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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: 1089962-AFC (Adult Foster Care) Investigator(s): Thomas Nixon 651-431-2155 Suspected Maltreatment Reported: Allegation One: It was alleged that a supervisory staff person (SP1) and a staff person (SP2) used alcohol and marijuana and could not meet a vulnerable adult’s (VA1) needs including: · VA1 fell due to clutter and trip hazards in his/her room, sustaining a head injury that bled. · VA1’s bed was soaked in urine and staff persons (SP1 and SP2) did not meet VA1’s needs. SP1 was intoxicated at the time of VA1’s fall. Allegation Two: It was alleged that SP1 and SP2 were verbally abusive to VA1 and another vulnerable adult (VA2). Date of Incident(s): Ongoing prior to April 5, 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 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 an unannounced site visit conducted on May 3, 2023; from documentation at the facility and medical records; and through seven interviews conducted with VA1, VA2, SP1, SP2, VA1’s guardian (G), VA2’s Family Member (FM), and an Emergency Medical Technician (EMT1). SP1 and SP2 were family members and both lived at the facility. Another Emergency Medical Technician (EMT2) was present at the scene. EMT1 was asked for contact information for EMT2, and EMT1 said that the information would be shared with EMT2 and EMT2 would call. However, at the time of this report, EMT2 had not yet called. VA1’s diagnoses included benign prostatic hyperplasia with urinary frequency, chronic atrial fibrillation, and major depressive disorder. VA1 enjoyed playing guitar, taking items apart and creating new items, and going to sales to purchase items. VA2’s diagnoses included schizophrenia with a history of obsessive compulsive disorder. VA2 enjoyed going out into the community with the FM, SP1, and SP2, watching TV, and going on walks in the neighborhood. The facility documentation showed that SP1 and SP2 were trained on the Reporting of Maltreatment of Vulnerable Adults Act. Allegation One: It was alleged that SP1 and SP2 used alcohol and marijuana and could not meet VA1’s needs including: · VA1 fell due to clutter and trip hazards in his/her room, sustaining a head injury that bled. · VA1’s bed was soaked in urine and staff persons (SP1 and SP2) did not meet VA1’s needs. SP1 was intoxicated at the time of VA1’s fall. VA1’s Resident Information noted s/he had an unsteady gait and his/her Residential Services Plan stated that s/he needed continence care. EMT1 provided the following information: · On April 17, 2023, in the nighttime EMT1 and EMT2were dispatched to the facility due to a 9-1-1 call that VA1 fell and was injured. · When they arrived at the facility, SP1 and VA1 were in VA1’s bedroom. VA1 had a “laceration” that was “not too deep” above the left eye and a “skin tear” on his/her right forearm. VA1 was on a blood thinning medication and was “bleeding pretty good.” · EMT1 saw that VA1 had a walker in his room for mobility and that his/her bedroom was “messy and kind of dangerous” including a “basket of random objects, tools maybe,” walkers, and “maybe a little trash here and there.” EMT1 saw that because of the items on the floor VA1 had a “minimal walkway” to get the walker from the bed to the door. · EMT1 suspected VA1 may have hit his/her head and arm on the metal objects on the floor. EMT1 attempted to explain to VA1 about how the items on the floor were a tripping hazard and dangerous, but VA1 appeared to not understand this. VA1 told EMT1 that SP1 and SP2 “don’t do much else besides feed me and stuff.” · VA1’s bed had “soaked and dried urine” and smelled as though it was not regularly changed. EMT1 thought it looked like “16 ounces” of fluid were on the bed. · EMT1 attended to VA1 while EMT2 talked with SP1. After, EMT2 told EMT1 that SP1 said s/he “had been consuming alcohol while providing care” to VA1. EMT1 did not see SP2 while at the facility. · EMT1 and EMT2 took VA1 via ambulance to the hospital for further medical evaluation. VA1 provided the following information: · On April 17, 2023, VA1 woke up in the nighttime and needed to use the bathroom. Sometimes VA1 used his/her cane to tap on the floor to get the attention of SP1 and SP2 to assist him/her out of bed. Other times VA1 used a handheld plastic urinal in the room at night if needed. (Note: At the time of the site visit (late morning) a urinal was hooked to a shower chair in VA1’s bedroom. The urinal held approximately 32 ounces and was half full of dark tan urine and also appeared to have sediment at the bottom.) That night VA1’s cane was “not available,” and s/he did not want to use the urinal so s/he got out of bed independently to go to the bathroom across the hallway. · Previously, VA1 attached a rope loop that hung a few inches above the floor. This allowed VA1 to his/her walker when s/he had difficulty with mobility. VA1 rested the ball of his/her foot on the loop while his/her heel continued to touch the floor. VA1 then pushed the walker with his/her arms and guided the foot on the loop forward. VA1 believed that as s/he attempted to get to the bathroom, s/he caught his/her foot on the rope loop which caused the fall. · VA1 did not believe that s/he tripped over any items on the floor. VA1 said his/her room that night was about the same cleanliness as the day of the site visit but with maybe a little more items on the floor. (Note: During the site visit, VA1 used his/her walker to walk from the door to the bed. The VA sat down, stood up, and walked back to the door without issue. VA1 also demonstrated the use of the foot loop apparatus.) · (At the time of the site visit, VA1’s bedroom had a clear garbage bag next to the bed with multiple soiled chux pads and adult disposable undergarments and had feces that was visible on the lining of the garbage bag. Next to the garbage bag was a cardboard box with canes, handheld saws, a block of wood, an outdoor extension cord, and metal poles. There were also three walkers in the bedroom. VA1’s bedsheet were stained urine color and a chux pad was on his/her bed with a brown substance.) · VA1 believed s/he was knocked out when s/he fell. When s/he came too, s/he saw blood and slid to the door and called out for SP1. SP1 and SP2 came to the bedroom to check on him/her. SP1 and SP2 helped the VA get to a chair in the bedroom. VA1 told SP1 and SP2 that s/he was “okay,” but SP1 and SP2 called an ambulance which VA1 did not think it was needed. · VA1 said it was possible s/he urinated at some time during the incident. VA1 went through a medical procedure a few years prior that now caused him/her to feel the urgent need to urinate regularly. VA1 typically used a protective bed chux to soak up urine if s/he was incontinent and s/he tried to clean up his/her incontinence when it occurred. VA1 said SP1 and SP2 did not help with this because, “I don’t ask, I don’t tell them.” · VA1 saw SP1 on several occasions with “lots of bottles” and s/he drank at home. VA1 believed that when SP1 drank s/he had “big mood swings” and caused SP1 to have a “temper.” · VA1 saw SP1 act “strange” in the facility as in under the influence of something but VA1 did not want to talk about what s/he saw or “make problems.” VA1 denied s/he saw SP1 unbalanced, with slurred speech, or smelled of alcohol on him/her. · VA1 denied s/he saw SP2 ever drink at the facility. VA1’s hospital Discharge Summary Note stated s/he “was going to the bathroom and leaning on [his/her] walker when the walker started to roll away and [s/he] fell.” The G provided the following information: · VA1 was supported and assisted 24/7 by SP1 and SP2 with meal preparation, medical appointments, attending outings in the community, and for his/her general wellbeing. Approximately nine years prior, the G became VA1’s guarding when VA1 decided to not follow medical advice. VA1 often blamed others saying they “did [VA1] wrong” including when VA1’s driver’s license was revoked and when VA1 had issues with the courts and medical care s/he received. · At times, VA1 was argumentative, angry, and blamed and swore at others. VA1 did not want SP1’s and SP2’s assistance to clean his/her personal space. VA1 often had chewing tobacco cans, urinals filled with urine, and other items that VA1 “tinkered with” that could be tripping hazards. When SP1 and SP2 attempted to intervene or clean VA1’s room, VA1 got angry and swore at them. SP1 and VA1 argued over the cleanliness of his/her bedroom several times. VA1 permitted SP1 and SP2 to “meet [his/her] needs as much as [s/he] allows.” · The G did not have concern about the care services provided by SP1 and SP2 because “they try best to help [him/her] if [s/he] allows it.” The G was aware VA1 had issues with incontinence and VA1 “refused for years” to shower and the G, SP1, and SP2 worked with him/her on this, and s/he now showered regularly. · SP1 called the G and told the G about VA1 falling and hitting his/her head and that as a result, VA1 bled “quite a bit,” and was taken to the hospital by EMT1 and EMT2. · VA1 told the G that SP1 drank alcohol. When the G talked with SP1 about it, SP1 said s/he only drank when SP2 was there to provide care to the residents. The G was told by SP1 that night about the fall, SP1 was out with a friend, got a ride home, and SP2 was at the facility to care for VA1. The G saw no issue if SP1 drank if someone was there to care for VA1. · The G was not aware of any marijuana used by SP1 and SP2 in the home. SP2 provided the following information: · The night of VA1’s fall and injury SP2 worked with the residents in the home because SP1 was out with a friend which SP1 did do very often. SP2 saw nothing unusual about SP1 when s/he arrived home. · SP2 and SP1 were downstairs and heard VA1 callout for assistance. SP2 went upstairs to VA1’s bedroom and saw VA1 on the floor. VA1 was conscious but appeared injured. SP2 immediately went to get SP1 because SP1 was more experienced with treating injuries. SP1 came upstairs to VA1’s bedroom and tended to VA1 while SP2 telephoned 9-1-1. SP2 said that VA1 did not tell him/her how s/he fell. · EMT1 and EMT2 arrived at the facility and told SP1 that items VA1 had on the floor, including a “container” of “metal stuff” s/he “tinkers with,” were dangerous. SP2 agreed the items were dangerous and s/he and VA1 brought some of the items to recycling after the incident occurred. · At times, VA1 was incontinent and did not always tell SP2 and/or SP1 about it. When VA1 told them, they assisted VA1 to clean it up and do VA1’s laundry. SP2 was in VA1’s bedroom “a couple times a day” and if s/he saw that VA1 had been incontinent, s/he cleaned it up. · SP1 drank alcohol at home “maybe once in a while” when the SP2 was present, but SP2 could not recall how often. SP2 denied seeing SP1 drunk at home. If SP2 saw SP1 drink at home, SP2 had not seen anything that caused concerns where SP2 felt the need to address it. · SP2 denied that s/he or SP1 used drugs. SP1 provided the following information: · VA1 liked to purchase various items at sales including metals parts to “tinker with.” VA1 wanted to have three different walkers in his/her room, chairs, and buckets of screws and bolts. SP1 and SP2 talked to VA1 about how s/he needed to keep his/her bedroom clean because it was a “safety hazard,” but VA1 told them it was “bull honky” and said, “You worry too much.” · At times, VA1 was incontinent and/or had urgent urination needs, so VA1 used adult disposable undergarments and had a urinal in his/her bedroom. VA1 independently emptied his/her urinal twice a day and would not allow SP1 and SP2 to empty it. Despite prompts from SP1 and SP2 to do so earlier, VA1 waited until the urinal was almost full before s/he emptied it, which then sometimes dripped or caused the urinal to spill which created messes. Sometimes VA1 poured the urine into another container and hid it in the room. VA1 was “prideful” and did not tell SP1 and SP2 if s/he was incontinent. SP1 and SP2 talked with VA1 about the smell of his/her room and were told by VA1, “Just leave it alone.” VA1 sat on the side of his/her bed and used the urinal which also sometimes spilled and caused stains on his/her bedding. When SP1 and SP2 attempted to work with VA1 to change the bedding they were told, “Stop worrying,” and that they were “being ridiculous.” SP1 and SP2 usually waited for VA1 to leave the room to clean up and VA1’s bedding was typically changed daily. · VA1 resisted SP1 and SP2 when they tried to put a garbage can in his/her bedroom and VA1 only allowed for a garbage bag. SP1 said VA1 filled a garbage bag daily with soiled briefs and the bags were regularly replaced. · On the night of the incident, SP1 was out with a friend, drank alcohol, and returned home around 10 p.m. About 15 to 20 minutes after SP1 got home, SP1 and SP2 were downstairs when they heard VA1 call out for SP1. SP2 went to check on VA1. SP2 immediately came downstairs and told SP1 VA1’s bedroom door was open and there was blood “everywhere.” SP1 and SP2 then went upstairs to VA1’s room where they found VA1 sitting on the floor next to his/her bed, “profusely” bleeding from above the left eyebrow. VA1 also had “scuffs” on his/her arms. SP1 believed VA1 fell and “hit [his/her] head pretty hard.” SP2 called 9-1-1 while SP1 got the first-aid kit and pressed gauze on VA1 and tried to stop the bleeding. SP1 asked VA1 how s/he fell and did not get a full response from VA1. VA1 did not want the ambulance called. · EMT1 and EMT2 arrived “not more than ten minutes” after SP2 called 9-1-1. EMT1 and EMT2 “were upset” because VA1’s room was “full of crap” with “tools and who knows” that were dangerous for VA1 to walk around. SP1 said that the previous day, VA1 brought more tool type items into the bedroom. The items were on the floor but not in the middle of the room, rather pushed to the sides and VA1 “had plenty of walkway.” · EMT2 told SP1 s/he smelled alcohol on SP1. SP1 said s/he had gone out with a friend. SP1 did not recall too much about it because was “upset” that EMT1 and EMT2 acted like VA1’s room was unsafe due to the items on the floor. · SP1 said s/he believed EMT1 and EMT2 did not ask or understand that SP2 was at home and present with the residents when s/he went out with his/her friend. · SP1 asked VA1 what occurred and VA1 said s/he fell but did not elaborate how. SP1 did not believe that VA1 fell due to the tool type items on the floor, but s/he might have caught his/her foot on the apparatus that hung from the walker which caused the fall. SP1 believed that the urine EMT1 and EMT2 saw was from either a spilled urinal or VA1’s incontinence that night as s/he tried to get to the bathroom and did not make it there. · SP1 said that when s/he went out that night, SP2 was at home and supported/assisted the residents. When SP1 drank alcohol at home, SP2 was always present to support/assist the residents. SP1 said, “There has to be somebody sober and aware of what’s going on in [the] house.” · SP1 denied drinking alcohol when SP2 was not present and SP2 never drank when SP1 did so. SP1 denied there was any drug use including marijuana. Relevant Rules and/or Statutes: Minnesota Rules, part 9555.6205, subpart 4, item B, subitems (1) and (2), states that each resident shall be provided with the following furnishings: a separate, adult size single bed or larger with a clean mattress in good repair; and clean bedding appropriate for the season for each resident. Minnesota Rules, part 9555.6225, subpart 1, states that the residence must be clean, as specified in part 4625.0100, subpart 2, and free from accumulation of dirt, rubbish, peeling paint, vermin, or insects. Conclusion for Allegation One: On April 17, 2023, during the nighttime, while SP2 was at the facility, SP1 was out with a friend and consumed alcohol. At some point after SP1 arrived home, VA1 fell. VA1 said s/he was in his/her bedroom and rose from the bed to use the bathroom. VA1 typically used his/her urinal or cane to tap on the floor to get alert SP1 and SP2 for assistance, but decided not to this time. VA1 used his/her walker to go from the bedroom to the bathroom and caught his/her foot on the rope loop which caused VA1 to fall. VA1 sustained a laceration above his/her left eye and tore skin on right his/her forearm. Because VA1 was on a blood thinning medication, VA1 had increased bleeding. VA1 did not believe s/he tripped over items on the floor. VA1 called out for SP1 and SP2, who immediately came upstairs to see what happened. SP1 and SP2 helped VA1 to sit on a chair, SP2 phoned 9-1-1, and SP1 tried to stop the bleeding with first-aid supplies. EMT1 and EMT2 arrived about ten minutes after the call and had concerns about the condition of VA1’s bedroom including that the objects on the floor were tripping hazards, that SP1 smelled like alcohol, and that VA1’s room smelled like urine. VA1, SP1, SP2, and the G were consistent that the state of VA1’s room was a continued issue at the facility that tried to be addressed with VA1 by SP1, SP2, and the G. VA1 liked to “tinker” with items that included parts that might cause injury if s/he fell on them. SP1, SP2, and the G talked with VA1 about the need to have his/her bedroom free from hazards and for him/her to be able to get around the room safely. VA1 often resisted their attempts to clean or assist VA1 with cleaning the room. SP1, SP2, and the G were consistent that VA1 was incontinent and may not tell SP1 and SP2 that s/he had been incontinent. VA1 might not inform SP1 and SP2 there was a need to change his/her bedding, his/her urinal needed to be emptied, or s/he has spilled urine in the bedroom. Although SP1 stated that VA1’s bag of soiled items was typically changed daily and that VA1 emptied his/her own urinal, on the day of the site visit in the late morning, there was a clear garbage bag next to the bed with multiple soiled chux pads and adult disposable undergarments and had feces that was visible on the lining of the garbage bag and the urinal was half full with dark urine, which a violation of Minnesota Rules, part 9555.6225, subpart 1. At the time of the site visit, VA1’s mattress and bedding were stained urine color and a chux pad was on his/her bed with a brown substance, which was a violation of Minnesota Rules, part 9555.6205, subpart 4, item B, subitems (1) and (2). SP1, SP2, and the G were consistent that when SP1 drank alcohol, SP2 supported and assisted the residents. VA1 believed that at times SP1 responded to situations in a manner that was elevated and s/he suspected alcohol played a role in this and at times VA1 acted “strange.” VA1 did not see SP1 act in a manner while s/he worked that indicated s/he was intoxicated by alcohol or under the influence of marijuana while on the job. SP1 and SP2 also denied there was any drug use. Although VA1 fell on his/her way to the bathroom, and that there were concerns regarding possible tripping hazards in VA1’s bedroom, given that items in VA1’s bedroom were a regular conversation between VA1and SP1, SP2, and the G, that they attempted to process and resolve with VA1 on multiple occasions; that the items in VA1’s bedroom where his/her own items that s/he was allowed to have, there was not a preponderance of the evidence whether there was a failure to supply VA1 with reasonable and necessary care. Although there was concern that SP1 drank alcohol and that SP1 and/or SP2 used marijuana, information was consistent that when SP1 had consumed alcohol, SP2 was present to provide support and assistance for the residents; that SP1 and SP2 each denied using drugs; and that there was no information to support that either used drugs, there was not a preponderance of the evidence whether there was a failure to supply VA1 with reasonable and necessary care. 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 alleged that SP1 and SP2 were verbally abusive to VA1 and VA2. VA1 said that s/he and VA2 sometimes got “chewed out” by SP1. VA1 described this as SP1 said the same thing to him/her several times that s/he did not want to hear, typically about the state of his/her bedroom. VA1 said that it was at times “pretty loud,” “pretty noisy,” and it got “pretty bad.” VA1 said SP1 did not swear or curse at him/her, but one time said, “You don’t like me, and I don’t like you.” VA1 said s/he got loud back at SP1 and called SP1, “A piss head.” VA1 denied that SP2 was hurtful to or insulted VA1. VA2 said s/he liked living at the facility and felt things were “pretty good” and SP1 and SP2 “do everything really well.” VA2 and SP1 “once in a great while” had disagreements and SP1 “comes down on me a little bit” such as when VA2 forgot to do a task. SP1 did “not hardly ever” raise his/her voice and they “got along really well.” VA2 denied SP1 or SP2 called him/her names or used insults. The G was told by VA1 that SP1 “yells a lot,” but SP1 had “a loud voice” in general. SP1 and VA1 had “arguments” and “butted heads,” but VA1 “liked to argue.” The G said the arguments between VA1 and SP1 were usually about VA1’s refusal to clean his/her bedroom and/or empty his/her urinal. The FM provided the following information: · VA2’s frequent urgent incontinence issues meant VA2 could not always make it to the toilet in time. When this occurred VA2 got feces in the bathroom outside of the toilet. · VA2 told the FM that SP1 got “irrigated” when the messes occurred, “raise [his/her] voice,” and use “abusive language towards [him/her].” VA2 did not provide any specifics regarding what SP1 said to VA2. · The FM said that SP1 can get “frustrated… angry… and fed up with something [VA2] cannot control” and “took it out on [him/her] verbally.” SP2 provided the following information: · SP2 heard interactions between SP1 and VA1 and considered them disagreements and not arguments. SP2 and SP1 talked with VA1 about how they did not intend to be “mean” when they remind him/her to tend to items such as room cleanliness. · SP1 was loud “once in a while” and got upset with VA2 after VA2 got feces on the bathroom floor and walls. SP2 did not think they were arguments with VA2 but SP1 told VA2, s/he needed to clean the bathroom after an episode occurred. · SP2 denied hearing SP1 insult or call VA1 or VA2 names. SP1 provided the following information: · SP1 got along with VA1 “pretty good” but there were times when they “bumped heads” over the cleanliness of VA1’s bedroom. SP1 said s/he had a loud voice to start with so when VA1 raised his/her voice, SP1 walked away from the situation. · SP1 did not think s/he told VA1, “You don’t like me, and I don’t like you,” called VA1 names, or insulted VA1. · SP1 denied yelling at VA2 apart from his/her already loud voice, and denied being “mean” to VA2, or insulting him/her. Conclusion for Allegation Two: It was consistent that SP1’s already loud voice and redirection or interactions with VA1 and VA2 could be interpreted as verbal aggression or that s/he yelled. While the G and the FM were informed that at times SP1 raised his/her voice and the FM was told by VA2 about “abusive language” used towards him/her, VA1, VA2, the G, the FM, and SP2 were not able to provide specific details of incidents, including dates and what was said by SP1. VA1 and VA2 each denied that SP1 swore at or insult them. Therefore, there was not a preponderance of the evidence whether all of SP1’s actions were therapeutic of whether SP1’s interactions with VA1 and/or VA2 would be considered 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). Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were adequate and were followed. The facility determined that there was not a need for additional training or corrective action. Action Taken by Department of Human Services, Office of Inspector General: On September 8, 2023, the facility was issued a correction order for the violations outlined in this report and for failing to provide VA2’s file as requested.
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