|
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: 1115023-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman/Alice Percy Minnesota Department of Human Services 641-431-6567 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was unsupervised on three occasions, even though s/he had 2:1 staffing. Allegation one: On February 18, 2023, the VA ingested 45 Benadryl tablets. Allegation two: On February 24, 2023, the VA ingested 6200 milligrams (mg) of Tylenol. Allegation three: On February 27, 2023, the VA ingested a bottle of soy sauce. Date of Incident(s): February 18, February 24, and February 27, 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 8, 2023; from documentation at the facility; and through eleven interviews conducted with two facility administrative facility staff persons (P1 and P2), five staff persons (SP1, SP2, SP3, SP4, and SP5), the facility’s maintenance staff person (M), the VA, the VA’s case manager (CM), and the VA’s guardian (G). Attempts were made by telephone and e-mail to contact a staff person (SP6), but s/he did not respond to the requests for an interview. The VA enjoyed playing basketball, shopping, and spending time with his/her friends and family members. The VA’s diagnoses included major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder (PTSD), borderline personality disorder, factitious disorder, and gender dysphoria. According to the VA’s Annual Plan, the VA had an extensive history of engaging in verbal and physical aggression towards others, eloping, property damage, severe self-harm, suicidal ideation, suicide attempts, and medication overdosing. The VA required 2:1 staffing at all times. The VA might not identify potentially dangerous situations. If the staff persons believed the VA was at risk of abuse, the staff persons were to redirect the VA from the situation. The VA had a history of severe self-injurious behaviors such as swallowing inedible items, choking him/herself, medication overdosing, and scratching and biting him/herself. In the past, the VA had ingested balloons, latex gloves, batteries, staples, razor blades, paper clips, safety pins, and screws. The VA had a history of elopement from the facility. According to the VA’s Awake Overnight Protocol, the staff persons were to conduct a room check before the VA went to his/her bedroom to sleep. A staff person was to remain in the VA’s bedroom until the VA fell asleep. At that time, the staff person could either remain in the VA’s bedroom or sit outside of the VA’s bedroom. If the VA woke, the staff would again remain in the VA’s bedroom while s/he was awake. According to the VA’s Medication Protocol, all medications were locked in the staff office except for when it was time to administer medications to the VA. At that time, the staff person was to bring the VA’s prepared medications to the VA in the kitchen and observe the VA swallow the medications. The G stated that the VA moved into the facility in October 2022. The VA initially required 2:1 supervision at all times and one of the staff person was supposed to be within arms-length of the VA and have “eyes on” the VA at all times. After the VA’s 45-day meeting with his/her interdisciplinary team (IDT), it was determined that the VA could be in the bathroom without a staff person present and the VA’s supervision requirements were decreased to only one staff person with the VA in the common areas of the house and that the staff persons could do half-hour checks when the VA was in his/her bedroom at night. The new protocols were not written, but were verbally communicated to the staff persons. The G stated that the VA had his/her “own version of the truth,” but that there was typically a “grain of truth” in what s/he said. The CM stated that the VA was allowed to use the bathroom without a staff person being in the room if the staff persons completed a “sweep” of the bathroom to check for anything the VA might use to injure him/herself prior to the VA entering the bathroom. While the VA was in the bathroom, a staff person remained outside the bathroom door. The VA’s sleep protocol was for a staff person to remain in the VA’s bedroom while the VA slept, with the two staff persons taking turns being in the bedroom every 30 minutes. The CM was not present at the VA’s 45-day IDT meeting and was not aware of a discussion about the VA not requiring a staff person in his/her bedroom while s/he slept. P1, P2, and the M provided the following information: · P1 stated that on October 12, 2022, when the VA moved into the facility, the staff persons were trained to keep the VA within sight at all times. If the VA had no behaviors, such as self-injurious behaviors, the staff persons did not have to remain in the VA’s bedroom while the VA slept, but were to sit close to the bedroom door and listen for any noise the VA made. They were also to conduct checks on the VA every thirty minutes. P1 stated that the VA had sleep apnea and snored loudly, so the staff persons could hear the VA while s/he slept. The staff persons were verbally notified about the VA’s sleep protocol. · P1 stated that prior to the VA moving into the facility, alarms were placed on the two entrance doors and one of the VA’s bedroom windows. P1 believed that the second window in the VA’s bedroom did not have an alarm because the company that installed the Lexan polycarbonate (see-through plastic) on that window had difficulty installing the Lexan over an alarm. P1 stated that s/he did not make the decision to not have an alarm on the second window in the VA’s bedroom. · P2 stated that s/he was present at the VA’s intake meeting when it was determined what care the VA required at the facility. It was determined that there would be alarms on the entrance doors and on one of the bedroom windows and Lexan polycarbonate on the other bedroom window. P2 stated that the staff persons “teetered in and out” on whether alarms needed to be installed on the second window in the VA’s bedroom. Given the VA’s physical size, it seemed unlikely that the VA would be able to climb through the window. In addition, the VA’s protocol called for one staff person to be in the VA’s bedroom while the VA slept, so an alarm was not installed on the second window. · The M stated that prior to the VA moving into the facility, the M installed alarms on the two entrance doors to the facility and on the main egress window in the VA’s bedroom. The M was told by P1 and P2 that the VA would not be able to fit through the second window in the VA’s bedroom so it did not require an alarm. The M placed Lexan polycarbonate on the second bedroom window. It was also decided that it was not necessary to place an alarm on the bathroom window because the window only partially opened. Allegation one: On February 18, 2023, the VA ingested 45 Benadryl tablet. The VA stated that on the night of February 18, 2023, when the VA went to his/her bedroom, SP1 sat in the bedroom with the VA for several minutes until the VA told SP1 that s/he “wanted some space,” so SP1 went to the facility’s living room. The VA stated that if s/he asked for “space,” the staff persons were supposed to give him/her some space. The VA waited a few minutes, “set up [his/her] bed to make it look like [s/he] was sleeping,” and climbed out of his/her bedroom window. The VA closed the window and walked to a gas station, which was approximately 30 minutes away. At the gas station, the VA took three boxes of Benadryl to the bathroom, opened up two boxes and put the tablets in his/her pocket, and then returned the third box to the shelf. The VA told the gas station employee that s/he swallowed the safety pins and razor blades because s/he wanted to go to the hospital. 9-1-1 was called and a law enforcement officer (LEO) and an ambulance arrived. The VA was taken to the hospital via ambulance, where the VA went to the bathroom and swallowed the Benadryl tablets in his/her pocket. The VA told a nurse that s/he swallowed the Benadryl and was put on monitors for several hours and then released the following morning. SP1, SP2, SP4, SP5, and the facility’s documentation provided the following information: · On February 18, 2023, at approximately 9:50 p.m., SP1 arrived at the facility for his/her work shift. At 10 p.m., SP2 arrived at the facility for his/her work shift. SP1 and SP2 watched television with the VA in the living room until approximately 10:45 p.m., when the VA told SP1 and SP2 that s/he wanted to go to bed. The VA went to his/her bedroom and closed his/her bedroom door, but SP1 told the VA that s/he had to keep the bedroom door open. SP1 and SP2 heard the VA snoring while they sat on the sofa that was near the VA’s bedroom. SP1 and SP2 provided consistent information that they were told by P1 that they did not have to stay in the VA’s bedroom while s/he was sleeping. · SP2 stated that at 11 p.m., s/he entered the VA’s bedroom and the VA “appeared to be under the blankets on [his/her] bed” and SP2 thought “all was good.” SP2 did not turn the light on in the bedroom, but looked into the room. At 11:15 p.m., a law enforcement officer (LEO) knocked on the facility’s door and told SP1 and SP2 that the VA went to a nearby gas station and swallowed some razor blades. The LEO told SP1 and SP2 that the VA was taken to the hospital by ambulance. SP1 and SP2 checked the VA’s bed and found several pillows placed underneath the VA’s blankets so that it appeared as though the VA was lying in the bed. SP1 telephoned the VA’s family member and an administrative staff person. · SP1 and SP2 drove to the gas station, which was approximately a mile from the facility, where they were told that the VA stole food and Benadryl. SP1 and SP2 then drove to the hospital. At 11:50 p.m., SP1 and SP2 arrived at the hospital, but had to wait before they were allowed to go to the VA’s hospital room. SP2 stated that x-rays were taken of the VA and it was determined that s/he did not ingest razor blades, but the toxicology tests showed that the VA had ingested Benadryl. The VA slept for a while and at approximately 4 a.m., woke. SP1 and SP2 asked how the VA got to the gas station so quickly since it would take approximately 20 minutes for him/her to walk to the gas station from the facility. The VA “went back and forth” as to whether someone met the VA outside the facility and drove him/her to the gas station. · It was later determined that the VA opened the window next to his/her bed and left the facility through the window. SP1 stated that s/he had been told by P1 that the window did not open, which was why there was no alarm on the window. SP2 stated that s/he had been told that the facility had a security system which monitored all of the windows in the facility. After the incident, SP2 found out that one of the windows in the VA’s bedroom did not have an alarm. SP5 stated that s/he had been told by P1 that alarms would be installed on all of the windows in the VA’s room “eventually.” SP5 did not know why there was an alarm on only one window in the VA’s bedroom at the time of the incident. · SP1 stated that the VA’s plans required that the VA leave the doors open whenever s/he entered a room. At night, the staff persons were required to do a safety check of the VA every hour, at which time they documented where the VA was and what s/he was doing. SP2 completed the safety check at 11 p.m., after checking the VA’s bedroom and believing the VA was in his/her bed. SP1 stated that since the VA was not on “lock down,” the staff persons did not have to remain in the VA’s bedroom while s/he slept as long as one staff person remained near the VA’s bedroom so that they could hear the VA. The other staff person could do chores around the facility. SP3 stated that during the first 45 days that the VA lived in the facility, the staff persons were required to remain in the VA’s bedroom while s/he slept, but that after 45 days, one staff person could sit near the VA’s bedroom door while the other staff person completed chores. According to the facility’s Internal Review, the staff persons were to remain in the VA’s bedroom until the VA fell asleep at night and could then sit near the VA’s bedroom and conduct half-hour checks on the VA. On the night of the incident, the staff persons did not remain in the VA’s room until s/he fell asleep, but did hear the VA snoring and checked on the VA at 11 p.m. The staff persons did not realize that the VA put pillows under his/her blankets and left the facility until the LEO told them s/he was at a gas station. Facility documentation showed that SP1, SP2, SP3, SP4, SP5, SP6, P1, and P2 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 incidents. Conclusion allegation one: On February 18, 2023, the VA left the facility without the knowledge or supervision of SP1 and SP2 and walked to a gas station, where s/he stole two boxes of Benadryl. At the time of the incident, it was unclear what the VA’s supervision requirements were for the nighttime hours. While a staff person was initially required to remain in the VA’s bedroom even when s/he slept, the staff persons were later told that a staff person no longer had to remain in the VA’s bedroom while s/he slept, as long as they remained near the VA’s bedroom door and conducted half-hour checks on the VA. SP2 conducted a half-hour check on the VA as required, but did not realize that the VA had placed pillows under his/her blankets to make it appear as though s/he was in bed and then climbed out a bedroom window before walking to the gas station. The VA told the gas station employee that s/he ingested razor blades, so 9-1-1 was called and the VA was taken to the hospital, where s/he swallowed the Benadryl that s/he stole from the gas station. While at the hospital, the VA was monitored, but did not require medical care. Although the VA was able to leave the facility without the knowledge of SP1 and SP2, given that the staff persons followed the VA’s updated protocol; that the VA took efforts to make it appear that s/he was in his/her bed; that it was unclear if all of the staff persons knew that one of the VA’s bedroom windows did not have an alarm and that the VA could fit through the window; and that the VA did not require any medical care even though s/he was taken to the hospital, there was not a preponderance of the evidence whether there was a failure to supply the VA with care and supervision which was reasonable and necessary to maintain the VA’s physical or mental 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: On February 24, 2023, the VA ingested 6200 milligrams (mg) of Tylenol. The VA stated that on the morning of the incident, s/he asked SP3 for the first aid kit so s/he could clean his/her arm where there were stitches. After s/he cleaned his/her arm, s/he “organized” the first aid kit and took several packets of acetaminophen from the first aid kit and placed them in his/her pocket. That evening, after the VA took his/her shower, the VA sat on the sofa next to the staff persons, put his/her blanket over his/her head, and swallowed the acetaminophen. Shortly after swallowing the acetaminophen, the VA showed the packets to SP4 and told him/her that s/he swallowed the tablets. The staff persons telephoned 9-1-1 and the VA was taken to the hospital, where s/he was monitored for two hours and then went back to the facility. SP3, SP4, SP5, and the facility’s documentation provided the following information: · On February 24, 2023, SP3 and SP4 worked at the facility with the VA. In the morning, the VA wanted to clean an area on his/her arm where there were stitches. SP3 went to the staff’s office, got the first aid kit from the locked medications cabinet and set it on the dining room table, where s/he and SP4 watched the VA use the antiseptic wipes to clean his/her arm. Later that day, SP4 went downstairs to do the VA’s laundry, leaving SP3 and the VA on the main floor of the facility. The VA again asked SP3 to get the first aid kit so that the VA could clean his/her arm. SP3 went to the staff’s office, got the first aid kit from the locked medications cabinet, sat on the floor, and placed the first aid kit on the floor between the VA and SP3. SP4 provided information that the first aid kit included bandages, alcohol wipes, gauze wraps, cold/heat pack, tweezers, and acetaminophen. SP3 stated that s/he did not know that there was acetaminophen in the first aid kit when the VA used it. · SP3 stated that s/he watched the VA the entire time the VA used the first aid kit. SP3 watched the VA clean his/her arm with the antiseptic wipes and then place things back in the first aid kit so that SP3 could close it and return it to the medications cabinet. SP3 stated that did not leave the room while the VA used the first aid kit and watched the VA while s/he used the first aid kit. SP3 believed the VA might have accessed the acetaminophen on another day when s/he used the first aid kit to clean his/her arm. SP5 stated that the VA was “very fast” and might take something if a staff person was distracted “for a second.” · The VA later turned in packaging that contained acetaminophen and told the staff persons that s/he consumed the tablets in the packaging. The VA had eight packages that each originally contained two tablets of acetaminophen. According to the Internal Review, all medications were to be locked in the medication cabinet. The VA was allowed to have access to the first aid kit, but one of the staff persons should have removed the acetaminophen from the first aid kit prior to giving it to the VA. However, the staff persons did not realize that there was any acetaminophen in the first aid kit when they brought it out of the staff’s office for the VA to use. The staff persons observed the VA while s/he used the first aid kit. According to the hospital’s test results, on February 24, 2023, the VA was tested for acetaminophen. The VA test results showed that s/he had a value of 30.7 for acetaminophen while the “reference range” was 10 – 25. Conclusion allegation two: On February 24, 2023, while using the facility’s first aid kit, the VA took several packets of acetaminophen, which s/he later ingested. SP3 brought the first aid kit to the VA and watched him/her use the antiseptic wipes to clean his/her arm, but did not see the VA take the packets of acetaminophen. SP5 stated that s/he did not know that there were any medications in the first aid kit. Given that the VA was allowed to use the first aid kit, that SP3 watched the VA use the first aid kit, that SP3 was unaware that there was acetaminophen in the first aid kit, and that the VA sustained no injury from ingesting the acetaminophen, there was not a preponderance of the evidence whether there was a failure to supply the VA with care and supervision which was reasonable and necessary to maintain the VA’s physical or mental 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 three: On February 27, 2023, the VA ingested a bottle of soy sauce. The VA stated that on the day of the incident, s/he wanted to hurt him/herself and decided to copy something s/he saw on the internet where a person swallowed a large amount of soy sauce. The VA believed SP5 and SP6 were each in the staff’s office when the VA went to the refrigerator and put 8 ounces of soy sauce in a cup. The VA then told SP6 that s/he made a “mixture of something that helps your throat.” The VA drank some of the soy sauce and then vomited. Approximately 30 to 40 minutes later, the VA drank more soy sauce and again vomited. The VA told SP5 and SP6 that s/he was feeling dehydrated and then went outside and began to walk. SP5 walked with the VA and SP6 remained at the facility. SP5 and the facility’s documentation provided the following information: · On February 27, 2023, SP5 and SP6 worked at the facility. While SP5 worked in the office, SP6 stayed with the VA in the kitchen/dining room area. The VA made a “concoction” of honey, flavored water, and other ingredients for his/her sore throat while SP6 watched him/her. The VA then told SP6 that s/he would not drink the mixture if SP5 “looked at” the VA, so SP5 told the VA s/he would not look at the VA as s/he drank. A few minutes later, the VA brought the empty soy sauce bottle to SP5 and told him/her that s/he drank it. The VA told SP5 and SP6 that s/he watched a person drink soy sauce on the internet and the VA wanted to harm him/herself by doing the same thing. · SP6 telephoned an administrative staff person (P3), who told SP6 to observe the VA because s/he might get a stomachache from drinking the soy sauce. SP5 told the VA that s/he did not think there was enough sodium in the soy sauce to cause harm to the VA. The VA did not have any reaction to drinking the soy sauce. · SP5 stated that one of the VA’s coping skills was to walk. After talking about drinking soy sauce, the VA went outside and SP5 followed him/her outside. The VA told SP5 to “shut up.” The VA then began to walk around the neighborhood and SP5 followed. The VA and SP5 walked for approximately one hour until the end of SP5’s work shift. SP5 telephoned SP6 and told him/her where they were and SP6 drove the night staff person to that location to stay with the VA. The VA told the staff persons that s/he was feeling light-headed, so they telephoned 9-1-1. The EMTs arrived and took the VA to the hospital. SP6 took SP5 back to the facility. According to the hospital’s test results, on February 27, 2023, the VA was tested for sodium. The VA test results showed that s/he had a value of 147 for sodium while the “reference range” was 135 - 145. Conclusion allegation three: SP5 stated that on February 27, 2023, the VA made a “concoction” of honey, flavored water, and other ingredients while SP6 watched him/her. The VA stated that s/he poured soy sauce into a cup and drank it. A few minutes later, the VA brought the empty soy sauce bottle to SP5 and told him/her that s/he drank it. Although the VA drank a partial bottle of soy sauce, given that the VA had access to the kitchen, that SP6 was in the kitchen with the VA as required, and that the VA did not sustain any injury during the incident, there was not a preponderance of the evidence whether there was a failure to supply the VA with care and supervision which was reasonable and necessary to maintain the VA’s physical or mental 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 not all of the facility’s policies were not adequate and the policies were not followed by the staff persons. After the incidents, all of the staff persons received retraining on the VA’s plans. A window alarm was installed on the second window in the VA’s bedroom. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
