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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: 1069088-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jason Pehler/Beth Virden 651-431-4830 Suspected Maltreatment Reported: Allegation One: It was reported that the facility did not provide adequate nutrition to a vulnerable adult (VA) causing weight loss. Allegation Two: It was reported that the facility did not provide adequate cares to the VA causing muscle stiffness and a dislocated hip. Date of Incident(s): Ongoing between 2010 and 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 June 12, 2023; from documentation at the facility; and through interviews conducted with the VA’s guardian (G) who was also the VA’s family member, facility staff persons (P1 and P2), and supervisory staff persons (P3 and P4). The VA was not interviewed due to his/her limited communication skills. The VA’s other family member (FM) provided information to the facility, which was included in this report. The VA’s support plan and support plan addendum provided the following information: · In 2010, the VA moved into the facility seeking support and services relating to his/her diagnoses, which included cerebral palsy and spastic quadriparesis (weakness in all four limbs). · The VA used a power wheelchair to move around and a power lift to transfer in and out of his/her wheelchair. “[The VA] requires physical assistance in all areas of [his/her] life.” · The VA used adaptive sign language to communicate his/her needs and wants. Staff were encouraged to ask yes or no questions; however, the VA had a history of saying “no” to things s/he “enjoyed.” “[The VA might] not always verbalize what [s/he] needs.” The VA lived at the facility with other housemates. The facility provided at least one staff person 24-hours a day for care and supervision. The facility’s policies and procedures included the following information: · The facility ensured they met the health needs of each client as assigned in their respective support plan and support plan addendum. This included monitoring health conditions according to written instructions from a licensed health professional; and using medical equipment, devices, or adaptive aides, or technology safely and correctly according to written instructions from a licensed health professional. · The facility documented all health changes and promptly notified the client’s legal representative and/or case manager when needed. Facility documentation stated that P1-P4 received training on the facility’s policies and procedures and the Reporting of Maltreatment of Vulnerable Adult’s Act. P1 and P2 received training on the VA’s support plan and support plan addendum; P3 and P4 were listed as creators and/or contributors of these plans. P1, P2, and P4 also received training on the VA’s “feeding” and “range of motion.” Allegation One: It was reported that the facility did not provide adequate nutrition to the VA causing weight loss. The VA’s support plan and support plan addendum provided the following information: · The VA needed assistance with all meal preparation and eating. · “Before staff feed me, I should be prompted to try and feed myself using my adaptive utensils. I know how to feed myself and it is important for my independence, but at times I prefer others to feed me. I should only be fed in the kitchen/dining room. I should be fed with staff sitting directly in front of me, spearing food onto my utensil and setting it down for me to pick up and feed myself with. Staff should be interacting with me throughout the meal and helping to teach/increase independence with my adaptable silverware.” · “I burn A LOT (emphasis in original) of calories every day, so it is very important that I get enough food and I eat 3 well balanced meals every day—meaning, meat, vegetable, fruit, grain, and dairy … Please give me VERY (emphasis in original) large portions right away as I do not tend to eat seconds - please offer seconds, I may agree if I really like the food!” · “If I become stubborn and refuse to eat, be persistent with different words and fun approaches. Try giving me finger foods … If I start to feed myself those items, make a joke out of it … If this doesn't work, assure me that I am being heard and understood. You can give me some ‘space’ from mealtime by offering me other short-term options (read a book, watch TV, etc.) for a while (20 minutes) before another attempt at feeding.” · “I am used to getting 2 snacks a day. I get a midafternoon snack of pudding or yogurt (let me choose). This snack helps me get in my calcium and a few extra calories. In the later afternoon, I get another snack. I may also eat fruit, peaches, pretzels, chips, etc.” · “Ultimately, I am the one who has to decide that I want to eat and no one else can force me.” At the outset of this investigation, the FM provided the following information: · When the VA moved into the facility in May 2010, s/he weighed 104 pounds (lbs.). At the time of this investigation in April/May 2023, the VA weighed 80 lbs. The FM believed the VA’s weight loss was due to not eating enough. The FM believed the VA was “underweight, if not anorexic.” · The VA needed “more” calories than a typical person. Staff were supposed to ask the VA more than once throughout the day if s/he was hungry and offer “healthy meals.” The G said, “[The VA] eats like a hog and so we think [staff] are not giving [him/her] enough food, not seconds or something.” The G typically visited the VA every three weeks and was “surprised” to hear the VA lost 24 lbs. since moving into the facility. The facility maintained a food intake log for the VA. This listed various foods under each mealtime, including pancakes, eggs, chicken alfredo, macaroni and cheese, and stir fry. [Note: The size of each food serving was not documented.] The facility had documentation of staff measuring and recording the VA’s weight monthly since 2021. Staff were supposed to make sure all extra items were removed from the VA’s wheelchair before assisting him/her onto the scale. Regarding this, P4 said, “I believe the higher (weights) are likely incorrect due to [the VA] wearing gear or staff forgetting to remove bags/things from [his/her] wheelchair when weighing [him/her].” The VA’s weight documentation for April 2021 through April 2023 included the following:
Facility documentation included the following: · On June 23, 2022, an interdisciplinary team (IDT) meeting was held. The VA’s IDT included the FM, the G, the VA’s case manager (CM), P4, and other supervisory staff persons. Topics discussed at this meeting included the VA’s goals, activities, and communication. There was no mention of diet or weight loss according to the IDT meeting minutes. · On January 19, 2023, an IDT meeting was held. P4 told the group that staff were continuing to “informally track” the VA’s activities, bowel movements, range of motion, skin checks, stander usage, and time outside. The VA’s goals were discussed, which included the goal to increase the VA’s use silverware. “[The VA] is already averaging 30% towards this goal and has used a fork or spoon an average of seven times per month since this goal was started. [The FM] questioned why the data varies by month and stated that [the VA] should be using silverware multiple times a day. [P4] shared that the goal is charted on every day, but [the VA] often refuses to use a fork or spoon and wants staff to do it for [him/her]. [The FM] made a comment about staff not feeding [the VA], but [P4] clarified that this data is not on whether or not [the VA] eats but solely on if [s/he] used a fork or spoon independently. [The VA] always eats well but typically prefers staff feed [him/her].” There was no additional mention of diet or weight loss according to the IDT meeting minutes. · On April 28, 2023, the FM contacted the facility with concerns that the VA had lost 24 lbs. since 2010. · Later that same day, April 28, 2023, P4 wrote an entry in the facility’s communication log, which staff were supposed to read each shift and add-to as needed. P4 wrote, “Please make sure [the VA] is getting plenty to eat, as [s/he] needs lots of calories in general and especially following [his/her] recent surgery. [The VA] should have salads or vegetables with every meal and should eat fruits 3 times a day. Always make sure to ask [the VA] if [s/he] would like more to eat, and always document [his/her] food intake on DataPlus. Please keep one of [the VA’s] water bottles on [his/her] wheelchair at all times and make sure to offer [him/her] drinks regularly throughout the day.” · On May 3, 2023, an IDT meeting was held. The FM raised concern about the VA weighing 80 lbs. P4 responded that the VA’s had weight remained around 85 lbs. for at least the previous two years but that in response to the FM’s concern, P4 instructed staff to encourage high calorie-foods for the VA. · On May 8, 2023, an IDT meeting was held. The FM told the IDT that the VA needed to “gain more weight.” The facility planned to incorporate more of the VA’s “favorite foods” in meals, switch-up which staff sat with the VA during mealtimes and connect with a dietician to train staff. · On May 23, 2023, an IDT meeting was held, and the meeting minutes stated, “We would like to get [the VA] up to a higher, healthier weight. Make sure [s/he] has [his/her] carnation milk every day after breakfast and that [s/he] always has large, well-balanced meals with protein, fruit/vegetables, grains, dairy, etc. Ideally, [the G and the FM] would like [the VA] to have a salad with every meal. When [the VA] is finished eating [his/her] first serving, [s/he] should always be asked ‘Do you want more?’, please ask this instead of asking if [s/he] is done.” P1-P4 provided the following information: · P1, P2, and P3 had each known the VA for over nine years and were not aware of concerns with his/her weight, including “a big gain or a big loss.” P2 said, “I think [the VA’s weight is] pretty close to the same.” P4 had worked with the VA for just over one year and believed the VA’s weight remained the “same” throughout that time, which was between 85 and 90 lbs. · P1 said that staff offered the VA food “all the time.” P2 and P4 each said that the VA “eats a lot.” P4 added, “[The VA] is definitely eating three meals a day plus snacks.” · P1 said that documenting everything the VA consumed on a food intake log was “time consuming.” There were four individuals living in the house, who needed attention and cares, which made this level of documentation “really frustrating.” There were some staff who did not consistently document on the log; however, this did not mean the VA was not eating. · P4 said that there was not a doctor’s order regarding the VA’s food intake or maintaining a food intake log. Rather, the facility tracked all of the housemates’ food intake, not just the VA’s. P4 was aware that staff were not always good about documenting. “I think there are some days that it doesn’t get documented, but [the VA is] still eating.” · P1 added that as the VA has grown older, “[S/he] doesn’t eat as much as they think [s/he] should … [The VA] doesn’t eat as much as [s/he] used to.” The VA’s appetite changed. P1 added, “I don’t want to feed [him/her] til [s/he] throws up.” Facility documentation also included various medical appointment summaries throughout the VA’s time living at the facility. There was no mention in these medical records of a concern with the VA’s weight or that the VA was underweight. Conclusion for Allegation One: Although the FM and the G expressed concern with the VA’s weight, facility documentation included a weight log, which showed s/he had maintained the same weight for at least the two previous years. The VA attended various medical appointments during this timeframe and there was no information of a doctor having concern with his/her weight. There was also no information of staff withholding food from the VA; rather, staff said the VA “eats a lot.” Without additional witnesses or information to suggest otherwise, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services, which were reasonable and necessary to maintain the VA’s 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).
Allegation Two: It was reported that the facility did not provide adequate cares to the VA causing muscle stiffness and a dislocated hip. The VA’s support plan and support plan addendum provided the following information: · The VA’s routine included waking around 7:30 or 8 a.m.; completing range of motion (ROM) exercises for 25 minutes; and having staff help with getting dressed. “Please always put my (ankle-foot orthosis, AFOs), white socks, and new balance tennis shoes on to protect my feet.” [Note: An “AFO” is a brace intended to control the position and motion of the ankle, compensate for weakness, or correct deformities.] · “It is very important for [the VA] to use [his/her] stander to work out [his/her] hips and legs. [The VA] will use [his/her] stander when possible, daily for 45 minutes.” [Note: A “stander” is an assistive mobility device that supports the person in standing.] · “Staff will complete range of motion (ROM exercises) twice daily” with the VA. At the outset of the investigation, the FM provided the following information: · “[The VA’s muscle] tightness is unbelievable, [his/her] feet are deformed because [s/he's] hardly worn [his/her AFOs], that happened over a course of time not just recently.” The VA’s left foot had become “swollen” and “sore;” and because of this, the VA’s primary care physician (PCP) now recommended s/he stop wearing his/her AFOs. · “[The VA] needs to use [his/her] stander so [s/he] doesn't dislocate [his/her] hip … because [the VA] isn't using [his/her] stander, [his/her] hip has been dislocated.” · “Please note [the VA] can no longer stand in [his/her] stander due to [his/her] feet and dislocated hip. Obviously, records can and are being falsified. There is not enough oversite at the house and there hasn't been for years.” · “[The VA’s] muscles are tight. So that is proof that [ROM] exercises are not being completed.” · “[The VA’s right hand] is contracted because no ROM exercise was being done, [s/he] can't clap at all. So sad as [the VA] loves to clap to [his/her] music, [s/he] can't hold something with [his/her right] hand and manipulate with [his/her] left.” The G said that staff should be assisting the VA with ROM exercises every day, “…but I have my doubts” if it was occurring or not. The VA’s muscles were “tighter over the last couple of months” (approximately February – April 2023). The VA developed an issue with his/her hip, which, according to the G, “Comes from not doing [ROM] exercises.” The VA also developed a sore on his/her foot, and because of this, the PCP discontinued use of the VA’s AFOs and stander until the sore healed. The facility’s Client Progress Review included the number of times staff documented the VA using his/her stander between June 1, 2022, and April 30, 2023 (334 days, to be completed once daily). This included two times each in June and July 2022; one time in August 2022; five times in October 2022; and zero times in September, November, and December 2022, and January through April 2023. The facility’s ROM exercise documentation included the number of times staff documented assisting the VA with ROM exercises between March 1 and April 30, 2023 (61 days, to be completed twice daily for 122 opportunities to complete). This included one time in March 2023 and four times in April 2023; all other days had no data. The facility’s medication administration records stated that the VA’s ROM exercises were completed five times in April 2023, and 48 times in May 2023, with the remaining days in May marked as “refusing” or not at home. Facility documentation included the following: · On June 30, 2022, via the facility’s health notes, the facility’s nurse checked on the VA. The VA was wearing compression socks, AFOs, and tennis shoes. The nurse removed the items and the VA “screamed and cried.” Staff told the nurse that the VA did that every time the AFOs were placed or removed. The nurse noticed redness on the VA’s left foot and recommended the VA be taken to urgent care. “However, [the FM and the G] declined the use of the [urgent care], so an appointment was made with [the PCP] on July 5th.” The nurse told staff to leave the VA’s AFOs off until after this appointment. · On July 5, 2022, via the facility’s health notes, the PCP instructed that the VA stop wearing his/her left AFO until his/her foot healed. · On July 11, 2022, via the facility’s health notes, P4 wrote that staff were applying the AFO to the VA’s right foot, but not his/her left foot. The left foot “appears now is baseline for [the VA].” “[P4] continues to send photos to [the PCP] twice weekly and leave the [AFO] off left foot.” · On July 29, 2022, via the facility’s health notes, the facility’s nurse was informed that the VA’s feet were at baseline. “[P4] will clarify with [the PCP] if/when to resume wearing [the VA’s] left [AFO].” The PCP recommended the VA return to wearing both AFOs. · In August and September 2022, via online messages between staff and the PCP, a discussion of the VA developing a blister on his/her left toe where the AFO was typically placed. At that time, the PCP wrote, “Recommend to avoid [AFOs] at the time being and do good skin care. I will confer with podiatry and we may need to have a follow-up appointment with them given the recurrent foot issues and whether there is a benefit to wearing these [AFOs] or not.” · On August 11, 2022, via the facility’s health notes, the facility’s nurse visited the VA and discussed the VA’s AFOs with staff. “Staff was unaware if client should be wearing [AFOs] or not. We still have not received contact back from [the PCP] about the [AFOs]. Will reach out again.” · On August 26, 2022, via the facility’s health notes, the VA was given the “okay” to resume wearing his/her AFOs. However, the VA developed a new sore on his/her left toe. Photographs were sent to the PCP. · On August 29, 2022, via the facility’s health notes, the facility reached out to the PCC in “inquire about usage of [AFOs].” · On September 8, 2022, via the facility’s health notes, the VA attended an appointment with the PCP. “[The PCP] was wondering why [the VA] needs to wear the [AFOs] and also why one shoe has a taller platform than the other. This writer in not aware, but will inquire with [the G].” The VA had also developed sores on both feet. “[The PCP] recommended to staff to leave [AFOs] OFF (emphasis in original) for now. · On September 9, 2022, via the facility’s health notes, a physical therapist attended the facility. “Stretching and range of motion program to train staff on.” · On September 21, 2022, via the facility’s health notes, the VA continued to not wear his/her AFOs. However, also developed a new sore on his/her left foot. “Per staff’s report, client has not been wearing [AFOs] or shoes.” Photographs were taken and sent to the PCP. · On October 13, 2022, via the facility’s health notes, the VA attended an appointment with podiatry. “Adjusted both AFOs, evaled [sic] shoes, way too large, can't tell exactly where pressure is coming from but more than likely from end of tongue area being too tight.” New shoes ordered for the VA. · On October 19, 2022, via the facility’s health notes, the VA was wearing AFOs since the podiatry appointment on October 13, 2023. The VA’s sore on his/her left foot remained unchanged. · November 3, 2022 – January 12, 2023, via the facility’s health notes, the VA’s foot sores “continue to improve … healing nicely.” “Staff have not been applying AFOs, which is what [the PCP] has requested for now.” · On March 23, 2023, via messages between staff and the PCP, “Hello [the PCP], [the VA’s] feet have been doing good lately, but [the G and the FM] are insistent that AFOs are worn regularly again. Do you think this is okay to try?” The PCP responded that s/he would reach out to another doctor to inquire. · On April 6, 2023, via messages between staff and the PCP, the facility followed up with the PCP asking if there was an update on the correspondence from March 23, 2023, in which they asked, “[The G and the FM] are insistent that [the VA’s] AFOs are worn regularly again. Do you think this is okay to try?” On April 13, 2023, the PCP responded with the following, “I heard back from [doctor] … [S/he] is fine without [the VA] wearing the [AFOs] as the benefit is low. [The VA] is not weight bearing and if it is causing problems with skin breakdown regularly and I have been told that [the VA] does not like wearing them, [the PCP] is fine without [the VA] using them.” · On April 24, 2023, via staff communication logs, P4 wrote, “Please continue to leave AFOs OFF (emphasis in original) per doctor’s guidance. [The FM and the G] are aware of this instruction. Please reach out to [P4] if [the FM and the G] state otherwise.” · On April 28, 2023, via staff communication logs, P4 wrote, “[The VA] should resume wearing [his/her] AFOs daily and nursing will continue to monitor. · Also on April 28, 2023, the VA’s medical records stated that s/he attended an appointment, in which, it was determined the VA’s hip was not dislocated. An appointment with an orthopedic doctor was scheduled for later that same month. · On April 30, 2023, via staff communication logs, a staff person wrote, “[The FM] called to check on [the VA] today and staff mentioned the slight swelling in [his/her] legs. [The FM] requested we leave AFOs off for a day or 2 until the swelling goes down.” · On May 1, 2023, via staff communication logs, P4 wrote, “If you completed or attempted to complete [the VA’s] stander or ROM in the past couple of months, please let me know so I can update my data. Going forward, be sure to always document these things in DataPlus, even if [the VA] refuses to do them.” · On May 3, 2023, via IDT meeting minutes, the facility told the team that the VA was not using his/her stander because, “[S/he] still screams and becomes very upset when using the stander.” The facility was creating ways to make the stander more fun for the VA. Regarding the VA’s ROM exercises, the facility planned to have a supervisory staff person observe staff completing these to ensure they knew how to do them. Regarding the AFOs, they were not being worn per the PCP’s recommendation to stop. · On May 8, 2023, via IDT meeting minutes, “[The VA] should not use [his/her] stander indefinitely … [The VA] should continue to have AFOs left off for the time being, and [the FM and the G] have [the VA’s AFOs] in their possession to ensure they are not being applied. · On May 23, 2023, a staff-meeting was held, which included various direct care staff, P4, and other supervisory staff persons. “[The VA] should not wear [his/her] AFOs for the time being, as they are irritating [his/her] legs/feet. [The VA] also cannot use [his/her] stander until further notice. Staff should continue doing [ROM] with [the VA] twice a day.” P1-P4 provided the following information: · P1, P2, and P3 had each known the VA for over nine years. P2 and P4 did not notice any changes with the VA’s wellbeing or physical health. P3 said that the VA’s desire to complete tasks decreased over the years, especially since the start of the COVID-19 pandemic. When the VA did not want to do something, s/he got “very vocal” and grabbed his/her wheelchair wheel to prevent from moving any further. · P2 and P3 each said that the VA’s routine changed over the past few years, especially since the start of the COVID-19 pandemic and there had been increasing staff turnover. The VA “does best” when s/he “knew what to expect.” “There’s just been a ton of change,” and the VA’s “routine got lost.” P2 added that newer staff did not know how to approach the VA for certain tasks. “It’s how you approach … Like, [s/he’s] saying ‘no,’ and they’re taking that but they’re not trying like a different approach.” · P1 routinely assisted with the VA’s ROM exercises. The VA was “fine” with P1’s help, but “It’s really hard with newer [staff] because [the VA] really fights and screams and bites.” When the VA got to the point of “crying and being sad … [s/he] just done … We can’t continue at that moment but will always try again later.” On days when the VA declined to complete his/her ROM exercises, staff played games with him/her, including catch with “light balls.” “Just to get [him/her] moving.” · P4 was aware of one staff person who might have historically declined to assist with the VA’s ROM exercises; however, that staff no longer worked for the company. P1-P4 were not aware of any other staff declining to assist or offer the VA’s ROM exercises, AFOs, and/or stander. · P4 said that the documentation of the VA’s ROM exercises, AFOs, and stander was not consistently recorded by all staff. There had been an issue with the computer system that prevented staff from recording accurately. This issue was not immediately conveyed to P4 and went unfixed for a period. · To better assist newer staff with the VA’s ROM exercises, AFOs, and stander, P4 created a training video and was also personally trained by the VA’s physical therapist, which was then relayed to staff. Relevant Minnesota Statutes and Rules: Minnesota Statutes 245D.05, subdivision 2, paragraph (a), clause (4), states that medication administration included documenting the administration of the medication or treatment or the reason for not administering the medication or treatment. Conclusion for Allegation Two: According to the VA’s support plan and support plan addendum, the facility was assigned responsibility for meeting the VA’s health needs. The facility had tracking documentation regarding the VA’s ROM exercises and stander; however, the documentation was missing data. This conduct was in violation of Minnesota Statutes 245D.05, subdivision 2, paragraph (a), clause (4), which states that the facility was responsible for documenting the administration of a treatment or the reason for not administering the treatment. Although the FM and the G expressed concern with whether the VA’s ROM exercises, AFOs, and stander were completed every day, P1-P4 were not aware of this being an ongoing issue. Rather, they said the VA’s routine changed during the COVID-19 pandemic, which prompted an increase in the VA declining to complete tasks. In addition, the VA’s AFOs caused injuries to his/her feet and so the PCP discontinued the use of the AFOs and the stander. Given this and without additional witnesses or information to suggest staff were declining to offer or assist with the VA’s cares or the VA’s muscle stiffness was directly related to staff declining to offer or assist with the VA’s cares and not caused by something else, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services, which were reasonable and necessary to maintain the VA’s 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 and determined that policies and procedures were adequate but not followed. The staffs’ documentation regarding the VA’s food log, range of motion exercises, and stander-use were not consistently documented by all staff. The facility provided additional training to staff regarding documentation and information specific to the VA’s care. Action Taken by Department of Human Services, Office of Inspector General: On August 11, 2023, the facility was issued a Correction Order for the violations outlined in this report.
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