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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.”
1068811-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: Allegation One: It was reported that a staff person (SP) threw a vulnerable adult (VA1) down the stairs and then locked VA1 in the basement. VA1 sustained bruising from this incident. Allegation Two: It was reported that a housemate attacked VA1 causing VA1 to need “staples” in his/her head. The staples were not removed or followed-up on as needed and caused VA1 “pain.” Allegation Three: It was reported that the SP was in a car accident with VA1 and two other vulnerable adults (VA2 and VA3) and did not have a valid driver’s license at the time. Allegation Four: It was reported that the SP administered VA3’s medications to VA1. Date of Incidents: Allegations One, Three, and Four: Unknown Allegations Two: Between June 12 and August 15, 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 2, paragraph (b), clauses (1), (3), and (4); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: · Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. · Use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and · Use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825. 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 16, 2023; from documentation at the facility; and through interviews conducted with VA1, VA1’s guardians (G1 and G2) who were also VA1’s family members, VA2, VA2’s guardian (G3) who was also VA2’s family member, facility staff persons (P1 and P4), and supervisory staff persons (P2, P3, and the SP). VA3’s guardian (G4) provided information via email. This investigator spoke with another housemate (H), but the H declined to participate in an interview. The H provided some information to the facility regarding the allegations and that information was included in this report. VA1’s support plan and support plan addendum stated that in December 2022, VA1 moved into the facility seeking supports and services relating to his/her diagnoses, which included autism spectrum disorder and cerebral palsy. VA2 moved in, in November 2003. VA2’s diagnoses included mild intellectual disability and borderline personality disorder. VA3’s diagnoses included autism spectrum disorder and mild development disability. VA3 moved into the facility in September 2010. VA1, VA2, VA3, and the H lived together at the facility, which was a single-family, one-story home. The facility provided at least one staff person 24 hours a day for care and supervision. Facility documentation stated that the SP and P1-P4 received training on the Reporting of Maltreatment of Vulnerable Adults Act. The facility did not have documentation that the SP, P1, and P4 received training on VA1’s-VA3’s respective support plans and support plan addendums; P2 and P3 were not required to receive this training. Despite the lack of training documentation, the SP, P1, and P4 were able to speak on the housemates’ cares and supports during the interview with this investigator. However, the failure to maintain personnel records in a manner that documented each employee’s qualifications, orientation, and training, including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor, was in violation of Minnesota Statutes section 245D.09, subdivision 5, paragraph (a), clause (2). Allegation One: It was reported that the SP threw VA1 down the stairs and then locked VA1 in the basement. VA1 sustained bruising from this incident. VA1’s support plan and support plan addendum provided the following information: · VA1 was susceptible to abuse from others. Staff persons were supposed to intervene in potentially dangerous situations, assist VA1 to safety, and/or report suspected or known maltreatment on VA1’s behalf. · “[G1 and/or G2] agreed to a relaxation spot for [VA1] when [his/her] behaviors are non-stop, [when] separation time from [others] are needed. [VA1] will have a relaxation spot in the basement for [him/her] to go. [VA1] does have a right to refuse to go to this area at any time.” [Note: At the time of the site visit, this investigator observed a small canopy tent in the staff office and was told this was VA1’s relaxation spot. There were various blankets and pillows on the floor in the tent.] There was a staircase to the basement off the kitchen. The door at the top of the stairwell had a lock, which, based on the locking mechanism, needed to be manually pushed down to lock. In the basement was storage, laundry, and a staff office. P1 provided the following information: · When P1 was initially hired, s/he was trained by the SP. “[The SP] trained us to put [VA1] in the basement to stop [him/her] from having behaviors. I thought it was crazy. [VA1] would stand at the top of the stairs pounding on the door” and yelling, “Get me out of here.” · “More than ten times,” P1 witnessed the SP lead VA1 downstairs and then shut and lock the basement door so VA1 could not come back upstairs. · VA1 would then remain in the basement, until someone opened the basement door, for 15 minutes, one to two hours, or from 7 a.m. to 3 p.m.; and during this time, there was no one else in the basement with VA1. · P1 saw the SP “push” VA1 “at least 4 or 5 times.” P1 did not see the SP push VA1 in a manner that caused him/her to fall down the stairs. P3 said that because of the shift the SP worked, there were few staff persons who worked directly with him/her. P1 and P4 were the SP’s main coworkers. P3 was not aware of other staff coming forward with concerns about the SP’s conduct. P4 said that s/he saw the SP “push” VA1 to the stairs and then once VA1 was in the stairwell, the SP locked the door preventing VA1 from leaving the stairwell/basement. When this occurred, VA1 was “banging on the door and trying to leave.” P4 saw this occur “more than once” and said that VA1 would then remain in the basement, until someone opened the basement door, usually around one to two hours later. The SP told staff to leave VA1 in the basement until s/he was calm. P4 saw another staff person put VA1 in the basement as a timeout for his/her behaviors but this staff person sat in the basement with VA1 until s/he was calm. P4 was not aware of other staff, except the SP, leaving VA1 in the basement alone or for hours. VA2 provided the following information: · VA2 was in the living room when s/he heard VA1 “putting [his/her] hands on [the SP] and pulling [the SP’s] hair and that kind of stuff.” VA2 then heard the SP “push [VA1] down the stairs.” “I heard a big thump.” · VA2 also witnessed staff persons lock VA1 outside on the porch and in his/her bedroom but VA2 could not recall which staff did this. VA2 said, regarding the number of times s/he witnessed this happen, “Quite a while.” The facility’s internal review included information from the H: · The H saw the SP push VA1 “about 4 times.” [Note: The H did not specify if this was involving the stairwell and/or the basement.] · The H said, “[The SP] will put [his/her] body weight to push [VA1] down” the stairs. The H heard about this happening from other staff “over ten times” and saw it happen firsthand four times. · The H saw VA1 with a bloody nose and a “black eye” after being pushed down the stairs; however, this was from VA2 pushing VA1, not the SP. The H did not state if s/he saw injuries caused by the SP. P2 and P3 provided the following information: · VA2 told P2 that s/he saw the SP “push [VA1] down the stairs and lock [him/her] down there.” P2 said that VA2 had a history of pushing VA1 and causing injury. P2 was not aware of prior concerns the SP pushed VA1 or caused injury. · P3 was not aware of prior concerns that the SP pushed or forced VA1 to remain downstairs. P3 was also not aware of unexplained injuries to VA1 or injuries consistent with being pushed down the stairs. VA1 had a history of causing injuries to him/herself by dragging his/her elbow against the wall. · P3 said that there was an ongoing conflict between P1 and the SP, which was regarding a personal matter. P3 did not know if P1 and the SP knew each other or were acquainted prior to working together at the facility. They had been working together for about one month when P1 initially raised concerns about the SP’s conduct. P1 then voluntarily ended his/her own employment the same day that s/he raised these concerns. P3 was not aware of other conflicts between staff, including P4 and the SP. · P2 said that VA2 did not have a history of “making up a story”; however, s/he did sometimes “embellish” a story. The H was “new” to the facility at the time of this investigation and P2 was not familiar with the H’s ability to provide accurate information. VA3 would not be able to provide information and VA1 had a history of misinterpreting conduct. For example, there had been times when VA1 attempted to go into an area where there was “smeared feces” present and when staff stopped VA1, s/he said that they were “hitting” him/her. “If you are [VA1’s] focus yesterday and something happens today, you did it.” The SP said that s/he did not “push” VA1 down the stairs. If s/he did this, VA1 would “tumble” down the stairs and the SP would not do that. The SP was trained to encourage VA1 to use his/her relaxation spot in the basement when s/he was having “behaviors.” However, VA1 could choose not to, and staff could not force him/her to do so. The SP never forced VA1 into the basement or locked the door to prevent him/her from leaving the basement. The SP believed the allegations were made against him/her because P1 did not like him/her. P1 and the SP had conflict over a significant other and a theft of a personal vehicle. G1 and G2 provided the following consistent information: · “[VA1] is extremely near sighted and legally blind and if [s/he] sustained any type of impact to the head, it could detach [his/her] retina.” · VA1 did not have “fine motor movement in [his/her] hands” and “doesn’t do well on the stairs.” “[S/he] doesn’t have depth perception. Stairs are particularly bad.” · G1 and G2 did not notice anything noteworthy about the interactions between VA1 and the SP. · G1 and G2 did not notice any noteworthy or concerning bruises on VA1. VA1 told this investigator that s/he liked living at the facility and liked the staff and his/her housemates. VA1 identified two staff persons that s/he “liked.” There were no staff who were “mean” to him/her. VA1 “liked staying down here,” in the basement. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clauses (4) and (6), stated that a person's protection-related rights included the following: · The right to be free from restraint, time out, seclusion, restrictive intervention, or other prohibited procedure identified in section 245D.06, subdivision 5, or successor provisions, except for: (i) emergency use of manual restraint to protect the person from imminent danger to self or others according to the requirements in section 245D.061 or successor provisions; or (ii) the use of safety interventions as part of a positive support transition plan under section 245D.06, subdivision 8, or successor provisions; · The right to be treated with courtesy and respect. Conclusion for Allegation One: A. Maltreatment: VA2, the H, P1, and P4 each provided information that more than once they saw the SP push or force VA1 down to and remain downstairs alone by locking the door preventing him/her from leaving the stairwell/basement. The SP denied the allegations. However, given that the SP had reason to minimize his/her actions; that although VA2 might “embellish” a story, s/he did not have a history of “making up a story;” that the H was “new” to the facility and there was no information the H had reason to provide inaccurate information about the SP; and that although there was conflict between P1 and the SP, there was no information that there was conflict between P4 and the SP, it was determined that the account of VA2, the H, P1, and P4 was more credible than the SP’s account. The conduct of pushing or forcing VA1 to remain downstairs alone by locking the door preventing him/her from leaving the stairwell/basement was inconsistent with a professional caregiver in a facility licensed by the Department of Human Services and it was in violation of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clauses (4) and (6). Information was provided VA1 “banged” on the door asking to be let out but that the SP left him/her in the basement, alone, for hours and told other staff to not let him/her out until s/he was calm. Locking any person in an area was not accidental or therapeutic conduct. Therefore, there was a preponderance of the evidence that VA1 was subjected to aversive or deprivation procedures. It was determined that an aversive or deprivation procedure occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to the use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825). Although it was initially alleged that the SP threw the VA down the stairs, there was no information provided that at any time VA1 fell down the stairs or sustained any injury while s/he was in the basement. Therefore, there was not a preponderance of the evidence whether VA1 was subjected to conduct, which could reasonably be expected to produce physical pain or injury. It was not determined whether physical abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). 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. The SP was responsible for VA1’s care and supervision. The SP received training on the Reporting of Maltreatment of Vulnerable Adults Act and although there was no documentation the SP received training on VA1’s support plan and support plan addendum, s/he was able to speak on VA1’s cares and supports during the interview with this investigator. The SP was responsible for maltreatment of VA1. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. 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. It was determined that the substantiated use of aversive or deprivation procedures for which the SP was responsible was recurring maltreatment because the SP was responsible for more than one incident of maltreatment. However, it was not serious because there was no information provided that VA1 sustained an injury which met the definition of serious maltreatment. The SP was disqualified from providing direct contact services. Allegation Two: It was reported that a housemate attacked VA1 causing VA1 to need “staples” in his/her head. The staples were not removed or followed-up on as needed and caused VA1 “pain.” VA1’s support plan and support plan addendum stated that s/he required assistance from staff persons, including to administer his/her medications as prescribed; and to schedule, transport, and attend appointments. “Staff working with [VA1] will seek medical care if needed.” P1 said that on June 12, 2023, VA1 was “attacked” by VA2. VA1 received medical attention, which included “staples in [his/her] head.” However, the staples remained in VA1’s head longer than necessary due to a lack of follow-up and caused VA1 “pain.” P1 did not provide additional information or details regarding his/her actions regarding the staples. G1 and G2 each recalled VA1 sustaining a head laceration and requiring staples but had no additional information about the specific incident and/or what followed-up was required. The facility was responsible for following-up on VA1’s medical needs. VA1’s medical records provided the following information: · On June 12, 2023, VA1 arrived at an emergency room with “laceration to scalp after altercation at [the facility].” Medical personnel closed the laceration with seven staples. “For follow up, these staples should be removed in 7-10 days by [VA1’s] primary care provider … Follow up with [primary care provider] in 1 week for staple removal.” · On August 15, 2023, VA1 and P2 arrived at an appointment with VA1’s primary care provider. “[P2] says ‘patient is in for a checkup, discuss staples in head … [VA1] apparently was seen in a local ER approximately 1 week ago with a minor head laceration and had a staple placed. They would like to have that removed … [VA1] has a single staple present on the back of the scalp on a wound that appears well-healed and not infected. There is no other sign of trauma to the head.” The staple was removed during this appointment. [Note: VA1 did not have more than one incident where staples were needed. The staple remaining on August 15, 2023, was from the incident on June 12, 2023.] P2 and P3 provided the following information: · P2 had been aware that VA1 and VA2 were in an altercation that required VA1 receiving staples in his/her head. The SP was responsible for scheduling and managing the housemates’ medical needs. P2 said, “I didn’t receive any follow-up (from the SP or other staff). Not sure when the appointment was scheduled … No one said anything to me.” · On an unknown date in August 2023, P3 was notified by staff that VA1 was “in pain” in his/her head from the remaining staple. It was at this point that P2 and P3 became aware that the staples were still in VA1’s head from the altercation with VA2 on June 12, 2023; however, only one of the seven staples remained. · P2 said, “I hurried up and made an appointment” and the remaining staple was removed on August 15, 2023. P2 asked the SP about this. “[The SP’s] excuse for not scheduling a follow up appointment was, ‘I haven’t had staff.’” P2 said that this was not a valid reason to not schedule an appointment. · P2 and P3 each said that after the final staple was removed, “Everything was good.” VA1 did not develop an infection or other concern by this incident. The SP recalled VA1 sustaining a head injury and requiring staples but said that the facility was “short staffed,” and the SP was unable to bring VA1 to his/her follow-up appointment. The SP reached out to P2 and another supervisory staff person asking for help, and they repeatedly told him/her that they were working on it. The SP was not aware of VA1 experiencing pain because of the staples. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.05, subdivision 1, paragraph (a) stated that 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 for Allegation Two: Consistent information, including medical records, stated that on June 12, 2023, VA1 received seven staples in his/her head to close a laceration. Medical records stated, “For follow up, these staples should be removed in 7-10 days by [VA1’s] primary care provider … Follow up with [primary care provider] in 1 week for staple removal.” On August 15, 2023, or almost two months later, VA1 attended an appointment where his/her single remaining staple was removed. Information had been provided that VA1 was experiencing “pain” in his/her head at some point prior to the removal of the staple on August 15, 2023. VA1 relied on staff to manage his/her medical appointment scheduling and attendance so the failure to ensure staff scheduled and transported VA1 to his/her follow-up appointment was a violation of Minnesota Statutes section 245D.05, subdivision 1, paragraph (a). However, although there was a delay in scheduling and ensuring attendance at VA1’s follow-up appointment to have his/her staples removed, at some point six of the staples fell out on their own and the remaining staple was eventually removed without incident or further injury or harm to VA1. Therefore, there was not a preponderance of the evidence whether there was a failure or omission to supply VA1 with care or services, which were reasonable and necessary to obtain or maintain VA1's physical or mental 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). Allegation Three: It was reported that the SP was in a car accident with VA1, VA2, and VA3 and did not have a valid driver’s license at the time. VA2 provided the following information: · The SP got into a car accident while driving VA1, VA2, and VA3. A “truck” struck the SP’s car from behind, which caused the SP’s car to strike the “car” in front of him/her. · VA2 was “shock up” by the accident. · The SP did not have a valid driver’s license. G3 said that VA2 told him/her about this car accident. VA2 said that the SP was smoking in the van, which VA2 did not like and that the SP was running his/her own errands with the housemates along. The SP got into “a fender bender” with another car but no one was injured. G3 did not know if VA2 would be a reliable reporter about this type of incident. However, VA2 typically did not have a history of remembering past events, but VA2 had told G3 about this car accident multiple times with the same detail. P2 and P3 provided the following information: · VA2 told P2 that the SP was in a car accident with VA1, VA2, and VA3 in the car. P2 was already aware of this car accident because the SP had already told him/her about it. The accident happened on the SP’s way to work; there were no housemates with the SP at that time. · The SP told P3 about his/her car accident and told P3 that the accident happened on the way to work without any housemates present. P2 and P3 had no other information that the SP’s car accident occurred while s/he was working or with housemates present. · P2 said that VA2 had a history of repeating what s/he heard from others. For example, one time, the SP was talking in front of the housemates about his/her personal upcoming move, and VA2 and VA3 then started repeating this and asking when they were moving. · P3 added, “I think [the SP] was talking about [his/her car accident] at work and [VA2] heard and so now they are involved in some way.” The SP denied being in a car accident with VA1, VA2, and VA3 and said that the facility had a van, which s/he used to transport the housemates, not the SP’s car. Records showed that the SP had a valid, and good-standing, Class D driver’s license. Conclusion for Allegation Three: Although VA2 said that the SP was in a car accident while driving the housemates and that the SP did not have a valid driver’s license, there was no other information or witnesses to support VA2’s account. In addition, the SP acknowledged being in a car accident but said that it happened on his/her way to work and not with any housemates present. P2 and P3 were each informed of the SP’s car accident and that it had occurred on the SP’s way to work and not with any housemates present. Records showed the SP had a valid driver’s license. Without additional witnesses or information to support VA2’s account, or to indicate a car accident occurred where the SP was responsible and housemates were injured or at risk, there was not a preponderance of the evidence whether there was a failure to supply the housemates with care or services that were reasonable and necessary to maintain health and safety. It was 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). Allegation Four: It was reported that the SP administered VA3’s medications to VA1. P1 said that s/he saw the SP administer VA3’s medications to VA1 when VA1 had “behaviors.” The SP did not record this on either housemates’ Medication Administration Record. This included VA3’s prescription clonazepam (antianxiety, anticonvulsant) at least five times and VA3’s prescription melatonin (sleep aid) one time. [Note: P1 told P2 that the melatonin was over the counter and not VA3’s prescription.] Facility documentation, P2, and P3 provided the following information: · VA3’s Medication Administration Record stated that s/he was prescribed clonazepam 1 milligram (mg) twice daily; and melatonin 5 mg at bedtime. · P3 said that at the time when this allegedly occurred, staff were not required to count VA3’s clonazepam; however, since this allegation, they have started daily counts. [Note: Clonazepam was a Schedule IV medication, which according to Minnesota Statutes section 152.02, meant that it has a low potential for abuse relative to the substances categorized as Schedule III. The facility’s policies and procedures stated that Schedule II medications were required to be double-locked.] · P3 reviewed VA1’s and VA3’s Medication Administration Records and did not find errors or indications of such. P2 and P3 were not aware of any missing doses of VA3’s medications or any indication or harm that VA1 might have taken someone else’s medications. The SP denied the allegations and reiterated that P1 did not like the SP due to a personal matter. The facility’s Policy and Procedure on Safe Medication Assistance and Administration provided the following information: · “The company is responsible for meeting health service needs including medication-related services of persons as assigned in the Support Plan and/or Support Plan Addendum.” · “Staff will compare the [medication administration record] with the label of each medication for the following: a. Right person; b. Right medication; c. Right date; etc.” · Staff persons recorded, on the individual’s medication administration record, “Notation of any occurrence of a dose of medication not being administered or treatment not performed as prescribed, whether by staff error, the person’s error, or by the person’s refusal, or of adverse reactions, and when and to whom the report was made.” · “Concerns regarding medication purpose, dosage, potential or present side effects, or other medication-related issues will be promptly communicated to the prescriber by staff, the manager, assigned nurse, or nurse consultant.” Conclusion for Allegation Four: P1 said that s/he saw the SP administer VA3’s clonazepam and melatonin to VA1. However, there was no other information or witnesses to support P1’s account and there was no documentation of missing doses or of any impact or harm to VA1. Therefore, there was not a preponderance of the evidence whether there was a failure to supply VA1 and/or VA3 with care or services that were reasonable and necessary to maintain their 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 and determined that policies and procedures were adequate and followed; and that there was not a need for additional training or other corrective action at this time. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. On January 10, 2024, the facility was issued a Correction Order for the violations outlined in this report.
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