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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: 1093705-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that near the end of May of 2023, a facility health care professional (SP) was told that a vulnerable adult (VA1) had dark and malodorous urine but took no action. A few days later, the SP was notified that a second vulnerable adult (VA2) might have a yeast infection but took no action. Date of Incident(s): Prior to June 21, 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 14, 2023; from documentation at the facility and the VAs’ medical records; and through interviews conducted with facility staff persons (P1, P2, P3, P4, and the SP. This investigator met the VAs, but VA1 communicated with vocalizations and VA2 was nonverbal. The VAs did not provide information regarding this investigation, and each was subject to guardianship. Facility documentation showed that VA1 was diagnosed with hypothyroidism, urinary incontinence, Alzheimer’s type dementia, and gastro-esophageal reflux disease. VA1 used a wheelchair for mobility and staff persons assisted him/her with medical needs and transported VA1 to and from medical appointments. VA1 had a history of having urinary tract infections (UTIs). Visits from family members were exciting for VA1 and s/he had a great smile. Facility documentation showed that VA2 was diagnosed with a traumatic brain injury, had a feeding tube, and used a wheelchair for mobility. VA2 was medically stable but his/her health needs were complex, and s/he required assistance from health care professionals to manage aspects of his/her care. VA2 depended on assistance from staff persons with all activities of daily living, including transporting him/her to and from medical appointments and attending the appointments with him/her. No information showed whether VA2 had a history of UTIs or bacterial infections. Listening to music and visiting with family members were two of VA2’s favorite activities. Facility documentation and interviews with this investigator provided the following: P1 and P2 provided consistent information that near the end of May of 2023, they verbally notified the SP that VA1’s urine was dark and had an odor that might indicate that VA1 had a UTI and brought up their concerns again to the SP on June 14, 2023. The SP told P1 and P2 that the odor might be from VA1’s incontinence and from adult briefs that became wet when VA1 was incontinent but took no action to determine whether VA1 had a UTI. On June 21, 2023, VA1 was evaluated by a physician and diagnosed with a UTI and a bacterial infection. In addition, P1 and P2 were concerned that VA2 had a yeast infection in late May of 2023 and raised the concern to the SP, but the SP said that VA2 was probably just a “hot sleeper” and sweaty but took no action and “acted like it was nothing.” In June of 2023, VA2 was evaluated by a physician and diagnosed with a bacterial infection and a yeast infection. P3 and P4, who were supervisory staff persons, each stated there were communications between P1 and P2, and the SP regarding the VAs’ health concerns, but the SP did not address anything. When P3 and P4 talked with the SP about issues with the VAs’ health needs, the SP became upset and P4 instructed staff persons to take the VAs for evaluation at medical clinics. P3 thought there were a breakdown in communication, but the VAs’ health concerns had been raised at staff meetings. P4 added that the SP’s work had deteriorated over the past weeks. On some occasions, the SP did not follow through with concerns raised by staff persons and did not spend as much time at the facility as s/he should have. Indications that VA1 or VA2 might have UTIs, or bacterial infections included changes to the way their breath smelled or changes in the color or smell of their urine, but indicators could be “hard to pick out” especially for newer employees. According to P4, P1 and P2 were seasoned staff persons who knew the VAs well. If VA1 was taken to a medical clinic, s/he might become upset and swear at health care professionals. Two staff persons accompanied VA1 to calm him/her and to assist VA1 to move from his/her wheelchair at the clinic, but s/he could travel to medical facilities when necessary. VA2 required substantial assistance from staff persons to travel to medical facilities but was evaluated by physicians more frequently due to his/her complex medical issues and was taken to emergency departments of hospital and to clinics as necessary. The details leading to VA2’s recent diagnoses of UTI and a bacterial infection were a bit “fuzzy” to P4 because s/he was unaware of the concerns regarding VA2’s health until after staff persons took VA2 to be evaluated. P4 requested that s/he be included in future communications between staff persons and the SP when they involved health concerns for all facility residents. The SP said that at a staff meeting on June 14, 2023, s/he became aware of P1 and P2’s concerns that VA2 might have a yeast infection, so s/he called VA2’s primary care physician’s office to ask about prescribing a medication to treat the yeast infection and thought that a prescription was sent to the pharmacy that VA2 used. The SP was then off work for a few days and when s/he returned to work on June 19, 2023, s/he learned that staff persons were taking VA2 to the emergency department of the hospital for a yeast infection that day and that no prescription had been received. The SP called the pharmacy and learned that the prescription had been picked up, but the SP was unsure what happened to it. The SP said that yeast infections were usually treated with over-the-counter medications and did not typically require a prescribed medication from a physician. On June 21, 2023, the SP called VA1’s primary physician’s clinic and left a message asking for a prescription for VA1 to treat a UTI. The SP thought that treating the UTI at the facility would be better for VA1 than going to the physician’s clinic because VA1 often became upset when s/he was taken on outings in the community. VA1 might use profanity directed at staff persons or health care professionals, hit them, or raise his/her voice. The SP later learned that VA1 was diagnosed with a UTI and an infection, so it “worked out” that s/he was evaluated by his/her primary care physician, but nothing indicated that VA1 might have an infection prior to June 21, 2023. The SP felt that there had been a breakdown in communication between the SP and staff persons and s/he discussed the incident with P3. In addition, there was interpersonal conflict between him/herself, P1, and P2 because of issues in their personal lives unrelated to work at the facility, which might have caused P1 or P2 to exaggerate information which reflected poorly on the SP or undermine the SP at the facility. The SP took notes when s/he worked at the facility and provided this investigator with information showing that on June 21, 2023, s/he expressed concerns to P1, P3, and P4 that it might be difficult for VA1 to travel to a clinic and offering to contact VA1’s primary care physician for guidance. The SP felt that solutions/standard nursing interventions s/he offered to staff persons were disregarded and expressed concerns to P3 and P4 regarding the way that staff persons assisted the VAs with personal hygiene that might have contributed to the frequency with which the VAs had UTIs. Progress notes (called T-logs) for the VAs in May and June of 2023, showed that on June 19, 2023, VA2 was diagnosed with a bacterial infection of the reproductive system and was prescribed an antibiotic that was to be given for seven days. On June 21, 2023, VA1 was diagnosed with a urinary tract infection and a bacterial infection of the reproductive system. Medication Administration Records (MARs) showed that on June 21, 2023, VA1 received a prescription for two antibiotics each of which s/he was to take for seven days to treat the infections. However, the T-logs showed that staff persons did not document their concerns that the VAs had UTIs or bacterial infections. In July of 2023, the SP documented in the T-logs that s/he was not informed that VA1 might have a UTI. No information showed that the VAs were in pain or had discomfort. VA1’s medical records showed that at 10:22 a.m. on June 21, 2023, the SP called a medical clinic and said that s/he thought that VA1 had a UTI and asked whether a medication could be prescribed for the UTI. However, just before 11 a.m. on June 21, 2023, VA1 was brought to the clinic by two unspecified staff persons for evaluation and diagnosed with unspecified abnormal findings in the urine, an unspecified noninflammatory disorder of the reproductive system, and bacterial and bladder infections. The staff persons who came with VA1 to the clinic said that his/her symptoms first started over a week ago and denied that VA1’s temperature had been elevated. VA1 was not in acute distress, had no distension of the abdomen, or tenderness, and no discharge noted when s/he was examined. VA1’s urine was malodorous, and s/he was prescribed medications. VA1 was to return to the clinic if his/her symptoms persisted or worsened. VA2’s medical records showed that VA2 was frequently evaluated by physicians because there were problems with his/her feeding tube. At 9:50 a.m. on June 19, 2023, VA2 was evaluated at the emergency department of a hospital for dermatitis on his/her bottom and a noninflammatory disorder but was diagnosed with a yeast infection and prescribed two medications to treat it. A white odorous discharge was present and VA2 was to follow up with his/her primary care physician if the symptoms persisted. The VAs had no standing orders for medications commonly used to treat their respective diagnoses on June 19 and 21, 2023. Personnel files showed that the facility trained its staff persons on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, and the VAs’ plans of care prior to May of 2023. Conclusion: P1 and P2 each stated that they told the SP of their concerns regarding VA1’s and VA2’s health in late May and mid-June of 2023. However, the SP did not act, but instead said that there might be an odor from VA1’s wet adult briefs and that VA2 was a “hot sleeper” and sweaty. P3 and P4 were aware of communications between P1, P2, and the SP about the VAs’ health, but the SP did not address the issues. P3 and the SP thought there was a communication breakdown between staff persons and the SP, and P4 asked to be included on future messages between staff persons when they involved health matters. The SP said that on June 14, 2023, s/he learned of concerns from P1 and P2 that VA2 might have a yeast infection and called VA2’s physician’s office to prescribe medication for the infection. The SP was then off work for a few days but thought that a prescription was sent to a pharmacy and picked up by staff persons. On June 19, 2023, when the SP came back to work, s/he learned that staff persons were taking VA2 to the emergency department at a hospital for a yeast infection and that no prescription had been received. Yeast infections were usually treated with over-the-counter medications and did not typically require the care of a physician, according to the SP. On June 21, 2023, the SP called a physician to request a prescription for VA1 to treat a UTI because VA1 became upset when s/he went to medical appointments. The SP thought it would be better for VA1 to receive treatment at the facility. There was interpersonal conflict between the SP, P1, and P2 because of issues in their personal lives which might have caused P1 or P2 to attempt to discredit or undermine the SP. In addition, the SP thought that nursing advice s/he gave to staff persons was disregarded and had concerns that the way staff persons assisted the VAs with personal hygiene might have contributed to the frequency with which the VAs had UTIs. Medical records showed that on June 21, 2023, VA1 was diagnosed with abnormal findings in the urine, a noninflammatory disorder of the reproductive system, and bacterial and bladder infections. VA1 was prescribed medications and instructed to return if his/her symptoms persisted or worsened. On June 19, 2023, VA2 was diagnosed with a yeast infection and prescribed two medications. There was also a discharge present and VA2 was to follow up with a physician if the symptoms continued. T-logs reviewed by this investigator showed that staff persons did not document their concerns that the VAs might have UTIs or infections. Although P1 and P2 said that the SP did not take prompt action when s/he was made aware of the VAs’ health concerns, given that no information in the T-logs showed that the health concerns were documented, that the SP said that s/he contacted the VAs’ physicians’ offices when s/he became aware of the concerns, and that no information showed that the VAs sustained an injury from the incidents, there was not a preponderance of the evidence whether there was a failure to provide VA1 or VA2 with care that was reasonable and necessary to obtain or maintain their health or safety. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an Internal Review which determined that its policies and procedures were adequate and were followed. The events investigated in the Internal Review were not similar to past events and it was decided that in the future, staff persons were to seek medical care for individuals when symptoms of medical issues were observed, contact the facility HCP and a supervisory staff person, then document/follow up with the individual’s recommended care. At the time this report was written, the SP was no longer employed at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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