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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: 1071091-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Henne 651-431-3444 Suspected Maltreatment Reported: Allegation One: It was reported that there were several concerns regarding the cares of two vulnerable adults (VA1 and VA2). Allegation Two: It was also reported that staff persons told VA1 that s/he “stinks” and to “keep quiet.” Date of Incident(s): Prior to March 20, 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 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. 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 April 12, 2023; from documentation at the facility; and through 14 interviews conducted with three supervisory staff persons (P1-P3), one administrative person (P4), five facility staff persons (P5-P9), a healthcare provider (HCP) who did not work for the facility but worked with VA2 at the facility, VA1’s guardian (G1), VA2’s guardians (G2 and G3), and VA1. This investigator met VA2, but s/he was unable to provide information due to his/her diagnoses. Attempts were made to obtain follow up information from P9, but the attempts were unsuccessful. VA1’s file stated that family was important to him/her. VA1 also liked the Green Bay Packers, the Minnesota Twins, and going on outings. VA1 was diagnosed with a mild developmental disability, epilepsy, and anxiety. VA1 had stroke in 2021 that affected his/her left arm, leg, and core muscles and therefore used a wheelchair. VA1 wore ankle-foot orthosis’ (AFO’s) to treat plantarflexion and inversion increased tone and required assistance from staff persons with putting them on and taking them off. VA1 required two staff persons for lift transfers and showering and also required assistance from staff persons with all of his/her hygiene tasks including changing his/her adult undergarment. VA2’s file stated that family was important to VA2. VA2 also liked to know what was happening next in the day, listening to music, and going on outings. VA2 was diagnosed with physical and cognitive limitations following a brain injury and spastic quadriplegia. According to VA2’s Community Support Plan, VA2 did not walk, used an electric wheelchair, and required staff person assistance to reposition him/her in his/her wheelchair and in his/her bed every two hours. VA2 also used a Hoyer and manual lift for transferring and needed assistance to complete all of his/her daily needs. VA2 was able to feed him/herself independently most of the time but there were times when staff persons needed to help assist him/her with certain foods that were hard to control on the utensil. VA2 required total assistance with bathing and dressing needs. VA2 participated in his/her hygiene and grooming, but staff persons set up his/her toothbrush and finished by going over his/her work for thoroughness. VA2 had a colostomy bag which needed to be changed twice a day and the stoma that needed changing once a week. VA2 also had a catheter bag and staff persons were required to change it when needed and a nurse changed the catheter monthly. All staff persons interviewed were trained on VA1 and VA2’s plans and on the Reporting of Maltreatment of Vulnerable Adults Act. Allegation One: It was reported that there were several concerns regarding the cares of VA1 and VA2. During VA1’s interview s/he stated that s/he had no additional concerns regarding his/her cares other than what was provided below. A call was made to VA1 to obtain additional information but VA1 ended the call before the completion of the interview. Regarding changing VA1’s adult undergarment: G1 said that s/he was concerned that VA1’s adult undergarment was not changed as frequently as it should be, about every three hours. VA1 wore a button/bell around his/her neck to alert staff persons when needed. However, VA1 was not always accurate and sometimes s/he thought his/her undergarment needed to be changed even when it was dry. VA1 was very verbal but was not always an accurate reporter of information. VA1 looked at the world from his/her point of view and what was important to him/her. VA1 did not always make good decisions and it was the staff persons job to ensure VA1 was motivated to do what needed to be done through a “positive and friendly approach” and by developing a relationship with VA1. G1 said it was all about “using the right approach” with VA1. P2 said that VA1 was not independent with toileting and wore an adult undergarment. P2 had no concerns with staff persons not changing it on time. P3 said that VA1 wore adult undergarments and told staff persons when s/he needed to be changed. There was also a schedule to change VA1 in the morning, around lunchtime, and after dinner/before bedtime. P4 said that VA1 wore an adult undergarment and was able to tell staff persons when it needed to be changed. If VA1 did not tell staff persons, they would still check it about three times during waking hours and again during the night. Sometimes, VA1 had to wait to get it changed if staff persons were busy with other clients. VA1 got “very uncompliant” if it needed to be changed at nighttime. P5 said that VA1 needed help with “basic cares” and adult undergarment changes. P5 was trained to change VA1’s adult undergarment three times a day or immediately as needed. P8 said that VA1 wore an adult undergarment that staff persons changed it when needed typically three to four times a day. VA1 also let staff persons know when it needed to be changed. P8 had no concerns with staff persons not changing it when needed. P9 said that VA1 had his/her adult undergarment changed when she got up in the morning, after lunchtime, before dinner time, and whenever s/he decided to go to bed, usually an hour or two after dinner. Although G1 had concerns that VA1’s adult undergarment was not changed as frequently as it should be, given that VA1 did not provide information whether staff persons did or did not change his/her adult undergarment in a timely manner; and that P2, P3, P4, P5, P8, and P9 each provided consistent information that staff persons changed VA1’s adult undergarment frequently and each had no concerns regarding it not being changed in a timely manner, there was not a preponderance of the evidence whether staff persons failed to change VA1’s undergarments when needed. Regarding VA1’s missed medications: A Medication Error Report stated that on March 26 and 27, 2023, VA1 missed a 5 p.m. medication (lacosamide 100 milligrams/anticonvulsant). The medication was not given because the facility did not have the medication. VA1’s medical provider was notified, and staff persons instructed to start the 5 p.m. dose once received. According to VA1’s Medication Administration Record, it stated to “order when low” and that insurance only covers 30 days. On April 2, 2023, VA1 missed another medication (norethindron/progesterone) due to “staff oversite.” VA1’s healthcare provider was notified of the error and staff persons were instructed to continue with VA1’s normal doses. Medication administration was reviewed with P5. G1 said that s/he was concerned regarding VA1 missing medications on March 27 and 28, 2023, and said the facility did not have the medications available because they were not ordered in advance to be delivered on time. However, G1 said the facility was “making changes.” G1 visited the facility on April 4, 2023, and P6 told G1 that VA1 had another missed medication over the previous weekend on April 2, 2023. After the seizure medication in March was missed, VA1 said s/he had some “twitching” around his/her eyes, but the twitching went away without any treatment. G1 said it was “borderline” seizure activity, but “no real harm” happened. The missed progesterone did not cause any harm. P2 said that VA1 had a missed medication around March 2023, but P2 did not remember which medication it was. P4 said that sometime at the end of March 2023, VA1 missed two doses of his/her seizure medication because the facility “ran out of it.” P8 said that sometime about three weeks prior to April 12, 2023, VA1 had a missed medication due to it running out. However, staff persons were waiting on VA1’s doctor to refill the prescription. Although G1 had concerns that VA1 missed medications on March 27 and 28, and April 2, 2023, given that the facility documented a medication error report, that according to G1, there was “no real harm” to VA1, and that there was not a pattern of missed medications, there was not a preponderance of the evidence whether staff persons failed to administer VA1’s medications as required. Regarding VA1’s AFOs: VA1 said that s/he wore an AFO on each leg and that s/he was “training” staff persons on how to put them on. In the past, staff persons put them on “too tight” but because VA1 was showing them how to put them on, they were “getting it.” If the AFOs were on too tight it was “ouchy” and VA1 was able to tell the staff persons if it hurt. When VA1 told them if it hurt, they loosened the straps. P1 said that at some point VA1 told P1, “Staff don’t give a fuck,” and that P5 put VA1’s AFO on “too tight” and would not listen. P1 stated that there were times when VA1 told P1, “Ouch,” and that the AFO was “tight” and then P1 loosened it. G1 said that s/he visited VA1 at the facility at least three times a week and helped VA1 do exercises in his/her bed. When those were done, G1 took off VA1’s shoes, socks, and AFO so that s/he could look for any pressure ulcers. There were issues with a pressure ulcer related to VA1’s right AFO for a period of time due to the AFO strap being too tight as well as VA1’s shoe tied too tightly. However, since then that AFO was “adjusted” and additional padding was added, but staff persons still needed to be reminded to not put them on too tightly. A couple of months prior to April 10, 2023, VA1 started to wear an AFO on his/her left foot and it was difficult to get on properly because VA1 was “spastic” in his/her left leg. "A couple of times,” G1 observed that staff persons did not put it on properly and was concerned that, it would not “do the job” and could cause a pressure ulcer. At some point, G1 explained to P2 how to correctly put them on and said that most staff persons required training at least twice to put on VA1’s AFOs and shoes correctly because there was a tendency to put them on too tight. P2 said that VA1 wore two AFOs daily and P2 thought it was because VA1’s feet were “crooked.” G1 trained staff persons on how to put the AFOs on VA1. P2 had no concerns with staff persons putting the AFOs on. However, P6 told P2 s/he was not comfortable putting them on VA1, but P2 told P6 that s/he would show him/her how to do it. P4 said that VA1 wore two AFOs to help keep his/her feet “straight” as well as an insert in one of his/her shoes. P4 had no concerns with staff persons training on VA1’s AFOs. P9 said that s/he made sure VA1’s AFOs were put on correctly because there was a “certain way” to put them on. G1 trained P9 and other staff persons how to put them on correctly. Although VA1 and G1 had concerns with how staff persons were trained to put on VA1’s AFOs, and that sometimes it was “too tight” and VA1 had a history of pressure wounds from it being too tight, given that VA1 was able to tell staff persons when they were tight and that staff persons readjusted them when requested, and that there was no information provided that VA1 had any recent pressure wounds as a result of the AFOs, there was not a preponderance of the evidence whether staff persons put on VA1’s AFOs in a manner that caused injury or harm to VA1. Regarding VA1’s injured toenail: An Incident Report stated that on February 22, 2023, at 7:20 p.m., P6 was doing VA1’s cares to prepare VA1 for bed. P6 noticed that VA1’s right big toenail “was coming off.” The toenail was dark pink and the toe was swollen. 911 was called and the emergency medical technicians (EMT) examined the toe but did not transport VA1 to the hospital. They advised staff to keep the area clean and continue to observe. VA1 said that on an unspecified date, P8 and P9 were both taking VA1’s socks off and they “ripped” one of his/her socks off “too hard.” VA1 told P8 and P9, “Ouch, it’s too hard.” P8 and P9 did not say they were sorry and they “just blew it off.” P7 called G1 about the incident and then G1 contacted the “emergency crew” who came to the facility to look at VA1’s toenail which had fallen off. They treated it with a Band-Aid and cream and staff persons continued to bandage it. P6 said that a couple months prior to April 12, 2023, P6 got VA1 ready for bed and took off VA1’s shoes and AFO. After P6 took them off, s/he noticed one of VA1’s socks had blood on it. VA1 wore a regular sock on one foot and a “really long loose” sock on the other foot. P6 took VA1’s socks off and saw one of VA1’s toenails were “coming up/hanging” and going to “break off” and saw “white flesh.” P5 contacted P2 and told him/her s/he was going to call the 911/paramedics because s/he saw “flesh.” (Note: P6 provided a screen shot of a text message sent on February 22, 2023, at 7:02 p.m. P6 also texted P3 a picture of VA1’s right toenail. This investigator saw the picture and the toenail was white and the flesh was red underneath.) P6 asked VA1 if his/her toenail hurt. VA1 said that it did, but s/he did not know when the pain started. The paramedics came to the facility and said there was not really anything they could do for the toenail, but they bandaged it. P7 was also working at the time of the incident but was next door at the adjoining facility. P6 said VA1 had “toe surgery” the next day. P7 said that a couple of months prior to April 25, 2023, sometime in the evening, P6 helped VA1 to bed and took his/her compression socks off and one of VA1’s toenails were “completely lifted.” P6 did not know what to do and called P7 who was working next door at the adjoining facility. VA1 told P6 and P7 that “maybe” a staff person put his/her sock on “the wrong way.” An ambulance, P2, and G1 were called. When the ambulance got to the facility, the story changed from a staff person putting his/her sock on wrong to “day staff, they never do anything right.” The EMT’s wrapped up the toenail and said the toenail would come off on its own. P1 said that s/he worked at the facility on a Monday and heard that sometime over the previous weekend on Friday or Saturday an EMT was called because VA1’s toenail “came off.” However, when P1 put VA1’s socks on that Monday morning, the toenail was not “off” but was “broken.” P1 remembered a week prior to the incident G1 clipped VA1’s toenails. P1 was not sure what happened with VA1’s toenail but thought that because VA1’s socks were “long” that staff persons may have “snatched” the socks off which caused the sock to get “caught” on the cracked toenail. A few days later, VA1’s toenail came off and P1 wrote instructions for staff persons to keep the area clean with soap and water, keep it dry, use bacitracin, and to wrap the area to ensure there was no infection. P1 made an appointment for VA1 to see his/her doctor for a follow up to make sure everything was okay and G1 took VA1 to that appointment. P3 said that G1 was responsible for VA1’s nail care. However, staff persons cared for them if needed. VA1’s nails looked “normal” and “healthy.” However, at some point, when P3 was not at the facility one nail “somehow” got “caught” when probably a staff person put VA1’s socks on. P3 was notified one evening when staff person, who P3 could not recall but possibly P6, took VA1’s sock off, there was an injury to VA1’s toenail, and the toenail was “pulled up.” Another staff person, who P3 could not recall, was also at the facility and both staff persons were “pretty concerned” about the toenail and called 911. A paramedic came to the facility that evening but said there was nothing s/he could do and if there were any problems to follow up with VA1’s primary doctor. P3 told the staff persons to fill out an incident report because there was an injury and also because 911 was called. P3 said that the VA1 probably could have just gone to urgent care instead of calling 911. VA1 had a follow up at some point after the incident but P3 was not aware of any instructions given after that appointment besides keeping the area clean and to monitor the injury. P3 did not know how a staff person could have “aggressively” taken off VA1’s sock. P2 said that G1 was very involved and was responsible for VA1’s nail cares. However, staff persons cleaned VA1’s nails. About a month prior to April 12, 2023, VA1 had an injured toenail that was caused from his/her compression socks and eventually the toenail fell off. P9 said that one Monday, an overnight staff person, who P9 could not recall, told P9 that over the previous weekend, VA1’s toenail came off. That staff person called 911 to assess VA1’s toenail. When P9 went to get VA1 ready on that Monday, VA1’s “entire toenail” on his/her right foot “was there” so P9 was “confused.” However, the next day when P9 got VA1 ready for his/her shower, P9 saw that the toenail was “sitting” on VA1’s toe but was not “connected” to his/her skin. G1 provided the following information: · On the evening of February 22, 2023, P7 (who primarily works at the adjoining facility) called G1 and told him/her that that when P6 took VA1’s socks off, one of VA1’s toenails was “ripped” and there was “lot of blood” in VA1’s sock. P6 and P7 “kind of panicked” and called 911. The paramedics bandaged the toenail and said VA1 did not need to go the emergency room. A couple of days later, the toenail fell off. · On March 10, 2023, G1 took VA1 to his/her doctor to follow up on the toenail. The doctor wanted a “non-stick” bandage to be used and said to keep the area clean. On March 13, 2023, G1 talked to P1 at the facility and agreed VA1’s toe needed to be cleaned and rebandaged every day. P1 took responsibility to do it every morning, but since s/he was not there on the weekends, P1 wrote directions for staff persons to do it. VA!’s left big toe also looked like it was “ripped” at some point but did not come off. There was a “vertical line” near the top and was not “flat.” · At some point after the incident, P1 told G1 that it could not have been bleeding all day and that the toenail probably got caught on the AFO sock. · G1 was the only person who cut VA1’s toenails unless VA1 went to a podiatrist. VA1’s toenails were “sharp” especially on his/her right foot where VA1 has had paralysis his/her whole life. G1 cut VA1’s toenails the week prior to the incident. However, VA1’s big toenail on his/her right foot had been ripped off in the past, and since then the nail had grown back “weird,” had a “rough edge,” and had not “grown out enough” to be cut. · On April 9, 2023, G1 cut VA1’s toenails again and thought that the toenail was maybe ripped, but it did not come off. G1 was concerned the incident could happen again. VA1 did not have surgery on his/her toe, the toe just needed to be bandaged and kept clean. · G1 told this investigator that as of September 2023, there was major improvement at the facility and the daytime staff at that time were the “best we have had” and really cared about each individual.
Although P1 had concerns that when staff persons removed VA1’s sock, it may have caused VA1’s toenail to get caught on the sock and later fall off, given that there was no information to show that staff persons removed VA1’s socks in a way that would have caused the toenail injury, that VA1 had a history of toenail issues, and that the treatment was to keep it cleaned and bandaged and needed no further medical attention, there was not a preponderance of the evidence whether VA1’s toenail to came off by staff persons actions or by any means other than accidental. Regarding VA1 being in bed too long: VA1 said that s/he went to bed around 6 p.m. and that it was “too early.” G1 said that s/he was “not sure what to think” about VA1 being in bed “too early” and that they had their evening meal in the late afternoon and then staff persons start getting the residents ready for bed after that. VA1 sometimes stayed in his/her wheelchair later but usually watched television from his/her bed or made several phone calls. VA1 did not “have” to go to sleep. VA1’s doctor recommended that VA1 be out of his/her wheelchair for a break each day due to the need for repositioning. However, VA1 was not interested in that and has been “opposed” to naps since s/he was a child and viewed lying in bed as taking a nap. G1 thought it would be good for VA1 to be out of his/her wheelchair after sitting in it all day. P1 was concerned that VA1 was in his/her bed too late in the morning and one time when P1 arrived at the facility around 12:30 p.m. when P9 was working, VA1 was still in bed. At nighttime, staff persons told VA1 to go to bed without asking VA1 if s/he wanted to. Although G1 was “not sure what to think” of VA1 going to bed after his/her evening meal and that VA1 said s/he went to bed “too early,” give that G1 said that VA1 was able to stay awake in his/her room and that it was good for VA1 to be out of his/her wheelchair according to VA1’s doctor so that s/he could relieve the pressure after sitting all day, and that there was no other information provided to show that staff persons forced VA1 to go to bed too early or stay in bed too long, there was not a preponderance of the evidence whether VA1 remained in bed too long. Regarding VA2’s catheter, colostomy bag, and infections: The HCP said s/he felt that the staff persons at the facility were “good people” and wanted to work there, but there was a “lack of direction and management.” There was a “change in staff” around the beginning of the year (2023) and the HCP felt that VA2’s cares had “gone down” with the new staff changes. VA2 had a Foley catheter for about one and a half years. The HCP had a “difficult” time keeping the Foley “working” so VA2 saw a urologist who ordered daily irrigation flushes. VA2’s insurance would not cover homecare for that, so the HCP taught the staff persons how to irrigate it. The HCP talked to P4 and “agreed” VA2 needed “daily flushes” and since then the staff persons in the last two weeks prior to April 14, 2023, started doing that. However, the HCP was still having problems with the catheter clogging and the HCP was unsure as to what the cause was and said there was not a lot of documentation regarding VA2’s catheter issues. VA2 had a lot of “sediment” in his/her catheter. P1 provided the following information: · VA2 had a catheter, and s/he was concerned with staff persons doing VA2’s cares because they were not trained on catheters. VA2 kept getting bladder infections. VA2 had a nurse that came to the facility twice a week to flush VA2’s catheter. At some point P1 and a manager were with VA2 at a doctor appointment and the doctor said VA2 might need to be “flushed” every day or every other day. P1 was concerned because staff persons were not trained for that. P1 was also concerned with VA2’s urine bag not being emptied because sometimes it would “back up.” P1 thought that was maybe the cause to some of the concerns with VA2’s bladder. . P1 was concerned the staff persons were not “competent” and staff persons said they were not trained. P1 attended a “four-minute” training but was still not comfortable with VA2’s catheter cares. · VA2 had a colostomy bag and P1 was concerned with how staff persons were trained on it. One morning when P1 came into his/her shift, VA2 had feces on him and P1 and P3 had to clean him up. · P2 and P3 were aware of P1’s concerns. P3 told P1 that they were going to “get this house straight” and talk about it at a meeting, but the meeting kept getting rescheduled and by March 29, 2023, when the meeting was schedule to take place, P1 no longer worked at the facility. At some point, P2 said s/he “ain’t doing no cares” and P1 never saw P2 do any cares. P1 had concerns with P2 because P2 knew about P1’s concerns and nothing was done about it. · P1 did not know who was responsible for the training of the cares at the facility, but P1 was trained by P3 and had no concerns with P3. However, P3 no longer worked at the facility. P2 said that VA2 had a colostomy bag and a catheter that needed “irrigate[ing].” P2 had no concerns with staff persons care of VA2. P3 said that VA2 had a “laundry list” of medical diagnoses and needed “full assistance” with his/her cares. VA2 had no use of his/her legs and had minimal use of his/her arms and used a “power chair.” VA2 was diabetic and had a Foley catheter. VA2 also needed skin checks due to immobility and skin break down and had in-home nursing that came to the facility a couple of times a week, or at least once a week, but more if the Foley needed to be changed or there was an issue. P3 stated sometimes urine “bypass[ed]” VA2’s catheter and staff persons could not really “nail down” what the cause was. Staff persons were responsible for “daily visuals” of the catheter to make sure it was functioning and in good order and were to drain the bag when needed. If there were any issues, staff persons were trained to call the nurse. Staff persons did not do any of the catheter cares. However, at some point, the nurses wanted to start having a staff person do the “flushes.” P3 said that they were not able to “pinpoint” what the problem was regarding VA2’s catheter. P3 did not ever see any issues with VA2’s catheter not being emptied by staff persons, but some mornings when s/he came to the facility that “naturally” the catheter would need to be emptied. P4 said that VA2 had “intense cares” and a homecare nurse provided some training to staff persons on VA2’s catheter cares including “flushing” VA2’s catheter. VA2 also had a colostomy bag, but P4 had no concerns with staff persons training on it. Between January and March 2023, VA2 was only hospitalized once. On February 11, 2023, VA2 went to the ER and was diagnosed with cystitis (urinary tract infection). VA2 was not admitted to the hospital but was prescribed an antibiotic. P5 said that VA2 had a urine and feces bag that needed to be changed by staff persons when it was full. P5 had no concerns with staff persons changing or emptying the bags. However, as of September 2023, P5 felt there was a lack of training for newer staff persons and there were some issues with VA2’s catheter bag and s/he got another bladder infection. P5 thought the bladder infection was treated with antibiotics. As of September 26, 2023, P5 said there was an improvement in VA2’s cares. P6 said that VA2 had a catheter and a nurse came to the facility two or three weeks prior to April 12, 2023, to train staff persons on how to “irrigate” it. However, P6 was not comfortable with it and did not feel it was “appropriate” for staff persons to be trained on something that should be a nurse’s job. P6 said that the facility could “get better” with training “new” staff persons, but it was something that was talked about, and it was “getting better.” P6 was not concerned with any “neglect” of VA2 but was more so concerned with the new staff persons and their training. VA2 also had a colostomy bag and staff persons were trained to empty it when it was full. P7 said that VA2 had a urine bag and was aware of one incident when VA2’s bag had a leak or a hole but s/he did not have any concerns regarding staff emptying it. P8 said that VA2 had a colostomy bag and a catheter. P8 was not yet trained on how to “irrigate” the catheter but was trained on how to “drain” it. A nurse trained other staff persons on how to irrigate the catheter. VA2’s colostomy bag was emptied when it was full, and staff persons were able to see when it was full. P8 had no concerns with any staff persons not emptying VA2’s colostomy bag. Sometimes the colostomy bag spilled while emptying it or if VA2 tried to pull the bag off. Staff persons would then clean VA2, wash VA2’s clothes, and put on a new bag. P8 said that a nurse came to the facility twice a week to check VA2’s catheter bag or wounds. P9 said that VA2 needed help with “everything.” VA2 had a urine and colostomy bag and an indwelling Foley catheter. The catheter sometimes got clogged, so staff persons irrigated the catheter to prevent clogging. Nurses trained staff persons on how to do that and would also come to the facility a twice a week to irrigate it. P9 had no concerns with staff persons when it came to VA2’s colostomy or urine bag. About a month prior to April 12, 2023, P1 told P9 that s/he was not comfortable irrigating VA2’s catheter. P1 also did not want to learn how to do “anything.” P9 tried to show P1 how to do different things and P1 said, “I am not doing that.” Although several staff persons had concerns regarding caring for VA2’s catheter and the training regarding how to care for VA2’s catheter, given that there was no information that staff persons failed to care for the catheter or colostomy bag, or that staff persons actions or lack of action caused harm to VA2, there was not a preponderance of the evidence whether staff persons failed to care for VA2’s catheter or colostomy. Regarding VA2’s pressure wounds and being in bed too long: The HCP said VA2 was a quadriplegic and “prone to wounds.” The HCP had some concerns with VA2’s wound care and wounds that reopened. On April 14, 2023, VA2 had a “new” wound on his/her back that was approximately two centimeters by seven centimeters and appeared as though it may have occurred from transferring VA2 with a Hoyer belt. The HCP was concerned with how often VA2 was getting out of bed especially with the new wound on his/her back. P1 provided the following information: · P1 was concerned with VA2’s wound care regarding “pressure sores” on VA2’s “bottom.” In December 2022, the pressure wounds were “real bad,” and recently (March 2023) started to get better because P1 “got the ball rolling” and got the nurses involved in the wound care. P1 did not think staff persons were trained on how to treat VA2’s pressure wounds. · Sometimes VA2 said “down” to P1, which meant s/he wanted to go to his/her bed. P1 thought VA2 said this because of the position s/he was in his/her wheelchair and was trying to communicate that s/he wanted to be repositioned. P1 was concerned that staff persons did not understand this and did not take the time to try to find out what VA2 wanted. P1 had concerns about VA2 being in bed too long. Sometimes VA2 asked P1 to go to his/her bed around 1 p.m. and P1 helped him/her into his/her bed. Sometimes s/he wanted to stay in bed until 4 p.m. However, when the next shift came in around 4 p.m. and VA2 wanted to get up and P1 had to leave, VA2 stayed in bed. Other times, VA2 would eat dinner around 4:30 p.m., and staff persons put VA2 to bed shortly after. P2 said that VA2 had wounds on his/her “bottom” and back that were there prior to P2 being hired. VA2 had “thin” skin and P2 was not sure if it caused from diabetes or not. VA2 also used “slings” to get into his/her bed and shower, so some of it was “unavoidable” in P2’s opinion. The nurses observed the wounds and twice a day staff persons applied a non-prescription cream that was helping it heal. A nurse came to the facility twice a week and for those days, staff persons were instructed to keep VA2 in his/her bed until the nurse arrived which was usually around 10 or 10:30 a.m. On the days a nurse did not visit, VA2 got out of bed around 8:30 or 9 a.m. From “time to time,” VA2 got tired and wanted to sleep in later in the morning or for the remainder of the day, but that “seldom” occurred. P2 tried to keep VA2 awake for as long as s/he could. P3 said that VA2 did not have any wounds while P3 worked at the facility and said that was “before [his/her] time.” Staff persons were trained to do visual skin checks on VA2’s entire body when dressing and undressing VA2 and staff persons documented if they saw any wound developing. VA2 was “up out of bed most of the day.” VA2 got up in the morning and was transferred to his/her wheelchair. VA2 did not have a specific “reposition protocol.” If VA2 was sick or if staff persons were waiting for a nurse to come, VA2 waited in bed until they arrived. P3 did not have any “major concerns” about VA2 being in bed too long but said there was “always room to improve” especially when new staff persons started working at the facility. P4 said that VA2 used a wheelchair and was unable to stand up on his/her own. Because VA2 was either in his/her wheelchair or his/her bed, pressure wounds were “bound to happen.” VA2 sometimes got pressure wounds on his/her back and/or buttocks, but it was not “real frequently” that they occurred. However, a homecare nurse visited the facility twice a week to monitor VA2’s wounds. Staff persons were trained to communicate with each other and document in the medical logs when a pressure sore was observed, and a cream was applied. If a homecare nurse was visiting in the morning, staff persons left VA2 in his/her bed until s/he arrived. Once VA2 was out of bed for the day, it was common that around 2 or 3 p.m., s/he would request to go back to his/her bed. However, P4 said that staff persons liked to keep VA2 up until after dinner, which was served around 4:30 or 5 p.m. P5 said that VA2 relied on staff persons for all of his/her cares such as bathing, dressing, getting in and out of his/her electronic wheelchair, and eating. VA2 went from his/her bed to his/her wheelchair and then back to his/her bed and P5 was unaware of any wounds. VA2 typically got up in the morning around 7, 8, or 9 a.m. and went to bed early usually around 6 or 7p.m. or at times as early as 4 p.m. when s/he was really tired. VA2 let staff persons know s/he wanted to go to bed. P5 received training on how to positions VA2 in bed in “different ways” to ensure his/her arms were up and was in a comfortable position to sleep. VA2 spend most of his/her time watching television in the living room or on his/her iPad and enjoyed having people around him/her. P6 worked overnight shifts and started at 10 p.m. P6 said that VA2 was not in his/her bed for “too long” and the only reason s/he would be was if the nurse was coming to the facility and wanted VA2 in bed for to be checked out. However, P6 said that VA2 liked to go to bed around 5:30 p.m. and as of September 2023, staff persons were recently trained to put pillows next to him/her and switch sides every two hours. P6 said that VA2 went to the hospital over the summer of 2023 and typically would come back to the facility with pressure wounds due to the hospital stay. However, the nurses that came to the facility would treat them and apply cream as needed. P8 said that when s/he came to the facility for his/her shifts around 4 p.m. VA2 would typically be in the living room and then after dinner VA2 wanted to lay down in his/her room. VA2 had wounds on his/her buttocks from being in a wheelchair all day. Staff persons were trained to put a cream on VA2 or use “bandages” to prevent infection. P8 worked morning shifts on the weekends and usually got VA2 out of bed by 9 a.m. However, there are times when VA2 wanted to lay down after lunch time for a couple hours. However, VA2 was “never in bed too long.” P8 did not have any concerns with staff persons in regard to VA2’s cares. P9 said that VA2 had thin skin on his/her “bottom” because s/he sat in a wheelchair when s/he was not in his/her bed. Nurses trained staff persons to “keep an eye” on the wounds and use a cream when needed. Around March 2023, VA2’s wounds had “gotten better” and as of April 12, 2023, had no “open” wounds. Although the HCP and P1 had concerns regarding VA2’s pressure wounds and how long VA2 was in bed, there was no information to show that the pressure wounds were a result of staff persons failure to provide VA2 with cares that were reasonable and necessary to maintain his/her health or safety. Therefore, there was not a preponderance of the evidence whether VA2’s pressure wounds were a result of staff persons failure to care for VA2. Regarding VA2’s personal cares: G2 said that s/he had no concerns with the facility and was “confident” in VA2’s cares being done, and the staff persons were “on top of stuff.” G2 had never seen anything that s/he believe was neglectful but mentioned one unknown holiday weekend the facility was short staff, and because the ceiling Hoyer lift was inoperable, VA2 was in bed until noon because two staff were needed to use the lift. VA2 was very limited in his/her ability to communicate and was not able to answer questions regarding his/her cares and was not able to accurately report information. However, s/he could “point” or “Here,” or, “Ouch.” G3 said that s/he had no concerns about the facility and said that it was “good for a long time.” G3 said that G2 was more involved with the facility. P1 said that s/he was concerned VA2 was not getting his/her face cream applied or “special” shampoo. P1 was also concerned that VA2 was not getting his/her teeth brushed. At some point during late February or March 2023, P1 had to buy VA2 a toothbrush and toothpaste because VA2 did not have any. After P1 bought them, s/he was still concerned that they were not being used. P2 said that VA2 got his/her teeth brushed by staff persons once a day in the morning. However, there was no documentation at the facility for this. P1 told P2 that before P2 was hired, VA2 did not have a toothbrush and that s/he purchased one for him/her. P2 had no concerns with VA2’s cares not being done. P3 said that VA2 “should” have had his/her teeth brushed twice a day by staff persons. There was a clipboard in VA2’s bedroom that staff persons were supposed to initial every day. However, it was not “running on one hundred percent.” P3 said there was not a “capability” to do things “they way” things were done when P3 started in the field due to “quality” of staff persons “deteriorate[ing]” over the years. P4 said that VA2 received a shower “at least” every other day. Staff persons were trained to brush VA2’s teeth daily and “hopefully” that occurred. However, the facility did not document toothbrushing because it was not ordered by a doctor. Staff persons should know to brush VA2’s teeth from the training they received. Because VA2 had diabetes, his/her fingernails and toenails were clipped by a homecare nurse. VA2’s face cream and shampoo were as needed (PRN). P5 said that VA2 got his/her teeth brushed in the morning and before bedtime, but P5 was not aware of VA2 missing a toothbrush. P5 worked shifts when VA2 got his/her teeth brushed and P5 never saw that s/he was missing a toothbrush. P5 said that the toothbrushing was not documented. P5 did not have any concerns with VA2’s cares not being done that included toothbrushing. P6 said that VA2’s cares were documented in the Medication Administration Record (MAR). VA2 had had a special prescription shampoo and a non-prescription cream for eczema on VA2’s face. VA2 had his/her own drawer with all of his/her “hygiene stuff” and heard that someone recently bought VA2 a new toothbrush, but P6 was not aware of VA2 missing a toothbrush. P7 said that VA2 had a cream for his/her face due to dry skin. The cream was documented in the MAR. P7 did not know anything about VA2 missing a toothbrush but did not work shifts that required teeth brushing. P9 said that VA2 got his/her teeth brushed twice a day, morning and night, and P9 did not know of a time when VA2 was missing his/her toothbrush. VA2 had dry skin so staff persons applied lotion to his/her face. P1 did not know how to do medication and did not want to learn how to do it. P9 tried to show P1 how to pass medications the correct way, but s/he did “not care to listen or learn.” Medication Administration Records (MARS) provided the following information: · Neutrogena T/SAL 3% shampoo was an as needed medication and was not used for the month of January 2023. · Ketoconazole 2% shampoo 120ML was to be applied to the “affected” area(s) topically on scalp every other day alternating with salicylic acid shampoo. However, it was not signed off by any staff persons for the month of January 2023. However, for February 2023, it was listed as a PRN and was given every other day. P4 provided information that VA2’s Ketoconazole shampoo was a standing order and given as needed. Although P1 had concerns regarding VA2’s personal cares that included VA2’s medicated shampoo and teeth brushing, given that no other persons expressed concern in these areas and that the MAR and P4 indicated the shampoos were as needed and not a daily prescription, there was not a preponderance of the evidence whether there was a failure to supply VA2 with cares that were reasonable and necessary to maintain the health and safety of VA2. Conclusion Allegation One: Although some persons had concerns regarding VA1’s and VA2’s cares at the facility, there was not a preponderance of the evidence whether staff persons failed to change VA1’s undergarments when needed; whether staff persons failed to administer VA1’s medications as required; whether staff persons put on VA1’s AFOs in a manner that caused injury or harm to VA1; whether VA1’s toenail to came off by staff persons actions or by any means other than accidental; whether VA1 remained in bed too long; whether staff persons failed to care for VA2’s catheter or colostomy; whether VA2’s pressure wounds were a result of staff persons failure to care for VA2; and whether staff persons failed to brush VA2’s teeth or use his/her medicated shampoo when it was needed. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct.) Allegation Two: It was also reported that staff persons told VA1 that s/he “stinks” and to “be quiet.” Regarding staff persons telling VA1 that s/he “stinks”: VA1 said staff persons never told him/her that s/he smelled. However, VA1 said staff persons said s/he smelled “like a trucker” if s/he did not have a shower since the weekend. VA1 said they said it in a “silly” and joking way and not a mean way. VA1 said that when they said that, s/he thought it was funny and s/he felt “great” because it meant it was his/her “queue” for his/her shower. P1 said that VA1 showered Mondays, Wednesdays, and Fridays. At some point, VA1 told P1 that P8 told VA1 that s/he “stinks.” P1 could tell VA1 was hurt/embarrassed by the comment from P8. P1 told VA1 that P8 should not have said that. P4 said that VA1 had an “every other day” shower schedule, but it depended on if s/he agreed to it. Staff persons prepared VA1 by letting him/her know it was his/her shower day in advance. In regard to staff persons telling VA1 that s/he “stinks,” P4 said that was a “touchy road” because G1 said staff persons needed to tell VA1 s/he “smells like a truck driver” in order for VA1 to understand that s/he needed a shower.
P2 said that VA1 showered every other day. VA1 was “not the best” with his/her hygiene, but P2 “found” if staff persons just got him/her up in the morning and “roll[ed]” VA1 into the shower, s/he was “fine.” G1 instructed staff persons to tell VA1 that s/he “smell[ed]” like a “trucker.” However, it was said in a polite way and P2 had never heard a staff person say it in a “rude” or “disrespectful” way. P5 said that s/he did not know of any staff persons telling VA1 that s/he stinks or smelled like a trucker and P5 did not say that to VA1. P8 said that G1 told staff persons that if VA1 refused a shower to say, “You smell like a truck driver.” However, P8 never said VA1 smelled, but would encourage VA1 to shower and said something such as it did not “smell good” in his/her room. P9 said that VA1 had every other day shower schedule. However, VA1 sometimes refused. P9 and VA1 had a “really good relationship” and P9 “joked around” with VA1 “a lot.” G1 told staff persons to “joke around” with VA1 so VA1 felt comfortable with staff persons and would take showers. G1 also said to say things such as, “Smells like a trucker’s bathroom.” However, staff persons never said that VA1 smelled or stinks in a “mean way.” VA1 laughed and went “along with it.” VA1 also gave P9 a “high five” and said, “Yep, we did it.” G1 said that staff persons had to encourage VA1 to get up in the morning and might have to try a few times. Staff persons reminded VA1 it was his/her shower day and might say something such as, “[VA1], it’s shower day, it’s shower day, you don’t want to be smelling like a truck driver.” VA1 would laugh and think it’s funny. However, if it was said in a was such as, “You stink” that would be “a negative.” It depended on the approach staff persons used. G1 did not recall any times when VA1 told him/her that it was said in a negative approach. Although P1 had concerns with staff persons saying VA1’s smelled, given that VA1 said staff persons never told him/her that s/he smelled but said staff persons joked in a “silly way” that s/he smelled “like a trucker” and VA1 thought it was funny and felt “great” because it meant it was his/her “queue” for his/her shower and that there was no information provided that it was done in a malicious manner, there was not a preponderance of the evidence whether the comments would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. Regarding staff persons telling VA1 to “keep quiet:” VA1 said that P5 was “known” to make VA1 wait for up to two hours to go to bed and “every weekend” when P5 worked, P5 told VA1 to “keep quiet” when P5 “chang[ed]” VA1. VA1 waited for P5 to help him/her get “changed” and ready for bed because P5 worked alone and was helping other clients. VA1 had a “call button,” but P5 did not like when VA1 used it. However, the other staff persons responded to the call button right away. VA1 told his/her concerns about P5 to P2. P2 told P5 “many times” “not to do that” but P5 “[kept] doing it.” However, at some point P5 stopped saying it. VA1 did not have any concerns with any other staff persons. P3 said that VA1 was able to communicate verbalize his/her needs to staff persons. However, VA1 was not always “aware” of all of his/her needs. VA1 was also known to “make things up,” “lie,” and “fixate” on staff persons and “create continued reasons” to “fixate” on them. For “whatever reason” VA1 did not like P5 and “constantly” said P5 told VA1 to “shut up” “one time” during the fall of 2022. P3 talked to P5 about it and asked P5 if s/he used those words. P5 said, “No, not exactly” and stated s/he used the words, “Be quiet” because P5 was the only staff person working and when transferring VA1 wanted to be able hear another client in a different room. P3 said the issue resolved itself and VA1 and P5 had no further issues. P3 also said that due to a “language barrier” it was difficult for VA1 to understand P5. P3 said that if staff persons were doing something else, VA1 could be “frustrated” if s/he had to wait for “five minutes.” However, P3 never saw staff persons not attend to VA1. G1 said that at some point VA1 told him/her that P5 told VA1 to “be quiet” when s/he was doing VA1’s cares at night. However, G1 said that VA1’s concept of time was “really fluid” so it could have happened months ago, but VA1 might still bring it up as if it happened yesterday. P5 was talked to regarding telling VA1 to be quiet and that s/he should be conversing with VA1 when giving him/her care and if VA1 was loud just to tell VA1 to use his/her “indoor voice.” P4 said that s/he heard that VA1 did not like P5, and P4 had no concerns with P5. P2 said that VA1 used a “call bell” when s/he needed something. P2 had no concerns with staff persons not attending to VA1 in a timely manner. P5 said that s/he had no concerns with staff persons in regard to VA1’s cares. VA1 was “very attentive to details” and complained about staff persons not doing things “exact.” VA1’s complaints were not always accurate. If VA1 needed help from a staff person, s/he rang a bell. Due to shortage of staff persons, sometimes VA1 would have to wait for a “few minutes” because a staff would be helping another client. P5 denied telling VA1 to “be quiet” and did not hear any other staff persons say that to VA1. Although VA1 said that P5 told him/her to “keep quiet,” given that VA1 said P5 stopped and P5 denied it to this investigator, there was not a preponderance of the evidence that telling VA1 to be quiet would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. Conclusion Allegation Two: Although there were concerns regarding how staff persons spoke to VA1, there was not a preponderance of the evidence whether comments referencing smelling like a truck driver or P5’s telling VA1 to be quiet could reasonably be expected to produce emotional distress. It was not determined whether 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: 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.) Action Taken by Facility: The facility completed an Internal Review and stated that VA1 and VA2’s policies and procedures were adequate but not followed. All staff persons were retrained on the medication administration policy and procedures/medication administration skills assessment, Maltreatment of Vulnerable Adults Reporting Policy, VA1’s and VA2’s plans, and the Program Abuse Prevention Plan. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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