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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: 1068639-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Alice Percy Minnesota Department of Human Services 651-431-3970 Suspected Maltreatment Reported: It was reported that on March 25, 2023, a vulnerable adult (VA) had issues with his/her catheter and his/her contracted catheter health care professional (HCP) recommended that the VA be taken to the hospital, but the VA was not taken to the hospital until March 29, 2023, at which time s/he was diagnosed with a urinary tract infection (UTI). Date of Incident(s): On-going, prior to March 30, 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 March 27, 2023; from documentation at the facility and medical records; and through seven interviews conducted with three facility administrative staff persons (P1 - P3), three staff persons (P4 – P6), and the HCP. The VA enjoyed going on van rides, going on community outings, and spending time with his/her friends. The VA’s diagnoses included intellectual disability, incontinence, osteoarthritis, tactile hypersensitivity, hearing impairment, and self-injurious behaviors. Although the VA was blind, s/he was able to walk independently in the facility. The VA was non-verbal and used body language to express his/her likes and dislikes. According to the VA’s Coordinated Service and Support Plan Addendum, the VA required the assistance of the staff persons with grooming, bathing, laundry, eating, and personal cares. The staff persons administered all of the VA’s medications to the VA. According to the HCP’s Service Notes, on March 22, 2023, the HCP documented that s/he told P2 that the VA should be taken to Urgent Care if s/he continued to have “bleeding and sediment or with any changes in condition.” The HCP noted that P2 told the HCP that “bleeding was totally normal” for the VA. On March 25, 2023, the HCP made a follow-up telephone call to P2 and advised P2 to take the VA to the emergency room if the VA’s bleeding continued. The HCP documented that P2 told the HCP that the VA continued to have bleeding, but that it was normal for the VA. The HCP expressed concern and advised P2 to take the VA to the emergency room to address the VA’s pain and bleeding. According to the facility’s General Events Report, on March 29, 2023, the HCP recommended that the staff persons take the VA to the emergency room (ER). The staff persons then took the VA to the ER, where a urine culture was taken and the VA’s catheter bag was changed. The VA tested positive for a UTI and was prescribed antibiotics. P1 – P6 and the HCP, and the facility’s documentation provided the following information: · Consistent information was provided that at the beginning of 2023, the HCP’s company was contracted by the facility to provide nursing services for the VA, including catheter care. The HCP visited the VA twice each week. The HCP stated that when s/he visited the VA in early March 2023, s/he observed bleeding around the VA’s catheter site and was told by the staff persons that bleeding in that area was “normal” for the VA. Although the VA was taken to the hospital, the staff persons provided inconsistent information to the HCP as to when the VA was taken to the hospital. · P4 stated that on an unknown date in March, the HCP told P4 that the VA’s catheter tube was “out,” so P4 telephoned P2 to tell him/her about the VA’s catheter. P4 believed that P2 ordered a new tube for the catheter. P2 stated that on March 25, 2023, P4 telephoned P2 and told him/her that there was a problem with the VA’s catheter and that the leg bag for the catheter was “dragging” and causing pain to the VA. P2 told P4 to call P3, who was the on-call manager that day, to discuss the situation. P2 did not know if P4 telephoned P3. P3 did not recall if anyone called him/her on March 25, 2023, with concerns about the VA’s catheter, but stated that there were frequently problems with the VA’s catheter because the VA sometimes pulled the catheter out, the catheter fell out, or the VA developed an infection. On an unknown date, P1 was told that the HCP recommended to P2 that the VA be seen by his/her physician, but P2 did not contact the on-call staff person and relay the HCP’s recommendations to him/her. P2 stated that s/he was unaware of any concerns about the VA’s catheter other than the leg bag tubing causing pain to the VA. · According to the facility’s On-Call Notes, on March 26, 2023, at 7:09 p.m., a staff person telephoned the on-call manager because the VA was running low on one of his/her medications. P2 stated that on March 28, 2023, the HCP telephoned P2 and asked him/her why the VA was not taken to the hospital. P2 told the HCP that s/he was unaware of any problem except for when the VA’s leg bag was loose and causing pain to the VA. · P1 stated that on March 29, 2023, s/he spoke to P2, who told P1 that the HCP had a concern with the VA’s catheter and wanted the VA to be seen by a physician. The facility’s van was not available until later in the day and a staff person planned to take the VA to the hospital when the van was returned to the facility. P1 also stated that s/he received a telephone call from the HCP, who told P1 that the staff persons “were refusing” to take the VA to the hospital as s/he recommended. P1 told the HCP that the VA would be taken to the hospital when the van was available to take the VA. On March 29, 2023, at approximately 10 p.m., the VA was taken to the hospital, where s/he was treated for the UTI and then released back to the facility. · On March 30, 2023, the VA was again taken to the hospital, where s/he remained until April 3, 2023, because the VA’s physician told the staff persons that the VA required additional antibiotics for the UTI. · P1 stated that the VA’s urine typically had a strong odor because the VA did not drink many liquids. P1 believed that the HCP “did not understand” that it was “baseline” for the VA’s urine to have a strong odor. P5 stated that the VA frequently had problems with his/her catheter not working correctly. P6 stated that the VA had more problems with his/her catheter once the HCP began working with the VA. P1 stated that administrative staff persons were typically responsible for taking the residents to the hospital. According to the hospital’s Discharge Order, on March 30, 2023, the VA was admitted to the hospital for a UTI and was prescribed an antibiotic for the UTI. Facility documentation showed that P1 – P6 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Conclusion: Consistent information was provided that the VA frequently had problems with his/her catheter. Given that the VA had a permanent catheter, the VA was prone to UTIs. The HCP was contracted to work with the VA on his/her health concerns, including the VA’s catheter. Information was provided that on March 25, 2023, there were concerns about the VA’s catheter, but inconsistent information was provided as to what problems the VA was experiencing with his/her catheter at that time. The HCP told P2 that if the VA continued to have pain or bleed at the catheter site, the VA should be taken to the hospital. On March 28, 2023, the HCP asked P2 why the VA was not taken to the hospital, but P2 was unaware of any health concerns about the VA other than his/her leg bag being loose and causing pain to the VA. On March 29, 2023, the VA was taken to the hospital, where s/he was diagnosed with a UTI and prescribed antibiotics. When the physician determined that the VA required additional antibiotics for the UTI, the VA returned to the hospital for the additional treatment. The HCP recommended that the VA be taken to the hospital on March 25, 2023, but the VA was not taken to the hospital until March 29, 2023. At that time, the VA was diagnosed with a UTI. However, given that the VA had a history of having problems, including bleeding, with his/her catheter; that s/he was prone to UTIs because of the catheter; and that it was unclear if the delay in being seen by a physician caused the UTI, there was not a preponderance of the evidence whether there was a failure to provide care or services to the VA which were reasonable and necessary to maintain the VA’s 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 and determined that the facility’s policies were adequate, but were not followed by the staff persons. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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