|
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: 1071928-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden/Thomas Nixon 651-431-6572 Suspected Maltreatment Reported: Allegation One: It was reported that a staff person (SP1) was “mean” to vulnerable adults (VA1-VA4). Allegation Two: It was reported that VA1 fell down the stairs and sustained a “gash” on his/her head, and that a staff person (SP2) did not seek additional medical attention.
Alleged Licensing Violations: It was reported that SP1 withheld food from VA1-VA4. It was reported that SP1 forced VA1-VA4 to sit on a couch for most of the day. It was reported that the overnight staff person left before the next shift arrived leaving VA1-VA4 unsupervised at the facility. Date of Incident(s): May 2 through 4, 2023, and other dates unknown 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 2, paragraph (b), clause (2); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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 June 8, 2023; from documentation at the facility; and through 14 interviews conducted with VA1, VA1’s guardian (G1), VA2, VA2’s guardian (G2), VA3, VA3’s guardians (G3 and G4), VA4, VA4’s case manager (CM), facility staff persons (SP1, SP2, P1, and P2), and a supervisory staff person (P3). [Note: VA3 declined to participate in the full interview and did not provide information for all of the allegations.] VA1-VA4 lived together at the facility, which was a single-family home. The facility provided at least one staff person 24 hours a day for care and supervision. VA1’s-VA4’s respective support plans and support plan addendums provided the following information: · VA1’s diagnoses included major depressive disorder. · VA2’s, VA3’s, and VA4’s diagnoses included mild intellectual disabilities. · VA4 was not subject to guardianship. Facility documentation stated that SP1, SP2, P1, P2, and P3 received training on the Reporting of Maltreatment of Vulnerable Adults Act. Documentation also stated that SP2, P2, P3, and P4 received training on VA1’s-VA4’s support plans and support plan addendums. However, there was no documentation that SP1 and P1 received this same training, which was in violation of Minnesota Statutes section 245D.09, subdivision 5, paragraph (a), clause (2); and states, in part, the license holder must maintain a personnel record of each employee to document and verify staff qualifications, orientation, training, and performance evaluations as required under section 245D.09, subdivisions 3 to 5. Allegation One: It was reported that SP1 was “mean” to VA1-VA4. VA1’s-VA4’s respective support plans and support plan addendums stated that VA1-VA4 were each susceptible to abuse from others. Staff persons intervened as necessary to ensure safety. P1 said that s/he witnessed “[SP1] talking rude” to VA1-VA4 and was “always” telling them, “No,” if they asked for anything. P1 believed that SP1 was “controlling” VA1-VA4, rather than “working for” VA1-VA4. VA1-VA4 provided the following information: · VA1 said that unspecified staff persons were “mean” during times when VA1 was sick or missed school. One staff person, whose name could not be recalled, called VA1 “bitch” and “rugged.” Another time, VA1 dropped a box of cereal and an unspecified staff “yelled” at him/her. · Regarding SP1, VA1 said, “[SP1] is pretty good” and did not say “mean” things to VA1. One time, SP1 asked for a cereal box that VA1 was holding and VA1 handed it to him/her. · VA4 said that one time an unspecified staff person told him/her to stay in his/her bedroom. VA4 said that the staff have not yelled at him/her, but they might have yelled at VA1-VA3. P3 yelled at times. · VA2 said that staff did not say “mean” things. “They treat me very nice.” P2 never heard staff call VA1-VA4 names or be “loud” towards them. P3 said that VA2 told him/her that staff were “loud at night during shift change.” P3 redirected these staff to be “quiet.” P3 was not aware of VA1, VA3, or VA4 having similar concerns. P3 was not aware of any instances where staff called an individual names. Regarding SP1, P3 never heard SP1 “raise [his/her] voice.” SP1 said that s/he “never” yelled at or said “unprofessional and hurtful things” to VA1-VA4 and did not witness this of other staff. Conclusion for Allegation One: P1 said that SP1 was “rude” and “always” said, “No,” to VA1-VA4. VA1 said that an unspecified staff person, not SP1, called him/her names and yelled; and VA4 said that staff might have yelled at VA1-VA3. SP1 denied the allegation, and P2, P3, and VA2 never witnessed or heard similar concerns. Given that there was a lack of information or witnesses to state which staff yelled or called names and whether this happened more than once or was a repeated occurrence, there was not preponderance of the evidence whether a staff person’s conduct included the use of repeated or malicious oral, written or gestured language toward VA1-VA4 or treatment which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. It was not determined whether emotional abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening). Allegation Two: It was reported that VA1 fell down the stairs and sustained a “gash” on his/her head, and that SP2 did not seek additional medical attention. VA1’s support plan and support plan addendum stated that s/he had a risk of falling. “[VA1] is unaware of falling. If [s/he] starts to run [s/he] may fall over forward as [s/he] goes too fast and loses [his/her] balance. REM staff will provide verbal reminders to slow down.” [Note: In the records provided by the facility and reviewed for this investigation, there was no mention of a need for support for VA1’s navigation of stairs and/or what supports staff provided to assist VA1 with navigating stairs.] P1 was trained that VA1 was not supposed to access stairs without a staff person present. On the night of the incident, VA1 was on the stairs unsupervised. SP2 should have been supervising VA1. VA1 fell down the stairs sustaining a “scraped-up face, forehead, nose, elbows, knees, and chin … [VA1] was in a lot of pain.” P1 was not working at the time but told later by P3 that VA1 was “fine” and not taken to an emergency room. VA1 said that on an unspecified date, either VA2 or VA3 pushed him/her down the stairs causing him/her to hit his/her head; “A nail went into my head.” VA1 also said that on May 9, 2023, the day prior to the investigator’s site visit, P3 or some other staff person pushed VA1 down the stairs causing him/her to sustain a broken leg; however, VA1 did not tell anyone about his/her broken leg. [Note: The investigator met and interviewed VA1 at the time of the site visit (May 10, 2023) and did not observe injuries consistent with a recent fall or a broken leg.] G1 said that VA1 had a tendency of opening the stairwell gate and attempting to “clean” the stairs. Staff redirected VA1 and at least once, VA1 “slipped” down the stairs. The gate was meant to stop VA1 from accessing the stairs, but s/he knew how to open it. Staff were supposed to be watching VA1 “at all times.” P2 and SP1 each said that VA1 had a history of walking “fast” and tripping or falling. Staff were supposed to walk next to VA1, hold his/her arm, and remind him/her to slow down. When on the stairs, staff were supposed to walk in front of or behind VA1 depending on the direction s/he was walking. P2 and SP1 each heard that VA1 fell down the stairs sometime in May 2023 and sustained bruises but were not aware of any head injuries. P3 said that in May 2023, VA1 fell down the stairs when SP2 was working. SP2 notified a supervisor that VA1 fell and sustained “scraps” on his/her knees and elbows. The supervisor advised that VA1 be “washed up” and receive first aid treatment, and that no additional medical attention was needed at that time. However, VA1 also had a “big mark on [his/her] forehead like a rugburn, like [s/he] hit [his/her] head” and SP2 did not communicate this injury to the supervisor. According to P3, had it been known at the time that VA1 might have a head injury, additional and immediate medical attention (e.g., emergency room visit) would have been advised. SP2 provided the following information: · On the day of the incident, VA2 had a temporary medical concern, which resulted in staff delivering his/her meals to his/her bedroom. Staff were running food trays to VA2 up and down the stairs throughout the day. · At dinnertime, SP2 brought a tray to VA2 and did not immediately realize that VA1 had followed him/her down the stairs. “[VA1] had a tendency to follow me. It was hard to stop [him/her]. I think [s/he] followed me down.” · On the way back up the stairs, SP2 was holding “food” in his/her hands and heard VA1 begin walking up the stairs behind SP2. SP2 turned around and saw VA2 on the second or third step from the bottom. VA2 made a sound, like “Ugh,” and while holding the railing began slipping on the steps. VA1 then slid down the steps with his/her body dragging across the carpet. SP2 dropped the food and ran to VA1’s aid. VA1 sustained “rugburns” on his/her arm, leg, and forehead. VA1 did not “bang” his/her head or strike it with any force. [Note: Consistent information was provided that staff were supposed to walk behind VA1 when s/he was walking up the stairs; this was not done by SP2 at the time of the incident. However, this level of care was also not documented in VA1’s support plan or support plan addendum. The facility was issued a recommendation to ensure VA1’s support plan or support plan addendum accurately recorded his/her needs and supports.] · SP2 called a supervisor who asked if VA1 “banged” his/her head, and SP2 said, “No.” The supervisor then advised that VA1’s rugburns be treated with first aid supplies, including “band-aids.” Following this conversation, SP2 called a second supervisor “to make sure we are good.” This supervisor also told SP2 that it was appropriate to clean VA1’s wounds and apply “band-aids.” · VA1 seemed “fine” throughout the incident and after. · SP2 did not see VA1 “bang” his/her head and did not hear any sounds that might suggest VA1 “banged” his/her head. SP2 did not document the incident or photograph VA1’s injuries. [Note: At the time of the site visit, VA1’s injuries were healed without issue.] Conclusion for Allegation Two: In May 2023, VA1 fell down the stairs. This incident was not documented making it difficult to determine what exactly happened. VA1 said that someone pushed him/her down the stairs; however, VA1’s description of events and injuries were not consistent with what happened and so it was not determined whether VA1 was speaking about the same incident. SP2, who was the sole witness to the fall, said that s/he did not know VA1 had followed him/her downstairs and saw VA1 fall when they were headed back up the stairs. VA1 sustained rugburns but did not “bang” his/her head. SP2 sought advice from two supervisors who each advised in-home first aid treatment. Although P3 said that had the supervisors been informed of the rugburn on VA1’s head, they would have advised s/he be taken to an emergency room for a possible head injury, SP2 was adamant that VA1 did not hit his/her head. For these reasons, and that VA1’s injuries healed without issue, without other witnesses or information, there was not a preponderance of the evidence whether SP2 failed to supply VA1 with care or services, which were reasonable and necessary for their health and 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). Alleged Licensing Violations: It was reported that SP1 withheld food from VA1-VA4. VA1’s-VA4’s respective support plans and support plan addendums provided the following information: · VA1’s diagnoses included lactose intolerance. “Prior to eating any foods with dairy, staff will administer Lactose Enzyme as directed.” · “[VA2] doesn’t have any special dietary needs.” · “[VA3] is on a sodium restriction. [VA3’s] doctor doesn’t want [VA3] to have more than 2,000 (milligrams) mg of sodium per day. [VA3] is unable to independently keep track of how much sodium [s/he] has had in a day … REM staff will monitor [VA3’s] sodium intake. Low sodium groceries will be purchased and [VA3] will be given verbal cues as to low sodium food choices when out in public.” · “[VA4] likes to have an excessive amount of food. [VA4] and staff will plan meals and go grocery shopping. It is recommended by the doctor that [VA4] watch [his/her] caffeine intake but [VA4] is [his/her] own guardian and doesn’t always want to listen to the doctors. Staff will need to remind [VA4] that caffeine intake will affect [his/her] mood and interrupt with [his/her] sleep and medications. [VA4] will also drink excessive amounts of water. When [VA4] consumes large amounts of liquids [his/her] sodium level goes low. [VA4’s] doctor would like [him/her] to limit the liquid intake during the day. The doctor also recommended to have [VA4 drink] a small Gatorade daily to quench some of [his/her] excessive thirst … Staff will encourage [VA4] to eat a balanced diet. [VA4’s] staff will also encourage [him/her] to drink caffeine-free drinks and limit other liquid drinks due to [him/her] overdrinking which causes low sodium.” P1 said, “[SP1] was only allowing [VA1-VA4] to eat certain things that [s/he] picked out.” One time, P1 saw SP1 “yank” a box of cereal out of VA1’s hands. VA1-VA4 provided the following information: · VA1-VA4 each liked the meals served at the facility, which might include hamburgers or chicken. If it was not a mealtime, VA1-VA3 typically ate a snack, which might include a piece of fruit or a muffin. · VA1 said that one time, P3 told him/her that s/he could not have any food because they were headed out to eat. · VA3 said that on May 9, 2023, the day prior to the investigator’s site visit, an unspecified staff person told him/her that the facility did not have any snack foods. · VA2 and VA4 each said that they were never told that they could not eat something. G2 said that the facility restricted VA2’s fluid intake. VA2 might drink a 12-pack of soda in one sitting if not monitored by staff. VA2 did not have food-related restrictions. G3 and G4 each said that VA3 was “food-focused” and had a history of making “poor choices for [his/her] health.” VA3 would “eat anything despite having kidney failure concerns.” VA3’s doctor ordered that s/he be on a restricted diet to keep him/her from having to undergo dialysis. VA3 did not like having a restricted diet. The facility was doing “amazing” and monitored and recorded everything VA3 ate. However, VA3 continued to “sneak … steal” food. The CM said that VA4 had a history of drinking “so much water … too much.” Staff were supposed to redirect VA4 away from drinking so much water; however, they were not supposed to restrict VA4’s water intake. This was not an official order from a doctor but rather a recommendation. VA4 did not have food-related restrictions. P2 and P3 each said that VA1-VA4 were able to eat snacks in-between meals. Staff were supposed to “encourage healthy (snack) options … Staff encourage and remind, or suggest they wait a while” but they did not decline food or drinks to VA1-VA4. P2 and P3 each never witnessed a staff person restricting or declining food or drink and were not aware of such a thing occurring. SP1 provided the following information: · SP1 recommended fruit as a snack between mealtimes for VA1-VA4. Sometimes they accepted and sometimes they wanted something else to eat. “If they refuse, it is their choice. They can have whatever they want.” SP1 did not restrict or decline to provide food or drinks. · VA2 and VA4 each were on a fluid restriction. SP1 reminded them of their fluid consumption and offered alternative activities or asked if they could wait. “… but they can have whatever they requested or whatever they asked for.” · SP1 “never” took or yanked cereal out of VA1’s hands. VA2’s medical records stated that in April and August 2022, his/her sodium levels were low. VA2 was put on a fluid restriction of 1,000-1,500 milliliters (mL)/day. This included tracking his/her fluid intake throughout each day. In September 2022, VA2’s sodium levels were within normal limits, and s/he remained on the fluid restriction. [Note: At the time of this investigation, the facility did not have tracking documentation regarding VA2’s fluid intake each day and the staff interviewed for this investigation stated that they did not track VA2’s fluid intake. The failure to meet VA2’s health service needs as assigned and monitor VA2’s health conditions according to written instructions from a licensed health professional was in violation of Minnesota Statutes section 245D.05, subdivision 1, paragraph (b), clause (2). In addition, despite VA2’s medical records regarding his/her fluid restriction, VA2’s support plan and support plan addendum stated, “[VA2] doesn’t have any special dietary needs.” The facility was issued a recommendation to ensure VA2’s support plan or support plan addendum accurately recorded his/her needs and supports.] VA3’s medical records stated that on/or around April 2019, s/he was diagnosed with chronic stage 4 kidney disease. At that time, VA3 was put on a low potassium diet and staff were supposed to “encourage 64 oz (ounces) of water (illegible word) daily.” In November 2020, VA3’s renal function tested “stable. At that time, VA3 was instructed to “continue renal diet.” In September 2021, VA3 was instructed to “continue low sodium, low phosphorus, low potassium diet.” Although P1 had concerns about food and drinks being withheld, given that VA1-VA4 did not have similar concerns and that P2, P3, and SP1 each said that food and drinks were not withheld, without additional witnesses or information, it was not determined to what degree food and/or drinks were withheld or if at all. Therefore, a licensing violation was not determined. It was reported that SP1 forced VA1-VA4 to sit on a couch for most of the day. VA1’s-VA4’s respective support plans and support plan addendums provided the following information: · VA2 had surgery on one of his/her feet and planned to have surgery on his/her other foot in the future. · VA1, VA3, and VA4 did not have restrictions on their movements or mobility. P1 said, “[SP1] would not let [VA1-VA4] walk around. They sit on the couch all day and cannot do anything but watch what [SP1] was watching on the TV.” P1 was not aware of other staff who “kept them on the couch.” VA1-VA4 provided the following information: · VA2 said that his/her doctor had recommended that VA2 not walk around so much to protect his/her feet and to, instead, “sit down and relax.” VA2 sometimes watched television upstairs and sometimes downstairs. · VA3 said that there were times when a staff person told him/her to watch television. · VA4 said that s/he was not a television-watcher and if others were doing so, VA4 might leave the room or do something else. G2 said that VA2 had surgery on his/her feet. G3 said that VA3 did not like watching television and instead, liked to be outside. VA3 was allowed to be in the yard or walk around the block unsupervised. G4 never heard anything about being restricted to the couch. According to G4, “They have freedom of movement.” P2 and P3 each never heard anything about VA1-VA4 being restricted to the couch and/or to watch television. P2 heard staff ask VA1-VA4 to watch television while they cooked dinner, but this was “optional.” SP1 provided the following information: · SP1 offered VA1-VA4 options on how they spent their time. “Usually, it’s their choice. Sometimes they don’t feel like [an activity] and so they don’t do it.” · VA1-VA4 spent “most of the time” watching television. · SP1 never forced VA1-VA4 to remain on the couch and/or watch television. “Nobody can force them. We can only give recommendations, or we can ask, ‘Hey, what do you want to do?’” Although P1 had concerns that SP1 restricted VA1-VA4 from leaving the couch and/or made them watch television, SP1 denied this and P2, P3, VA1-VA4, G2, G3, and G4 each had no information that this occurred. Therefore, a licensing violation was not determined. It was reported that the overnight staff person left before the next shift arrived leaving VA1-VA4 unsupervised at the facility. VA4 said that there had been times when the overnight shift left to go home before the next shift arrived, which left the individuals without supervision. This happened more than once and at least one time, there was not a staff person at the facility until 12 noon when the next staff arrived. P3 said that s/he had no information of staff leaving before the next shift arrived and if this occurred, it was never relayed to P3. However, there was at least one time when an unspecified individual reported there were no staff present, but P3 later learned that there were two staff, and one was in the office and the other in the garage, but they never left the facility or left the individuals unsupervised. SP1 never heard anything about staff leaving before the next shift arrived. The CM said that VA4 had a history of making comments, like, “[Staff] treat me terrible. [Staff] don’t give me money. I don’t need [staff].” According to the CM, these were “classic [VA4] comments.” VA4 was not an accurate reporter of information. Given that there was a lack of information or other witnesses to state when or if staff left before the next shift arrived, a licensing violation was not determined. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed. The facility provided additional training to SP1 “regarding [his/her] approach-to make sure [s/he] clearly phrases things so people understand they have choices.” Action Taken by Department of Human Services, Office of Inspector General: On August 9, 2023, the facility was issued a Correction Order for the violations outlined in this report, and a recommendation to review client records to ensure they accurately record each person’s needs and supports.
|
