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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: 1069156-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: Allegation One: It was reported that a staff person (SP3) took a vulnerable adult (VA) to the grocery store and the VA went inside by him/herself. When the VA came out, SP3 was not there, and the VA had to wait 30 minutes and went back inside the grocery store because it was cold. Allegation Two: It was reported that a staff person (SP2) exposed him/herself to the VA and was masturbating under a blanket while s/he was supposed to be caring for the VA’s needs. Allegation Three: It was reported that staff persons argued, screamed, and cursed at the VA. Allegation Four: It was reported that there were transactions on the VA’s debit card that the VA did not make and through Cash App (a mobile payment service) that included a staff person’s (SP1’s) name. Allegation Five: It was reported that staff persons were neglecting the VA including; the VA missed medical and dental appointments, SP1 instructed the VA to chew gabapentin pills (used with other medications to prevent and control seizures, also used to relieve nerve pain following shingles in adults) to feel “higher,” SP1 took the VA on a “drug deal” and had the VA handle the transaction, SP1 had his/her significant other over to the facility and they went into the basement leaving the VA unsupervised for up to 30 minutes, SP1 took the VA to a party where items of the VA’s including a vape pen and lighter went missing, and that traces of “methamphetamine” were found in the downstairs staff bathroom. Allegation Six: It was reported that the VA’s medications including gabapentin were not administered properly and that the VA ran out of his/her gabapentin. Date of Incident(s): Ongoing prior to February 26, 2023, and May, 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 9, paragraph (b), clause (1); 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. In the absence of legal authority, a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. 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 23, 2023; from documentation at the facility and medical records; and through twelve interviews conducted with a supervisory staff person (P2), a facility administrator (P4), five staff persons (SP1-SP3, P1, and P5), the VA, a facility health care professional (HCP3), and three non-facility persons who worked with the VA (CP1-CP3). This investigator also attempted to contact HCP1, HCP2, and P3 through various means; email, telephone, and mail to request an interview but the attempts were unsuccessful. The VA’s diagnoses included anxiety, depression, and attention deficit hyperactivity disorder, and the VA had a history of substance use disorder. The VA enjoyed attending church, caring for his/her dog, and cleaning. The VA was not subject to guardianship. Facility records showed that SP1-SP3, P1-P3, HCP1, and HCP2 were all trained on the Reporting on Vulnerable Adults Act, the facility’s policies, and the VA’s plan. Allegation One: It was reported SP3 took the VA to the grocery store and the VA went inside by him/herself. When the VA came out, SP3 was not there, and the VA had to wait 30 minutes and went back inside the grocery store because it was cold. The VA’s Coordinated Services and Supports Plan (CSSP) stated that staff persons “are asked to have close observation of [the VA] while shopping due to shoplifting behavior.” The VA’s Self-Management Assessment dated November 2022, said that the VA “knows that [s/he] is to have staff [persons] present with [him/her] when going into the community” and that the VA “does not have any [unsupervised] time in the community at this time.” The VA provided the following information when interviewed by this investigator and for the facility’s Internal Review: · The VA was not able to identify the staff person who drove him/her to the grocery store when asked by this investigator, but the VA told the facility that SP3 brought the VA to the grocery store. The VA stated s/he told SP3 to stay in the car as it was cold outside, and the VA wanted the car warm. The VA went into the grocery store with his/her dog. · The VA went to the deli and purchased fried chicken, mashed potatoes, and coleslaw. The VA went outside and did not see SP3. The VA stated s/he walked halfway down the parking lot. The VA stated s/he waited at least 30 minutes. The VA did not want to freeze so s/he went back inside the grocery store. · The VA then saw P3, who was off duty, at the grocery store. P3 helped the VA find SP3. SP3 provided the following information to this investigator and for the facility’s Internal Review: · SP3 did not normally work at the facility but picked up shifts when needed. On March 6, 2023, SP3 worked from 3-10 p.m. The VA wanted to get chicken for dinner so SP3 drove the VA to the grocery store. SP3 asked the VA if s/he wanted SP3 to come in and the VA said, “No.” The VA told SP3 to drop the VA off and wait in the car as it was cold out. · SP3 dropped the VA off and made sure the VA went inside with his/her dog. The VA told SP3 s/he would come out a certain door so SP3 drove around in the parking lot. SP3 said the VA came out 20-30 minutes later with P3 and told SP3, “I came out and did not see you.” SP3 said s/he did not leave the parking lot. · SP3 said it was cold that day. SP3 read the VA’s plans but was still not aware of the VA’s level of supervision so SP3 did not know that the VA could not be in the grocery store without a staff person. According to www.wundergound.com, on March 6, 2023, between 3-10 p.m., the temperature ranged from 1-13 degrees Fahrenheit (°F) and conditions were fair. This investigator attempted to contact P3 through various means; email, telephone, and mail to request an interview but P3 did not respond. Relevant Rule and/or Statute Minnesota Statutes, section 245D.09, subdivision 1 states the license holder must provide the level of direct service support staff supervision, assistance, and training necessary to ensure the health, safety, and protection of rights of each person; and to be able to implement the responsibilities assigned to the license holder in each person’s support plan or identified in the support plan addendum, according to the requirements of this chapter. Conclusion for Allegation One: On March 6, 2023, SP3 drove the VA to the grocery store to pick up food for dinner. The VA told SP3 to stay in the car so the car would stay warm. The VA went into the grocery store and purchased food for dinner. When the VA came out, s/he did not see SP3. The VA stated s/he walked halfway down the parking lot and after 30 minutes went back inside because it was cold. The VA ran into P3 who was not working and P3 helped the VA find SP3. SP3 stated that s/he was driving around the parking lot and did not leave. The VA came out of the grocery store after 20-30 minutes with P3. SP3 did not normally work at the facility but picked up shifts. SP3 read the VA’s plans which stated that the VA did not have unsupervised time in the community, but SP3 stated that s/he was not aware of the VA’s level of supervision. Although the VA was in the store without staff person supervision which was inconsistent with the VA’s plans and a violation of Minnesota Statutes, section 245D.09, subdivision 1, and the VA stated that s/he waited outside for 30 minutes, given that SP3 stated the VA came out of the grocery store after 20-30 minutes with P3 and was not harmed, and that SP3 stated that s/he did not leave the parking lot of the store remaining nearby, there was not a preponderance of the evidence whether SP3 failed to provide reasonable and necessary care and services to the VA. 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 reported that SP2 exposed him/herself to the VA and was masturbating under a blanket while s/he was supposed to be caring for the VA’s needs. The VA and the facility’s Internal Review provided the following information: · On an unknown date, the VA was in his/her room, and s/he came out into the living room where SP2 was on the couch, lying on his/her back under a blanket, and SP2 “jumped up real quick.” · The VA stated that s/he did not see “anything,” SP2 did not expose him/herself, and the VA did not see what SP2 was doing under the blanket, but the VA “wondered” if SP2 was “playing with” him/herself. SP2 and the facility’s Internal Review provided the following information: · SP2 stated that s/he did cover up his/her feet with a blanket when s/he was sitting on the couch because the facility was cold. SP2 stated that s/he would be texting people or playing games on his/her phone while on the couch. When the VA was in his/her bedroom, staff persons were available if the VA needed anything. · SP2 denied ever exposing him/herself to the VA and denied masturbating under the covers of the blanket. Law enforcement investigated and took no further action. Conclusion for Allegation Two: Although it was reported that SP2 exposed him/herself to the VA and masturbated while s/he was supposed to be caring for the VA’s needs, the VA stated that SP2 did not expose him/herself to the VA. One occasion the VA saw SP2 was under a blanket and “jumped up real quick” but the VA did not see what SP2 was doing under the blanket. SP2 stated s/he covered up with a blanket and SP2 denied exposing him/herself to the VA or masturbating under the blanket.
Given that the VA did not see anything and only “wondered” what SP2 was doing, there was a preponderance of the evidence that SP2 did not expose him/herself or masturbate under the blanket. It was determined that emotional abuse did not occur (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). Allegation Three: It was reported that staff persons argued, screamed, and cursed at the VA. The VA said staff persons yelled at their phones and at him/her. The VA was not able to provide names or specific information to this investigator. CP2 was told by the VA that SP1 was “bossing [the VA] around.” P4 stated that the VA overheard SP1 and HCP1 arguing over medication. P4 said that the VA became verbally “aggressive” with staff persons when things did not go the VA’s way. P1 told P2 that staff persons were “rude” to the VA and “screamed” at him/her. P2 said that staff persons from that facility also worked at other facility locations and there were no “issues.” SP1 stated the VA complained a lot. There was a recording this investigator listened to that the VA sent to a family member in which the VA and SP1 talked about an issue with a television (T.V.). There were times that the audio was not comprehendible. The VA’s voice was loud, and s/he used curse words. SP1’s voice was loud as SP1 tried to explain that the VA’s television did not work and that the staff persons’ television needed to be moved back into the living room. The VA “screamed” at SP1, “You’re wrong.” “Not touching my T.V.” “You fucked mine up.” To which SP1 responded, “No, you fucked it. That is the house’s T.V.” The VA and SP1 continued to “argue” about the television and the VA “screamed” and swore at SP1. During that time, SP1 stated the following: “Unbelievable.” “Get out of here and go to bed.” “Your T.V. doesn’t work out here, you ruined it, ruined the staff [person] T.V.” “My stuff is stuck on your fucking T.V…Thanks [VA].” “I am so irritated; you have no fucking clue.” “I have three fucking Rokus at home.” Conclusion for Allegation Three: The VA stated that staff persons were “rude” to him/her and “yelled” and “screamed” at him/her but was not able to provide more specific details. The VA told CP2 that SP1 was “bossing [the VA] around.” P4 stated that the VA became verbally “aggressive” when things did not go his/her way. There was a recording in which the VA and SP1 were arguing over a television, and both used a loud voice. SP1 stated in the recording that s/he was “irritated.” Both the VA and SP1 used curse words during the conversation but not directed at each other. SP1 was heard in the recording to use inappropriate language and a loud voice while speaking with the VA which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. However, given that the language used was not directed at the VA, and there was no information that this happened on more occasions, there was not a preponderance of the evidence that SP1’s conduct rose to the level of emotional abuse. In addition, although the VA stated that staff persons were “rude,” and “yelled” and “screamed” at the VA, given that the VA was not able to provide details regarding occurrences or staff persons’ names and that P2 stated that staff persons who worked with the VA worked at other facility locations and did not have any “issues,” there was not a preponderance of the evidence that any staff persons engaged in conduct that could be reasonably expected to produce emotional distress to the VA. It was determined that emotional abuse did not occur (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). Allegation Four: It was reported that there were transactions on the VA’s debit card that the VA did not make and through Cash App that included SP1’s name. The VA’s CSSP stated, “[The VA] does need extra cash as s/he is only allowed [a certain amount] in personal needs money and this does not cover the cost of feeding [his/her dog] or veterinarian services.” The facility’s Funds and Property Procedures of the Individuals We Serve policy stated, “Must ensure separation of funds of person served by the program from funds of the license holder, the program, or program staff [persons].” The VA, CP1, CP2, CP3, P1, P2, and SP1 all stated that the VA was in charge of his/her own finances. The VA said SP1 took the VA’s debit card but was not sure how SP1 got it. The VA stated that SP1 “must” have had the VA’s card to give the VA $30 that SP1 borrowed to the VA. The VA was not able to figure out why a transaction to a gas station was so high, and then said s/he “usually” went to a different gas station. The VA said SP1 “maybe” gave the VA money for food and cigarettes once. The VA said s/he “always” paid SP1 back. SP1 told the VA s/he would give the VA $30 if the VA did not go to the police about the “credit card thing.” SP1 wrote in the “book” that s/he gave the VA $30 to buy dog food, but that “was a lie.” SP1 said that if the VA did not remember where something was, the VA thought it was “automatically” stolen by a staff person. SP1 said that the VA had him/her look at the VA’s bank statements because the VA claimed not to have gone to a gas station where a purchase was made with the VA’s debit card. SP1 told the VA s/he brought the VA to different locations of the gas station chain several times where the VA made purchases. The VA had SP1 call the gas station to dispute the charges, and they informed SP1 and the VA to make a police report. SP1 told P2 about that and P2 said that the VA could make a report. SP1 said the VA needed money to buy dog food so SP1 gave the VA $30 through Cash App. The next day, the VA told P1 that SP1 gave the VA money because SP1 stole money from the VA’s bank account. SP1 stated that s/he had purchased pop and cigarettes for the VA multiple times with SP1’s money before and the VA paid SP1 back. SP1 would buy the VA items when the VA did not have money because SP1 wanted the VA to have a “good day” with “no issues.” SP1 denied using the VA’s debit card for him/herself. In the Daily Log Notes for February 25, 2023, SP1 wrote that the VA went through his/her bank statements and claimed that all the transactions at a gas station company were fraudulent and that somebody had stolen the VA’s card. The VA called the bank and the gas station. The VA did not want to spend all night making a police report, so SP1 gave the VA $30 because SP1 cared about the VA’s dog (the VA did not have enough money in his/her bank account to buy dog food). P1 was told by the VA about an overdraft to his/her bank account and felt like someone had the VA’s debit card and used it. P1 saw transactions to a gas station where the VA would not choose to go, nor would the VA know where it was located. There were transactions listed from Cash App with SP1’s name in reference. CP1 said the VA brought concerns to his/her team about bank statements. CP1 reviewed and saw withdrawals to Cash App with SP1’s name next to them. CP2 said the VA was “upset” and the VA told CP2 that SP1 took money out of the VA’s account and was “essentially” repaid through Cash App. CP3 said the VA called him/her and was “sure” SP1 used the VA’s debit card at a nearby gas station. P4 was told by SP1 that s/he gave the VA money for pop. P4 said this was against the facility’s policy and that SP1 was retrained on the policy. P2 did not see bank statements, but was told that SP1 was “Cash Apping” the VA. P2 stated that s/he did not know if the VA went to the gas station the card was used at but stated that the VA used to work for that company. The VA’s bank statement showed two transactions on January 8, 2023, with a description, “Point of sale withdrawal Cash App [SP1’s name],” one for $5 and one for $20. On January 11, 2023, the VA’s bank account showed a transaction, “Point of sale withdrawal Cash App [SP1’s name],” for $10. On January 12, 2023, the VA’s bank statement showed a transaction, “Point of sale deposit Cash App cash out San Francisco,” for $24.56. On February 25, 2023, the VA’s bank statement showed a transaction, “Point of sale deposit Cash App cash out San Francisco,” for $30. In total, $35 was withdrawn from the VA’s account via CashApp and $54.56 was deposited into the VA’s account via Cash App. Additionally, the VA’s bank statement showed five transactions between December 1, 2022, and February 28, 2023, totaling $90.66, to the gas station company that the VA stated s/he did not go to. Law enforcement investigated and took no further action. Relevant Rule and/or Statute: Minnesota Statute section 245A.04, subdivision 14, paragraph (b), item 3 states the license holder shall monitor implementation of policies and procedures by program staff persons. Conclusion for Allegation Four: Between December 2022 and February 2023, there were five transactions on the VA’s debit card to a gas station company totaling $90.66. The VA stated s/he did not go to this gas station. SP1 stated that s/he took the VA to different locations of that gas station company several times and P2 stated that the VA used to work for that company. There were three transactions through Cash App that listed SP1’s name by them on the VA’s bank statement for withdrawals totaling $35. There were two deposits made to the VA’s bank account through Cash App totaling $54.56. While these did not notate SP1’s name, one was made for $30 on February 25, 2023, which was the date in the VA’s Daily Log Notes that SP1 wrote s/he gave the VA $30 for dog food. The VA said SP1 “maybe” gave the VA money for food and cigarettes once. The VA said s/he “always” paid SP1 back. SP1 stated that s/he purchased pop and cigarettes for the VA before and the VA paid SP1 back. SP1 would buy the VA items when the VA did not have money because SP1 wanted the VA to have a “good day” with “no issues.” SP1 denied using the VA’s debit card for him/herself. Although the VA stated s/he did not go to the gas station where transactions were made and thought SP1 took his/her debit card, given that SP1 stated that s/he took the VA to the gas station to make purchases several times, that SP1 denied using the VA’s card or funds for his/her own purchases, that the VA handled his/her own finances and debit card, and there was no further information regarding anyone else having the VA’s debit card in their possession, there was not a preponderance of the evidence whether SP1 or any staff person willfully used the VA’s card in the absence of legal authority. In addition, although SP1 purchased items for the VA with SP1’s money and borrowed the VA money using CashApp to transfer money to the VA and then back to SP1 to pay him/her back which was against facility policy and a violation of 245A.04, subdivision 14, paragraph (b),item 3, given that there was money both withdrawn and deposited, that SP1 stated that the $30 withdrawn from the VA’s account was for $30 SP1 borrowed the VA to dog food, and that there was no further information regarding the transactions, there was not a preponderance of the evidence whether SP1 willfully used the VA’s funds without legal authority. It was not determined whether financial exploitation occurred (in the absence of legal authority, a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). Allegation Five: It was reported that staff persons were neglecting the VA including: the VA missed medical and dental appointments, SP1 instructed the VA to chew gabapentin pills to feel “higher,” SP1 took the VA on a “drug deal” and had the VA handle the transaction, SP1 had his/her significant other over to the facility and they went into the basement leaving the VA unsupervised for up to 30 minutes, SP1 took the VA to a party where items of the VA’s including a vape pen and lighter went missing, and that traces of “methamphetamine” was found in the downstairs staff person bathroom. Regarding the VA’s missed medical and dental appointments: The CSSP stated, “[The VA] had sleep apnea but was not currently using his/her CPAP [continuous positive airway pressure].” (CPAP was a machine that used mild air pressure to keep breathing airways opened while a person slept). The VA, CP1, and P1 provided the following information: · CP1 stated that due to a missed dental appointment, the VA was not able to chew foods s/he should eat. CP1 stated this was missed due to inclement weather and was rescheduled, but it was for three weeks later. CP1 stated the VA also missed a sleep apnea related appointment. · The VA stated that staff persons did not like to tell him/her when s/he had an appointment. The VA stated s/he missed “a few appointments.” The VA said there was a calendar, but his/her appointments were not always written down. The VA said s/he missed a dental appointment due to bad weather. The VA stated s/he missed a therapy appointment. The VA stated that in the past s/he had to reschedule appointments due to staffing shortages or issues. · P1 stated the VA missed “several” medical appointments and one reason given for why the VA missed an appointment was that a staff person did not have a driver’s license so could not take the VA. P1 did not provide further information. P2 and SP1 provided the following information: · P2 stated that CP2 attended a lot of appointments with the VA. On one occasion a staff person had a broken ankle and also had an appointment, so another staff person was covering his/her shift and that staff person did not have a driver’s license so could not drive the VA to the appointment. The appointment was rescheduled. · P2 said that the VA’s sleep apnea appointment was a follow-up appointment, and it was scheduled for the same day as a veterinary appointment for the VA’s dog. The VA choose to go to the veterinary appointment over his/her own, so the sleep apnea appointment was rescheduled. P2 stated that the VA refused to wear his/her CPAP machine. · SP1 stated that the VA usually did not have appointments during SP1’s shift. SP1 said there was a calendar that CP2 wrote the VA’s appointments on that was visible to staff persons. Regarding SP1 instructing the VA to chew gabapentin pills to feel “higher”: The VA said that SP1 told the VA, “You know if you chew them [gabapentin] you get better effect on all this stuff.” The VA told P1 that SP1 told the VA to chew gabapentin to get “higher.” SP1 stated that s/he did not think you could get “high” off gabapentin. SP1 stated that at times s/he had to redirect the VA when the VA talked about obtaining and using substances in the past before s/he moved to the facility. According to www.drugs.com, persons “should swallow a capsule or tablet whole and do not crush, chew, break, or open it.” According to www.americandrugrehabs.com, “People get high and abuse gabapentin by taking extremely high doses of the drug, mix it with other medications, and even mix it with alcohol.” “When you’re high on gabapentin, you may experience the following: Elevated mood, euphoria, sense of calm, extreme relaxation and improved sociability.” Regarding SP1 taking the VA on a “drug deal” and handling the transaction: The VA provided the following information: · SP1 took the VA to an apartment building where the VA was told to sit in the back seat. SP1 opened the window a crack, a person handed SP1 money, and then SP1 handed the person something. · SP1 was moving out of his/her home and the VA went with SP1 in the car one time to pick stuff up. · SP1 had an “obscene” amount of cash and the VA thought SP1 and his/her significant other were “drug dealers” due to the amount of cash they had. SP1 stated s/he brought the VA with when SP1 was moving things from his/her old house to his/her new house. When moving, SP1 had $300 cash to pay some family members to help him/her move. SP1 was at work and took the VA with to pay the family members. SP1 denied brining the VA on a “drug deal.” P1 was told by the VA that SP1 and the VA did a “drug deal” in the company vehicle and SP1 had the VA handle the money and the drugs. P2 said that the VA told P2 that SP1 took the VA on a “drug deal” to a gas station. SP1 told P2 that did not happen. Regarding SP1 having his/her significant other over, going into the basement, and leaving the VA unsupervised for up to 30 minutes: The VA’s CSSP stated the VA “can be [without supervision] in the community and [at the facility] for a few minutes to allow staff [persons] to use the restroom.” The VA stated that SP1 and his/her significant other went into the basement “a lot.” On one occasion, SP1 was down there by him/herself for over 30 minutes so the VA went down to make sure everything was alright. The VA stated that the bathroom door was locked. The VA said SP1’s significant other was over “all the time” and they “made out” on the couch. SP1 stated that his/her significant other picked SP1 up at the end of his/her shift and brought pop and cigarettes for the VA. SP1 said that when s/he was moving s/he asked P2 about storing a table in the basement. SP1 said his/her significant other brought the table over and they carried it down into the basement. One time the significant other helped SP1 move some heavy boxes. SP1 thought the significant other was in the facility five to ten minutes. SP1 stated that s/he used the bathroom downstairs. CP1 heard from the VA that SP1’s significant other spent a “good amount of time” at the facility. CP3 was told by the VA that SP1’s significant other was over and s/he and SP1 went into the basement and locked the door. CP2 was told by the VA that SP1 allowed his/her significant other in the facility and that the VA was “scared” of SP1’s significant other. The VA told P1 that SP1’s significant other was at the facility “several” times. P2 thought SP1’s significant other had been over to the facility. SP1 was retrained in January 2023, on the Employee Conduct and Discipline Policy. The Employee Conduct and Discipline Policy stated that employees were prohibited from “having children or other unauthorized persons or pets at work.” Regarding SP1 taking the VA to a party where items went missing: The VA said that SP1 took him/her to a birthday party and while at that party the VA’s vape pen and lighter went missing. The estimated cost of those items was between $15-30. P2 knew that SP1 took the VA to a birthday party. SP1 stated that s/he took the VA to a birthday party to go swimming. SP1 stated that in the past the VA claimed that “every single” staff person had stolen groceries or stolen the VA’s cards and spent money when the VA misplaced his/her card or was not able to find right away. The facility reimbursed the VA $30 for the items that went missing. Regarding traces of “methamphetamine” being found in the downstairs staff person bathroom: In December 2022, P1 stated s/he found a powder around the toilet seat in the basement bathroom that was designated as the staff persons’ bathroom. P1 said s/he thought it might have been powder from a doughnut. P1 said it was “flaky like confectioner sugar, almost seemed glittery even.” P1 did not know what it was so s/he cleaned it up and did not say anything. P1 said s/he found the substance once and P3 found it a different time, sometime in January or February 2023. P1 said that P3 told him/her it was remnants of methamphetamine. P1 did not know how P3 knew this. P2 heard that P3 and P1 were working together when they found traces of an unknown powder in the downstairs bathroom and cleaned it up. They did not notify anyone else at the time. P4 heard P1 and P3 found white residue in a bathroom and did not tell anyone when it happened. The facility’s protocol was to report anything suspicious so it could be checked out by law enforcement for being potential drugs. In the Internal Review, the VA said s/he saw the white powder before P1 and P3 cleaned it up and believed because the powder had a shine, it appeared to be methamphetamine. However, when this investigator spoke with the VA, s/he said s/he did not see the “white powdery stuff;” s/he did not go into the basement. The VA heard P3 saw the powder. This investigator tried to contact P3 through various means; email, telephone, and mail to request an interview but P3 did not respond. Conclusion for Allegation Five: Regarding the VA missing medical and dental appointments: The VA, CP1, and P1 stated that the VA had missed more than one appointment. One of the appointments was a dental appointment and as a result CP1 stated that the VA was not able to chew food, s/he should eat. The dental appointment was rescheduled due to inclement weather. The VA said that although there was a calendar, not all of his/her appointments were written down and staff persons did not always tell the VA when s/he had appointments. P2 said that on one occasion a staff person covering a shift did not have a driver’s license, so the VA’s appointment had to be rescheduled and on another occasion the VA chose to take his/her dog to a veterinary appointment instead of an appointment for him/herself which was then rescheduled. Although there were concerns that the VA missed some medical and dental appointments, given that the missed appointments described were rescheduled, that the VA chose to take his/her dog to an appointment rather than go to his/hers, and that there were no further details regarding other missed appointments, there was not a preponderance of the evidence whether staff persons failed to provide the VA with reasonable and necessary health care or 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). Regarding SP1 instructing the VA to chew gabapentin pills to feel “higher”: The VA stated that SP1 told him/her to chew gabapentin to feel “higher.” SP1 did not think you could get “high” off gabapentin and stated that in the past, SP1 had to redirect the VA from talking about obtaining and using substances. Www.drugs.com stated not to chew gabapentin, according to www.americandrugrehabs.com, to get “high” off gabapentin it required an extremely large dose, mixing it with other medications, or mixing with alcohol. However, if the SP did suggest to the VA that s/he chew the gabapentin, the VA stated that s/he did not, so without further information to support or refute either account, there was not a preponderance of the evidence whether SP1 omitted or failed to provide reasonable and necessary care or services to the VA. 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). Regarding SP1 taking the VA on a “drug deal” and handling the transaction: The VA told P1 that s/he went with SP1 on a “drug deal” and SP1 made the VA handle the transaction. The VA told this investigator that SP1 was handed money by someone and gave the person something in exchange. The VA stated that SP1 had an “obscene” amount of cash and so the VA thought SP1 was a “drug dealer.” The VA told P2 that SP1 took the VA “on a drug deal” to a “gas station.” SP1 stated that s/he took the VA with him/her when s/he went to pay some family members who helped SP1 move. SP1 denied taking the VA on a “drug deal.” Although the VA believed SP1 was a “drug dealer” based on the amount of cash SP1 had on him/her and stated to P1 that the VA handled the transaction on a “drug deal,” given that the VA told this investigator that SP1 handled the transaction, SP1 stated that s/he had cash to pay family members for helping SP1 move, and SP1 denied taking the VA on a “drug deal,” there was not a preponderance of the evidence whether SP1 took the VA on a “drug deal,” or failed 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).
Regarding SP1 having his/her significant other over, going into the basement, and leaving the VA unsupervised for up to 30 minutes: The VA stated that SP1’s significant other was at the facility “all the time” and they went into the basement “a lot.” On one occasion, SP1 was in the basement by him/herself for over 30 minutes, so the VA went downstairs to make sure everything was alright. The VA told CP1-CP3, and P1 that SP1’s significant other was over at the facility. SP1 stated that his/her significant other picked SP1 up at the end of his/her shift and sometimes brought the VA pop and cigarettes. When SP1 was moving, his/her significant other brought a table to the facility to store in the basement, so s/he went inside the facility then and one other time to move some boxes for SP1. SP1 thought it was five to ten minutes. Although the VA stated it happened “all the time” and having SP1’s significant other to the facility was against the Employee Conduct and Discipline Policy, given that SP1 stated that it was only twice, that one occasion that the VA stated SP1 was downstairs for over thirty minutes, SP1 was alone and the VA was not harmed, and there was no further information regarding SP1 not supervising the VA as required or the VA being harmed, , there was not a preponderance of the evidence whether SP1 failed to provide supervision to the VA or failed 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). Regarding SP1 taking the VA to a party where items went missing: The VA, SP2, and P2 all stated that SP1 took the VA to a birthday party. At that party the VA stated that items of his/hers went missing including a vape pen and lighter. SP1 stated that in the past the VA claimed that “every single” staff person had stolen groceries or stolen the VA’s cards and spent money when the VA misplaced items or could not find items right away. Although the VA’s vape pen and lighter went missing, given that the VA was at a community place where anyone could have taken the items, that the VA could have misplaced the items, and there was no information that there was a concern about any staff person taking the items, there was a preponderance of the evidence that no staff person willfully used or withheld the VA’s property. It was determined that financial exploitation did not occur (in the absence of legal authority, a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). Regarding traces of “methamphetamine” being found in the downstairs staff person’s bathroom: In December 2022, P1 found traces of a white powder in the downstairs bathroom. At the time s/he thought it was from a doughnut, so s/he cleaned it up, and did not report it. In January or February 2023, P1 heard from P3 that s/he had also found a white powder in the bathroom and P3 told P1 it was remnants of methamphetamine. In the Internal Review, the VA stated s/he had seen the white powder before P1 and P3 cleaned it up. The VA told this investigator that s/he did not see the white powdery stuff as s/he did not go into the basement but heard P3 saw the powder. P3 did not respond to attempts made by this investigator to request an interview so no further information was able to be obtained from P3. Although P1 stated there was a white powder found and the VA thought it was methamphetamine, given that there was no further information to support or refute that the white powder was methamphetamines or any other substance, there was not a preponderance of the evidence whether any staff person exposed the VA to methamphetamines or any substance compromising the VA’s 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). Allegation Six: It was reported that the VA’s medications including gabapentin, were not administered properly and that the VA ran out of his/her gabapentin. Regarding the VA’s gabapentin: The Medical Administration Record (MAR) for January showed the VA received one and one-half tablets (600 milligram tablet) of gabapentin by mouth twice daily and one (600 milligram) tablet of gabapentin at lunch. Gabapentin was not listed on the February 2023 MARs. The VA said SP1 asked the VA about his/her gabapentin and “begged” the VA for the gabapentin. The VA did not give his/her gabapentin to SP1. The VA said the gabapentin came in a bubble pack and then was set up in a pill container with the days of the week on it. The VA asked SP1 “what happened” to his/her gabapentin and SP1 told the VA, “Oh, I thought you wouldn’t mind that I took them.” SP1 said there was a meeting on February 24, 2023, with the VA’s team, HCP1, and HCP2. SP1 was not as this meeting but worked the next day and the VA’s gabapentin was no longer at the facility. SP1 thought it was discontinued and had been “pulled.” SP1 said the gabapentin was not on the February 2023, MAR. SP1 said medications were set up by HCP1 or HCP2 and went in a medication case for the week. SP1 knew the VA’s dosage and stated that the VA was able to tell someone if s/he did not receive the gabapentin. SP1 denied taking the VA’s gabapentin. P2 said HCP2 was responsible for medication set up and that staff persons distributed medications to residents from the pill container. In February 2023, gabapentin was not listed on the MAR (the pharmacy provided the facility with MARs that listed the resident’s medications) but was still delivered by the pharmacy. P2 called the pharmacy and was not provided an explanation why gabapentin was not on the MAR. CP2 said the VA told him/her that SP1 took the VA’s gabapentin, and the VA was out for four days, and no one called for a refill. CP3 was told by the VA that his/her gabapentin was missing. This investigator tried to contact HCP1 and HCP2 through various means; email, telephone, and mail to request an interview with each about this allegation but HCP1 and HCP2 did not respond. HCP2 provided information in the Internal Review that s/he knew the VA’s gabapentin was not on the February 2023, MAR, but that the VA still “got it.” HCP2 stated that s/he had SP1 assist with medication set up even though SP1 was not trained to do so. HCP2 knew the dosage that the VA was supposed to get. HCP2 stated that the pharmacy had the medication on automatic refill. When interviewed for the Internal Review, HCP2 was provided the VA’s February 2023, MAR and asked how to set up the gabapentin based on it. HCP2 “wandered off in [his/her] conversation” and then realized that the gabapentin was not on the February 2023, MAR. HCP1 provided information in the Internal Review that the VA’s gabapentin was listed on the VA’s MAR for January 2023, but not for February 2023. On February 27, 2023, HCP1 discovered the VA had not had gabapentin for four days. HCP1 tried to get a refill, but the pharmacy said that it could not be refilled yet. HCP1 knew the VA’s dosage and stated that the VA was able to tell someone if s/he did not receive the gabapentin. HCP1 did not respond to this investigator’s requests for an interview so further information regarding how HCP1 discovered the VA had not had gabapentin for four days was not able to be obtained. Regarding the VA’s medication not being administered: On May 30, 2023, the VA was admitted to the hospital for shortness of breath. The VA and P1 thought the VA did not receive all of his/her medications in the days prior. P1 and a family member went to the facility to see the VA’s medications. They were not able to look at them, but P1 saw the May 2023 MAR and it was not filled out and there was nothing in the Daily Log. The VA stated that an unknown staff person did not know “anything” about the VA’s medications and the VA had to tell him/her what to do. P4 and P5 stated that if a medication was not documented there was a two-step check to make sure it was administered. The first was to check the med minder (a pill box dispenser), the second was to confirm with staff persons that the medication was administered. P4 said if staff persons forgot to sign off, they were to place an “A” on the MAR. P5 said the VA advocates for him/herself if s/he did not get medications. P5 said the “progress notes” were also used to verify medication administration. P5 stated the VA was in the hospital due to “afib (atrial fibrillation).” HCP3 stated that s/he started to oversee the facility in April 2023, and there had been several medication changes since then. HCP3 stated that the VA went from doctor to doctor, so the VA’s PRNs (as needed medications) were constantly being changed and the pharmacy was having trouble keeping up with the changes. In May 2023, HCP3 had a meeting with the VA’s primary physician and started typing up the MAR for the VA. HCP3 stated that when medications arrived from the pharmacy, a trained staff person took the medications from the bubble packs, compared it to the MAR, and placed the medications into the medication minder for administration of the medications at the prescribed time. HCP3 provided consistent information with P4 and P5 as to the steps taken if staff persons did not sign off on the VA’s MAR. Medical Records showed the VA was admitted with recurrent chest pains, shortness of breath, and had a rapid ventricular rate. Medical Records stated the VA had been taking his/her medications. The VA underwent a transesophageal echocardiogram and cardioversion. The VA was discharged to the facility with changes in his/her medications. The VA was diagnosed with OSA (obstructive sleep apnea). On June 3, 2023, this investigator reviewed images of the VA’s May 2023 MAR which was missing staff person initials for May 26, 27, 28, and the morning of May 29, 2023. The image of the VA’s Daily Log, cut off the date, but there were several entries that showed medications were given. Facility documentation reviewed on June 14, 2023, showed the VA’s MAR with an “A” documented on the empty dates of May 26, 27, 28, and the morning of May 29, 2023. There were also notations on the back of the MAR that the medications were verified to have been given. The Daily Log showed the dates and had the same consistent information that was reviewed above noting that medications were given. The facility’s Safe Medication Assistance, Administration, and Psychotropic Medication Monitoring Policy and Procedure stated: · “Medication setup” (245D.05, Subd. 1a, para (a)) meant the arranging of medication(s) according to instructions from the pharmacy, the prescriber, or a licensed nurse for later administration when the license holder was assigned responsibility in the support plan or the support plan addendum. A prescription label or the prescriber’s written or electronically recorded order for the prescription was sufficient to constitute written instructions from the prescriber. · “Medication administration” (245D.05, Subd. 2) meant: 1. Checking the person’s medication record; 2. Preparing the medication as necessary; 3. Administering the medication or treatment to the person; 4. Documenting the administration of the medication or treatment of the reason for not administering the medication or treatment; and 5. Reporting to the prescriber or a nurse any concern about the medication or treatment, including side effects, effectiveness, or a pattern of the person refusing to take the medication or treatment as prescribed, Adverse reactions must be immediately reported to the prescriber or nurse. Relevant Rule and/or Statute: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (a) states for the purpose of this subdivision, “medication setup” means the arranging of medications according to instructions from the pharmacy, the prescriber, or a licensed nurse, for later administration when the license holder is assigned responsibility in the support plan or the support plan addendum. A prescription label or the prescriber’s written or electronically recorded order for the prescription is sufficient to constitute written instructions from the prescriber. Minnesota Statutes, section 245D.05, subdivision 2, paragraph (a), clauses (1-4) state for the purposes of this subdivision, “medication administration” means: 1. Checking the person’s medication record; 2. Preparing the medication as necessary; 3. Administering the medication or treatment to the person; 4. Documenting the administration of the medication or treatment or the reason for not administering the medication or treatment. Law enforcement investigated and took no further action. Conclusion for Allegation Six: Regarding the VA’s gabapentin: In February 2023, the VA’s gabapentin medication was not listed on the MAR, however HCP2 still set up the medication to be received by the VA. On February 27, 2023, HCP1 discovered the VA had not had his/her gabapentin for four days and tried to get the pharmacy to refill it, but the pharmacy said it could not be refilled yet. The VA stated that SP1 had “begged” for the VA’s gabapentin and when the VA asked SP1 about it, SP1 stated “Oh, I thought you wouldn’t mind that I took them.” On February 24, 2023, SP1 stated that there was a meeting with the VA’s team, HCP1, and HCP2. The next day the VA’s gabapentin was not in the facility and SP1 thought it had been discontinued. SP1 denied taking the VA’s gabapentin. Although the VA likely did not take gabapentin for four days as prescribed and the MAR did not list gabapentin, both which were violations of Minnesota Statutes, section 245D.05, subdivision 1, paragraph (a), and subdivision 2, paragraph (a), clauses (1-4), and the VA stated that SP1 “begged” for the VA’s gabapentin, given that the pharmacy was responsible for the MAR, that HCP2 stated s/he set up the gabapentin for the VA as prescribed, that there was no information that the VA had adverse effects if s/he did not take gabapentin, and that SP1 denied taking the gabapentin and other staff persons had access to the gabapentin, there was not a preponderance of the evidence whether SP1 or any other staff person took the VA’s gabapentin or whether there was a failure to provide the VA with reasonable and necessary care and services. It was not determined whether financial exploitation or neglect occurred (in the absence of legal authority, a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult; 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). Regarding the VA’s medication not being administered: In May 2023, the VA went into the hospital for shortness of breath. The VA and P1 thought the VA had not received his/her medications in the days prior to being admitted to the hospital. Images of VA’s May 2023 MAR, reviewed by this investigator on June 3, 2023, showed that there were dates that were not initialed by staff persons to indicate the medications were administered. On June 14, 2023, facility documentation showed the VA’s May 2023 MAR was filled out with the corresponding “A” to state it was verified by staff persons that the VA’s medication was administered, however not initialed on the MAR. The facility’s Daily Log also documented that medication was administered. P4, P5, and HCP3 each stated that if medications were not marked on the MAR there was a two-step process to verify if the medications had been administered. The first was to check the medication minder to see if the medication was still in the dispenser and then to check with the staff person to ask if they administered the medication. An “A” was written in the corresponding date on the MAR and on the back was it was documented that it had been verified that the medication was administered. Both P5 and HCP3 stated that the “progress notes” might also show medication was administered. Although the VA and P1 thought the VA did not receive his/her medication prior to being admitted to the hospital and there were dates on the MAR where staff person’s initials to indicate medication was administered were missing, given that those missing dates were followed up on and staff persons verified that the VA was administered the medication and staff persons omitted their initials and that the VA’s medical records stated that the VA was taking his/her medications, 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 conducted an Internal Review and found their policies adequate, but not followed. All staff persons violated the Safe Medication Assistance, Administration, and Psychotropic Medication Monitoring Policy and Procedure by not following the February 2023 MAR. SP1 failed to follow the Employee Conduct and Discipline Policy by having his/her significant other to the facility, and SP3 did not follow the VA’s CSSP by letting the VA go into the grocery store by him/herself. SP2 was retrained on the VA’s CSSP. HCP2 no longer worked at the facility, SP1 and SP2 no longer worked with the VA. Action Taken by Department of Human Services, Office of Inspector General: On September 22, 2023, the facility was issued a Correction Order for violations outlined in this report.
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