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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: 801558-RMI (Residential Treatment and Services for Adults with Mental Illness) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that in July 2021 when a vulnerable adult was discharged from the hospital, a urology appointment was recommended regarding a mass on the VA’s kidney; however, the appointment was not completed. In January 2023, when the VA was again hospitalized, a computerized tomography (CT) scan showed a worsening of kidney masses. Date of Incident(s): After July 2021 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 February 21, 2023; from documentation at the facility and hospital medical records, and through five interviews conducted with three facility health care professionals (HCP1-HCP3), and two facility medical doctors (MP1 and MP2). At the time of the site visit, the VA was not interviewed due to being hospitalized and subsequently passed away a week later. The VA voluntarily returned to the facility from a provisional discharge in July 2021. The VA’s diagnoses included schizoaffective disorder, bipolar type and antisocial personality disorder. The VA enjoyed his/her family and writing comics. The VA was described as polite and friendly. The facility’s policy titled Emergency Medical Transfers of Patients outlined the process for managing transfers from the facility to acute medical care facilities and back to the facility. The policy stated that, “Patients who have been referred for emergency medical care will be accepted back at [the facility] when the need for acute care no longer exists. Prior to returning the patient to [the facility], the medical practitioner (a medical doctor, a certified nurse practitioner, etc. referred to as MP in this report) will consult with the practitioner (MP) at the acute care facility regarding the patient’s care and condition.” In addition, prior to the patient’s return, a health care professional (HCP) gathered information necessary to continue care upon return to the facility. Facility information showed that the VA was initially seen in an emergency room on July 17, 2021, in Mankato, MN, and was diagnosed with pancreatitis, bowel issues, and/or possible cancer. Due to “bed space,” the VA was transferred to a Mayo Hospital in Rochester. The VA was subsequently discharged on July 20, 2021, after a discussion between a Mayo HCP and a facility HCP took place. Documentation showed the VA was diagnosed with acute pancreatitis that subsided with unknown etiology and no treatment was needed for the pancreatitis. An x-ray revealed an enlarged lower colon with an excessive amount of stool that was treated with laxatives. A separate notation also showed that there was a telephone discussion between a Mayo MP and facility MP prior to the VA’s discharge back to the facility; however, no specifics of that discussion were documented. HCP1, a supervisory person, stated that a checklist was followed in preparation of a patient being discharged from a hospital and returned to the facility that ensured important discussions occurred and information was shared. After a patient returned, the checklist was not retained. HCP1 said that the facility HCP accepting a patient back to the facility had “some responsibility” for reviewing the discharge paperwork; however, their role was to address what was needed immediately and discharge paperwork often had numerous pages. In the VA’s case, at the time of the July 20, 2021, discharge, his/her needs were “GI (gastrointestinal) or bowel focused” and the HCPs focus would have been on immediate orders and/or medications. A facility MP would have also received the discharge paperwork. HCP2 worked at the facility for over 10 years and said that when a patient was hospitalized, a facility HCP called the hospital each shift and had a conversation with a hospital HCP providing care to the patient so that discharge planning and care was coordinated. When a discharge was planned, a facility MP also needed to speak to a hospital MP. Regarding the paperwork that accompanied a patient upon discharge, HCP2 believed that facility MPs reviewed the paperwork for medication changes, treatments, or lab work. HCP2 also believed that diagnoses or plans of care were communicated between the hospital and facility MPs. HCP2 said that although s/he generally “read through” discharge paperwork, some were lengthy “like 100s of pages.” Regarding the VA, HCP2 did not recall “any talk about cancer” when s/he spoke to the hospital HCP about the VA’s discharge in July 2021. Around November or December 2022, the VA had a lot of complaints regarding low back pain and there were medication changes to address these complaints. Towards the end of December 2022, the VA was seen in an emergency room for chest pain and an x-ray and labs showed “no findings of significance” and the VA was discharged back to the facility. HCP2 said there was no discussion of cancer at that time. HCP3 had no additional information to add to this report. The following information came from the facility, the Office of the Ombudsman, and/or the Forensic Nursing Home: · On July 16, 2021, the VA had abdominal pain, decreased oxygen saturation, and elevated blood pressure and s/he was admitted to a local hospital. · Upon discharge from the hospital on July 20, 2021, paperwork printed by the Mayo hospital included 24 pages of documentation. Information was extensive in commenting on the colon and did not mention any results of a computerized tomography (CT) scan related to a renal mass. A section of the discharge paperwork titled Discharge Recommendations showed three recommendations: MiraLAX twice a day along with Dulcolax every other day, outpatient colonoscopy as regular age-related cancer screening, and “urology outpatient referral for follow-up for renal masses concerning for RCC (renal cell carcinoma).” There was no additional context provided related to the urology follow-up and no appointment was made by Mayo regarding that recommendation. · On July 20, 2021, several emails circulated from HCP2, another health care professional (HCP4), and a pharmacist, that showed the VA’s discharge information was shared with MP1, MP2, and a psychiatric provider (MP3). · After the VA’s discharge back to the facility in July 2021, the VA struggled with chest and back pain and a chest x-ray was completed in September 2021. At that time the MP1 documented the x-ray “returned as normal.” · In March 2022, the VA had a cyst on his/her back and a discussion between the MP and the VA determined that removal would not occur at that time. · On April 5, 2022, the cyst on the VA’s back was removed at a Mankato clinic. · On May 12, 2023, the VA was evaluated for hematuria (blood in the urine) and a urinalysis was ordered. Results were “not notable for blood.” · On May 31, 2022, the VA was evaluated at an emergency room for chest pain and was diagnosed with thrombocytopenia (bone marrow does not make enough platelets). A later follow up of platelet level showed no evidence of thrombocytopenia. · On June 1, 2022, the VA was seen by a facility MP for “generalized health concerns.” · In September 2022, the VA tested positive for COVID-19, and was seen by facility MPs at least three times due to intermittent complaints of chest and back pain, elevated blood pressures, and gastrointestinal issues. The VA also had a urinalysis that was negative for blood. A lumbar spine series was ordered and completed on September 27, 2022. · On October 7, 2022, a comprehensive evaluation was recommended, but the VA declined stating that s/he “had several of these previously.” · Between October and December 2022, the VA’s primary physician (MP1) documented meeting with the VA six times due to chest and back pains. · On December 27, 2022, the VA went to an emergency room where a chest x-ray and electrocardiogram (EKG) were found to be normal. · On January 4, 2023, the VA complained of shortness of breath and arm pain and was taken to the hospital and diagnosed with pleural effusion (fluid between the lungs and chest) and a CT scan indicated cancer (multiple lytic lesions in the bond of the thorax and spine). The VA was informed s/he likely had renal cell carcinoma, metastatic to multiple places in the bone and lung. It was at this time renal masses at the time of the VA’s previous hospitalization (July 2021) were referenced. · On January 6, 2023, the VA had shortness of breath and was taken to the emergency room where s/he was admitted. A CT of abdomen and pelvis showed a “slight interval increase of 2 separate enhancing right renal masses.” · Upon discharge from the hospital on January 12, 2023, the VA was admitted to the Forensic Nursing Home. · On January 17, 2023, the VA was readmitted to the hospital due to respiratory concerns. · On January 19, 2023, a discussion with oncology confirmed the VA had renal cell carcinoma that was metastatic. · On January 25, 2023, the VA had a CT scan that documented progression of cancer. · After the VA’s hospital admission on January 17, 2023, the VA did not return to the Forensic Nursing Home and remained hospitalized until his/her death on February 28, 2023. MP1 was not working at the time of the VA’s discharge from the hospital on July 20, 2021. Around January 2023, after it was discovered the VA did not have a urology follow-up as recommended in July 2021, MD1 further reviewed the VA’s hospital paperwork and saw a “single comment” about the urology recommendation; however, there was no mention of any scan results within that paperwork. MP1 was “uncertain” if a urology follow-up would have improved the VA’s outcome and said if the cancer was detected earlier, treatment may have started sooner; however, it was possible that the VA could have still died or died sooner as a result of complications. MP2 said that another staff person (MP4) was the “back up” for MP1 on July 20, 2021, when the VA was discharged from the hospital back to the facility. Because MP4 was going to be unavailable at the time of the VA’s discharge that afternoon, MP2 was filled in on the MP to MP discussion that took place between MP4 and the hospital MP. MP2 did not believe there was any mention of cancer during that MP to MP discussion because MP4 “certainly would have passed that on.” MP2 further reviewed the VA’s discharge paperwork and said there was no mention of the VA having cancer at that time and there was a brief mention of a urology “referral for RCC.” There was no detail as to what lead to that recommendation. There was one CT scan minimally described with no mention of any significant concern beyond the megacolon, and the actual CT report was not included in the discharge paperwork. Although MP2 said that a referral to a urologist may have led to the diagnosis of an earlier stage of cancer; it was not known if it would change the prognosis or the actual outcome. An internet search showed that symptoms of renal cell carcinoma included blood in urine, pain in the side between hips and ribs, a firm lump in the abdomen or low back, fever, night sweats, and unexplained weight loss. Facility staff persons were trained regarding the facilities polices and procedures and the Reporting of Maltreatment of Vulnerable Adult Act. Conclusion: Information showed that the VA was taken to an emergency room on July 16, 2021, due to abdominal pain, decreased oxygen saturation, and elevated blood pressure. The VA was transferred that same day to a Rochester hospital where s/he was diagnosed with acute pancreatitis that subsided without treatment and an x-ray revealed an enlarged lower colon with an excessive amount of stool that was treated with laxatives. Prior to the VA’s discharge back to the facility on July 20, 2021, necessary telephone conversations took place between the HCPs and MPs. Multiple persons (MP1-MP3, HCP2, and HCP4) received the July 20, 2021, discharge paperwork for the VA, but at that time no one took notice of a recommendation within the 24 pages for a “urology outpatient referral for follow-up for renal masses concerning for RCC (renal cell carcinoma).” However, over the next 18 months, the VA was seen by numerous MPs regarding various health concerns. In October 2022 when the VA complained of chest pain, a comprehensive evaluation was recommended but the VA refused. Although it was concerning that an initial recommendation for a urology follow-up did not occur, and unfortunate that the VA was not formally diagnosed with renal cell cancer until January 2023, and subsequently died the following month, given the VA’s array of medical appointments and tests to address the his/her medical concerns over the 18 months prior to his/her death, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. 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 polices and procedure were followed but were not adequate. Specifically, the facility recognized a need for an internal process to follow up on outpatient procedure results as well as documentation from outside providers. A form titled “Return from Medical Leave” was developed to prompt HCPs to ask about follow-up appointments among other important aspects when a patient transition back to the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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