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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: 1106900-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Tessa Ripka Suspected Maltreatment Reported: Allegation One: It was reported that a vulnerable adult (VA1) fell, and staff persons did not call 9-1-1 until a manager arrived. It took 90 minutes for a manager to arrive and VA1 had a fractured arm. Allegation Two: There were multiple concerns about two staff persons (SP1 & SP2) including: · SP1 verbally abused the individuals, slammed cupboards to watch a vulnerable adult (VA2) jump and then laughed at VA2, made VA1 go to bed 8 p.m., and made the individuals eat larger portions of meals than they wanted to. SP1 and SP2 fought during their shifts. · SP1 forcefully took items away from the individuals and was rough when transferring VA2. · SP2 slept during his/her shifts and chastised the individuals for not doing things properly or not asking for help before an episode of incontinence. · VA1 went a week without his/her anti-depressant and sleep medications. · Staff persons did not complete VA2’s doctor ordered range of motion exercises and walking. Date of Incident(s): Prior to July 20, 2022, and ongoing 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), clauses (1) and (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: · Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. · 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 a site visit conducted on August 16, 2022; from documentation at the facility; and through eight interviews conducted with four facility staff persons (SP1, SP2, P1, P2), two case managers (CM1, CM2), VA1, and VA2. The facility was a one level home with a basement. Through the main entrance was a living room. Past the living room was a kitchen and dining area. To the right of the living room was a hallway, which contained two bedrooms, a staff office, and a bathroom. VA1 was diagnosed with a traumatic brain injury. VA1 enjoyed going shopping and to the movies. VA2 was diagnosed with cerebral palsy and developmental disabilities. VA2 enjoyed playing cards and games. All staff persons were trained on the Reporting of Maltreatment of Vulnerable Adults Act, the VA’s plans, and the facility policies. Allegation One: It was reported that VA1 fell, and staff persons did not call 9-1-1 until a manager arrived. It took 90 minutes for a manager to arrive and VA1 had a fractured arm. VA1’s Self-Management Assessment stated that VA1 was at risk of falling due to right side paralysis. If VA1 fell staff persons checked VA1 for injuries. Staff persons made VA1 as comfortable as possible and then called another staff person for assistance in getting VA1 up and back into his/her chair or his/her wheelchair. Staff persons did not pick up VA1 by themselves. The Incident and Emergency Form said that on June 25, 2022, VA1 became dizzy and fell to the floor. P2 called P1 for assistance with transferring VA1. VA1 required a two-person transfer, so P1 came to the facility and then called 9-1-1. VA1 said that on one occasion, at approximately 6:20 p.m., VA1 fell and hurt his/her back. Staff persons did not call 9-1-1 until 7:50 p.m. P2 told VA1 there was a protocol that P2 had to wait until P1 could assess VA1. VA1 did not get off the floor until approximately 7:50 p.m. after P1 had arrived at the facility and called 9-1-1. VA1 had fractured his/her back and had to wear a brace for a period. P1 said that on the date of the incident, s/he got a call from P2 that VA1 had fallen. P2 did not describe the severity of the fall. P2 was the only staff person working at the time and needed assistance to get VA1 up so P1 called several other staff persons. P1 could not find any staff person to come in, so P1 finished what s/he was doing and “got here as fast as I could.” When P1 arrived at the facility VA1 would not transfer and said s/he wanted to call 9-1-1. P1 called 9-1-1 and VA1 was transported to the hospital. VA1 was prescribed oxycodone for pain and returned to the facility later that evening. P2 said on the day of the incident, VA1 fell in the kitchen and hit his/her head on the wall. VA1 was not bleeding but said s/he hurt his/her back. P2 called P1 to discuss the fall and it was agreed that P1 would come into the facility to assess VA1. VA1 said s/he wanted to go to the hospital and would not let P2 move him/her or put pillows under VA1. P1 did not arrive to the facility until an hour and a half later and then s/he called 9-1-1. P2 said that P1 did not understand the situation from the phone call and thought it was a “normal fall.” Staff Daily Communication Log noted that on June 25, 2022, VA1 was bringing his/her dishes to the sink, when s/he fell and hit his/her head on the wall and fell on his/her back on the floor. VA1 was “scared” to move, and an ambulance brought VA1 to the hospital for tests. Hospital paperwork showed VA1 was seen at the emergency department on June 25, 2022, for a fall. A computed tomography (CT) scan showed a subtle nondisplaced fracture through the distal right transverse process of L2 (broken bone in the spinal column). An as needed pain medication was prescribed. On June 29, 2023, VA1 was again seen for another fall. A CT scan showed the “previously described right L2 transverse process fracture was not definitely visible.” Conclusion for Allegation One:
Although an ambulance was not immediately called for VA1 after a fall and s/he laid on the floor for a period of time, given that VA1 expressed to P2 that s/he did not want to be moved, that P2 waited for P1 to arrive for further directives, that P1 called 9-1-1 immediately after arriving and assessing the situation, and that although VA1 was injured it was likely that the time spent on the floor did not have an effect on the injury, there was not a preponderance of the evidence that P1 or P2’s actions failed to provide care to VA1 that was necessary or reasonable to maintain VA1’s 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: There were multiple concerns about SP1 & SP2 including: · SP1 verbally abused the individuals, slammed cupboards to watch VA2 jump and then laughed at VA2, made VA1 go to bed 8 p.m., and made the individuals eat larger portions of meals than they wanted to. SP1 and SP2 fought during their shifts. · SP1 forcefully took items away from the individuals and was rough when transferring VA2. · SP2 slept during his/her shifts and chastised the individuals for not doing things properly or not asking for help before an episode of incontinence. · VA1 went a week without his/her anti-depressant and sleep medications. · Staff persons did not complete VA2’s doctor ordered range of motion exercises and walking. VA1’s Self-Management Assessment stated that VA1’s medications were locked and administered by staff persons per doctor’s orders. VA2’s Self-Management Assessment stated that VA2 needed to have his/her food cut up in bite sized pieces and asked staff persons to assist as necessary. VA2 was unable to walk without a wheelchair or walker. VA2’s Service Outcome and Support stated that VA2 had an outcome to walk from his/her bedroom to the kitchen table with staff person assistance twice a day. VA1 provided the following information: · A staff person (not SP1 or SP2) slept in the afternoon when s/he arrived for work. The staff person told the individuals that s/he would take a nap and then get up and make them dinner. This used to happen whenever the staff person worked but had not happened the last “couple” times. · When SP1 and SP2 worked on the same shift, they fought. SP1 got loud during the fighting. At times, SP1 did not like the way SP2 did things and then SP2 got upset. · SP1 roughly put VA2 in his/her wheelchair. VA2 told VA1 that SP1 pushed VA2’s legs down roughly and VA2 said, “Oww.” SP1 got mad at VA1 and VA2 when they had bowel incontinence and said things like, “Do you really have to do that in your pants?” and “You’re not a child.” SP1 did not give VA1 privacy and barged into VA1’s bedroom to start completing cares. · SP1 always had his/her headphones on and did not pay attention to the individuals and did not acknowledge the individuals were there. · VA2 did not like loud noises and SP1 slammed the cupboard doors loudly and then laughed about it. · On Friday nights, the evening staff person left at 8 p.m., and the individuals had to take their medication at 8 p.m. VA1 did not like to rush to get all of his/her cares completed by then. VA1 did not feel s/he should have to take his/her medications at 8 p.m. VA2 provided the following information: · SP2 got upset when VA2 had bowel incontinence and told VA2 had s/he had to drink more water because his/her bowel movement was “dinky.” This made VA2 feel bad. · VA2 liked the food at the facility and felt s/he received enough food. One time SP1 gave VA2 food and the pieces were not cut small enough. VA2 asked for the food to be cut into smaller pieces and SP1 said that s/he would in a minute. SP1 cut the food into smaller pieces and VA2 was able to eat the food. · VA2 liked to go to bed at 8 p.m. and got up at 5 a.m. in the mornings. Staff persons assisted VA2 with his/her exercises each day. VA2 did not have any complaints with how staff persons assisted him/her with personal cares. P1 provided the following information: · VA2 said a staff person that worked one shift every other weekend was sleeping while s/he was working. The staff person was given counselling and corrective action. · When VA2 moved in, s/he stated that s/he liked to go to bed at 8 p.m. because s/he wakes up so early. VA1 did not like to go to bed early and sometimes didn’t want to go to work in the morning because s/he was up late. The evening staff person completed VA1’s bedtime routine and gave medications before they left for the night at 10 p.m. VA1 could stay awake in her bed for as long as s/he liked after that. · There was one medication for VA1 that the medical provider “messed up.” The pharmacy sent requests to the medical provider several times. P1 called the medical provider and pharmacy to get the situation resolved. VA1 missed three to four days of that medication. · VA2 had a goal to walk a certain number of steps but as his/her cerebral palsy has worsened it was progressively more difficult for VA2 to walk. A new goal was implemented, and staff persons were trained on this. VA2 still completed some walking and range of motion exercise each day. · P1 was not aware of any staff person being rough with the clients or yelling at the clients. On one occasion, VA1 was in the bathroom and SP2 asked if VA1 needed help. VA1 said SP2 was “yelling” at VA1. · VA1 and VA2 ate independently but VA2 sometimes asked for assistance if s/he was having a spasm. On one occasion, VA2 asked SP1 for assistance. SP1 was feeding VA2 larger bites than s/he preferred. VA2 told SP1 and the situation was resolved. · On one occasion, SP1 spoke to SP2 about the correct way to transfer VA2 so SP2 did not hurt his/her back. This may have been perceived as them fighting. SP1 provided the following information: · SP1 said s/he did not fight with SP2 at the facility. On some occasions if an individual was in the shower or they were in different areas of the facility, SP1 raised his/her voice so SP2 could hear. · SP1 did not remember a time when s/he slammed the cupboard. When SP1 put dishes away, s/he warned VA2 that there was going to be some noise. SP1 did not yell or shout at the individuals. · When SP1 served meals, s/he asked the individuals if the quantity of food was okay. VA2 normally finished all his/her food and often asked for more. VA1 did not eat as much. If there was left over food, it was thrown away. Both VA1 and VA2 fed themselves, but VA1 might ask for assistance cutting his/her meat. · VA2 completed range of motion exercises daily, but did not like to walk. It was VA2’s goal to walk. SP1 did not feel s/he was rough with the individuals when transferring them. SP1 was a CNA (certified nursing assistant) and had been doing care at other facilities with no complaints. · VA2 liked to go to bed right after his/her shower at 8 p.m. VA1 was given his/her medications at 8 p.m. and then went to the bathroom. The medications made VA1 sleepy, and s/he usually went to his/her bedroom after that but didn’t always go to bed. SP1 had never made the individuals go to bed if they did not want to. SP2 provided the following information: · SP2 did not remember ever yelling at SP1. SP1’s voice may be louder if s/he called for SP2 and SP2 was downstairs. SP1 and SP2 did not discuss personal matters at work. · While eating, the individuals were given more food as requested. The individuals were not required to finish all the food on their plates and any left on the plates was thrown away. · VA2 walked regularly with a special belt and walker. At times VA2 had pain and was not stable. Staff persons used to record VA2’s daily steps which were typically around 130 steps. This had recently been reduced. · SP2 had never yelled or gotten upset with the individuals when they were incontinent and did not feel s/he was rough with the clients. · The individuals took their nightly medications at 8 p.m. and went to bed when they wanted to. Staff persons encouraged them to go to bed by 9 p.m. as they both sat in their wheelchair all day. VA1 usually went to bed at 8 p.m., while VA2 went to bed around 9 or 10 p.m. CM1 said VA1 expressed not liking the way that staff persons preformed services. There was a team meeting scheduled to help better serve VA1. CM2 had not heard any concerns about the facility or staff persons from VA2. Medications Administration Records indicated that in July 2022, venlafaxine (antidepressant) 150 mg caps were not given on July 18-25, 2022, and trazodone (antidepressant) 150mg tablets were not administered July 13-18, 2023. Staff Daily Communication Log indicated that on July 18, 2022, VA1’s medical professional was “called about” trazodone. VA1 was to continue usage of trazodone which was now available as part of her 8 p.m. medication. An additional note from July 23, 2023, stated, “Please communicate to other staff [persons] and clients when we are out of med[ication]s so people can look into it. To reason to why clients have been without some med[ication]s since [July] 18 and 20.” After this investigator completed his/her site visit, there were additional concerns that P1 said VA1 was racist, that P1 no longer brought his/her family to the facility to visit the individuals because of the investigation, that P1 said s/he could lose his/her license for the facility because of VA1, and that although VA1 apologized to P1, P1 said s/he did not believe VA1. P1 said s/he never called VA1 racist or said P1 would lose his/her license. P1 went over the initial allegations with both VA1 and VA2 while completing the facility’s internal review and expressed some concern to VA1 that s/he had violated VA2’s privacy when VA1 talked about what had gone on while VA2 was in the bathroom and VA1 did not like that. P1 had been limiting his/her time at the facility since the investigation started as P1’s presence seemed to make the situation worse. This investigator made attempts to contact VA1 by phone to ask further questions, but VA1 did not respond. Conclusion for Allegation Two: Regarding SP1’s and SP2’s conduct: VA1 said that when SP1 and SP2 worked on the same shift they fought, and the arguments were loud. SP2 put VA2 roughly down and his/her wheelchair. SP1 got mad at VA1 and VA2 when they had bowel incontinence and said things like, “Do you really have to do that in your pants?” and “You’re not a child.” SP1 did not give VA1 privacy and barged into VA1’s bedroom to start completing cares. SP1 slammed the cupboard doors loudly and then laughed about it and often wore headphones and did not acknowledge the individuals. VA2 said that SP2 got upset when VA2 had bowel incontinence and told VA2 had s/he had to drink more water because his/her bowel movement was “dinky” which made VA2 feel bad. VA2 did not have any complaints with how staff persons assisted him/her with personal cares. P1 was not aware of any staff person being rough with the clients or yelling at the clients. On one occasion that P1 observed, VA1 was in the bathroom and SP2 asked if VA1 needed help. VA1 said SP2 was yelling at VA1. On another occasion, SP1 spoke to SP2 about the correct way to transfer VA2 so SP2 did not hurt his/her back. This may have been perceived as them fighting. SP1 said s/he did not fight with SP2. On some occasions if needed SP1 raised his/her voice so SP2 could hear. SP1 did not remember a time when s/he slammed the cupboard. When SP1 put dishes away, s/he warned VA2 that there was going to be some noise. SP1 did not yell or shout at the individuals. SP2 said s/he did not remember ever yelling at SP1. SP1’s voice may be louder if s/he called for SP2 and SP2 was downstairs. SP1 and SP2 did not discuss personal matters at work. SP2 had never yelled or gotten upset with the individuals when they were incontinent and did not feel s/he was rough with the clients. While it was possible that staff persons including SP1 and SP2 engaged in language and actions that were not therapeutic conduct, which was inconsistent with the role or a professional caregiver in a facility licensed by the Minnesota Department of Human Services, given the conflicting information regarding the details of the interactions between SP1, SP2, and VA1 and VA2, that P1 did not witness SP1’s and SP2’s conduct in a manner consistent with VA1’s statements, and that SP1 and SP2 denied yelling, shouting or being rough with VA1 and/or VA2, there was not a preponderance of the evidence whether all of SP1’s and SP2’s conduct was therapeutic or whether SP1’s and SP2’s conduct produced or could reasonably be expected to produce physical pain or injury or emotional distress. It was not determined whether physical or 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; 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; use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and/or use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825). Regarding missed medications: VA1’s Medication Administration Records for July 2022, indicated that VA2 did not receive his/her trazodone 150mg for six days and his/her venlafaxine 150mg for eight days. Staff Daily Communication Log indicated that on July 18, 2022, VA1’s medical professional was “called about” trazodone. VA1 was to continue usage of trazodone which was now available as part of her 8 p.m. medications. An additional note from July 23, 2023, stated, “Please communicate to other staff[persons] and clients when we are out of med[ication]s so people can look into it.” P1 said that there was a medication that the medical provider “messed up.” The pharmacy sent requests to the medical provider several times. P1 called the medical provider and pharmacy to get the situation resolved. Although VA1 did not receive two of his/her antidepressants for several days, given that there appeared to be some issues with the pharmacy and medical professional with refilling, and that VA1 resumed the medications with no noted side effects, there was not a preponderance of the evidence whether staff persons failed to supply VA1 with healthcare that was reasonable and necessary to maintain VA1’s physical or mental health. Regarding range of motion/walking: VA2 said that staff persons assisted VA2 with his/her exercises each day. P1 said VA2 had a goal to walk a certain number of steps but as his/her cerebral palsy has worsened it was progressively more difficult for VA2 to walk so a new goal was implemented. VA2 still completed some walking and range of motion exercise each day. SP1 said VA2 completed range of motion exercises daily but did not like to walk even though it was a goal. SP2 said that staff persons used to record VA2’s daily steps which were typically around 130 steps. This had recently been reduced. Given that VA2 said that staff persons assisted him/her with his/her exercises each day, that both P1 and SP1 said that range of motion exercises were completed each day, that P1 said that VA2’s walking goal had been recently changed due to the fact that it was more difficult for VA2 to complete it, and that there was no information found of any doctor’s orders for specific walking or exercises, there was not a preponderance of the evidence whether staff persons failed to supply VA2 with care that was reasonable and necessary to maintain VA2’s physical health. 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 policies and procedures were followed and adequate. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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