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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: 1071660-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that on December 10, 2023, a vulnerable adult (VA) experienced leg pain and medical care was not sought until December 12, 2023, at which time the VA was diagnosed with a blood clot in his/her leg. Date of Incident(s): Prior to December 12, 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 for this investigation was obtained remotely; from documentation from the facility and the VA’s medical records; and through seven interviews conducted with the VA, the VA’s guardians (G1 and G2), the VA’s case manager (CM), a management staff person (P1), a facility staff person (P2) and the VA’s medical doctor (MD). Although this investigator contacted another staff person (P3), P3 did not respond to requests to be interviewed. The VA’s Action Plan showed that s/he was a “sociable person” with a “great sense of humor.” The VA used an electric wheelchair for mobility. The VA’s support plan showed that some of his/her diagnoses included cerebral palsy and a mild developmental disability. The VA’s Health Needs Record showed that the VA had a history of blood clots, which could include symptoms such as “pain, swelling in extremities, tenderness or warm skin.” As a result, staff persons were to “monitor” the VA “daily for changes in [his/her] condition.” FM1 provided the following information: · On December 11, 2023, the VA, who had a history of having a blood clot in his/her right leg in 2020, called FM1 and was “crying” because the VA’s left leg was “in pain.” FM1 described the VA as being “emotional.” · Shortly after the call began, the VA handed the phone to P2. P2 told FM1 that the VA’s leg was “hurting,” and that the VA had been receiving pain medication “all weekend.” When FM1 asked P2 if s/he had contacted P1, P2 said that P1 was not working that weekend. FM1 stated that s/he was “frustrated” by this. · Later on December 11, 2023, the VA called FM1 again and wanted to go to an emergency room (ER) because the VA had a “lump” on his/her leg. Because the VA had previous “fatty cysts” on his/her leg, FM1 told the VA that it was not necessary to go to the ER for that and the VA should tell staff persons the next day to take him/her to urgent care. · The following morning, December 12, 2023, FM1 received a phone call from P1. P1 told FM1 that the VA was being transported to the hospital because his/her leg was “severely swollen.” The VA was transferred to a different hospital for treatment and it was determined that the VA had a blood clot in his/her left leg. While the VA was hospitalized, it was determined that the VA did not have a femoral vein, which “further complicated things” in terms of the VA’s treatment for the blood clot. FM2 said that on December 10, 2023, FM2 saw the VA at the facility. Upon arrival, P2 told FM2 that the VA “was not feeling the best.” When FM2 went to the VA’s bedroom, the VA was in his/her wheelchair. FM2 gave the VA, who was wearing long pants, some snacks and asked the VA if s/he was in pain. The VA said that s/he “was a little better.” FM2 did not see the VA’s leg at the time. The facility’s staffing schedule showed that P1-P3 were the staff persons that worked at the facility between December 10, 2023, and December 12, 2023. The VA provided the following information: · Since the time that the VA was born, the VA had “no feeling” in his/her left leg. · When FM2 visited the VA on December 10, 2023, the VA did not have any leg pain. · The VA did not remember the date but remembered that his/her left leg was swollen in the morning and that the VA had difficulty getting dressed. When that happened, the VA went to the hospital. Prior to that day, the VA did not have swelling in his/her leg. · The VA did not remember requesting pain medication from staff persons prior to going to the hospital. The VA did not remember calling FM1 prior to going to the hospital. A review of the VA’s medication administration record for December 2023, showed that s/he received Tylenol for pain two times, December 9 and 10, 2023, and the reasons cited were “headache, fever, minor aches and pains.” The VA’s medical records showed that the VA was initially seen at one hospital, but then transferred to a different hospital and admitted on December 12, 2023. The VA was diagnosed with a blood clot, treated with a variety of medications, and had an “abnormal common iliac vein that is either congenitally absent or chronically occluded, the procedure was not as successful as hoped.” The VA was discharged from the hospital on January 29, 2024. The MD stated that the onset of a blood clot varied and could take “days” or “weeks” to show symptoms. The MD also stated that pain from a blood clot could be “variable” and because the VA was missing a “particular vein” in his/her left leg, the blood clot could have formed for that reason. P2 provided the following information: · P2 did not remember specific dates but remembered that the VA was previously on some type of medication used to “prevent” blood clots and FM1 talked to the VA’s doctor to have that medication discontinued about one month prior to the VA having the blood clot. · At some point on December 11, 2023, the VA asked P2 to look at his/her legs. When P2 did that, s/he noticed that the top of the VA’s left “foot” looked “quite swollen, but the VA did not have complaints of pain. P2 called P1 and P1 told P2 to “watch” the VA and let him/her know if symptoms worsened. At some point, the VA asked to talk to FM1 and during that conversation, P2 talked to FM1, P2 told FM1 that the VA’s foot was a “little bit swollen.” FM1 told P2 that s/he should watch the VA and to call if symptoms worsened. · P2 worked the overnight shift from December 11, 2023, into the morning of December 12, 2023. On the morning of December 12, 2023, the VA’s left leg “looked about the same” as the day before. P2 did not observe any swelling on the VA’s leg and did not see any changes in the VA’s sleeping habits that night. · P2 did not remember the time that s/he left on the morning of December 12, 2023, but remembered that P1 came into work and later that day, P1 told P2 that the VA had been taken to the hospital because his/her left leg looked “really bad.” P1 stated that P2 called him/her on the afternoon of December 11, 2023, because the VA’s left foot was a “little red.” P1 told P2 to put the VA’s feet “up.” When P1 saw the VA the following day, December 12, 2023, the VA was sleeping on the couch and told P1 about some “sores” in the VA’s private area. When P1 asked the VA to come to the office so P1 could evaluate the sores, P1 assisted the VA with removing his/her pants and noticed that the VA’s left leg was “swelled up.” As a result, the VA was taken to the hospital. P1 stated that it was not uncommon for the VA’s legs to be somewhat red because the VA had “poor circulation.” FM1 also said that when the VA had the blood clot in 2020, the VA was put on Eliquis (a medication used to treat blood clots), the VA was only supposed to be on that medication for three months and in October 2023, FM1 realized that the VA was still taking that medication so s/he asked the VA’s doctor to discontinue it so it was. The facility’s Physical Examination Form for the VA, dated October 2, 2023, showed that the Eliquis was discontinued. Information from the investigation also showed that the VA previously was ambulatory but began using the electric wheelchair for mobility within the past year. The VA’s case notes provided the following information: · On December 10, 2023, P2 documented that the VA “didn’t feel well” and “hurt” his/her left side by his/her “ribs” and received pain medication. · P2 also documented on December 11, 2023, that the VA had pain medication for “pain under ribs.” · On December 12, 2023, P1 documented that when the VA went to the office to “show staff [persons] a sore [the VA] had in [his/her] groin area and staff [persons] noticed that [his/her] leg was swollen.” The VA was taken to the hospital. The facility’s training records showed that P1 and P2 were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to December 12, 2023. Conclusion: According to FM1, the VA called him/her on December 11, 2023, due to leg pain, but the VA did not recall that conversation. There was no documentation from the facility and no information from staff persons that showed that the VA had leg pain. According to P2, the VA called FM1 on December 11, 2023, and wanted to go to the ER because the VA had a “lump” on his/her leg, but because the VA previously had “fatty cysts” on his/her leg, FM1 told the VA that it was not necessary to go to the ER. On the morning of December 12, 2023, P1 noticed that the VA’s left leg was “swelled up” so the VA was taken to the hospital, but transferred to another hospital. The VA was admitted, treated with various medications, and it was determined that the VA had a blood clot in his/her left leg. The VA was discharged from the hospital on January 29, 2024. Although it was reported that the VA had leg pain which ended up being caused by a blood clot and that staff persons did not seek medical care, given that there was no information from staff persons or the VA that the VA had leg pain and that once P1 noticed the VA’s leg was swollen medical attention was sought, 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 Investigation and the information contained in that report was similar to the information in this report. The review also showed that policies and procedures were adequate, followed, and that no additional training was needed. Action Taken by Department of Human Services, Office of Inspector General: No action taken at this time.
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