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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: 1071729-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: It was reported that staff persons allowed a vulnerable adult (VA) to lie on his/her bedroom floor for approximately 70 consecutive hours before calling 9-1-1. The VA developed a stage 2 pressure ulcer on his/her buttocks and a laboratory result showed concerns with his/her liver and/or gallbladder. Date of Incident(s): Ongoing between January 13 and 16, 2023. The Department of Human Services received the report on July 28, 2023.
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 14, 2023; from documentation at the facility and medical records; and through interviews conducted with facility staff persons (P1 and P2), and supervisory staff persons (P3, P4, and P5). Attempts by telephone and mail to contact and interview the VA’s guardian (G), who was also the VA’s family member, were unanswered by the completion of this investigation. The VA’s case manager (CM) was contacted, and s/he did not have additional information. At the time of the site visit, this investigator met the VA, but did not ask questions about the allegations due to his/her limited communication skills and the amount of time that had passed since the incident. The VA’s support plan and support plan addendum provided the following information: · In 2008, the VA moved into the facility seeking supports and services relating to his/her diagnoses, which included Down syndrome and intellectual disabilities. · The VA might not be able to defend him/herself against abuse from others and might not report abuse to an appropriate person. Staff persons were supposed to intervene when needed, ensure the VA’s safety, and report suspected or known abuse on the VA’s behalf. · “[The VA] has a high pain tolerance and will not always report if something is wrong. If asked [s/he] may say [s/he] is okay … [S/he] may not be able to convey [his/her] symptoms to a doctor. [The VA] relies on staff to observe for signs and symptoms and assist.” Staff were responsible for scheduling the VA’s medical appointments and then transporting and accompanying him/her to the appointments. · The VA did not require help with mobility and was able to walk around independently but might need help on icy surfaces. · “[The VA] is also prone to getting [urinary tract infections]. Staff will bring [the VA] to the doctor or walk-in clinic if they note [the VA’s] urine is dark in color, particles in it, smells or [the VA] is refusing to stand or walk.” [Note: The records reviewed for this investigation did not include other mentions of, or what to do when, the VA declined or “refused” to stand or walk.] The facility was a single-family home where the VA lived with three housemates. The facility provided at least one staff person 24 hours a day for care and supervision. The VA’s bedroom was on the main floor along with two of his/her housemates’ bedrooms. The main floor also contained the kitchen, dining room, living room, and bathrooms. The basement contained another bedroom, laundry room, and staff office. The floor in the VA’s bedroom was hardwood, without carpet or a rug. The facility’s progress notes stated the following: [Note: Some progress notes were missing or not completed by staff. That, which is recorded below, is the entirety of what was provided by the facility for this investigation.]
The VA’s medical records provided the following information: · On January 16, 2023, at 12:17 PM, the VA arrived at the emergency room. “Concerns of generalized weakness … Poor oral intake, ‘refusing everything.’” The VA “looks chronically ill, somewhat anxious.” · The VA had an elevated heartrate at 103 beats per minute and an elevated blood pressure at 123/93. Other vital signs were within normal ranges. · Laboratory tests were negative for urinary tract infection, bowel inflammation, and bowel obstruction. It was noted that the VA had a thickening of his/her gallbladder wall, which might be indicative of acute or chronic gallbladder disease. · A doctor determined, “The laboratory/physical findings are more consistent with a viral illness than gallbladder disease … [The VA] does react to pain and [s/he] doesn’t seem to have abdominal pain.” The VA was diagnosed with viral gastroenteritis (“stomach flu”) and acute cholecystitis (gallbladder inflammation). The VA was admitted to a hospital for “supportive care and monitoring.” · The VA also had “Stage 2 open wounds both buttocks. No cellulitis.” The VA was referred to wound care. [Note: There was no other mention in the medical records regarding the VA’s wounds or wound care.] · On January 20, 2023, the VA was discharged back to the facility with new prescriptions for “as needed” Zofran (nausea and vomiting prevention) and one dose of injectable influenza (flu) vaccine to be taken the next day. [Note: There was nothing mentioned in the discharge instructions regarding the VA’s after-visit wound care or wound-related prescriptions.] P1, P2, and P4 provided the following information: · P1, P2, and P4 each said that the VA had a history of declining or “refusing” cares or to stand and walk during the winter months. P1 said that it was like “seasonal depression,” and for the VA it typically occurred between November and March/April every year. In the past, or prior to January 2023, staff had been able to convince the VA to stand and/or receive help. P1, P2, and P4 were not aware of previous times the VA remained on the floor for an extended time. · P4 said that on Friday, January 13, 2023, the VA arrived home from work but declined to get off of the bus. Staff, with the help of the bus driver, lifted the VA into the bus company’s wheelchair and then pushed the wheelchair into the house. Once in his/her bedroom, the VA “dropped [him/herself] to the floor” and refused to stand. · P4 called P5, who said that this was “normal behavior [for the VA] at this time of year.” P5 suggested moving a stationary chair close to the VA so that s/he could lift him/herself up when s/he was ready. P5 told P4, “[The VA] can get up on [his/her] own.” P4 wanted to call 9-1-1, but P5 said that they could not call 9-1-1 because the situation was not an emergency. · P4 did not agree with P5’s instructions and believed the VA needed to get off of the floor. P4 and P1 lifted the VA into his/her bedroom recliner. · Later, P1 and P2 entered the VA’s bedroom to change his/her brief. While doing so, the VA yelled, “No,” and “straightened [his/her] legs out” making it so they were unable to change his/her brief. The VA then “dropped [him/herself] to the floor” and “refused” to stand. P1 and P2 used verbal redirection, attempted to physically lift, and offered the VA’s favorite food or drink; however, the VA remained sitting on the floor and “refused” to stand. They brought the VA’s walker over and encouraged him/her to sit on it, but s/he refused to move. · P2 described the VA as “heavier and difficult to lift.” · P1 said that the VA was “swatting” at staff when they approached and, “[The VA] locks [his/her] arms and puts [his/her] arms out” to prevent staff from lifting him/her up. · P1 and P2 decided to change the VA’s brief while s/he remained on the floor. At that time, the VA had a preexisting “rash” on his/her genitals and buttocks. P1 applied antibiotic ointment to the affected area. P1 and P2 then left the room with the intent to return later. At that time, the VA was sitting on the floor and appeared “happy” and “content.” P1 and P2 relayed what was happening to P4 and P5. · According to P2, P5 told him/her, “If [the VA] got [him/herself] on the floor, [s/he] can get [him/herself] back up.” P5 said that staff should offer “sips of water” but nothing additional as far as food or drink while the VA remained on the floor. P5 told P2 that offering all cares and supports, and food and drink might make the VA believe it was “okay to stay on the floor.” P2 did not agree with P5’s instructions, and instead continued to provide all cares and supports, offer food and drink, and ask repeatedly if the VA was ready to stand. P2 also contacted a supervisor at a different house within the same company and asked this supervisor for help. However, this supervisor immediately contacted P5, who “wasn’t happy” that P2 called the other supervisor. P2 added that s/he would have contacted someone with more supervisory authority than P5, but according to P2, all of the staff phone numbers had previously been removed from the house. · P1 called P4, who said to “keep an eye on” the VA. · P1 felt “uncomfortable” leaving the VA on the floor and reached out to the G for help. The G arrived at the house and remained for three to four hours attempting to lift or “coax” the VA to stand, including offering his/her favorite drink. The VA refused the G’s attempts, and when the G left the facility, the VA remained sitting on his/her bedroom floor. · P1 checked on the VA every 20 to 30 minutes. Each time, s/he encouraged the VA to stand and each time, the VA refused. P1 brought the VA food and drink, and his/her scheduled medications; the VA was receptive these items while still declining to stand. A chux (disposable, absorbent) pad was placed under the VA. · When the overnight staff person arrived, P1 and this staff person attempted to lift the VA up from the floor. The VA yelled, “No,” and tried to hit them; and so again the VA remained on the floor. The overnight staff person planned to check on the VA and encourage him/her to stand throughout the night. · The next morning, January 14, 2023, P1 arrived and discovered the VA still on the floor but now without pants or a brief. The overnight staff told P1 that the VA “ripped off” his/her brief and declined a new one. P1 completed the VA’s morning hygiene cares while s/he remained on the floor, but it was “difficult” because the VA repeatedly tried to hit P1. Throughout that day, P1 encouraged the VA to stand, but the VA continued to refuse. · Later that day, P1 observed newly present pressure sores on the VA’s buttocks. P1 called P4, and P4 came to the house to check on the VA. P4 instructed staff to keep the area clean and continue applying antibiotic ointment. P1 next repositioned the VA onto his/her side to relieve pressure on his/her buttocks. That night, P1 remained in the VA’s bedroom until the VA fell asleep while lying on the floor. · On January 15, 2023, P1 attempted more than once to put a brief on the VA and/or encourage the VA to stand; each time, the VA refused, yelled, and/or swatted at P1. However, even with this occurring, the VA did not appear lethargic and, instead, was “very responsive.” “[The VA] was sitting up most of the time … as long as you didn’t try to get [him/her] up, or like, ask [him/her] to get off the floor or anything, [s/he] was like, happy, like content just sitting there.” In comparing his/her demeanor while on the floor to his/her baseline demeanor, “[The VA’s] not as combative as [s/he] was during that time, but [s/he’s] pretty happy go lucky.” · In addition, during the time the VA was on the floor, s/he urinated on the chux pad a few times and defecated once, which prompted P1 or other staff to clean the VA and/or replace the chux pad. Staff provided the VA with food and drink and his/her scheduled medications. Staff did not check or record the VA’s vital signs. The VA’s input and output (urine and bowel movement) were within a normal range for him/her. · P4 did not receive any phone calls or updates from staff over the weekend, January 14 and 15, 2023, regarding the VA’s condition. · P1 said that on January 16, 2023, the VA remained on the floor, but his/her condition had changed. S/he was now “lethargic” and refusing all food and drink. P1 reached out to P4, who said to call 9-1-1. The VA was transported via ambulance to an emergency room. P5 provided the following information: · P5 could not recall the specific incident involved in this investigation. The VA refused to stand from the floor “multiple times.” “I witnessed it multiple times in a row.” · The VA would tell staff that s/he wanted to stay on the floor and so staff made sure s/he was comfortable using blankets and pillows and brought-in his/her favorite coloring book and crayons. One time, P5 colored with the VA on the floor for 45 minutes and still the VA did not want to stand. · P5 previously reached out to an administrative staff person regarding the VA’s behavior. This administrator told P5, “[The VA] has rights,” and could chose to not stand. “We can’t force [him/her].” P5 could not recall the name of this administrator but believed they discussed this in a staff meeting in which at least one other staff person was present. · P5 instructed the staff to make sure the VA was comfortable, check on him/her, and every hour or two, encourage him/her to stand. “It is our job as [his/her] provider to ensure [s/he] is kept clean and fed, given water and is comfortable.” P5 denied telling staff to limit the VA’s food or drink. P5 told staff to call in a second staff if needed or to call P5 for help. · P5 said that the VA was a “bigger individual” and “not all staff could pick [him/her] up.” There might only be one staff person working who was half the size of the VA. The VA kicked and/or tried to bite staff, and one time, “head butted” staff. “[Staff] can’t spend 100% of their time getting [the VA] off the floor.” There were three other individuals living in the house who also needed care and supervision. “I can understand why staff might not want to spend all day trying to get [the VA] off the floor.” P3 provided the following information: · P3 was not employed or affiliated with the facility in January 2023. · P3 spoke with staff and reviewed records and did not find any evidence the VA missed any meals or medications in January 2023. · P3 did not have, and was not aware of others having, concerns with the staffs’ conduct, including that of P1, P2, and P4. · P3 was not aware of previous incidents when the VA was on the floor for an extended time. · P3 created a plan for what to do during future incidents. Staff were supposed to encourage the VA to stand; and if that did not work, they were supposed to call the G. If the G was unable to help, the staff were supposed to call 9-1-1. This should all take place within the first hour of the VA declining to stand. P3 added that in August 2023, seven months after January 2023, the VA again declined to stand from the floor. Staff followed the newly created plan and it worked. The facility’s Service Recipient Rights Policy stated that the VA had the right to refuse or terminate services and be informed of the consequences of refusing or terminating services, the right to be treated with courtesy and respect, and the right to engage in chosen activities. Facility documentation stated that P1-P5 received training on the VA’s support plan and support plan addendum, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a), states the license holder must provide services in response to the person's identified needs, interests, preferences, and desired outcomes as specified in the coordinated service and support plan and the coordinated service and support plan addendum, and in compliance with the requirements of this chapter. License holders providing intensive support services must also provide outcome-based services according to the requirements in section 245D.071. Conclusion: On January 13, 2023, in the afternoon, the VA “dropped [him/herself] to the floor” and “refused” to stand. The VA remained on the floor until January 16, 2023, at approximately 11:30 a.m. P1-P5 each said that the VA had a history of doing this during the winter months, and that s/he typically did not remain on the floor for an extended time. The VA’s support plan and support plan addendum stated, in part, “Staff will bring [the VA] to the doctor or walk-in clinic if they note [the VA’s] urine is dark in color, particles in it, smells or [the VA] is refusing to stand or walk.” The failure to bring the VA to the doctor or walk-in clinic when the VA initially refused to stand or walk was inconsistent with the VA’s support plan and support plan addendum, and a violation of Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a). However, P1, P2, and P4 did immediately, and more than once, seek help and guidance from P5 and a supervisor from another house who then called P5. Although P5 denied it, information obtained showed that P5 told staff persons that while the VA remained on the floor, they should limit his/her food and drink. This instruction by P5 was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. According P5, s/he had been previously told by an administrative staff person, “[The VA] has rights” and could chose to not stand. “We can’t force [him/her] … [The VA] can get up on [his/her] own.” Regarding this incident, P5 suggested moving a stationary chair close to the VA so that s/he could lift him/herself up when s/he was ready. P5 told P4 that staff could not call 9-1-1 because it was not an emergency. Despite P5’s instruction, P1, P2, P4, and/or other staff persons repeatedly encouraged the VA to stand; attempted to lift the VA; provided food, drink, and scheduled medications to the VA; repositioned the VA on the floor to relieve pressure; and applied antibiotic ointment to the VA’s preexisting rash and newly formed pressure sores. The VA accepted cares but refused to stand and swatted at staff when attempts were made. P2 provided information that during this time, the VA did not appear lethargic and, instead, was “very responsive.” “[The VA] was sitting up most of the time … as long as you didn’t try to get [him/her] up, or like, ask [him/her] to get off the floor or anything, [s/he] was like, happy, like content just sitting there.” In comparing his/her demeanor while on the floor to his/her baseline demeanor, “[The VA’s] not as combative as [s/he] was during that time, but [s/he’s] pretty happy go lucky.” There was nothing noteworthy about the VA’s input or output. Information was also provided that the VA’s input and output, during this time, were within a normal range for him/her. On January 16, 2023, the VA’s condition changed. S/he was now “lethargic” and refusing all food and drink. Staff called 9-1-1, and the VA was transported to an emergency room where s/he was diagnosed with a stomach flu and prescribed anti-nausea and -vomiting medication and a flu vaccine. There was no mention of additional after-care or prescriptions relating to a concern that the VA had developed pressure sores. Given that the VA’s condition did not initially indicate a need for emergency medical care but that additional care was immediately sought once the VA’s condition changed; and that although the VA remained on the floor, staff interacted with the VA, provided the VA with activities, cleaned the VA as needed, applied ointment, and repositioned the VA to relieve pressure, and gave the VA food, drink, and medications, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services, which were reasonable and necessary to maintain 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. “Revisions have been updated to [the VA’s] assessments identifying [his/her] refusals of getting off the floor, risks of this behavior and steps staff will take when [s/he] displays these refusals.” Staff received training on the VA’s updated plans and the Reporting of Maltreatment of Vulnerable Adults Act. Action Taken by Department of Human Services, Office of Inspector General: On October 6, 2023, the facility was issued a Correction Order for the violation outlined in this report.
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