 10:49 a.m., P1 called ATD and stated that s/he was not “in charge” of the VA after January 28, 2022, and that s/he was “confused” as to why ATD was asking for paperwork when they had filled it out “three times” and that ATD should have the dental records needed. The ATD staff person “apologized” to P1 for having to fill it out again. P1 told the ATD staff person that s/he would inform the new staff person of the information and that s/he would decide if the VA would continue with ATD or would look for something “closer to home.” · According to the facility’s meeting minutes notes, on September 13, 2022, at an annual meeting, it was discussed that the VA was due for a dental appointment. P2 stated that the VA was on a waiting list because s/he needed to be “put under” when s/he had dental work completed. · There was no more information from ATD after aforementioned dates until January 3, 2023, when a facility staff person called the ATD ER line the night prior and stated the VA had a “broken tooth.” The D said that s/he only saw the VA on one occasion. (Note: According to ATD records, this appointment was on January 4, 2023.) The VA’s oral hygiene was “really poor”, and the D had concerns because s/he saw “so much food” in the VA’s mouth and all of the VA’s teeth were “pretty much decayed.” Because of the decay, the VA needed to have all of his/her teeth extracted because there was no way to “save the teeth in any valuable way.” The D was unsure whether the decay was because the VA was not “tolerating” the oral hygiene, whether “no attempts” were made, or whether the attempts that were made were not “adequate enough.” However, the VA not seeing a dental provider on a regular basis contributed to the decay. It “takes a long time” to “properly” brush and floss and clean a person’s mouth especially if they are “fighting” or “not leaning back” so the amount of time it would have taken to do “everything properly” every single day, twice a day or more, would be a “lot” and a “big time commitment.” The condition of the VA was not “completely unexpected” because of how much time and effort it would have taken to “prevent that.” The D said that according to the VA’s chart, there were a “lot” of phone calls, missed communication, and attempts to be seen under IV sedation. The Internal Review and facility shift notes provided the following information: · On March 2, 2020, the dentist said the VA had three cavities and “lots of plaque.” The VA needed to be sedated to get the cavities filled due to aspiration risk and the dentist needed to use water to fill the cavities. Progress notes on March 2, 2020, stated the dentist will give staff names of dentists who could assist the VA with cavities. · According to a shift note on April 14, 2020, a staff person noticed one of the VA’s front bottom teeth was “chipping away.” A facility LPN also looked at the VA’s tooth and said that because it was not causing the VA any pain at the time, a dentist would not see him/her due to COVID-19. The LPN said to contact the local dentist office if it became painful and that staff should assist the VA with tooth brushing and assess the tooth each time. · According to a shift note on December 24, 2020, a staff person wrote a progress note that stated the VA said s/he wanted to go to the dentist. The staff person said s/he would tell the program coordinator. · According to a shift note on January 5, 2022, the VA’s right eye was droopy and a little swollen. The VA also said his/her tooth at that side of her face hurt. · According to a shift note on October 14, 2022, the VA complained of tooth pain after brushing his/her teeth. The staff person at that time said that s/he complained of tooth pain for the last couple of days. The HCP recommended the VA visit a dentist. · According to a shift note, on November 7, 2022, the VA had a “toothache” and could not chew “anything.” · The VA was seen by a dentist on January 4, 2023, after cracking a tooth. It was recommended that the VA have all teeth pulled. An appointment for oral surgery was set for April 2023. P1-P3 were trained on the VA’s plans. P1-P3 and the HCP were trained on the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rules and/or Statutes: Minnesota Statutes 245D.05, subdivision 1, paragraph (a), states the license holder is responsible for meeting health service needs assigned in the coordinated service and support plan or the coordinated service and support plan addendum, consistent with the person's health needs. Conclusion: A. Maltreatment: Information obtained showed that the facility was responsible for making, coordinating, and transporting the VA to and from medical and dental appointments. After a dental appointment on March 2, 2020, the VA did not receive dental care until January 4, 2023, which was a violation of Minnesota Statutes 245D.05, subdivision 1, paragraph (a). Some of the delay was due to various reasons out of control of the facility such as completion of some paperwork, sedation services ending at ATD, and illness of the VA. However, at the VA’s appointment on March 2, 2020, the VA was directed to return in six months and ADT made several calls to the facility in an attempt to get the VA seen by a dentist, but the VA did not see a dentist until almost three years later on January 4, 2023, after the VA’s tooth cracked. Given that the VA had tooth decay as of March 2, 2020, and was required to be seen again in six months; that the VA complained of tooth pain multiple times from October 2022 to January 3, 2023, yet was not taken to a dentist until his/her cracked tooth; there was a preponderance of the evidence that there was a failure to supply the VA with the care and services which were reasonable and necessary to maintain his/her dental health. There was a preponderance of the evidence that neglect occurred (The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. Given that staff persons at multiple levels of authority including direct care staff, program supervisors, program directors, and area directors were involved with the oversight of the VA’s care during the almost three year period when the VA did not receive dental care, it was determined that individual staff persons responsibility for the maltreatment was mitigated and the facility was responsible for maltreatment of the VA. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. P1 and P2 said that the VA needed teeth extracted prior to January 2023. However, P2 said s/he heard it from P1 at some point in 2021, P1 stated s/he heard it from ATD towards the end of the time s/he was the PD (January or February 2022), but there was no information in the ATD file prior to January 4, 2023, that the VA needed teeth extracted. Given the conflicting information from P1 and P2 regarding the dates they believed the VA needed teeth extracted and the lack of information in the ATD records prior to January 4, 2023, it was more likely that it was not learned that the VA needed his/her teeth extracted until his/her tooth cracked in January 2023. Given it was three years since the VA had seen a dentist, that when the VA did see the dentist s/he required all his/her teeth to be pulled, it was determined that the substantiated maltreatment for which the facility was responsible was “serious” maltreatment. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but were not implemented as applicable. The facility completed retraining and a corrective action for supervisors involved. Action Taken by Department of Human Services, Office of Inspector General: On July 19, 2023, the license holder was ordered to forfeit a fine of $5000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the order to forfeit a fine are each subject to appeal.
|
