|
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: 1071921-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jason Pehler/Alice Percy Minnesota Department of Human Services 651.431.4830 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) did not ensure that a vulnerable adult (VA) received medical attention when the VA became ill. Date of Incident(s): February 17, 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 9, 2023; from documentation at the facility and medical records; and through four interviews conducted with a facility administrative staff person (P1), SP1, SP2, and the VA. The VA enjoyed sewing, knitting, playing games, and spending time with friends and family members. The VA had a job in the community. The VA used a walker when moving from one area to another. The VA had 12 hours of unsupervised time in the facility or in the community. The VA’s diagnoses included diabetes, heart failure, schizoaffective disorder, borderline personality disorder, primary pulmonary hypertension, secondary parkinsonism, hyperlipidemia, hypothyroidism, major depression, and chronic respiratory failure with hypercapnia. The VA was not subject to guardianship. According to the VA’s Support Plan, the VA was at risk of hospitalization due to multiple medical and psychiatric conditions. The VA used oxygen continually. The VA was able to call for help from the staff persons or to telephone 9-1-1, if necessary. According to the VA’s ISSA Assessment Detail, the VA scheduled his/her medical appointments and the staff persons sometimes assisted the VA with providing transportation to the appointments at the VA’s request. According to the facility’s Shift Notes: · On February 17, 2023, SP2 documented: Upon my arrival at 8 a.m., [the VA] had [his/her] meds [already], [s/he] was in the washroom sitting on the toilet but not using the washroom. For breakfast, [s/he] had oatmeal with berries, for lunch [s/he] didn’t want anything to eat which is unlike [the VA]. [The VA] had a 2 p.m. appointment there [sic] was cancelled and eventually about 4:35 p.m., [the VA] went to the emergency room, [s/he] wasn’t feeling good all day after [s/he] came out of [his/her] room, [s/he] came into the living room and said [sic] in the rocking chair and [s/he] really didn’t talk much or anything but [s/he] was very upset when [s/he] had to cancel [his/her] doctor’s appointment. · On February 18, 2023, P1 documented: I did not have any personal contact with [the VA], but I did receive a call from one of [his/her] staff stating that [s/he] had missed an appointment earlier yesterday (February 17, 2023) and was feeling a lot of pain and just overall very week. [The VA] had called the nurse’s line to get directives on what to do and they had instructed [him/her] to go to the emergency department. A staff took [the VA] to the emergency department, where [the VA] was admitted due to low oxygen, high CO2, and extreme lethargy. I called for an update on [the VA’s] condition and they are still trying to get [his/her] oxygen up and CO2 down. They also said [the VA] is still very weak and lethargic. The VA stated that on the morning of February 18, 2023, s/he felt “kind of sick, but that was not anything out of the normal.” The VA did not recall what the staff persons did or said to the VA that day. The VA recalled that his/her legs were swollen and that in the hospital, they “took off a half a gallon of water from my system.” The VA did not recall being taken to the hospital or much of what occurred at the hospital when s/he first arrived there. A hospital staff person later told the VA that his/her lips “were all purplish” when s/he got to the hospital. The VA believed that s/he did not feel well the night before s/he was admitted to the hospital, but did not think that s/he told the staff persons s/he felt unwell. The VA did not believe that “anyone did anything wrong” on the day of the incident. P1, SP1, SP2, and the facility’s documentation provided the following information: · On February 17, 2023, at 7:30 a.m., SP1 began his/her work shift at the facility. At 7:50 a.m., SP2 began his/her work shift at the facility. Another staff person (P2) was scheduled to begin his/her work shift at 2 p.m., but was late and did not clock in until 2:54 p.m. The VA had a medical appointment that day at 2:30 p.m. that was a follow-up appointment because of swelling in his/her legs. Because of his/her medical restrictions, SP1 was unable to take the VA to his/her medical appointment unless a second staff person accompanied them. SP1 and SP2 decided that they would take the VA to his/her medical appointment when P2 arrived at the facility for his/her work shift at 2 p.m. · The VA had an oxygen tank that s/he used whenever s/he was in the facility and a portable oxygen unit that s/he took with him/her when s/he left the facility. P1 stated that the VA used the oxygen tanks “24/7.” SP1 stated that the VA had problems with edema in his/her legs for years. That day, when the VA woke up, s/he took off his/her ventilator mask and his/her face and lips were purple, but once the staff persons had the VA sit up in his/her bed, the color returned to the VA’s face. SP1 believed the VA’s lips were discolored because of the way s/he was lying in bed since the color of the VA’s face returned to normal when s/he sat up. The VA ate breakfast and did some sewing. · That morning, when SP1 changed the compression bandage on the VA’s leg, the VA’s leg “doubled in size,” which was not out of the ordinary for the VA. Because of the swelling, it was difficult to fit the VA’s leg brace on his/her leg, but the staff persons were able to put the brace on his/her leg. The VA behaved normally and did not appear ill. SP2 stated that the VA frequently complained about his/her leg and on the day of the incident, the VA “wasn’t complaining about anything but [his/her] leg.” SP1 and SP2 each stated that they did not believe the VA needed to be taken to the hospital because s/he had a medical appointment that afternoon and the VA’s condition did not worsen until s/he got to the hospital. P1 stated that s/he telephoned SP1 and they talked about who would take the VA to his/her medical appointment. · P2 did not arrive at the facility at 2 p.m., as scheduled, so at 2:30 p.m., SP1 had the VA telephone his/her physician to reschedule his/her appointment for the following day. SP1 then left the facility for a short period of time to run an unexpected personal errand. When s/he returned to the facility, s/he learned that the VA’s physician’s nurse told the VA to go to the hospital. At approximately 4 p.m., SP2 telephoned P1 to tell him/her that the VA needed to go to the hospital. P1 believed the staff persons should have contacted him/her earlier in the day to let him/her know that the VA was unable to go to his/her medical appointment. SP2 telephoned 9-1-1 and the VA was taken to the hospital via ambulance. SP1 telephoned SP2 and told him/her that the VA was going to the hospital. SP2 met the VA at the hospital. SP1 then went to the hospital to bring some items and medications to the VA. SP1 stated that when s/he got to the hospital, the VA told SP1 that s/he “did not feel good.” The VA remained in the hospital for four days. P1 stated that the VA was very “confused” during the first two days of his/her hospital stay because his/her oxygen levels were so low and his/her CO2 levels were so high. According to the hospital’s Inpatient Discharge Summary, the VA was admitted to the hospital on February 17, 2023, and was discharged on February 21, 2023. When the VA arrived at the hospital, s/he had worsening lower extremity edema and shortness of breath, as well as lethargy. The VA told the physician that his/her shortness of breath and edema worsened over the previous few days. The VA was admitted to the intensive care unit for treatment of “acute on chronic congestive heart failure and acute on chronic COPD exacerbation with acute on chronic respiratory failure with hypercapnia and hypoxia.” The VA’s oxygen level was in the 70s to low 80s and his/her CO2 was at 76, which was up from 60 at a medical appointment in November 2022. The VA was “quite somnolent.” Facility documentation showed that SP1, SP2, and P1 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Conclusion: On the morning of February 17, 2023, when the VA woke, his/her lips and face were “purple,” but the color of the VA’s face returned to normal when s/he sat up. One of the VA’s legs was swollen and the staff persons had a difficult time putting on his/her leg brace, but consistent information was provided that the VA’s leg was frequently swollen. The VA also had a medical appointment scheduled for 2 p.m. that day so that the VA’s physician could check on the VA’s leg. P2 failed to show up for his/her work shift at 2 p.m., so SP2 asked the VA to reschedule his/her medical appointment for the following day. When the VA telephoned his/her physician to reschedule the appointment, the nurse told the VA to go to the hospital instead. SP1 telephoned 9-1-1 and the VA was taken to the hospital, where s/he remained for four days until his/her oxygen and CO2 levels were regulated. Although the VA was hospitalized and found to have low oxygen and high CO2 levels, given that s/he did not appear to be experiencing medical difficulties after s/he initially got out of bed, that s/he was using an oxygen machine throughout the day, and that s/he was able to telephone his/her physician, who told him/her to go to the hospital, there was not a preponderance of the evidence wither there was a failure to provide care or services to the VA which were reasonable and necessary to maintain the VA’s physical 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). Action Taken by Facility: The facility completed an internal review and determined that the facility’s polices were adequate and were followed by the staff persons. The staff persons were retrained on the facility’s policies on when to contact the facility’s nurse and supervisors. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
