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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: 1075481-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) lost weight because s/he did not receive the correct amount of a nutritional supplement via a feeding tube. In addition, another individual’s medication was placed in the VA’s medication bin at the facility, and there were concerns that the VA received the individual’s medication. Date of Incident(s): Prior to April 10, 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 May 3, 2023; from documentation at the facility and medical records; and through interviews conducted with facility staff persons (P1, P2, P3, and P4), and information from the VA’s guardians (G1 and G2). This investigator met the VA, but s/he did not provide information regarding the allegations in this report. Facility documentation showed that the VA was diagnosed with a developmental disability, spasticity, and cerebral palsy. The VA used an electric wheelchair for mobility for long distances, but s/he had a lighter weight manual wheelchair for short distances. When the VA was weighed at health care clinics, s/he was weighed in the lightweight manual wheelchair, and his/her weight was obtained by subtracting the known weight of the wheelchair from the weight of the wheelchair when the VA sat in it on a clinic scale. The VA’s verbal communication was limited, and s/he used an electronic device to assist him/her to communicate with others. The VA ate pureed food but also had a gastrostomy tube (G-tube) which was a surgically placed tube used to deliver supplemental nutrition, fluid, or medication. The Coordinated Service and Support Plan Addendum Summary (CSSP) for the VA documented that the VA ate a “pancake mix” to supplement his/her caloric intake but eating only the pancake mix was not considered eating a full meal. According to a recipe provided to the facility by G1, pancake mix was made with one box of frozen pancakes, one box of frozen waffles, one stick of butter, whole milk and syrup in quantities specified by G1, one box of bran cereal, and one box of whole grain cereal flakes. The dry ingredients were blended using a “mixer” and put into a bin. The pancakes and waffles were microwaved until cooked and then the stick of butter was melted and poured over the pancakes/waffles which were then “ripped” into small pieces. Milk and syrup were added to the blender, then one scoop of the dry cereal mix and 1/3 of the pancake/waffle mix was added, and then pureed in the blender. The pancake mix was to be thin enough to pour into serving bowls (which were cereal sized plastic bowls provided by the Gs) and then placed in the refrigerator. The process was repeated to make additional bowls of the mixture and the bowls of the pancake mix were to be provided to the VA at each meal after s/he had eaten the main entrée. The VA’s Emergency Data Form (EDF), which was completed in early 2017, showed that staff persons were to give the VA one 474 milliliter (ml) “jevity” (a liquid high calorie form of balanced nutrition) treatment if the VA did not eat a “full meal.” The VA was prescribed albuterol sul 2.5 milligrams/3 ml soln in a vial used in a nebulizer treatment once every four hours as needed for respiratory issues. The VA was slender, and his/her weight typically ranged from 90 to 95 pounds in 2017 according to the EDF. The VA’s Individual Abuse Prevention Plan (IAPP) stated that the VA might become frustrated when s/he thought that s/he had little control over his/her life and decline to eat. When the VA declined to eat, his/her intake was supplemented with jevity in the G tube. The VA might also “clamp down” on the inside of his/her mouth and require assistance from staff persons to release it. The CSSP showed that the facility assisted the VA with transportation, medication administration, personal cares, meals, and other supports. The Gs “handled” most of the VA’s medical appointments, but the facility took the VA to the appointments when the Gs could not. Medication administration meant checking a person’s medication record, preparing medications, administering the medications and treatments, documenting the administration of medications and treatments or the reason for not administering them, and notifying a prescriber or a health care professional if there were concerns about medications or treatments including side effects, effectiveness, or a pattern of a person declining to take medications or treatments as prescribed. The VA required 24 hour a day care, had no unsupervised time, had three hours of one-to-one staffing each day, and one hour of one-to-one staffing each day for community outings. The VA was very social, enjoyed meeting new people, liked wearing boots, and attended a day program that provided services to persons with disabilities. A facility tour during the site visit showed that medications for the VA and other individuals at the facility were stored in individual bins labeled with the individuals’ names in an area of the facility that was not accessible to the individuals. When the facility learned of the concerns with the VA’s medications, all medications were moved to locked cabinets at the facility. Interviews with this investigator, facility documentation, the VA’s medical records, and the facility’s Internal Review provided the following: G1 said that on March 27, 2023, s/he obtained vials of albuterol for the VA to use in a nebulizer breathing treatment from the bin in which the VA’s medication was stored at the facility because the VA having an overnight visit at his/her residence. G1 took three vials and gave the VA one vial that evening and another one on the morning of March 28, 2023. Later that day, G1 brought the VA back to the facility and told a staff person that s/he had administered the medication and it was discovered that vials of another individual’s albuterol was in the VA’s bin. G1 realized that s/he had given the individual’s medication to the VA and was concerned that staff persons had also given the individual’s medication to the VA. In addition, on April 6, 2023, G1 took the VA to be weighed and learned that the VA had lost about 15 pounds between October of 2022, and April of 2023. G1 thought that staff persons might not give the VA jevity three times a week in addition to the pancake mix and three meals a day that individuals usually ate but considered the pancake mix to be meal itself. G1 had observed partial bags of jevity in the VA’s bedroom and heard staff persons ask the VA whether s/he “wanted to be done” after eating two to three bites of food. G1 thought that the pancake mix was more like a dessert and was to be given to the VA with each meal, but staff persons whose identities G1 could not recall were unaware that the VA should receive the pancake mix or additional calories. Because the VA was diagnosed with spasticity, s/he burned calories at a very fast rate and needed additional calories to maintain a healthy weight between 100-105 pounds. The VA was unable to feed him/herself and required assistance from staff persons to eat. A March 27, 2023, Incident Report completed by P1 (a supervisory staff person) showed that the individual’s medication (ipratropium albuterol .5 – 3 (2.5) mg/3ml was in the bin with the VA’s prescribed medication (levalbuterol 1.25 mg/3ml sol). Ipratropium albuterol was used to control the symptoms of asthma, chronic bronchitis, or emphysema, and to treat air flow blockage and prevent the worsening of chronic obstructive pulmonary disease. Levalbuterol was used to prevent or treat bronchospasm in persons who had asthma and other lung diseases. The last time the VA was administered levalbuterol was on March 23, 2023, according to the facility’s electronic records and there was no paper “back-up” record of the medication being administered or a count of how many vials of medication were in the bin prior to the date of the incident. It was unknown how long the individual’s medication was in the bin with the VA’s medication, how it came to be in the VA’s bin, or whether staff persons administered the individual’s medication to the VA. The individual’s medication was immediately removed from the VA’s bin, a report was quickly made to DHS, staff persons were “pulled” from administering medications until they were retrained on medication administration and were instructed to triple check medications as required by facility policies prior to administering them in the future. No information showed that the VA required the care of a physician or felt unwell. P2 (a supervisory staff person), P3, and P4 provided direct care to the VA and provided consistent information that the VA might have received a medication that belonged to an individual who resided at the facility but was presently in a rehabilitation facility because s/he was injured in a fall. The individual’s medications were not sent with him/her to the rehabilitation facility. It was unknown when or how the individual’s medication was placed into the VA’s bin or whether s/he received doses of the medication, but the VA did not recently require the care of a physician for respiratory issues and no information showed that the VA was harmed by taking the medication. P2, P3, and P4 each stated that the VA might decline meals that were offered to him/her, but s/he could have a preferred food choice if s/he did not want the meal that was prepared. Staff persons might ask the VA whether s/he wanted to continue eating or whether s/he was done. Prior to concerns being raised regarding the VA’s weight, the VA received jevity three times a week, but presently received jevity five times a week. A pump was used to give the VA jevity at night through his/her G tube that s/he might dislodge which caused the VA to receive less than the recommended amount of jevity or caused jevity to spill onto the VA’s bedding. Staff persons checked on the VA every two hours during the overnight shift and might not immediately notice that the tube was dislodged because they did not turn on the overheard light in the VA’s bedroom. There were printed step by step instruction sheets at the facility for giving the VA jevity via the G tube and assisting the VA when s/he bit the inside of his/her jaw. According to P2, the VA was assisted to eat a bowl of the pancake mix after each meal, but the VA might decline to eat it. However, G1 said that the VA was to eat the bowl of pancake mix after eating the main entrée “no ifs, ands, or buts.” It might take two hours to assist the VA to eat, and it could be difficult to assist him/her while also assisting other individuals at the facility. P2, P3, and P4 provided consistent information that they did not notice that the VA lost weight. The VA had always been slender and P2 said that the VA did not look different to him/her. The VA’s medical records from September of 2022 to July 12, 2023, were reviewed and showed that on September 2, 2022, the VA was evaluated at his/her primary care physician’s clinic for an annual examination. The VA was doing well but continued to need help with tube feedings and had a history of chronic obstructive pulmonary disease/mild intermittent asthma according to the records. There were no concerns, and the VA was given a vaccine, but his/her weight was not noted. On September 21, 2022, the VA had an office visit with a health care professional, but s/he came to the clinic in his/her electric wheelchair, so s/he was not weighed. An appointment was scheduled for October 6, 2022, for the VA to return with his/her manual wheelchair to obtain his/her weight. On October 6, 2022, the VA weighed 104.6 pounds, and which was within his/her “recommended weight of 100-105 pounds,” based on his/her past weight history. The VA’s weight had been stable over the past 6 months with three tube feedings a week, and the VA had been eating well. It was recommended that the VA continue getting jevity three days a week, and that s/he return in six months for a weight check. On January 6, 2023, the VA’s feeding tube was replaced. There was no documentation of the VA’s weight or of concerns regarding his/her weight. On March 14, 2023, the VA was evaluated for respiratory concerns. The VA had an elevated temperature and was diagnosed with a suspected viral respiratory infection. The VA was not weighed and was not admitted to a hospital for additional care. On April 6, 2023, the VA weighed 90 pounds at the primary care physician’s clinic which was a loss of 14.6 pounds from October of 2022. Staff persons were instructed to increase the VA’s tube feedings from three days a week to five days a week, providing an additional 576 calories for five days and the VA was to be weighed again in a month. On April 18, 2023, the VA was evaluated for a rash and on April 24, 2023, the VA was evaluated for respiratory concerns, but was not weighed or admitted to a hospital for care on either date. Medical records showed that on June 20, 2023, the VA weighed 99 pounds and 12.8 ounces at the clinic. The VA continued to receive jevity five times a week, his/her G tube was changed, and it was recommended that s/he return in three months. The VA’s progress notes (called T-logs) written between December of 2022 and April of 2023, showed that staff persons did not consistently document whether the VA consumed all his/her meals and his/her pancake mix. However, on February 12, 2023, the VA ate the evening meal and declined to eat the pancake mix. Personnel files, including training information was reviewed. The facility trained its staff persons on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, and the VAs’ plans of care prior to March of 2023. Relevant Statutes: Minnesota Statutes, chapter 245D.05, subdivision (1), paragraph (a) states that the license holder is responsible for meeting health services needs assigned in the support plan or the support plan addendum, consistent with the person’s health needs. Minnesota Statutes, chapter 245D.05, subdivision (2), paragraph (a) clause (5) item (b) subitem (1) states that if responsibility for administering medications is assigned to the license holder, the license holder must implement medication administration procedures to ensure that a person takes medications and treatments as prescribed. Conclusion: Regarding the VA’s weight: The VA’s diagnoses included spasticity and cerebral palsy, and s/he was regularly weighed at health care facilities. Information was consistent from the VA’s documentation, medical records, G1, P1, P2, P3, and P4 that the Gs usually accompanied the VA to medical appointments, with the facility transporting the VA to medical appointments only when the Gs were unable to. The VA’s medical records showed that s/he lost 14.6 pounds between October of 2022 and April of 2023. G1 thought that the VA lost weight because s/he did not receive jevity three times weekly as recommended and because some staff persons did not give the VA jevity as specified, did not give the VA pancake mix at each meal, or stopped assisting the VA to eat after a few bites. When the VA’s health care team became aware of his/her weight loss in April of 2023, s/he began receiving jevity five times a week. On June 20, 2023, the VA weighed almost 100 pounds. P2, P3, and P4 provided consistent information that the VA might decline meals that were offered to him/her but there were alternative meals the VA might have if s/he did not want the food that was prepared. Some staff persons asked the VA whether s/he was finished eating and the VA might accidentally dislodge the G tube which caused the VA to receive less jevity than s/he should because jevity was pumped onto the VA’s bedding. Although the VA lost almost 15 pounds between October of 2022 and April of 2023, given that P2, P3, and P4 said they did not notice the VA’s weight loss and that no information showed that staff persons declined to assist the VA to eat, and that when the VA’s jevity was increased, s/he gained weight, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services that were reasonable and necessary to obtain or maintain the VA’s health. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Regarding the VA’s medication: G1 said that on March 27, 2023, s/he obtained three vials of albuterol from the VA’s medication bin at the facility when the VA had a planned overnight stay at G1’s residence. G1 used two vials for the VA and when s/he returned the third vial to the facility, s/he realized that the medication was a similar medication that was prescribed for another individual who resided at the facility but was not the VA’s medication. P1 confirmed that the individual’s medication (ipratropium albuterol) was in the VA’s bin. The individual’s and the VA’s medication (levalbuterol) were both in vials and both used to treat respiratory issues. The last time the VA was administered levalbuterol at the facility was on March 23, 2023, and there was no count of how many vials of levalbuterol were in the bin prior to the date of the incident. It was unknown how long the individual’s medication was in the VA’s medication bin, how it came to be in the VA’s bin, or whether staff persons gave the individual’s medication to the VA. The VA did not require medical care and no changes in his/her behavior were noted. The individual’s ipratropium albuterol was in the VA’s bin and there were concerns that the VA received it, which was inconsistent with the facility’s policies and procedures and was a violation of Minnesota Statutes 245D.05. However, given that the last documented dose of the VA’s levalbuterol given by staff persons was on March 23, 2023, that it was unknown whether staff persons gave the individual’s medication to the VA, that no information showed that the VA sustained an injury or required medical care, and that it was unknown when the medication was placed in the VA’s bin, or by whom, there was not a preponderance of the evidence whether there was a failure to provide the VA with care that was reasonable and necessary to obtain or maintain the VA’s health or safety. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an Internal Review of each allegation which determined that its policies and procedures were adequate but were not followed regarding medication triple checks. When the facility became aware of medication concerns, the individual’s medication was immediately removed from the VA’s bin, a report was made to DHS, and staff persons were not permitted to administer medications until they were retrained on medication administration and triple medication checks. The facility did not usually accompany the VA to medical appointments including appointments at which the VA was weighed, and the VA had no plans instructing the facility to monitor his/her weight. Action Taken by Department of Human Services, Office of Inspector General: Because the facility took immediate action when it became aware of issues regarding the VA’s medication, a correction order was not issued.
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