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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: 1079590-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA), who required supervision while eating, was left unsupervised for about 15 minutes while eating. The VA choked, vomited, and needed to lay down after the incident. Date of Incident(s): August 9, 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 August 25, 2023, from documentation at the facility; and through six interviews conducted with two facility management staff persons (P1 and P2), two facility staff persons (P3 and P4), the VA’s case manager/guardian (CM/G), and a staff person (SP). Although this investigator met the VA and conducted an interview, the VA did not provide information related to the incident. The VA and three other clients lived at the facility. The facility had a kitchen and another room (sensory room) attached that had a table and a love seat. The room had a door with glass windows so staff persons could view inside the room. The facility also had a living room near the kitchen and although staff persons could likely see into the sensory room, they would only be able to see the part of the room where the love seat was and not the table. There was a door that led from the kitchen/sensory room to the backyard. The VA ate his/her meals in the sensory room, with the door closed, according to P2, P3, and the SP because the VA preferred a quieter environment when eating. The VA’s support plan showed that s/he enjoyed going out to eat, spending time with family, and assisting with meal preparation. The plan showed that the VA was diagnosed with autism, “fetal alcohol effects” and a mild developmental disability. The VA’s Intensive Support Services Assessment showed that the VA “may eat too quickly or put too much food in [his/her] mouth at once. Staff [persons] need to be within visual range and provide verbal prompts to slow down.” The facility’s staffing schedule, dated August 9, 2023, showed that P3 worked from 2-10 p.m., P4 worked from 1-9 p.m., and the SP worked from 4-9 p.m. P2 stated that the schedule identified the initials of the client that each staff person would be working with on the particular shift. P3 and P4 were each assigned to work with a client and the SP was assigned to work with the VA. P2 also said that the facility previously assigned specific duties to staff persons, such as cooking, cleaning, and medication administration, but that the facility stopped that practice because the expectation was that all staff persons coordinated with one another to ensure that all duties were completed. P1 said that on August 9, 2023, P1 received a phone call from P2 because P2 had received a phone call from P3 that the VA had “choked” and “vomited” while eating and that the SP, who was supposed to be supervising the VA, was outside on his/her phone. P3 provided the following information: · On the day of the incident, P4 prepared the dinner meal, which consisted of some type of “rice” dish and P3 took the VA’s food into the sensory room. At some point, the SP went outside to the backyard without telling anyone. · While P3 cleaned the kitchen and supervised the VA eating in the sensory room, P3 heard the VA coughing. P3 opened the door leading to the backyard and told the SP that something was “happening in here,” but the SP “ignores me” and did not come inside. When P3 went to the sensory room, the VA began spitting up some of his/her food. After the VA stopped coughing, the VA was “normal” and fine.” The SP returned inside about 30 minutes after the incident. Later, P3 called P2 and told him/her about the incident. P3 said that the SP typically spent a good amount of time on his/her cell phone instead of taking care of the clients. P4 provided the following information: · P4 prepared “rice” and some type of “stew” for dinner and P3 served dinner to the VA and one other client. Two other clients did not eat at the time. Shortly after the VA began eating dinner in the sensory room, P4 assisted another client in the bathroom. While P4 did that, P3 came to the door and said that something was “going on.” · When P4 left the bathroom, P4 noticed that the SP was outside talking on his/her cell phone in the backyard. P4 got to the sensory room and noticed that the VA was coughing. Within a minute, the VA stopped coughing, but coughed up some food. P4 asked the VA if s/he was okay and the VA said, “Yes.” After that, the VA continued eating without further issues. · The SP came back inside within five to ten minutes but was still “talking” on his/her phone. · The SP typically spent a good amount of time on his/her cell phone instead of taking care of the clients. The VA’s case notes, written by an unknown staff person and dated August 9, 2023, stated that the VA “ate too fast and began to choke. Staff [persons] brought paper towels as [the VA] coughed up the food. [The VA] had no lingering side effects and was [his/her] normal self.” The CM/G stated that the VA did not have a history of choking and that staff persons were to provide visual supervision of the VA while the VA was eating. The SP provided the following information: · When the SP got to the facility the day of the incident, s/he was not feeling well so s/he rested in the sensory room for a few minutes. The SP told P4 that s/he was not feeling well. · The SP did not specifically remember who gave the VA his/her dinner, but when it was served to the VA, the SP was sitting in the living room watching the VA eat in the sensory room. P4 was also in the living room at the time of the incident and P3 was in the kitchen. · Even though the sensory room door was partially closed, per the VA’s request, the SP heard something in the sensory room that sounded like coughing. When that happened, the SP got up to check on the VA, but the VA had stopped coughing and appeared to be fine. The SP denied being outside at the time of the incident but acknowledged that s/he went outside after the incident happened. The facility completed an Internal Investigation and the information provided by P1, P2, P3, and P4 was similar to the information they each provided to this investigator. The review determined that the SP, who did not provide information for the review, was “outside on [his/her] phone versus being with [the VA].” All staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to August 9, 2023. Conclusion: According to P4, P4 prepared dinner on August 9, 2023, and P3 served dinner to the VA in the sensory room. The VA began coughing and spit up some food but was “fine” according to P3. The VA’s Intensive Support Services Assessment showed that the VA “may eat too quickly or put too much food in [his/her] mouth at once. Staff [persons] need to be within visual range and provide verbal prompts to slow down.” Information from the investigation showed that the VA preferred to eat in the sensory room because it was quieter. There was conflicting information regarding where P3, P4, and the SP were when the VA ate and began coughing. P3 said that s/he watched the VA from the adjacent kitchen. P4 said that s/he was helping a client in the bathroom. P3 and P4 each stated that the SP was outside on his/her phone. The SP stated that s/he was in the living room with P4 and could see the VA while the VA ate. The facility’s Internal Investigation stated that the SP was outside at the time of the incident and that the SP did not follow the VA’s supervision plan. Although the SP was assigned to supervise the VA the day of the incident and was likely not in visual range of the VA the entire time the VA ate, and the VA coughed while eating, given that information showed that at least one staff person visualized the VA while s/he was eating, that when the VA was coughing staff persons went to the VA, and that the VA was at baseline after, there was not a preponderance of the evidence whether staff persons failed to provide reasonable and necessary care and supervision to the VA while eating. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility’s Internal Investigation showed that the SP did not follow the VA’s “supervision plan” and that no additional training was needed because the SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No action taken at this time.
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