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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: 1115203-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady 651-431-6557 Suspected Maltreatment Reported: It was reported that on multiple occasions, a vulnerable adult (VA), who required supervision from two staff persons at all times, was able to obtain and ingest items including batteries, medications, and a fishhook. Date of Incident(s): Multiple between June 4 and August 2, 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 July 21, 2023; from documentation at the facility and medical records; and through interviews conducted with nine facility staff persons (P1-P9) and the VA’s family member/guardian (FM). The VA lived in a single level home in a residential neighborhood. The VA was the only individual living at the home. The main level of the home included a common living area, a dining area, a kitchen, the VA’s bedroom, a staff person office, and an unused bedroom. The VA’s bedroom and the office were at opposite ends of a hallway. The hallway was open at each end and could be access from the common living area and from the dining area. The VA’s bedroom was visible from parts of the common living area and there was a couch poisoned with a view of the VA’s bedroom. The bathroom was next to the office between the office and the dining area. There was also a lower level with a laundry room and another staff person office. The VA’s support plans stated: · The VA had several diagnoses related to his/her mental health. The VA had a history of engaging in self-injurious behaviors included the ingestion of inedible objects. · The VA was to have two staff persons supervising him/her 24 hours a day. The VA could have one staff person supervising him/her in “extenuating” circumstances and emergencies with supervisor approval. · The VA had a history of “cheeking” his/her medications and leaving without staff person supervision. · The VA enjoyed outdoor activities including biking, hiking, and walking. The VA also enjoyed playing video games. Information showed that although the VA required two staff persons to be with him/her at all times, due to staffing shortages and a lack of available staff persons, at times there was only one staff person working with the VA. On those occasions, it typically occurred during the afternoon/evening shift. The VA’s interdisciplinary team was aware that at times the facility was not able to have two staff persons working with the VA. P6, a supervisory staff person, provided the following information: · The VA could only be in the bedroom and bathroom without being within sight of a staff person. When the facility had only one staff person scheduled staff persons could not use the restroom and follow protocol at the same time. · Staff persons were to search the bathroom and the VA’s bedroom before the VA used them. At night, staff persons did a thorough check of the bathroom as the VA hid things in the folds of the shower curtain. · P6 said that staff persons had a packet of information that they needed to go through before working with the VA and then they had to do at least a four-hour shadow shift before working a regular shift with the VA. Some staff persons were trained as fill in staff persons. · At the time of the incidents where the VA obtained medications, there were lock boxes by the main floor office and basement office. The main office door shut and locked automatically. At some point, the VA “cracked” the code on the lock boxes. At that point, a larger secure lock box was installed outside of the basement office and only supervisory staff persons had the code to access to the office. There were two sets of keys and staff persons carried keys on their person (on the day of the site visit a set of spare keys were hanging in the main floor office). If one staff person was working, the second set of keys were kept in the main floor office. · At the time of the investigation, changes already made included the VA’s pills being crushed in food or they were in liquid form, an office door was installed that was self-shutting and self-locking, and cameras were installed in the hallway between the VA’s bedroom and the main floor office. Staff persons were trained on the updates. The FM stated that s/he was concerned that the VA was to have two staff persons working with him/her at all times and was still accessing medications. The FM was aware that the facility had issues with providing the VA with the required staffing. The FM said that the facility was working through concerns and taking some actions like switching rooms around, putting in a camera, and getting a safe to lock up medications. Unless otherwise noted below, staff persons interviewed were aware that the VA was to be supervised by two staff persons at all times, but at times there was only one staff person working. This investigator met the VA, but due to possible behavioral triggers taking about the incidents, this investigator did not ask the VA about the incidents. Unless otherwise noted in the following information, the VA declined to provide information about the incidents to facility staff persons. Regarding June 4, 2023 P1 provided the following information in documentation and in an interview with this investigator: · On June 4, 2023, P1 arrived at 2 p.m. P1 did not regularly work with the VA and that day was the second shift P1 worked with the VA. The first shift was a “training” shift with another staff person. When P1 arrived, a supervisory staff person (P10) was working with the VA. At 3:50 p.m., P10 left so P1 was the only staff person working with the VA. P10 told P1 could call him/her if s/he had questions. P1 said that s/he could not use the restroom because s/he was the only staff person working with the VA. · After P1 was alone with the VA, the VA requested to go on a community outing and P1 told the VA since P1 was the only staff person working, they could go for a walk. The VA became agitated and started to rock the dinner table. P1 asked the VA where s/he wanted to go, and the VA said s/he wanted to go to a nearby park. At that point, P1 was not aware whether s/he could not take the VA to the park, but because the VA was upset, P1 decided to take the VA to the park for a walk. · While at the park, the VA was in a calm mood. On the way home, the VA said that s/he wanted to stop at Target to purchase something to drink. P1 told the VA that s/he could get water at home and that s/he did not “feel comfortable” taking him/her to Target. At that point, VA became agitated, raised his/her voice, and told P1 that s/he could not violate his/her basic rights. P1 wanted to avoid the VA getting agitated and exhibiting challenging behaviors while P1 was driving so s/he took the VA to Target. At first P1 and the VA walked around the store together. The VA then asked P1 to get some personal supplies for him/her out of the van. P1 told the VA that it was against protocol to leave him/her in the store without supervision. The VA became agitated and started walking between aisles trying to hide from P1. P1 called P10 as the VA was not cooperating with P1 and P10 told P1 to handle the situation by him/herself. When the VA saw P1 talking to P10, the VA said that s/he wanted to use the restroom. After the VA used the restroom (P1 did not go in the restroom with the VA), the VA agreed to leave with P1. P1 did not see the VA take anything at the store. · After arriving home, the VA sat on the couch watching television. P1 called P10 who told P1 to have the VA empty his/her pockets. The VA did and s/he had nothing in his/her pockets. At about 8:50 p.m., P1 asked the VA if s/he wanted to take his/her bedtime medications. P1 could not watch the VA while s/he set up medications in the office. The VA replied that s/he did not need his/her medications and that s/he took Zyrtec, an allergy medication. The VA told P1 that s/he overdosed and wanted to go to the hospital. The VA showed P1 two pills s/he had in his/her hand gave them to P1 and then s/he got another pill off of the floor and handed it to P1. The VA told P1 that s/he the Zyrtec from Target. P1 called the on-call supervisor and later the VA was taken to the hospital for evaluation. P1 was with the VA at all times on the outing and did not see the VA taking any Zyrtec from Target. Hospital records stated that blood and urine tests were conducted on the VA, but there was no information that the VA required any treatment. Facility documentation showed that P1 received training on the Reporting of Maltreatment of Vulnerable Adults Act and training specific to the VA. Regarding June 9, 2023 The internal review report stated that on June 9, 2023, at 1:30 a.m., the VA was eating applesauce and told P2 and P3, the two staff persons working at the time, that s/he put olanzapine (antipsychotic) tablets in his/her applesauce. The VA told P1 and P2 that s/he obtained two bubble packs of olanzapine from the main floor office on June 8, 2023, during the 2 to 10 p.m. shift. (Each bubble pack contained 31 bubbles each with 1 tablet of olanzapine 5 milligrams. It was not known how many were in each pack at the time the VA took them.) The VA initially declined to provide any information in the facility internal review about the incident, but then later provided the following information. On June 8, 2023, the VA went into the main floor office during the 2 to 10 p.m. shift. The office was unlocked. The VA went in the office when P4 was outside. The VA punched some of the pills out of a bubble pack and put them in his/her pocket and then put the bubble packs under his/her bed. At some point, pizza was delivered and P4 went to side door to get the pizza. During the overnight shift, the VA took the pills out of his/her pocket and put them in his/her applesauce. P2 and P3 provided the following information in the internal report and in an in interview with this investigator: · During the overnight shift while the VA was eating applesauce and talking with P2 and P3, the VA asked P2 and P3 to follow him/her into his/her bedroom where s/he lifted up his/her mattress and showed P2 and P3 two bubble packs of his/her olanzapine. The olanzapine was an as needed medication (PRN). One bubble pack was full and one bubble pack had two pills remaining. The VA said that s/he ingested the whole bubble pack. · P2 believed that s/he gave the VA olanzapine one time. P3 was not sure how often the VA was given olanzapine and s/he never gave it to him/her. · P2 and P3 then took the VA to emergency room. At the emergency room after the VA was checked into a room, the VA became agitated and said that s/he was fine and wanted to go home. The VA initially refused to have blood work done and was told by hospital staff persons that if they had to, they would hold him/her down to draw blood. The VA then allowed them to take blood and after, fell asleep. At some point, P3 went back to the facility to search for more medications and did not find anything then s/he returned to the hospital. Hospital staff persons kept checking on the VA and said that tests were coming back normal but that they did not have a way to test for olanzapine. The VA was discharged after 9:15 a.m. A hospital staff person told P2 and P3 that there was no sign of an overdose. · P2 and P3 each said that the office door was locked when they came into work and they did not witness the VA put any medications in his/her applesauce or witness him/her swallow any medications. · P2 and P3 each received training specific to the VA and followed the VA’s support plans when they worked with the VA. P4 provided the following information in the internal report and in an in interview with this investigator: · On June 8, 2023, P4 was the only staff person working the 2 to 10 p.m. shift. The VA was in the living room for most of the shift. P4 ordered pizza for dinner which was delivered around 7:30 p.m. P4 met the delivery person at the side door of the facility to get the pizza. At that time, the VA sitting in the living room. The VA was out of sight of P4 for about 90 seconds and at no other time during his/her shift was the VA out of his/her sight. · P4 went into the main floor office twice, both times to get the VA’s medications. P4 locked the door each time s/he left the office. The VA was never in the office. P4 did not know how the VA would have been able to access the olanzapine. P4 never went outside without the VA with him/her. The office was locked when P4 arrived at work. · P4 received training specific to the VA and followed the VA’s support plans when s/he worked with the VA. The internal review stated (from hospital records): Reason for visit identified as “overdose, intentional.” Blood work and EKG [electrocardiogram] were completed. The blood work and toxicology report showed no signs of overdose and no signs of olanzapine in [his/her] system. The EKG was normal. No further treatment was identified and no orders for treatment were given. P6 stated that the VA’s medications were kept in the locked office on the main floor inside a locked file cabinet. Medications were set up in the office and then the office was locked up and medications were brought out to the VA. The VA took medications with apple sauce or yogurt and staff persons asked the VA to open his/her mouth after medications to make sure s/he swallowed them. At the time of the investigation the VA’s medication were liquid or in capsule form and the capsules were emptied out into yogurt or apple sauce. (P2, P3 and P4 gave consistent information about the administrating the VA’s medications) Documentation showed that P2, P3, and P4 each received training on the Reporting of Maltreatment of Vulnerable Adults Act and training specific to the VA. Regarding June 24, 2023 The internal review stated that on June 24, 2023, the VA swallowed at least ten Zyrtec pills. P5 and P6 provided the following information in the internal report and in an in interview with this investigator: · P5 stated that on June 24, 2023, P5 worked from 6 a.m. until 10 p.m. P5 was the only staff person working from 2 to 10 p.m. During the evening shift, the VA took a shower. P5 sat outside the bathroom with the door open. The VA was behind a shower curtain. The VA pulled the curtain aside and showed P5 that s/he had a bag of ten white pills and then swallowed them. P5 did not know what the pills were. P5 asked the VA where s/he got the pills and the VA said out of the staff person office. P5 called 9-1-1. Then the VA showed P5 two empty bubble packs of medications that s/he had under his/her mattress. Shortly after, the VA was transported to the emergency room. · P6 stated that pills that the VA took were the Zyrtec that were left over from the incident on June 4, 2023, and were locked in the basement office. The two empty bubble packs were the olanzapine bubble packs from incident on the June 9, 2023, that were also locked in the basement office. P6 believed that the VA took the bubble packs and the bag of Zyrtec at the same time. · P5 said that the office door on the main level office was locked when s/he arrived on shift. Anytime P5 went into the office to get something or the VA’s medications, s/he locked the door when s/he left. P5 did not see the VA access the office. The VA and P5 went down the basement one time to do laundry either that day or the day before. The VA did not get near the basement office, s/he was just in the laundry room. P5 had never been in the basement office and did not have a key to get into the office. P5 said that during the shift, s/he went outside for a few minutes because s/he had to get personal items out of his/her vehicle and left the VA without supervision in the facility. · P5 received training on the VA’s support plans and followed those plans when s/he worked with the VA. · P6 stated that s/he did not know how the VA was able to access the basement office. At the time, there was a key in a lock box outside of the door. Only supervisory staff persons were to access the basement office, but P6 suspected that other staff persons were going though things in that office. Medications generally were not kept in that office. The internal review stated (from hospital records): [The VA] was in the hospital from June 24, 2023, and discharged on June 28, 2023. Discharge paperwork states that [the VA] arrived in the [emergency room] on June 24, 2023, due to intentional overdose of olanzapine. History was somewhat unclear. Reportedly patient took between 10 and 90 tablets of 5 mg [milligrams] olanzapine 45 minutes prior to arrival in the emergency department. In the [emergency department], frothy sputum was noted and patient was anxious and incontinent of urine, tachypneic, with course lung sounds, mumbling unintelligible words and having tremors. UA [urinalysis] [was] normal; pregnancy test negative, acetaminophen, salicylate, and ethanol negative. Per poison control it was recommended [to provide] supportive care with monitoring. Overnight patient developed a fever and was started on medications for possible aspiration. [The VA] required initiation of BiPap [bilevel positive air way pressure]and was transferred to an ICU [intensive care unit] on June 25, 2023, for further care. On arrival to [the ICU], [the VA] was breathing comfortably on BiPap. [The VA was] put on medications for presumed aspiration pneumonia. Psychiatry evaluated [the VA] on June 26, 2023, and felt the events were consistent with impulsive behavior as opposed to a suicide attempt. Patient denied suicidal ideations. Mental status had improved and it was clarified that the ingestion was likely Zyrtec rather than olanzapine (Zyprexa). [The VA] was discharged on June 28, 2023, with antibiotics and a few med changes. [The VA’s] blood draw and toxicology report show no evidence of overdose or toxicity. The internal review stated that P5 did not follow facility procedure when s/he left the VA without supervision while P5 was outside. Facility documentation showed that P5 received training on the Reporting of Maltreatment of Vulnerable Adults Act and training specific to the VA. Regarding June 30, 2023 The internal review stated that on June 30, 2023, the VA swallowed a AAA battery from a television remote control and a magnet from a dry erase board in the main floor staff person office. P6 provided the following information in the internal report and in an in interview with this investigator: · On June 30, 2023, P6 worked from 6 a.m. until 10 p.m. P6 worked alone on the 6 a.m. to 2 p.m. shift and worked training P7, a new staff person, from 2 to 10 p.m. After dinner, the VA wanted to get something that s/he thought was in the basement. At that time, the VA paced from the living room from the kitchen to the living room and to his/her bedroom. The VA then stopped in the kitchen. At that point, P6’s laptop with a remote control on top of it was sitting on the kitchen table. P6 went to check to make sure the main floor office door was locked as P6 had noticed that it was not always latching (it was not a self-shutting door at that time) and the VA grabbed the remote took out a AAA battery and swallowed it before P6 could get around the table and stop him/her. The VA then went to the couch in the living room and took a drink. At that point, P6 saw a small black object in the VA’s hand which the VA told P6 was a magnet that s/he took from the main office white board earlier that day. The VA swallowed the magnet. · P6 then took the VA to the emergency room and an x-ray and scan showed that the VA swallowed both items. The VA went to another hospital the following morning where the items were removed via an endoscopy. · P6 said that s/he could not follow protocol when s/he was alone during the morning shift. When alone, P6 was gathering items for an appointment for the VA and had to leave the office door open while s/he gathered the items in the office. While P6 was in the office, the VA came into the office. Later in the day, P6 and P7 were each in the office as P7 had a question about setting up medications. P1 believed that the VA took a magnet off a whiteboard in the office when P6 and P7 were in the office. · P6 said that s/he should not have left the remote control on his/her laptop, s/he should have brought it with him/her. P6 believed that P7 was outside and did not see the VA swallow the battery or the magnet. · P6 stated that after the incident, the facility purchased a rechargeable remote control so the VA did not have access to batteries. Magnets were also removed from the facility. A cabinet that was in the office on the main floor with office supplies was moved to the office in the basement. P7 stated that s/he did not see the VA swallow the items or see the how the VA accessed the items. The internal review stated (from hospital records), “[The VA] was brought to [the emergency room at one hospital] and they transferred [him/her] to [a different hospital] to have an endoscopy done to remove the battery and magnet. The removal was successful.” The internal review stated that P6 did not follow facility procedure when s/he allowed the VA to enter the staff person office. Facility documentation showed that P6 and P7 each received training on the Reporting of Maltreatment of Vulnerable Adults Act and training specific to the VA. Regarding August 2, 2023 The internal review stated that on August 2, 2023, the VA swallowed a fishhook at Cabela’s. P8 and P9 provided the following information in the internal report and in an in interview with this investigator: · P8 and P9 took the VA shopping at Cabela’s. The activity was approved by a supervisory staff person. It was P9’s first time s/he worked at the facility. · The VA walked around the store including an area with some fishing tackle. P8 and P9 were each by the VA’s side the entire time in the store. At one point, the VA asked to use the restroom. P9 went into the restroom and checked the bathroom while P8 was outside the bathroom with the VA. The VA and P9 then went into the bathroom and P9 was outside the VA’s stall with the door cracked. After using the bathroom, they left Cabela’s. · Later around 8:30 p.m., after returning to the facility, the VA said that s/he swallowed a fishhook. The VA was then transported to the hospital. · P8 and P9 each stated that they were with the VA the entire time at Cabela’s and never saw the VA take any items including a fishhook. · P8 said that it was the about the third day s/he worked with the VA. P8 received training on the VA’s support plans and also did shadow shifts with staff persons. When P9 arrived, P8 “transferred” what s/he knew from his/her first few days of work to P9. · P9 stated that s/he did not receive training regarding the VA before working with the VA that day. P9 did not read any support plans. P8 just told P9 to watch the VA. P6 stated that trip to Cabela’s was approved outing. The main purpose of the trip was for the VA to see the animal display. After the incident, Cabela’s was no longer approved as an outing for the VA. The internal review stated (from hospital records), “[The VA] was in the hospital from August 2 until August 4, 2023. [The VA] had no effects from the fishing hook. The discharge instructions were to follow up with general surgery if needed to evaluate the position of the fishing hook.” Facility documentation stated that P8 and P9 each received training on the Reporting of Maltreatment of Vulnerable Adults Act; that P8 received training specific to the VA on July 30, 2023; and that P9 received training regarding the VA on August 2, 2023, with a notation that /he received the training again on August 16, 2023, at which time P9 signed the documentation that s/he received training specific to the VA. Conclusion: Regarding the VA ingesting items: On June 30, 2023, the VA swallowed a battery and a magnet. At one point, P6’s laptop with a remote control on top of it were sitting on the kitchen table. P6 went to check to make sure the office door was latched and shut. P6 then saw the VA grab the remote and take out a AAA battery and swallowed it before P6 could get around the table and stop him/her. The VA then went to the couch in the living room and took a drink. At that point, P6 saw a small black object in the VA hand which the VA told P6 was a magnet that s/he took from the office white board earlier that day. The VA swallowed the magnet. P6 stated that s/he believed that the VA took a magnet off a white board in the office while P6 and P7 were together in the office discussing the VA’s medications. The VA was brought to the emergency room and transferred to another hospital where they did an endoscopy and successfully removed the battery and magnet. The VA was able to obtain the magnet without staff persons knowledge while staff persons were in the office engaging in work related activities. The VA was also within sight of P6 when the VA took the battery from the remote control while P6 ensured that the office door was shut and locked. Because the VA obtained the objects in brief opportunities while staff persons were engaged in work related tasks, there was not a preponderance of the evidence whether there was a failure to provide the VA with supervision which was reasonable and necessary to maintain his/her safety. On August 2, 2023, P8 and P9 took the VA shopping at Cabela’s. Later that day around 8:30 p.m., after they returned to the facility, the VA told P8 and P9 that s/he swallowed a fishhook. The VA was transported to the hospital. The VA was in the hospital from August 2 until August 4, 2023, and “had no effects from the fishing hook.” P8 and P9 each stated that the VA was within sight of both P8 and P9 while the store except when s/he used the restroom during which time s/he was within sight of P9 while in the bathroom. P8 said that it was the third day s/he worked with the VA. P8 received training on the VA’s support plans and also did shadow shifts with staff persons. P8 said that when P9 arrived, P8 “transferred” what s/he knew from his/her first few days of work to P9, but P9 stated that s/he did not receive training regarding the VA nor did s/he read any of the VA’s support plans. P9 said that P8 just told P9 to watch the VA. Although P9 stated that s/he was not trained on the VA before working with the VA, there was no information that the VA was not provided with the required supervision while s/he was at Cabela’s and was able to obtain the fishhook. Because the VA obtained the fishhook while two staff persons were supervising the VA, there was not a preponderance of the evidence whether there was a failure to provide the VA with supervision which was reasonable and necessary to maintain his/her safety. Regarding the VA obtaining and ingesting medications: On June 4, 2023, the VA ingested some Zyrtec, an allergy medication. The VA told P1 that s/he obtained the Zyrtec earlier in the day from Target when s/he was with P1. The VA was taken to the hospital and did not require medical care. P1, who was working his/her second shift with the VA, said that on the way home from a park, the VA wanted to stop at Target to purchase something to drink. P1 did not want to take the VA in the store alone and told the VA that s/he could get water at home. The VA then became agitated. P1 wanted to avoid the VA exhibiting behaviors while P1 was driving so s/he took the VA to Target. At first P1 and the VA walked around the store together. The VA then became agitated and started walking between aisles trying to hide from P1. At one point while P1 was talking with P10 on the phone, the VA said that s/he wanted to use the restroom. After the VA used the restroom, the VA agreed to leave with P1. P1 was with the VA at all times other than the bathroom and did not see the VA taking any Zyrtec from Target. Although P1 did not want to take the VA to the store by him/herself, given that the VA became agitated in the vehicle because P1 would not take the VA to Target and P1 did not want to be driving while the VA was agitated, P1 chose to take the VA to store. Although the VA was able to obtain Zyrtec while being supervised by P1, given that P1 was working alone, it was reasonable for P1 to make a quick decision regarding going to Target as the VA was becoming agitated in the vehicle and P1 stated that s/he supervised the VA at all times, except when the VA was in the restroom. Therefore, there was not a preponderance of the evidence whether P1 failed to provide the VA with supervision which was reasonable and necessary to maintain his/her safety. On June 9, 2023, at 1:30 a.m., the VA was eating applesauce and told P2 and P3, the two staff persons working at the time, that s/he put olanzapine tablets in his/her applesauce. The VA then showed P2 and P3 two bubble packs that were under his/her mattress. One bubble pack was full and one bubble pack had two pills remaining. The VA said that s/he ingested the whole bubble pack. The VA was taken to the hospital. Hospital records stated that the VA’s blood work and toxicology report showed no signs of overdose and no signs of olanzapine in his/her system. No further treatment was identified and no orders for treatment were given. The VA said that s/he obtained two bubble packs of olanzapine from the staff person office on June 8, 2023, during the 2 to 10 p.m. shift while P4 was outside and the office door was unlocked. The VA then hid the bubble packs under his/her mattress. P4 was the only staff person working the 2-10 p.m. shift. Around 7: 30 p.m., a pizza was delivered and P4 met the delivery person at the side door of the facility to get the pizza. At that time, the VA was sitting in the living room. P4 said that the VA was out of sight of P4 for about 90 seconds and at no other time during his/her shift was the VA out of his/her sight. P4 went into the staff person office twice, both times to get the VA’s medications. P4 locked the door each time s/he left the office. The VA was never in the office. P4 did not know how the VA would have been able to access the olanzapine. P4 never went outside without the VA with him/her, but the VA was out of sight of P4 for 90 seconds when the pizza was delivered. The office was locked when P4 arrived at work. Because at the time of the incident, the VA might have been able to access the lock box to get into the office and access keys to get in medication cabinet in the office, it was possible that the VA access the office even if it was locked. However, it was likely that the VA would need more than 90 seconds of time to access the office and medications and lock everything up again. P4 had reason to minimize his/her own actions, but the VA also could have accessed the medications at a different time as well. Therefore, there was not a preponderance of the evidence when or how the VA obtained the medications. On June 24, 2023, P5 was the only staff person working from 2 to 10 p.m. During the evening shift, while the VA took a shower, P5 sat outside the bathroom with the door open. During the shower, the VA pulled the shower curtain aside and showed P5 that s/he had a bag of ten white pills and then swallowed them. P5 did not know what the pills were. P5 asked the VA where s/he got the pills and the VA said out of the staff person office. After the VA was out of the shower, the VA showed P5 two empty bubble packs of medications that s/he had under his/her mattress. P5 called 9-1-1 and the VA was transported to the emergency room. The VA was hospitalized from June 24 to June 28, 2023. When admitted the VA was anxious and incontinent of urine, with course lung sounds, mumbling unintelligible words and having tremors. Overnight the VA developed a fever and was started on medications for possible aspiration, was placed on a BiPap machine and was transferred to a different hospital. When the VA was discharged, the VA was prescribed antibiotics and some medications changed. The VA’s blood draw and toxicology report show no evidence of overdose or toxicity. P6 stated that the VA got the Zyrtec and olanzapine bubble packs from the basement office where they were stored since the past incident. At the time of the incident, there was a key in a lock box outside of the door, but P6 did not know how the VA was able access the downstairs office. P5 said that during the shift, s/he went outside for a few minutes because s/he had to get personal items out of his/her vehicle and left the VA unsupervised in the facility. The VA and P5 went down the basement to do laundry one time either that day or the day before. The VA did not get near the office downstairs, s/he was just in the laundry room. P5 was never in the staff person office downstairs and did not have a key to get into the office. While P5 was outside it was possible that the VA was able to go downstairs, access the basement office, take the pills, and return to the main level without P5 knowing. However, given that the VA could have accessed the office anytime between June 9 and 24, 2023, it was not determined when or how the VA accessed the basement office. Therefore, there was not a preponderance of the evidence whether P5 failed to provide the VA with supervision which was reasonable and necessary to maintain his/her safety. Regarding all the incidents Information showed that the facility was not always able to have two staff persons working with the VA and that the interdisciplinary team was aware of some staffing issues. Information also showed that at times the facility scheduled inexperienced staff persons, such as P1 who was working his/her second shift with the VA, being alone with the VA; and P9, who was working his/her first shift, and said s/he was not trained to work with the VA, going on a community outing with P8, who was working his/her third shift. However, it was not determined if any of the incidents that occurred or reportedly occurred when one staff person was working or inexperienced staff persons were working, would have been prevented if two more experienced staff persons were working at the time. In addition, the facility took actions after the incidents to further restrict the VA from getting non edible items and accessing either the main or basement offices. Therefore, there was a not a preponderance of the evidence whether the facility failed to take adequate action to prevent the VA from accessing items that posed a risk to his/her physical health and safety. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an internal review of the incidents and determined that their policies and procedures were adequate, but not followed. P5 and P6 each received correct action and/or retraining. Staff persons were trained on the VA’s updated support plans that were updated on June 19, 2023. Weekly team meetings were held with the VA’s support team. The VA plans were to be updated again after August 25, 2023. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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