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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: 1069030-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that on July 17, 2023, a vulnerable adult was taken to the emergency department of a hospital with low sodium, anemia, and abnormal labs. The VA was diagnosed with “re-feeding syndrome” and had a pressure sore on his/her coccygeal region. Date of Incident(s): Prior to July 21, 2023 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on October 26, 2023; from documentation at the facility and the VA’s medical records; and through interviews conducted with facility staff persons (P1, P2, and P3), the VA’s guardian (G), and a community health care professional (CHCP). This investigator met the VA, but s/he was non-verbal and unable to provide information. Facility documentation showed that the VA was diagnosed with a seizure disorder, microencephaly, cerebral palsy, osteoporosis, and a developmental disability, and was vulnerable to all forms of maltreatment. Staff persons who provided care to the VA were health care professionals (HCPs) who were supervised by an HCP with an advanced degree. The VA was diagnosed with colon cancer in November of 2020 and the cancerous parts of his/her colon were surgically removed and s/he had an ileostomy procedure at the same time to pass feces out of his/her digestive system into an ileostomy bag. The VA had a wheelchair for mobility, continuously used oxygen, and previously used a ventilator at night to ensure adequate ventilation and reduce the level of carbon dioxide in his/her blood. The VA’s Quarterly Health Reviews (QHRs) from July 1, 2022, to June 30, 2023, showed that on February 12, 2023, the ventilator was discontinued. However, staff persons were to take at least two full tanks of oxygen with the VA when they went out on community outings. Eye contact, facial expressions, and some vocalizations helped the VA communicate his/her wishes, but s/he did not use spoken language. The VA might smile, make eye contact, or laugh to say “yes” or to communicate happiness, and might kick his/her legs and shake his/her arms when s/he was excited. The VA might cry, wince, or vomit when s/he was in pain or uncomfortable, and might say “no” by looking down, grimacing, crying out, or moaning. Staff persons were to monitor the VA for signs or symptoms of illness or injury and check on the VA “constantly” according to his/her One Page Description because s/he had a tracheostomy which might make it difficult for staff persons to hear him/her. The VA’s heart rate went down when s/he was cold and staff persons were to check the VA’s temperature and implement the Hypothermia Protocol as needed and dress the VA appropriately each shift to prevent hypo/hyperthermia. The Hypothermia Guidelines showed that staff persons were to monitor the VA’s temperature four times a day and as needed at the facility. If the VA’s tympanic (ear) temperature was 96.5 degrees Fahrenheit (F) or less, warming techniques were to be implemented including putting a hat and additional clothing or blankets on the VA, then monitoring his/her temperature hourly until it reached 97.6 degrees F. Staff persons then removed hats, clothing, and blankets to prevent the VA from overheating. The VA was unable to reposition him/herself, was vulnerable to skin breakdown at pressure points, and had a long history of getting pressure sores on the coccyx and heels. The VA used adult briefs that staff persons were to change every two hours and his/her skin was monitored daily when staff persons assisted the VA with hygiene tasks. The VA was to be in the wheelchair for two hours at a time, but time in the wheelchair was flexible to allow for activities. Staff persons ensured that the VA was seated in the wheelchair correctly by positioning the VA’s back flush against the wheelchair. When the VA was not in the wheelchair, staff persons were to reposition him/her every two hours. The VA could lie on his/her sides or his/her back, or on a futon or his/her bed on an air pressure mattress in positions s/he chose for one to two hours provided that the VA’s spine was aligned, and his/her hips were supported. Staff persons did passive range of motion exercises with the VA five to seven times a week. The VA received nothing by mouth and was given all nutrition/hydration via a feeding tube according to his/her Self-Management Assessment (SMA). On November 10, 2022, a Medical Referral Form showed that staff persons noted that the VA gained two pounds, so s/he was evaluated by a physician and a dietician instructed staff persons to give the VA 3.3 cans of liquid nutrition plus 830 milliliters (mls) of water and nine scoops of beneprotein at a rate of 100 mls per hour which was a slight decrease in the VA’s caloric intake. Staff persons were instructed to schedule a follow up appointment for the VA in nine months to determine whether the plan was working, which would have been in early August of 2023. No other changes were made to the VA’s nutrition. If the VA had a medical emergency, staff persons were to call 9-1-1 if it was a life-threatening, then contact a facility HCP or supervisory staff person for instruction about additional care for the VA. The VA’s QHRs showed that the facility was aware of a recurring pressure sore on the VA’s coccyx, which was treated with daily cleansing, and applying a thin layer of protective barrier cream on the sore two to three times a day and as needed in 2022 and 2023. No recent edema was noted in the QHRs, but in August of 2022, the VA had mild edema in his/her left leg that resolved with elevation and compression by December of 2022. The VA enjoyed visiting with his/her family members, listening to music, and going on community outings. Facility documentation, the VA’s medical records, and interviews with this investigator provided the following: · The CHCP said that on July 17, 2023, the VA was evaluated at a hospital for low potassium, low sodium, and abnormal laboratory (lab) blood test results, then admitted. The facility had the abnormal lab results for three days before the VA was brought to the hospital and took no action according to the CHCP. In addition, the VA was anemic upon admission. · It was discovered during the July 2023 hospital admission that there was a seton (a thin rubber drain to prevent abscess formation) inside the VA’s body likely from a previous surgical procedure. A review of the VA’s records with the hospital’s health care system showed that the VA had surgery for colon cancer and ileostomy placement at the hospital in November of 2020, but the facility did not bring the VA for timely follow up appointments after the surgery. The seton was removed in July of 2023. Information regarding the unexplained seton within the VA’s body was referred to the Minnesota Adult Abuse Reporting Center. · During the July 2023 hospitalization, the VA was diagnosed with “re-feeding syndrome” which was an electrolyte imbalance that might affect multiple organ systems that occurred as a complication for persons who received artificial nutrients. Possible complications from refeeding syndrome might include blood pressure changes, bowel obstruction, cardiac arrest, heart rhythm changes, paralysis, seizures, respiratory problems, confusion, diarrhea, or fluid retention. It was better to prevent refeeding syndrome, but it was treated by adjusting the nutrition formula, then taking steps to correct electrolyte imbalances. · The VA’s medical records showed that on July 17, 2023, s/he was admitted to the hospital and diagnosed with a urinary tract infection (UTI) with sepsis, hyponatremia (low sodium levels), and anemia. Tests to determine whether the VA was bleeding internally determined that there was no internal blood loss. The VA initially required care in the intensive care unit but was soon moved to the “general medicine ward.” The VA’s low sodium “over corrected” and s/he required increased water via the feeding tube to bring the levels to normal. The VA frequently had UTIs and aspiration pneumonia, and his/her bowel movements at the facility had recently been watery, which might have resulted in abnormal lab results. The VA developed pneumonia on July 21, 2023, and was treated for it through August 1, 2023. The seton that was discovered inside the VA’s body was removed, but the VA did not “appear to be having losses from there.” · A physician at the hospital who evaluated the VA wrote that the VA’s sodium levels were likely initially too low because the VA received a smaller than required amount of liquid nutrition. The VA was evaluated by a hospital dietician and his/her nutritional recommendations were changed with input from a facility dietician. The VA responded well to changes in his/her diet and the UTI was successfully treated. A physician later documented that it “appear[ed] that inadequate nutrition stemmed from [the] formula itself not due to lack of scheduled feeds.” The VA’s discharge examination showed that his/her vital signs were within normal limits except his/her pulse, which was 107 beats per minute. The VA’s sodium levels were stable for the week prior to his/her discharge from the hospital on August 2, 2023, back to the facility. · Regarding follow up after the colon cancer surgery and ileostomy, facility Progress Notes showed that on December 16, 2020, the VA had a follow up appointment at a specialty clinic where staff persons learned how to correctly care for the VA’s ileostomy. A physician evaluated the VA and determined that no follow up appointments were needed according to the Notes. All surgical incisions were free from infection and healing well. · P1 (an administrative staff person) said that the VA received much of his/her medical care at the facility because it was difficult for the VA to make frequent trips to health care providers in the community. The VA’s primary care physician (PCP) visited the VA at the facility at least once monthly and more often when needed. A company that drew the VA’s blood for lab testing also came to the facility as needed. Information in the VA’s records at the facility showed that a written referral from a hospital in July of 2023 mentioned the seton, and that notes from a physician at the hospital stated that the VA was doing well. The seton was not likely a contributor to the VA’s medical concerns in July of 2023, according to the referral. · P2, a supervisory staff person who was also an HCP with an advanced degree, said that the VA’s blood was drawn on July 14, 2023, because the VA took a medication prescribed for seizures and the level of the medication in the VA’s blood was routinely evaluated. The facility became aware of the VA’s abnormal lab test results on July 17, 2023, when the PCP’s office contacted the facility with the results. The facility was instructed to have the VA evaluated at the emergency department of a hospital and staff persons immediately took the VA to the hospital. There was no delay in seeking care for the VA when the facility became aware of the abnormal lab results. · P1 and P2 were not aware of new or unusual changes to the VA’s blood pressure or bowel output or consistency after the July of 2023 hospitalization. No information showed that the VA had cardiac arrest, heart rhythm changes, paralysis, seizures, respiratory problems, confusion, diarrhea, or fluid retention that varied from his/her baseline condition after s/he was discharged from the hospital. · The VA’s Medication Administration Records (MARs) Progress Notes, and wound care documentation at the facility showed that the VA was given liquid nutrition and beneprotein as specified on the MARs. Staff persons noted various concerns with the VA’s skin in the Progress Notes and documented treatments of skin issues, the VA’s intake and output, and assistance provided with hygiene tasks multiple times each day and as needed. · A Progress Note from July 17, 2023, showed that the VA’s PCP’s office called and instructed staff persons to take the VA to the hospital for low potassium levels, lethargy, and a high white blood cell count. The VA was immediately taken to the hospital and was admitted. On July 28, 2023, the facility was planning for the VA’s discharge and revised his/her dietary plan with the assistance of a hospital dietician. The VA had a gradual weight loss on the previous diet and lost 11.3 pounds between January 10 and July 11, 2023. Upon returning to the facility, staff persons were to give the VA a different brand of liquid nutrition that would provide the VA with a higher caloric intake, more protein, and a better balance of vitamins and minerals (including potassium chloride) than the previous regimen and increase the amount of water the VA received daily. · Progress Notes for the VA from December 11, 2020, to early late June of 2023, were reviewed and showed that the VA’s weight fluctuated between 115 and 126 pounds, and the amount of his/her recommended liquid nutrition was adjusted by dieticians based on his/her weight. On February 17, 2021, a dietician from a hospital told staff persons that the VA’s goal weight was between 110 and 116 pounds. On July 21, 2021, the VA had an initial appointment with his/her present PCP, who ordered baseline lab tests. Staff persons checked the VA’s skin daily for potential problems and documented any concerns in the Notes. · On January 12, 2022, a dietician from a hospital instructed staff persons to decrease the VA’s liquid nutrition to the level it was when the report was received (from 4.5 cans of liquid nutrition to 3.5 mixed with 830 mls of water) and increased the number pf beneprotien scoops from 7 to 9 to give the VA additional protein to heal the wound on his/her coccyx, but also resulted in a 200 calorie decrease per day. The dietician scheduled a follow up appointment in four months to determine whether the nutrition plan maintained the VA’s weight between 100-117 pounds. On February 7, 2022, the VA was evaluated by his/her PCP, and the VA weighed 127.4 pounds, but no issues were noted, and a follow up appointment was to be made in six months or sooner if there were dramatic changes to the VA’s weight. The VA was evaluated monthly or more often, if necessary, by his/her PCP, and was evaluated or had appointments several times each month with physicians who specialized in gastroenterology, dermatology, sleep, neurology, oncology, and other fields during the same time frame. No issues regarding weight or sores noted, but when concerns were raised about other matters, documentation consistently showed that staff persons followed up with medical providers and monitored the VA’s health. The G felt that the facility provided excellent care to the VA and was upset that maltreatment was alleged. Personnel files showed that the facility trained its staff persons on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, and the VA’s plans of care prior to July of 2023. Conclusion: The VA had several serious diagnoses and required extensive care at the facility. HCPs cared for the VA, and they were supervised by an HCP with an advanced degree. In addition, the VA’s PCPs evaluated him/her at least monthly, his/her blood was drawn monthly, and the facility was updated on any abnormal lab results. The VA had a history of skin breakdown especially on the heel and coccyx and his/her weight fluctuated. In November of 2020, the VA was diagnosed with colon cancer and had surgery to remove the cancerous parts of his/her colon and had an ileostomy surgery at the same time. On December 16, 2020, the VA had a follow up appointment, which determined that no additional follow up appointments were needed. On July 14, 2023, the VA’s blood was drawn at the facility and on July 17, 2023, the PCP’s office contacted the facility and instructed staff persons to take the VA to a hospital because the VA’s potassium and sodium levels were low. The VA was taken to the hospital and admitted, then diagnosed with re-feeding syndrome, urinary tract infection with sepsis, low sodium levels, and anemia. In the hospital, the VA developed pneumonia. The CHCP thought that the facility had the VA’s abnormal lab results for three days prior to seeking care for the VA and was concerned about the nutrition the VA received because s/he had re-feeding syndrome. The VA’s health stabilized, and on August 2, 2023, s/he was discharged back to the facility. The VA’s medical records showed that a physician at the hospital documented the VA likely had low sodium levels because s/he received a smaller amount of liquid nutrition than required, but that inadequate nutrition was likely caused by the nutrition the VA received, not because of the frequency with which s/he received it. A hospital dietician and a facility dietician re-evaluated the VA’s nutritional needs together and the VA responded well to the changes made to his/her diet. Although the CHCP said the facility did not seek prompt medical care for the VA and there were concerns that the VA’s nutrition was inadequate, given that the facility immediately took the VA to the hospital when told to, that a physician wrote that the VA’s health problems were likely caused by his/her prescribed diet itself not by missing feedings, and information was consistent that the facility followed the dieticians’ recommendations for the VA, there was not a preponderance of the evidence whether there was a failure to provide the VA with food or health care that was reasonable and necessary to obtain or maintain the VA’s health or safety. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an Internal Review which determined that its policies and procedures were adequate and were followed. Action Taken by Department of Human Services, Office of Inspector General: A report was made to the Minnesota Adult Abuse Reporting Center regarding the seton that was removed from the VA in July of 2023.
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