|
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: 1091064-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a vulnerable adult (VA) had a seizure and a staff person (SP) did not provide a seizure rescue medication. Date of Incident(s): September 25, 2022 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 November 1, 2022; from documentation at the facility, and medical records; and through five interviews conducted with two facility supervisors (P1 and P2), the VA’s case manager (CM), the VA’s guardian (G), and the SP. The VA was hospitalized during the investigation and had a very limited ability to communicate. Facility documentation showed the VA was a very social person and had a good sense of humor. The VA enjoyed music, watching television, bowling, and playing in a baseball league. The VA’s family was important to him/her, and the VA liked spending time with friends. The VA was able to dress him/herself, but needed help with putting his/her arms and legs in/through clothing. The VA required hand over hand assistance with daily hygiene tasks such as brushing teeth, and trimming fingernails. The VA enjoyed being active, and used a walker and a wheelchair. The VA was diagnosed with developmental disabilities, spastic diplegic cerebral palsy and hydrocephalus with a shunt, seizure disorder, and hip subluxation (partial dislocation). It was noted those supporting the VA should be “aware” of his/her “seizure disorder and shunt.” The VA’s Coordinated Service and Support Plan Addendum (CSSPA) provided the following information: · Staff persons were trained to observe the VA and his/her seizures. The VA’s seizure could include the following activity; cold extremities, looking away with a distant look in his/her eyes, being unresponsive, having convulsive muscle spasms, and putting his/her fingers in his/her ears. Staff persons were to report concerns to a supervisor. Staff persons should be “aware” of the VA’s seizures. · Staff persons administered all medications to the VA. The VA had an emergency seizure medication (Diazepam Intensol) which s/he was to receive at the “start” of a seizure. Staff persons were to place the medication in the side of the VA’s cheek. Staff person were to call 9-1-1 if the seizure continued for longer than five minutes after the seizure medication was given. · The VA was also prescribed three other medications related to seizures. Those medications were provided on a daily basis. · The VA had two seizures during the winter of 2021-2022 (no dates stated) and thereafter was prescribed a new seizure medication in conjunction with the two previously prescribed. The VA completed a neurology appointment and bloodwork in June 2022, and “everything came back normal.” The VA’s Medication Administration Record (MAR) from September 2022 was reviewed, and the VA was provided his scheduled medications as prescribed. An Ambulance Report provided the following information: · On September 25, 2022, an emergency call was received at 8:18 a.m., regarding the VA. The call was assigned, and an emergency medical Service (EMS) crew was enroute at 8:20 a.m. The ambulance arrived at the facility at 8:25 a.m., and a medical assessment and care of the VA was completed. · The VA was “unresponsive,” and the chief complaint was a seizure which was noted as “10 minutes.” The SP informed EMS s/he found the VA “shaking in bed,” at 7:50 a.m., and moved the VA to the ground after “about” seven minutes and called 9-1-1. The SP said the VA had received his/her daily prescribed medications on September 24, 2022, and the SP had not yet provided the VA with any medication on September 25, 2022. · EMS stated the VA “stopped and started seizing two to three times,” and at around 8:30 a.m., EMS administered an injection of Midazolam to the VA’s left shoulder due to the continued seizing. EMS continued to provide care and treatment to the VA and then transported the VA to a hospital. The VA’s medical records provided the following information: · The VA was admitted to the hospital on September 25, 2022, and discharged on January 3, 2023. The VA’s primary diagnosis was seizure disorder, and it was noted the VA had “subtherapeutic antiepileptic” (low seizure medication) levels. The VA had a “longstanding history of a seizure disorder and had been previously well controlled.” · On September 25, 2022, at 7:50 a.m., the VA was found having a “generalized tonic-clonic seizure.” EMS was contacted, and the VA was provided “10 milligrams of midazolam with cessation of the generalized tonic-clonic movements.” The medical facility intubated the VA and provided additional treatment and testing. The VA was transferred to “General Neurology” on October 1, 2022, however had frequent episodes of “projectile emesis,” as well as impacted stool. The impacted stool was managed by an “aggressive bowel regimen,” and there was no obstruction noted. The VA had a jejunostomy tube (j-tube) inserted on October 27, 2022. · The VA had multiple follow-up appointments after discharge from the hospital. These included appointments with his/her primary doctor, neurology, nutrition, endocrinology, and gastroenterology. · The VA was provided a tube feeding program and instructions were given to the facility. The VA was also on a dysphagia diet level five requiring the VA’s food to be “minced and moist” with “thin regular fluids.” The VA diet would be re-evaluated per swallowing therapist re-evaluation. The facility completed an Incident and Emergency Report (IER), and Internal Review (IR) provided the following information: · On September 25, 2022, at 6 a.m., the SP completed a check on the VA and the VA was “normal” in bed and the SP went to complete morning routines with the other facility residents. · Around 8 a.m., the SP returned to the VA’s bedroom and upon removing the VA’s blanket the VA started to have a seizure. The SP assisted the VA to the floor and moved items away from the VA. The SP contacted P1 and P2 via phone, however neither P1 nor P2 answered. Thereafter the SP immediately called 9-1-1. The SP stayed with the VA until EMS arrived at the facility. · Around 8:15 a.m., EMS arrived, and the SP timed the VA’s seizure on his/her phone and noted the VA had “seized off and on for over seven minutes.” Additionally, the day prior (September 24, 2022), the VA felt “a little warm” but his/her temperature was 98.7 degrees Fahrenheit (F). · The SP noted the VA received his/her prescribed medications on September 24, 2022, however had not yet received his/her morning (8 a.m.) medications on September 25, 2022. The SP provided the following information: · The morning of the incident, the SP said s/he heard a noise in the VA’s bedroom and went to check on the VA (the SP did not recall what the time was). The SP found the VA on the floor and the VA was having a seizure. The SP described the situation as “scary,” and the SP attempted to assist the VA. The SP moved objects that were near the VA, tried to contact P1 and P2, and then contacted 9-1-1. The SP did not believe s/he provided the VA with his/her emergency seizure medication. · The SP said this was the first-time s/he experienced an incident as described, and did not “fully remember everything.” The SP said s/he was “frazzled,” and “traumatized” by the incident. · The SP said s/he contacted 9-1-1 within “a few minutes,” but did not remember exactly how long. The SP said s/he was assisting other facility residents prior to observing the seizure. The CM believed there were discrepancies between the information provided by the SP, the facility’s report, and the medical observations from doctors. The CM said it was “hard to know” if the incident was a “large seizure” or not. The CM said the VA had been discharged from the hospital with the need for a “higher [level of] medical care” after the incident and a doctor was concerned “neglect” had occurred. The G said s/he was informed the VA’s seizure lasted seven minutes, but believed the seizure was longer. Furthermore, the VA had been affected by the incident, and the VA was “paralyzed” on his/her left side, and had damage to the right side of his/her brain. The G was not sure when the seizure started, but said the SP did not provide the VA with his/her emergency medication. P1 and P2 were not present for the incident, but the SP attempted to contact them prior to calling 9-1-1. P1, P2, and the SP were trained on the VA’s client specific information, the facility’s policies and procedures, medication administration, and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rules and/or Statutes: Minnesota Statutes section 245D.05, subdivision 1, paragraph (a), states the license holder is responsible for meeting health service needs assigned in the support plan or the support plan addendum, consistent with the person's health needs. Conclusion: It was reported that on September 25, 2022, the VA had a seizure, and the SP did not provide an emergency seizure medication. The VA had a history of seizures, and the VA’s seizure protocol stated that staff persons were to give the VA Diazepam Intensol at the “start” of a seizure. The SP said s/he was assisting other facility residents prior to the observing the seizure, and the situation was “scary.” The SP did not provide the VA with an emergency seizure medication but did respond to the observed seizure activity by contacting P1 and P2, and then 9-1-1. EMS arrived at the facility at 8:25 a.m., and provided care/treatment to the VA at that time. Within the information obtained, specifically, the facility’s documentation and the SP statements to this investigator and EMS, there were inconsistencies related to the exact time frames of the incident and when the seizure was first observed, and how quickly the SP contacted 9-1-1. The following information was inconsistent: · The SP told EMS that s/he found the VA having a seizure at 7:50 a.m., but told this investigator s/he observed the VA at 8 a.m. · The SP told this investigator s/he heard a noise prior to going to the VA’s bedroom, and found the VA on the floor. However, the SP informed EMS s/he assisted the VA to the floor, and the IER stated the SP was found “shaking in bed.” · The SP stated s/he had contacted 9-1-1 within “a few minutes,” however, the ambulance report showed an emergency call was not received until 8:18 a.m. The VA was hospitalized due to the seizure, however there was no information which established if or for how long the VA had been having a seizure prior to the SP’s observation. The SP stated the seizure activity was “on and off.” Additionally, medical records showed the VA’s seizure medication level was determined to be subtherapeutic, however the MAR showed all scheduled medications had been provided. There was no other information which showed the VA had not been receiving his/her daily prescribed medications. Although the SP did not follow the VA’s seizure protocol by administering the seizure medication which was a violation of 245D.05, subdivision 1, paragraph (a), given that the SP took action after s/he observed the VA having seizure activity, which included moving items away from the VA, calling P1 and P2, and calling 9-1-1, that it was not able to be determined when the VA started to have seizure activity, and that the VA’s medical records did not establish whether or not the emergency medication affected the length or severity of the VA’s seizure, therefore there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. 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 and determined that the policies and procedures were adequate, but not followed. The VA’s programming was not implemented, and the facility completed additional training with the SP regarding responding to seizures, and medication administration. The incident was no similar to past events, and there was no additional corrective action the facility took to ensure the safety of the persons served. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate corrective action to address the violation outlined in this report, a Correction Order was not issued. No further action was taken.
|
