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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: 1098668-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Henne/Alice Percy 651-431-3444 Suspected Maltreatment Reported: Allegation one: It was reported that a staff person (SP1) served food containing mushrooms to a vulnerable adult (VA), causing the VA to have an allergic reaction. Allegation two: It was also reported that the VA reported feeling dehydrated and then “passed out” and fell in the hallway. Date of Incident(s): The first incident occurred on December 26, 2022, but was not reported to the Department of Human Services until June 25, 2023. The second incident occurred on June 12, 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 July 26, 2023; from documentation at the facility and medical records; and through eight interviews conducted with four facility administrative staff persons (P1 – P4), one staff person (P5), SP1, the VA, and the VA’s guardian (G). Attempts were made by telephone and letter to contact a staff person (SP2), but SP2 did not respond to the requests for an interview. The VA enjoyed spending time with family members and friends. The VA’s diagnoses included major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder (PTSD), borderline personality disorder, chronic pain syndrome, anorexia, and dysphoria. According to the VA’s Intensive Support Self-Management Assessment, the VA was aware of al of his/her allergies. The list of his/her allergens included mushroom. The staff persons were to assist the VA with his/her allergies. The VA sometimes experienced dehydration due to a lack of nutrients. According to the VA’s Emergency Data Report, the VA had multiple allergies, including an allergy to mushrooms, which caused the VA to have hives. Allegation one: It was reported that SP1 served food containing mushrooms to the VA, causing the VA to have an allergic reaction. The VA stated that on the day of the incident, s/he took a bite of a casserole and saw something “that could have been a mushroom” and asked SP1 if there was cream of mushroom soup in the casserole. The VA’s throat “began to close” and s/he had trouble breathing, so s/he asked SP1 to get the VA’s EpiPen from the bathroom. SP1 “just stood there” and the VA asked another resident to get the VA’s EpiPen. SP1 “might” have asked the VA where his/her EpiPen was stored. The VA used the EpiPen and asked SP1 to call 9-1-1, but SP1 told the VA that s/he had to call P1 first. While SP1 talked to P1, the VA called 9-1-1. A law enforcement officer (LEO) arrived at the facility and gave oxygen to the VA. The ambulance arrived after the LEO, but the VA chose not to go to the hospital. P1, P2, P3, P4, P5, SP1, and the facility’s documentation provided the following information: · On December 26, 2022, SP1 worked at the facility. At dinner, green bean casserole was on the menu. P2 stated that prior to that day, the residents chose the menu for the meal since it was a delayed Christmas dinner and P2 typed up the menu for the staff persons to use when preparing the meal. P2 talked to the VA about what was on the menu and told the VA that the other residents wanted green bean casserole on the menu and that there was typically cream of mushroom soup in the casserole. The VA told P2 to “go ahead” and use cream of mushroom soup in the casserole because the other residents “loved it.” P2 stated that P5 prepared the foods on that day’s menu and placed them in the refrigerator. P2 stated that the VA frequently asked the staff persons about what was being served and what items were included in the various dishes. The VA sometimes chose not to eat the meals the staff persons served. · SP1 stated that s/he was aware that the VA was allergic to mushrooms, but did not know cream of mushroom soup was used in the preparation of the casserole because P5 prepared the casserole earlier in the day. When it was time for the residents to eat, SP1 took the prepared food from the refrigerator and placed it in the oven to heat prior to serving it to the residents. · SP1 stated that the VA took some of the green bean casserole along with the other foods. After taking a bite, the VA told SP1 that his/her throat “was closing” so SP1 went to the VA’s bedroom to get the EpiPen for the VA. While SP1 looked for the EpiPen, another resident went to the VA’s bedroom and helped SP1 look for the EpiPen. SP1 found the VA’s EpiPen and gave it to the VA, who self-administered it. SP1 stated that although the VA told SP1 that his/her throat was closing, the VA was still able to talk, so SP1 was uncertain if the VA had an actual allergic reaction. SP1 then telephoned P1, who told SP1 that if the VA felt that s/he needed to go to the hospital after being administered the EpiPen, s/he should call 9-1-1. SP1 stated that the VA was “fine” after using the EpiPen, so SP1 took the green bean casserole off the VA’s plate and the VA finished eating the other foods on his/her plate. P1 stated that s/he talked to the VA and the VA wanted to call 9-1-1, so P1 told the VA to make the call. · SP1 stated that after the VA called 9-1-1, the LEO and the ambulance arrived at the facility. The EMTs evaluated the VA and told the VA that s/he was “fine,” but they would take the VA to the hospital if s/he wanted to be seen by a physician. The VA declined going to the hospital and told the EMTs and LEO that s/he was “fine.” P2 stated that the staff persons were trained to contact an administrative staff person when an EpiPen was used and to contact 9-1-1 immediately if the situation was serious. P3 stated that the staff persons were trained to call the on-call supervisor whenever there was a medical incident. P4 stated that s/he was told that the VA chose to eat the green bean casserole and after eating it told SP1 that s/he “felt a little itchy.” · P1 stated that when the VA moved into the facility, the staff persons were told that the VA had an allergy to mushrooms, but that s/he experienced hives when s/he ate mushrooms. P1 stated that in the past, the VA told P2 that s/he ate food containing mushrooms and did not have any allergic reaction. The VA’s allergies were listed on his/her Medication Administration Record (MAR) and the staff persons were trained on the residents’ allergies.
The G stated that the VA and the staff persons were aware that the VA was allergic to mushrooms. When SP1 served a casserole containing cream of mushroom soup, s/he told the VA that the casserole contained mushrooms, but the VA “insisted” on eating the casserole anyway. The VA was not always an accurate reporter of events. The G had no concerns about the care the VA received at the facility. According to the facility’s Therap notes, on December 26, 2022, at 9:11 p.m., SP1 documented, “[The VA] was in the downstairs commons area watching TV when staff arrived [the VA] was in a good mood in tell {sic] supper time when [the VA] ate green bean casserole that had mushrooms in it and had allergic reaction staff gave [him/her] EpiPen and staff gave on-call a call and they said that [s/he] would have to call 9-1-1 and [s/he] called 9-1-1 they came out and looked at [the VA] no concerns.” According to the LEO’s Incident Report, on December 26, 2022, at 5:28 p.m., the LEO arrived at the facility after a 9-1-1 call from the facility. The VA was “alert and conscious . . . and able to talk.” The LEO gave the VA oxygen until the EMTs arrived at the facility. The VA refused to be taken to the hospital. The LEO then left the facility. Facility documentation showed that SP1, SP2, P1, P2, P3, P4, and P5 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies, and the VA’s plans prior to the incident. Conclusion for allegation one: In December 2022, P2 prepared the menus for the facility, including the meal for December 26, 2022. P2 stated that all of the residents, including the VA, had input as far as what foods would be served. The VA told P2 to include green bean casserole, which included cream of mushroom soup, on the menu for that day because the other residents liked it. On the morning of December 26, 2022, P5 prepared the food and placed it in the refrigerator. That evening SP1 heated the food, including the green bean casserole, and served it to the residents. The VA took a bite or two of the green bean casserole and told SP1 that his/her throat “was closing” and that s/he needed his/her EpiPen. Although the VA stated that SP1 “just stood there,” SP1 stated that s/he and one of the other residents went to the VA’s bedroom and got the VA’s EpiPen. The VA self-administered the EpiPen and 9-1-1 was called. The EMTs arrived at the facility and checked the VA and determined that s/he was “fine,” but offered to take the VA to the hospital, which the VA declined. Although the VA stated that SP1 did not assist the VA when the VA told SP1 that the VA’s throat was closing, given that information was provided that the VA knew that the green bean casserole contained mushrooms prior to eating it, that the VA’s Emergency Data Report provided information that the VA’s typical reaction to mushrooms was hives, that SP1 did not prepare the green bean casserole that was served to the residents, and that the SP stated that s/he got the VA’s EpiPen from the VA’s bedroom when the VA asked for it, there was not a preponderance of the evidence as to whether there was a failure to supply the VA with care which was reasonable and necessary to maintain the VA’s physical 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 also reported that the VA reported feeling dehydrated and then “passed out” and fell in the hallway. The VA stated that on an unknown date, s/he went downstairs and asked SP2 for Tylenol because s/he “wasn’t feeling right” and then asked SP2 to follow him/her upstairs so that s/he did not fall backwards down the stairs. Once they were upstairs, SP2 opened a closet door to get a beverage for the VA and the VA walked toward his/her bedroom and “passed out.” SP2 asked the VA if s/he was okay and the VA told SP2 that s/he did not feel well. SP2 then told the VA to “hang on and I’ll be right back” and went downstairs. The VA stated that SP2 did not call 9-1-1 “or anything” and the VA crawled to his/her bedroom. SP2 checked on the VA and asked if s/he was okay. The VA told SP2 that s/he was okay. According to the facility’s Internal Review, on June 12, 2023, at 6:10 p.m., the VA told SP2 that s/he felt “dehydrated” and “not feeling well” and s/he asked SP2 to get a nutritional shake for the VA. The VA walked to his/her bedroom and then fell to his/her knees and then sat on the floor. The VA told SP2 that s/he was “okay,” but had heartburn. SP2 told the VA to stay where s/he was until SP2 got equipment to check the VA’s vitals from the staff office. When SP2 returned, the VA was in his/her bed. SP2 asked the VA if s/he wanted SP2 to call 9-1-1, but the VA declined the offer. The VA told SP2 that s/he did not eat or drink adequately that day. P1, P2, P3, P4, P5, and the facility’s documentation provided the following information: · P2 stated that s/he was not aware of any incident when the VA passed out in the hallway, but in the past the VA had problems with becoming dehydrated. The VA was prescribed several medications that included side effects of dizziness and dehydration. At times, the VA also chose not to eat or drink. The staff were trained to encourage the VA to eat and drink and to monitor when the VA refused to eat or drink. The VA frequently used the term “black out,” but P2 “had never seen it” and stated that the VA had various scans, but nothing was found to cause it. Whenever the VA fell, the staff were to document the fall. · The VA frequently wanted to go to the hospital and then sought pain medications. P4 stated that the VA sometimes stood up “too fast” and became light-headed. The VA had a history of falling and the staff persons encouraged the VA to use his/her walker when s/he experienced dizziness. P4 stated that if the VA fell, the staff persons were trained to see if s/he can stand on his/her own. If not, the staff persons were to call 9-1-1 rather than assist the VA to his/her feet. The VA had a history of not eating during the day and was receiving medical care for an eating disorder. Conclusion for allegation two:
On June 12, 2023, the VA told SP2 that s/he felt unwell and then fell in the hallway. While SP2 went to get equipment to check the VA’s vitals, the VA went to his/her bedroom. The VA told SP2 that s/he was okay, but had heartburn and that s/he had not eaten that day. SP1 offered to call 9-1-1 for the VA, but the VA declined. The VA had a history of falling and of not eating and sometimes became light-headed. While the VA stated that SP2 left the VA alone on the floor without offering assistance, given that SP2 immediately reacted to the VA’s fall and went to get equipment to take the VA’s vitals and then offered to call 9-1-1, there was not a preponderance of the evidence whether there was a failure to supply the VA with care and services which was reasonable and necessary to maintain the VA’s physical 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 the facility’s policies were adequate and were followed by the staff persons. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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