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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: 1116914-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Henne 651-431-3444 Suspected Maltreatment Reported: It was reported that a vulnerable adult’s (VA1’s) teeth were “black from the gums up” and VA1 had not seen a dentist in a year and a half. During the course of the investigation, there were concerns of a lapse of dental cares for three other vulnerable adults (VA2, VA3, and VA4). Date of Incident(s): Ongoing prior to March 6, 2023 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on March 29, 2023; from documentation at the facility and medical records; and through fourteen interviews conducted with one community person (CP), one facility staff person (P2), six supervisory staff persons (P3-P8), one facility nurse (N), VA1’s guardian (G1), VA2’s guardian (G2), VA3’s guardian (G3), and VA4’s guardians (G4 and G5). VA1-VA4 did not provide information for this investigation due to their diagnoses. Attempts were made via certified and non-certified mail to contact and interview another staff person (P1), but the attempts were unsuccessful. According to facility job descriptions: · The program manager (PM) directs the daily operations in a community-based residential program and was responsible for overseeing medical, financial, social, and emotional needs of individuals served as well as day-to-day operations of the residential program. The program manager supervises direct care staff and ensures that services and activities comply with licensing regulations and with Hammer’s policies and person-centered philosophy, exercising good judgment to adapt and apply the guidelines to specific situations. · The program director (PD) oversees operations for five to ten community-based residential programs and was responsible for providing leaderships for 5-10 program managers who oversee the services for approximately 50 individuals served. The program director supervises program managers in all aspects of their work performance and ensures the program’s operations comply with regulatory requirements. · The nurse’s responsibility was to promote optimum development and health of the individuals served and assist staff persons in meeting regulations and licensing. The nurse was also to report changing health conditions to appropriate team members, teach and counsel the individuals served and staff persons in the areas of health and disease and promote self-responsibility and independence whenever possible. The nurse was to also arrange for appropriate medical and remedial services and incorporate recommendations as well as implement all health service policies and procedures in compliance with that and/or federal regulations. The nurse also assisted in instructing staff persons in medically related orientation classes and annual continuing education need. P2, P3, P6, P7, P8, P9, P10, and the N were trained on the Reporting of Maltreatment of Vulnerable Adults Act. However, there was no documentation to show P4 or P5 were trained on the Reporting of Maltreatment of Vulnerable Adults Act, which was a violation of Minnesota Statutes, section 245A.65, subdivision 3, that states in part, the license holder shall ensure that each new mandated reporter receives orientation of the mandated reporting requirements (626.557 and 626.5572—The Reporting of Maltreatment of Vulnerable Adults Act) within 72 hours of first providing direct contact and annually thereafter. P2, P7, P8, P9, and P10 were trained on VA1-VA4’s plans. P2 and P5 were trained on VA1’s, VA2’s, and VA4’s plans and P3 was trained on VA1’s and VA3’s plans. However, there was no documentation to show P2 and P5 were trained on VA3’s plans; no documentation that show P3 was trained on VA2’s and VA4’s plans; and no documentation to show P4 or P6 were trained on VA1’s-VA4’s plans. These were violations of Minnesota Statute 245D.09, subdivision 4a, which states in part, that before having unsupervised direct contact with a person served by the program, the staff person must review and receive instruction on the requirements of the person served including a review of the person’s support plan and support plan addendum. During the course of the investigation the CP had other concerns not related to the maltreatment allegations in this report, including the following: front door not latching, no alarms on doors, and unlocked chemicals. These concerns were forwarded to the licensing unit for further review for any licensing violations and/or maltreatment. Relevant Rules and/or Statutes: Minnesota Statutes 245D.05, subdivision 1, paragraph (a), states the license holder is responsible for meeting health service needs assigned in the coordinated service and support plan or the coordinated service and support plan addendum, consistent with the person's health needs. Regarding VA1 The facility’s file for VA1 stated that s/he moved into the facility in September 2019. VA1 was diagnosed with blindness, hearing loss in left ear, infantile cerebral palsy, and severe intellectual disability. According to VA1’s Coordinated Service and Support Plan Addendum and Intensive Support Services, VA1’s health service responsibilities assigned to the license holder included assisting with or coordinating medical, dental, and other health service appointments. VA1 needed full assistance with medical needs and was provided with the scheduling of appointments along with transportation to the appointments. VA1 did not initiate self-care tasks and staff persons were needed to ensure the tasks were completed. VA1 needed to be “cued” to brush more than the right lower half of his/her mouth and staff persons would finish brushing the rest of VA1’s teeth to verify all teeth were reached. Medicated mouthwash was also brushed around VA1’s teeth since VA1 was unable to “swish” mouthwash. According to the facility’s Health Care Provider Appointment Schedule VA1 was to be seen by a dentist every three months. VA1’s medical and dental records provided the following information: · Health Source Dental records stated that VA1 was seen on August 14, 2019, for an examination and was recommended to return in three months. Dental notes from that visit stated VA1 had moderate plaque, moderate/heavy calculus, and moderate bleeding. VA1’s oral hyenine was fair/poor and staff assisted VA1 with cares. On November 26, 2019, an appointment was not attended, and dental notes did not show a reason. Emails between this investigator and the dental coordinator stated that the dental office left a message on the facility phone to reschedule, but they never heard back. The dental office also sent out yearly consent forms whether or not a client was seen, which the guardian signed. Health Source Dental had no other records of VA1’s dental appointments after the aforementioned dates. (Note: As of May 8, 2023, Health Source Dental’s name was changed to Special Care Dentistry.) · According to Bluestone Physician Services, on June 8, 2022, they came to the facility for a physical exam. However, there was no information regarding VA1’s oral health. · According to dental records from an emergency dental clinic in Roseville, MN, VA1 was seen on Thursday March 16, 2023, for a consult/referral for sedation. Dental notes stated that VA1 “had pain with lower front teeth” and P3, who accompanied VA1 at the appointment, wanted to see if the clinic could do anything that day, and if not then s/he was told a referral for sedation at Apple Tree was needed. The intraoral exam findings indicated that VA1 minimally cooperated with opening his/her mouth, s/he had lower four incisors missing, had visible stained calculus and gingivitis and swollen gums, and apparent periodontitis and tooth loss. At that time, no x-rays were taken but a referral to Apple Tree Dental for sedation dental care was made. · According to Apple Tree Dental (ATD) records, VA1 was seen on March 17, 2023, for “limited oral evaluation – problem focused.” Dental work under anesthesia was recommended to allow for better care, cleaning, and intervention if needed and consent was needed from G1. VA1 also needed “some teeth pulled.” Clinical findings were “perio and major bone loss,” loose teeth and “probably more strong infection odor.” · According to ATD, on March 31, 2023, VA1 had a limited oral evaluation using tele dentistry (via telephone). ATD notes stated that VA1’s past dental history was unknown and that staff persons were concerned about VA1’s dental treatment needs due to “changes in behavior.” Staff persons attempted oral care twice a day but was challenging due to VA1 tightening his/her lips and resisting opening his/her mouth. Halitosis and lack of regular routine dental care was also noted. A some point during the call, P3 asked, “How long would it take someone’s teeth to look like that?” Reviewed radiograph findings further and explained evidence of bony changes including moderate to severe bone loss, which usually occurred over a period of years. “What would be more telling would be the juxtaposition of past radiographs with Panorex x-ray taken to determine the rate and progression of the periodontal disease.” P3 understood the information and had no further questions. They discussed the plan for sedation and provided available dates and times. · According to Apple Tree Dental records, on May 5, 2023, VA1 had a limited oral evaluation using tele-dentistry. G1 was present for the tele dentistry appointment and mentioned VA1’s “lack of regular, routine dental care” and noted “change in dental care” at the facility during the COVID-19 pandemic. At the appointment, VA1’s evidence of “bony changes” including moderate to severe bone loss, “which usually occurs over a period of year” was discussed. G1 stated that natural teeth be “maintained as long as possible.” The dentist explained that prognosis would be fully assessed during sedation. · According to Apple Tree Dental records, on July 14, 2023, a comprehensive oral evaluation was done as well as an initial exam. Radiographic findings were that VA1 had missing teeth and generalized to severe crestal bone loss. Clinical findings were that VA1 had poor hygiene, significant halitosis, and advanced periodontal disease in all quadrants. G1 was concerned about the possibility that VA1 had pain. At the appointment, VA1 was assessed for treatment needs, had a full mouth radiographs, periodontal charting/full mouth probe, and 23 tooth extractions. On July 25, 2023, VA1 was seen for a post-op appointment. “Everything” looked “very well” and was healing “great.” An oral antibiotic prescription was sent to VA1’s pharmacy. “RTC” (return to clinic) for impressions, preliminary, for “complete dentures.” · According to a representative from Apple Tree Dental, during the COVID-19 pandemic the clinic was closed for hygiene (cleaning) services from March 17, 2020, to an unknown date in July 2020. However, during that time they continued to see patients on an emergency basis. At the end of summer 2020, they opened for all appointments. P2 said that on February 4, 2023, s/he was brushing VA1’s teeth and VA1 “pulled back” and his/her two bottom teeth were “hanging by a thread” and two other bottom teeth were “severely loose.” Minutes later, P2 noticed the two teeth that were “hanging by a thread” were “gone” and VA1 “had to have swallowed them.” P2 called the N first, but it was his/her weekend off so s/he did not answer. P2 then called an on-call nurse (P2 could not remember the nurse’s name). The on-call nurse had “no comment” and said s/he would let the N know. The N called P2 the following day (Sunday, February 5, 2023, and said s/he would look at VA1 Monday (February 6, 2023) since it was a weekend when P2 was working. P2 also let P3 know about VA1’s teeth and P3 said to let the N know, which P2 did. The facility’s nursing notes stated that the N visited the facility on February 7, 2023, at 3:16 p.m. The N evaluated VA1’s teeth and wrote VA1 appeared to have red/inflamed gums and at least one loose tooth, though it was difficult to evaluate due to VA1’s reluctance to be evaluated. The N recommended VA1 see a dentist to evaluate very soon and would follow up with the program manager regarding scheduling a dental appointment. The N provided the following information: · Sometime in early February 2023, after seeing VA1’s red gums and a “wiggly” tooth, the N emailed the PM (P9) to make a dental appointment for VA1. P9 called Maplewood Family Dental and scheduled an appointment for February 24, 2023. The N “made sure” VA1’s as needed prescription (PRN) that s/he needed to go to the dentist, was “up to date” and VA1’s doctor said that they “sent it over” to VA1’s pharmacy. The night before the appointment, P9 called the N and said that s/he did not have VA1’s PRN. The N messaged the portal of the providers regarding VA1’s prescription, but it was filled too late for the appointment on February 24, 2023. The dental appointment was rescheduled for a later time, but the N said that P9 did not communicate the date to the N. Two weeks later, at the end of February 2023, P9 no longer worked at the facility. · The N said that when P9 left, there was no communication to P3 (the new PM) about the dental appointment. P3 could not “figure out” where the “new appointment” was. However, P3 made VA1 a dental appointment for the first week in March 2023. (Note: In an email between the N and this investigator, the N said this appointment was at an “emergency dental clinic.”) P3 went to the appointment with VA1. At that appointment, they “barely” looked at VA1’s teeth and said VA1 needed “special care” and referred VA1 to Apple Tree Dental because they had sedation services. The N took VA1 to Apple Tree Dental (ATD) two days later on March 15 or 17, 2023, where VA1 had an exam and x-rays completed. At that appointment, the dentist said VA1 needed extractions due to advanced gum disease and loose teeth. However, ATD needed to do a follow up virtual appointment to determine VA1’s treatment and IV sedation plan. At the March appointment, the virtual appointment was scheduled for March 31, 2023. · VA1 saw a dentist twice in 2018 at Health Source Dental and had not been seen by a dentist since. At VA1’s last visit in 2018, the dentist recommended VA1 to see them “regularly” (not specified), but the N said the facility policy was twice a year. P3 provided the following information: · P3 started working at the facility “in the middle of COVID” and in 2022, but did not have access to ongoing dental information because everything was “shut down.” P3’s main priority at that time was direct care for the clients and to maintain the home. (According to facility records, P3 was the PM from September 2021 to May 2022, when s/he became the PD.) P3 did not know whether VA1 had any dental appointments during that time. · VA1’s last dental visit was in either 2018 or 2019. The program manager was responsible for scheduling appointments and if there was not a program manager, then it was the responsibility of the program director. Clients “ideally” had a dental appointment every six months. Sometime in 2022, P3 was concerned about VA1’s mouth odor so P3 talked with VA1’s primary physician at Bluestone about it and s/he said VA1 needed to see a dentist. At some point after that, P3 reached out to a dentist in Cambridge that VA1 previously went to, and the clinic had to “restart” VA1 as a new patient. However, P3 did not remember if an appointment was scheduled or not. VA1 needed “some sort” of sedation services for dental visits and those appointments were planned out “long term.” The previous program manager (P9) scheduled an appointment with Apple Tree for February 2023, but due to a snowstorm, the appointment was cancelled. At some point after March 2, 2023, P3 called Emergency Dental in Roseville and got VA1 in the next day, but VA1 “refused” treatment at the appointment. The emergency dental clinic gave VA1 a referral to Apple Tree Dental and later that same week, the N took VA1 to an appointment where they were able to get x-rays and schedule VA1 for a telehealth appointment prior to extractions. G1 said VA1 had not been to a dentist since 2018, partially because the dentist s/he was going to was no longer taking “those cases” or went out of business, then COVID came along, and then “somebody dropped the ball.” VA1 now needed to have all of his/her teeth pulled. G1 was “very unhappy” and said other people including him/herself went to a dentist several times over the COVID time period so s/he did not think it was an excuse. As of March 24, 2023, G1 received mail regarding VA1’s dental cares at a new dentist and requesting G1’s signature to approve X-rays. G1 thought VA1 went to the dentist once a year. The facility’s Internal Review stated there was a pattern of no dentist appointments since VA1 moved to the facility September 2019. During the pandemic, in 2020, it was recommended that persons only attend necessary appointments. In 2021, as a result of the turnover of staff persons and program managers, dentist appointments had “fallen through the cracks.” On March 17, 2023, VA1 was seen at Apple Tree Dental, and they recommended extraction of all of VA1’s teeth due to severe periodontal disease. The next appointment was scheduled for telehealth on March 31, 2023, to refer to a periodontist for extractions. P4 said that s/he worked at the facility from February to August 2021. (Note: According to facility information, P4 was a program manager from March 8 to August 20, 2021). P4 did not remember anything about VA1’s dental appointments and did not take VA1 to any dental appointments during that timeframe. P4 thought the clients were to be seen every six months by a dentist. P5 said that s/he worked at the facility December 2016 to January 2021 and had a few different positions during that timeframe including assistant supervisor, program supervisor, and designated coordinator. (Note: According to facility information, P5 was program manager from December 9, 2015, to January 22, 2021.) P5 recalled that VA1 went to a dentist in Cambridge, MN. However, during “COVID” a lot of things were closed down unless it was an emergency. During COVID, P5 started working from home and VA1 moved to another “house operated by the same license holder.” Prior to COVID, there were no concerns with VA1’s teeth and P5 said that VA1 had “beautiful teeth.” Prior to COVID and when P5 worked with VA1, VA1 went to the dentist every three months. P6 said that s/he worked at the facility from August to December 2022 and at some point, around one or one and a half months after P6 started working, s/he was promoted to the PM. When P6 first started working at the facility, s/he saw that VA1’s teeth were “really bad,” “loose,” “bleeding,” and “falling out.” When P6 saw the condition of VA1’s teeth, s/he told P3. P3 told P6 to make VA1 a dentist appointment so P6“tried” to start setting up an appointment. However, according to P6 at that time, s/he did not have “access” to schedule any appointments so it was P3’s responsibility to set up the appointment and then P6 would take VA1 to the appointment. However, P3 never set up a dentist appointment and P6 thought it may have “slipped [P3’s] mind.” P6 said s/he did not follow up with P3 because it also “slipped” his/her “mind” about the dentist appointment because they were short staffed and P6 was covering a lot of shifts and P3 was not often at the facility P6 was not aware of any dental appointments for VA1 around December 2022. P7 said that s/he worked at the facility as the PD from October 2019 to August 2021. P7 did direct care from “time to time” but was not a “regular thing.” It was difficult to brush VA1’s teeth because s/he would bite the toothbrush or not even open his/her mouth. However, P7 did not remember any concerns with VA1’s teeth. The lead staff and PM were responsible for making medical appointments. P7 did not remember anything about VA1’s dental appointments, but typically clients went every six months or once a year unless a primary doctor pushed it out further if they needed general anesthesia. VA1 had to go under general anesthesia for dental work because s/he could not “tolerate” dental visits without it. Regarding VA2 The facility’s file for VA2 stated s/he was diagnosed with Down Syndrome with profound intellectual disability. Some of his/her appointments needed to be completed under sedation/general anesthesia and s/he relied on others to make all of his/her appointments including dental and provide the transportation to and from them. Staff persons were to ensure that all recommendations and orders from the appointment were implemented. According to VA2’s Coordinated Service and Support Plan Addendum and Intensive Support Services, VA2’s health service responsibilities assigned to the license holder included assisting with or coordinating medical, dental, and other health service appointments. VA2’s dental records provided the following information: · According to Bluejay Family Dental records, VA2 was seen on January 11, 2019, and it was recommended to return in three months and information from this appointment was discussed with P5. Dental notes stated that G2 was informed that the dental clinic was unable to effectively clean and examine VA2’s teeth due to VA2’s “behavior.” VA2 had two “very loose” teeth on the lower right and two slightly loose teeth on the lower left and it was recommended extraction of the very loose teeth on the lower right due to dangers of swallowing or inhalation if the teeth came out themselves. Apple Tree Dental and U of MN Physicians Dental Clinics were recommended as possible providers who might be able to meet VA2’s dental needs including sedation services for a thorough cleaning/exam and extractions. The last dental note from Bluejay Family Dental stated that on December 9, 2019, P5 spoke with the dental clinic over the phone and P5 asked for VA2’s X-Rays to be emailed to Health Partners dental clinic. [Note: VA2 was not seen at Bluejay Dental between January 11 and December 9, 2019.] · According to Health Partners White Bear Lake General Dentistry dental records, on December 9, 2019, VA2 had a dental exam as a new patient. Dental notes stated that VA2’s previous dentist stopped taking his/her insurance. VA2 “present[ed]” to the clinic with G2 and P5. They did not suspect VA2 had any dental pain, but said VA2 had loose teeth, bad breath, and needed a cleaning. The dentist noted that during the appointment, s/he was unable to examine VA2’s entire dentition because VA2 was unable to sit in a dental chair, but overall VA2 had poor hygiene, heavy plaque/calculus, and erythematous gingival margins generalized. It appeared VA2 was missing approximately eight teeth (#19-#27) and appeared to have maxillary teeth from at least #3 to #14 A referral was placed for possible hospital dentistry care. · According to dental records, on April 8, 2021, VA2 was seen at another Health Partners dental clinic (Midway General Dentistry) for a dental exam. VA2 presented with a loose tooth. Dental notes stated that VA2 had heavy plaque and food debris throughout his/her mouth. It was recommended that VA2 have extractions as necessary at the U of M under general anesthesia. The next planned visit was to the U of M for a comprehensive dental exam. · According to dental records, on May 5, 2021, VA2 had a dental examination at Health Partners Midway General Dentistry and was placed under general anesthesia. “Operative findings: Soft tissue exam revealed no masses or lesions. No decay was detected on radiographs or in the clinical examination. There was moderate to severe bone loss in four quadrants” and VA2’s periodontal probing’s ranged from 3 to 6 millimeters (mm) and bled when probed. VA2’s gingiva were grossly inflamed, and s/he had heavy supra subgingival calculus on all tooth surfaced. Teeth numbers 28 and 29 were exhibited and +3 mobility and were deemed unrestorable. Tooth numbers 18, 19, 30 and 31 exhibit +1 mobility (moved). VA2’s postoperative diagnoses was moderate to advanced periodontal disease. The next recommended examination was for six months with a periodontal maintenance in three months. However, due to VA2’s “behavior” VA2 was not allowed in a clinic setting so it was planned to have VA2’s next examination in 12 months and his/her periodontal maintenance in six months. Health Partners dental records provided no further information after the aforementioned information. P2 said that also on the weekend February 4 to 6, 2023, s/he noticed that VA2’s teeth bled as s/he brushed them and that the last time that happened VA2 had to get some teeth pulled. VA2’s teeth also smelled like they were a “rotting dumpster.” P2 documented the information. P5 said that VA2 was seen by a dentist at least once a year and at some point, during the timeframe P5 worked at the facility, P5 thoughts VA2 might have needed some teeth taken out but was not sure what happened with that. P5 remembered VA2 being seen by a dentist at Health Partners. P6 said that when she worked at the facility (August to December 2022) s/he did not know of any dental appointments made for any of the clients at the facility and that VA2 only had “like two teeth.” G2 said s/he was concerned with VA2’s lack of dental care and said VA2 had not been to the dentist in “quite a long time” probably since the “pandemic” started. VA2 had some teeth removed during “two different sessions” and as of May 3, 2023, G2 thought VA2 last time VA2 went to a dentist was “at least two years ago.” VA2 had gone to a dentist for years, but then that dental office stopped taking VA2’s insurance and since then, VA2 did not have a place to go for dental care. Since the fall 2022, G2 had asked P3 about dental care for VA2 and was told they were “looking into it,” but had not heard anything about it. G2 said that VA2 did not need to be sedated for dental cares. However, at one dental appointment VA2 had to sit in a “regular” chair because s/he would not sit in the dental chair. The facility’s Internal Review stated that VA2 had dental appointments on January 11, 2019; and April 8 and May 5, 2021. On May 5, 2021, the dental office attempted to clean VA2’s teeth but were unable to complete the cleaning due VA2’s behavior and noted that VA2 needed to be sedated to do the work. VA2’s next appointment was scheduled for September 5, 2023, but might be sooner because the facility was working with Apple Tree Dental Mobile to come out to the facility within the next month (July 2023). Regarding VA3 The facility’s file for VA3 stated that s/he was diagnosed with profound intellectual disability. According to VA3’s Coordinated Service and Support Plan Addendum and Intensive Support Services, VA3’s health service responsibilities assigned to the license holder included assisting with or coordinating medical, dental, and other health service appointments. VA3’s dental records provided the following information: · According to Apple Tree Dental, VA3 attended an appointment on May 13, 2019. Dental notes stated that VA3 had “moderate” plaque, “calc and bleeding/stain” and the tissue on his/her upper anterior was “very inflamed.” VA3 was diagnosed with generalized gingivitis (severe on the upper anteriors) with moderate deposit/stain throughout. It was recommended that s/he had an exam every six months. On November 11, 2019, VA3 had a dental exam and “light” plaque, calculus, and “bleeding/stain” were noted. VA3 had mild generalized gingivitis with slight deposit/stain. VA3 was scheduled for the next appointment on May 11, 2020. On May 4, 2020, the appointment was postponed due to COVID-19. On December 14, 2020, VA3 had a dental appointment and dental notes stated that VA3 had moderate generalized gingivitis (severe on the upper anteriors) with moderate deposit/bleeding/ throughout. Notes also said that VA3 had “heavy” plaque and his/her gums were “very inflamed” but VA3 had no cavities. VA3’s next exam was to be in six months or June 2021, but records did not show it was scheduled. · Dental notes dated November 19, 2021, stated that the dental clinic called VA3’s pharmacy and that it had been almost one year since VA3’s last appointment and VA3’s dental refill for chlorhexidine was denied. The dental clinic told the pharmacy that they would contact the patient and offer to schedule a hygiene appointment. On November 22, 2021, the dental clinic left a voice message with the facility to schedule an appointment (Note: There was no information regarding what number was called or who from the dental clinic made the call). On April 4, 2023, dental notes stated the facility called and requested to have VA3’s notes for past three previous visits faxed and the dental clinic faxed them to the number on file. On May 5, 2023, notes stated the patient had not been seen in two years and changed to “inactive.” P4 did not recall any dental appointments for VA3 while s/he worked at the facility. P7 said that s/he remembered two dental appointments for VA3 during the timeframe s/he worked at the facility (October 2019 to August 2021). P8 said that s/he had nothing to do with VA3’s dental appointments when s/he worked at the facility. The facility’s Internal Review dated June 5, 2023, stated that VA3 had a dental appointment on December 14, 2020, and his/her next appointment was October 4, 2023, at Apple Tree dental. However, it might be sooner because the facility was working with Apple Tree Dental Mobile to come out to the facility within the next month (July 2023). Regarding VA4 According to the facility’s file for VA4, s/he was diagnosed with profound to severe intellectual disability and was non-verbal. According to VA4’s Coordinated Service and Support Plan Addendum and Intensive Support Services, VA4’s health service responsibilities assigned to the license holder included assisting with or coordinating medical, dental, and other health service appointments. VA4’s dental records provided the following information: · According to dental records, VA4 attended two dental appointments at Health Source Dental on March 14 and July 30, 2019. Dental notes from March 14, 2019, stated that VA4 had moderate/heavy plaque, moderate/heavy bleeding, and that his/her oral hygiene was “poor.” Notes from the July 30, 2019, appointment stated VA4 had “fair” oral hygiene and slight to moderate plaque and bleeding. On December 5, 2019, the facility cancelled an appointment, but no reason was provided in the dental notes. · On March 24, 2020, and April 21, 2020, the dental clinic cancelled VA4’s appointment due to COVID. On October 7, 2020, Health Source Dental called the number they had on file to schedule an appointment since VA4 was due for one, but they were unable to leave a message. · On May 23, 2022, VA4 was seen for a dental exam and a six-month return was recommended. VA4 was next seen on June 2, 2023, because the dental clinic reached out to the facility on June 1, 2023, because they had a cancellation and noticed VA4 needed to be seen. P5 said that while s/he worked at the facility, VA4 had “good” teeth, but it was hard for staff persons to brush them. VA4 was to go to the dentist every three months. G4 said that VA4 had not been seen at a dental clinic since May 23, 2022. Prior to that, was 2019 when VA4 had his/her teeth cleaned. VA4 had an appointment scheduled for December 2022 but it was cancelled by the dental clinic because there were not any dental hygienists available at that time. The dental clinic did not reschedule another appointment for VA4 but said they would let G4 know when someone was available to set up another appointment. VA4 needed special services for dental visits and went to a dental clinic in Cambridge, MN for that. At some point, P3 told G4 that the other clients at the facility also needed dental appointments. G5 said that s/he did not have any information regarding VA4’s dental visits because G4 kept up on VA4’s appointments. The facility’s Internal Review stated VA4 had a dental appointment on July 30, 2019; May 23, 2022; and June 2, 2023. Conclusion: A. Maltreatment: Information obtained showed that the facility was responsible for making, coordinating, and transporting VA1, VA2, VA3, and VA4 to and from medical and dental appointments. After a dental appointment on August 14, 2019, VA1 did not see a dentist until March 16, 2023 (three years-seven months later); and did not receive dental care until July 23, 2023 (three years-nine months later), which was a violation of Minnesota Statutes 245D.05, subdivision 1, paragraph (a). At a dental appointment on January 11, 2019, the dentist ordered VA2 to be seen in three months, but VA2 was not seen by a dentist until December 9, 2019 (eleven months later). From that point, VA2 did not see a dentist until April 8, 2021 (one year-four months later); had work completed on May 5, 2021 (one year-five months later); and as of the date of this investigation had not yet seen a dentist again (two years-three months later), which were violations of Minnesota Statutes 245D.05, subdivision 1, paragraph (a). In 2019, VA3 saw the dentist on two occasions. On November 11, 2019, an appointment was scheduled for May 11, 2020. However, due to COVID that appointment was cancelled and VA3 was seen on December 14, 2020. Given that dental clinics had minimal cleaning appointments due to COVID, the delay in dental care between November 2019 and December 2020, was reasonable. However, after VA3’s dental appointment on December 14, 2020, as of the date of this instigation had not yet seen a dentist again (two years-eight months), which was a violation of Minnesota Statutes 245D.05, subdivision 1, paragraph (a). In 2019, VA4 saw the dentist on two occasions. On December 5, 2019, the facility cancelled the appointment for an unknown reason, and two appointments (March 24 and April 21, 2020) were cancelled due to COVID. VA4 was next seen May 23, 2022 (two years-one month since the last COVID cancelled appointment); and then on June 2, 2023 (one-year later), which were violations of Minnesota Statutes 245D.05, subdivision 1, paragraph (a). According to a representative from Apple Tree Dental, during the COVID-19 pandemic the clinic was closed for hygiene (cleaning) services from March 17, 2020, to an unknown date in July 2020 (four months). However, during that time they continued to see patients on an emergency basis. At the end of summer 2020, they opened for all appointments. Although dental offices were closed during part of 2020 due to the COVID-19 pandemic, for the following reasons there was a preponderance of the evidence that there was a failure to supply VA1-VA4 with reasonable and necessary care: · VA1 saw a dentist on August 14, 2019, and it was recommended VA1 be seen again in three months. At that time, although VA1’s oral hygiene was fair/poor, there was no information that VA1’s teeth were loose or needed to be extracted. VA1 did not see a dentist again until July 23, 2023, (three years-nine months later) and s/he required extraction of all of his/her teeth. During the three years-nine months, multiple staff persons were aware of the condition of VA1’s teeth including that his/her teeth were “hanging by a thread,” “severely loose,” “wiggled,” “really bad,” “loose,” “bleeding,” and “falling out.” · Between January 11, 2019, and this investigation there were multiple lapses in VA2’s dental care including eight months, one year-four months, and two years- three months. In January 2019, VA2 had two “very loose” teeth that needed extraction which placed VA2 in danger of swallowing or inhaling if the teeth came out themselves and it was recommended that VA2 be seen again in three months. On December 9, 2019, VA2’s next appointment, VA2 was missing eight teeth and had poor hygiene. On May 5, 2021, VA2 was placed under general anesthesia and his/her dental care was provided for. At that time, it was recommended VA2 be seen again in three months. At the time of the investigation VA2 had not yet seen a dentist. Multiple staff persons were aware of the condition of VA2’s teeth including that his/her mouth “smelled like a rotting dumpster.” · Although VA3’s dental care prior to and during COVID was reasonable, at VA3’s appointment on December 14, 2020, it was recommended that VA3 be seen again in six months. However, VA3 had yet not seen a dentist at the time of this investigation (two years-eight months). · Although VA4 had appointments cancelled due to COVID, there were lapses in VA4’s dental care for two years-one month and one year. Information showed that VA4 was to be seen either every three months or every six months. It was determined that 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.) B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. Multiple staff persons at multiple levels of authority including direct care, supervisory, administrative staff persons, and a nurse were involved with the oversight of VA1’s-VA4’s dental appointments and cares during approximately four-year period. In addition, the facility failed to ensure all staff persons were trained on VA1’s- VA4’s plans. Therefore, it was determined that the individual staff persons responsibility for the maltreatment was mitigated, and the facility was responsible for maltreatment of VA1, VA2, VA3, and VA4. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. On August 14, 2019, VA1 had moderate plaque, moderate/heavy calculus, and moderate bleeding but no information that VA1 needed extractions. Given that it was over three years since the VA had received care from a dentist and following a March 17, 2023, appointment s/he needed all of his/her teeth pulled, it was determined that the substantiated maltreatment of VA1 for which the facility was responsible was “serious” maltreatment. On January 11, 2019, VA2 had a dental appointment and was told s/he needed extractions. Given that VA2 needed extractions in 2019 and there was no information to show that the lapses in dental visits from December 9, 2019, to April 8, 2021; and then again from May 5, 2021, until this investigation, required additional extractions, it was determined that the substantiated maltreatment of VA2 which the facility was responsible did not meet statutory criteria to be determined as serious. VA3 had a lapse in dental visits from December 14, 2020, until at least May 5, 2023, (two and a half years). However, given that on May 13, 2019, VA3 was diagnosed with generalized gingivitis (severe on the upper anteriors) with moderate deposit/stain and that the current status of VA3’s oral health was unknown and there was no information to show that s/he needed extractions or how his/her dental care may have worsened or required additional treatment, it was determined that the substantiated maltreatment of VA3 which the facility was responsible did not meet statutory criteria to be determined as serious. VA4 saw a dentist on July 30, 2019; May 23, 2022; and June 2, 2023. Although VA4 had lapses in dental care, given there was no information to show that VA4 needed extractions or how his/her dental care may have worsened or required additional treatment, it was determined that the substantiated maltreatment of VA4 which the facility was responsible did not meet statutory criteria to be determined as serious. Action Taken by Facility: The facility completed an Internal Review for VA1-VA4 and stated their policies and procedures were adequate and followed. However, corrective action by the program to protect the health and safety was needed as well as additional staff training. In-person training for all individuals mouth care will be completed with current staff and the nursing team. The facility posted directions on how to brush everyone’s teeth and how to uses mouth wash for the staffing agency’s training and required them to sign a signature sheet one they received it. Action Taken by Department of Human Services, Office of Inspector General: On October 13, 2023, the license holder was ordered to forfeit a fine of $8000 as a result of the substantiated maltreatment for which the facility was responsible. The maltreatment determination and the order to forfeit a fine are each subject to appeal.
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