|
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: 1070713-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt / Emily Kearns Suspected Maltreatment Reported: Allegation One: It was reported that a staff person (SP) yelled at, swore at, and “physically abused” a vulnerable adult (VA). It was also reported that the VA sustained a black eye. Allegation Two: It was reported that staff persons did not put the VA in a stander for 60 minutes daily, as prescribed by a doctor, resulting in physical decline. During the investigation, it was reported that the VA’s adult undergarment was not changed on June 11, 2023. Date of Incident(s): Prior to August 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) and (2); 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. · The use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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 30, 2023; from documentation at the facility and the VA’s medical records; and through ten interviews conducted with the SP, two facility staff persons (P1 and P2), a facility management staff person (P3), the VA’s two guardians (G1 and G2), a physical therapist (PT), a medical doctor (MD), and two community health care professionals (CHCP1 and CHCP2). Although this investigator met the VA and attempted to conduct an interview, the VA was unable to provide information. The VA’s Support Plan and medical records showed that the VA was non-verbal but could use some hand gestures to communicate when asked yes or no questions (G1 stated that the VA used his/her fist to “shake” side-to-side for “no” and up and down for “yes”). This was dependent upon the VA’s dexterity on a given day, which had been on the decline. The VA liked attending movies and professional sporting events, video chatting with his/her family, and sitting outside in the sunshine. The VA’s diagnosis included cerebral palsy, quadriplegia, chronic spasticity, and recurrent aspiration-related pneumonia. P1, a supervisory staff person, stated that overall, communication with the VA declined from when the VA first started receiving services at the facility. The VA was aware of what a person was saying and would be able to point to a communication board, but with the decline in dexterity with the VA’s hands, pointing was not always easy. Additionally, the VA “was not a very good speller,” making it hard for staff persons to follow what the VA was trying to spell, which frustrated the VA. The VA previously would do well with head nodding or holding up fingers, “one for yes, two for no,” or first choice verses a second-choice option regarding answering questions. Some staff persons were able to communicate with the VA using facial gestures such as a smile versus a serious look. The VA never wanted to “tell on” staff persons as s/he “loves [his/her] staff [persons].” P2 stated that the VA was “what I perceive to be a people pleaser,” and would answer questions differently based on how they were phrased. Communication methods with the VA described by P2 were similar to what was described by P1. The facility was a single-floor residence with an open kitchen and living room area. Beyond the kitchen was a hallway with four bedrooms. The VA’s bedroom was in the back, right corner off of the hallway. Facility documentation showed that all facility staff persons interviewed for this investigation were trained on the reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans. P3 stated that an outside source provided stander training to some staff persons, and those staff persons would train newer staff persons, but that the facility did not maintain that documentation. Allegation One: It was reported that the SP yelled at, swore at, and “physically abused” the VA. It was also reported that the VA sustained a black eye. Information from interviews and documentation provided the following information regarding the VA sustaining a black eye: · On August 15, 2023, G1 was at a doctor’s appointment with the VA and the SP. G1 and the MD noticed that the VA had a black left eye. When G1 asked the VA what happened, the SP responded that the VA hit him/herself in the eye. · The SP stated that s/he was told by “my staff [persons]” (no names were mentioned) that they had determined, by asking the VA how s/he had gotten the black eye, that it was a result of him/herself hitting him/herself in the eye on the car ride home from a recent court hearing. The court hearing gave the final decision that the VA would have to move to another facility that could provide a higher level of nursing care. · P1 stated that s/he read facility documentation that the VA was upset with staff persons because s/he would have to move and was able to tense up his/her body and ended up moving his/her arm to “where it connected with [his/her] face.” · P2 stated that the VA “told” him/her that s/he got mad after finding out that s/he had to move and “punched” him/herself in the face. · G1 stated that s/he had “mixed feelings” about how the VA got the black eye and acknowledged that the VA could have done it to him/herself. G1 also stated that the VA protected the staff persons at the facility at times so that there were not “repercussions” to the VA. · When the VA was asked how s/he received the black eye, (G2 did not say who asked) G2 felt like the VA did not want to respond and G2 thought that the VA “did not want to throw anyone under the bus because [s/he] is living there.” G1 stated that at the appointment with the MD, the MD asked the SP to leave the room and G1 asked the VA additional questions in the presence of the MD. When the VA was asked if s/he had been physically abused by the SP, the VA responded by shaking his/her fist indicating “yes.” When the VA was asked if s/he had been verbally abused (specifically, sworn at) by the SP, the VA responded by shaking his/her fist indicating “yes.” When the VA was asked if s/he had been sexually abused by the SP, the VA responded by shaking his/her fist indicating “no.” When the VA was asked if anyone else abused him/her, s/he indicated “no,” with his/her fist. When this investigator spoke with the MD, s/he corroborated G1’s description of the office visit with the VA. On August 22, 2023, CHCP1 saw the VA at the facility and documented that there was no “suspicion of patient abuse, neglect and/or exploitation” but stated that CHCP1 was unable to ask questions regarding abuse due to staff persons being present during the entirety of the visit. P1 stated that the VA thought swearing was funny. A former staff person would say, “What the fuck?” to the VA and the VA would smile. P1 said that G2 would “flip [the VA] off and it would be funny,” but it had never been in a “derogatory way.” P1 added that the incidents were not “aggressive or abusive in any way, shape, or form.” P1 did not have any concerns that staff persons were “mistreating” the VA. P2 stated that s/he had no concerns as to how staff persons were treating the VA other than newer staff persons had challenges communicating with the VA and understanding the VA’s needs or wants. P2 had not witnessed any swearing or yelling at the VA by staff persons. The VA would communicate to P2 if s/he was unhappy or if the VA had been “verbally” or “physically abused.” The following information was obtained from CHCP2 in an interview and from documentation at the facility: · CHCP2 met the VA on or around July 13, 2023, and asked the VA if s/he was being “abused.” The VA indicated “yes” by moving his/her hand up and down. Present at this time, were G2 and the SP. CHCP2 stated that the SP seemed “surprised” by this and acted like s/he “didn’t know what it was about that [the VA] was indicating [abuse.]” CHCP2 stated that during the appointment, the SP was in the room approximately 75% of the time. CHCP2 asked the VA if s/he wanted everyone to leave the room, and s/he was “okay” with everyone being in the room. When the VA was asked if s/he felt safe, the VA indicated “yes.” CHCP2 tried to ask the VA if the “abuse” was physical, emotional, or financial, and the VA was unable to indicate either way for each question. Per CHCP2’s notes, the VA indicated “yes” to physical abuse. In the narrative of the notes for the visit on July 13, 2023, G2 said that s/he believed that the VA was indicating “yes” due to getting “aspiration pneumonia” twice in the past. At this visit, it was determined that the VA would start receiving weekly home health care visits. · On August 22, 2023, CHCP2 documented that there was no “suspicion of patient abuse, neglect and/or exploitation.” G2 provided the following information: · During the assessment (July 13, 2023) for the VA with G2, the SP, the VA, and CHCP2, CHCP2 asked the VA if s/he was “abused.” The VA used the “wrist movement” to indicate “yes.” When asked if the VA said what type of abuse, G2 said it was not sexual abuse. When CHCP2 asked the VA who abused him/her, the VA did not respond and it did not seem like the VA wanted to say at the time. G2 stated that it might have been because the SP was in the room. Later in the assessment, the VA indicated, via shaking his/her wrist, that P2 and the SP “weren’t treating [him/her] very well.” G2 did not know what the VA meant. · When the VA was asked by G2 if staff persons were checking in at night as they were supposed to (hourly), the VA indicated “no.” G2 thought this upset the VA. The VA was supposed to be moved from side to side to avoid getting bedsores. As a result, G2 wanted to put a camera in and was told that it could only have video. So, during the first part of July 2023, G2 put a camera in the VA’s room, but within the hour, staff persons had turned the camera off, saying it could not be in there. The following day, the VA received an eviction notice. The SP’s recollection of the conversation regarding the VA’s answers about abuse at the facility was consistent with the information provided by CHCP2 and G2. The SP said that s/he did not swear or raise his/her voice at the VA, even in a joking manner, and did not swear while at work. The SP was aware of a former staff person who swore in the presence of the VA in a joking manner and the VA would laugh. In the past, the VA kicked and hit the SP several times but then there were days when the VA thought the SP was the “funniest person on the earth.” The SP denied being physically abusive towards the VA. Conclusion for Allegation One: Information provided by G1, G2, the MD, and CHCP2, showed that when the VA was asked by the MD if s/he was specifically physically and verbally abused by the SP, the VA indicated “yes” by shaking his/her fist. CHCP1 and CHCP2 each documented that there was no “suspicion” that the VA was being abused. However, when both CHCP1 and CHCP2 talked to the VA, other persons were present in the room, including the SP. P1 and P2 had no concerns regarding how staff persons were treating the VA and the SP denied physically abusing or swearing at the VA. Given the context and the manner in which the VA was asked questions, coupled with the VA’s limited ability to provide detailed answers to the questions, as well as there being no corroborating information to support whether abuse took place and that there was a reasonable explanation for the only noted injury to the VA which was a black eye that the VA told others s/he inflicted on him/herself, there was not a preponderance of the evidence whether the SP or any other staff person engaged in conduct that would be reasonably expected to produce pain or emotional distress to the VA. It was not determined whether physical or emotional 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 and/or the use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening). Allegation Two: It was reported that staff persons did not put the VA in a stander for 60 minutes daily, as prescribed by the doctor, resulting in physical decline. During the investigation, it was reported that the VA’s adult undergarment was not changed on June 11, 2023. The stander consisted of a padded chair with a strap to go around the waist area with a seatback mounted onto a frame. There were platforms for two feet with straps to keep the feet or shoes on the platforms. A tray was in the front and was hinged to fold down flat, or up and out of the way. When flat, the front of the tray had an adjustable pad, designed to make contact with the user’s stomach, providing additional support. There were two adjustable arm bars. On either side of the arm bars were adjustable poles with grips for the user to hold on to while standing. Two curved pads were attached to make contact with the front of the legs to keep them straight when the user was standing upright. A bolster was placed on the lower back area of the seat, but was not attached to the stander. (Investigator’s note: When attempting to get documentation of a doctor’s order for use of the stander, facility staff persons were unable to locate it, but said that the VA had been using the stander for years). G1 provided the following information: · G1 believed that the VA had not been in his/her stander for over two years. Several years back, the VA was previously using the stander for 60 minutes per day. In the last year, the VA’s posture was “more slouched,” with weakened strength and mobility in his/her legs. · G1 stated that G1 and G2 were told by staff persons (G1 did not give names) that newer staff persons were not trained to use the stander. At the request of G1 and G2, CHCP1 visited the facility and told G1 and G2 that it was hard to get the VA into the stander. G1 and G2 talked to the physical therapist (PT), who worked with the VA for many years, who told G1 that the VA should have been using the stander at least 10-15 minutes per day to increase his/her strength. The PT also told G1 that the stander at the facility was the same stander that the VA used with the PT at the PT’s clinic. · G1 requested that CHCP1 do a training with facility staff persons on the use of the stander. (Facility documentation showed that this occurred on August 22, 2023.) · G1 was also concerned that on June 11, 2023, the VA was left in his/her soiled sheets for too long after urinating. (Facility documentation showed that on June 11, 2023, the VA had a fever, so s/he was given medication and staff person checked on the VA “frequently.” G1 and G2 were at the facility that day and assisted the VA to shower and change. Cares were noted and completed that day.) The following information was obtained from CHCP1 in an interview and from documentation at the facility: · CHCP1 was not sure when the VA began using the stander as s/he had recently taken over the VA’s case, but believed that the stander orders came from the PT. · CHCP1 thought that the VA was required to use the stander due to limited mobility from having cerebral palsy and needed to build up muscle strength in his/her legs. The VA should have been in the stander daily for one hour. This would have previously been a two-person transfer, but after the most recent home assessment, if the VA needed to go in the stander, s/he would need three or more persons to assist with getting the VA in and out of it. Additionally, CHCP1 told G1 that s/he no longer felt safe putting the VA in the stander because the VA was at a greater risk using it than not using it at all due to the VA’s “postural deformities.” CHCP1 stated that the VA’s inability to properly use the stander would have “come to light sooner” had staff persons been using it. · After CHCP1’s assessment of the stander, s/he determined that if the stander was used, s/he was concerned that specific injuries such as skin tears/breakdowns and additional sores due to friction would occur. There were many parts on the stander that could catch the VA’s legs or elbows. Manually bending the VA’s legs to get him/her in the stander properly could injure the VA while attempting to force his/her legs to go into the right position. The VA’s “head and neck kind [of] slouch down” with his/her current posture, so lifting the VA’s head and neck back would put him/her at risk for injury as well. · CHCP1 said that not using the stander as prescribed would “progress the loss of muscle tone.” “It’s not just from using the stander but also [the VA’s] disease progressing. So, the goal of the stander was to kind of slow the progression of the disease.” · Staff persons told CHCP1 that they were not using the stander because they “were not trained and every time they scheduled a training, the non-trained staff [persons] would not show up.” CHCP1 said that s/he knew of three staff persons, including P2 and the SP, who were trained on using the stander but was unsure how many total staff persons worked at the facility. · CHCP1 told the MD and G1 that the VA should no longer use the stander. P1, a supervisory staff person, provided the following information: · P1 felt like there had been a lot of recent changes with staff persons that were difficult for the VA. It took a while for new staff persons to be able to understand the VA’s communication skills and as a result, the VA did not seem as happy anymore. The VA would “hold grudges” such as refusing cares from staff persons, and it would not be one staff person, it would be all staff persons. · G1 and G2 brought concerns forward about the VA’s care, such as the VA not making it to appointments, the VA was being left in bed, and the VA was once “wet” when G1 and G2 came to visit the VA. P1 felt that some of these concerns were due to staffing levels, especially during Covid-19, and that on some occasions, the VA refused to go to appointments due to the VA’s pain level. · The VA’s stander had been broken a lot during the last several years. The service company would come out to fix it and would need to order new parts. Due to Covid-19, parts would be backordered. One thing might get repaired, but then something else on it would not work, or the parts “would not fit right,” making it unusable. Then, new staff persons would need to be trained on how to use the stander and the VA had to willingly participate to go in the stander for staff persons to be trained. Most recently, the VA’s mobility had changed so the VA no longer sat the same way in the stander. P1 also suggested that a new stander could be ordered, but that those types of decisions were handled by G1 and/or G2. · P1 was unsure, historically about how many years the VA had been using the stander, but it was before P1 started working at the facility. At the time, when it was in regular use, the stander functioned well, but the VA did not have as many mobility or dexterity issues at that time. The VA was stiffer in his/her body now, so s/he was not able to move as much. More recently, the VA’s tolerance for length of time being in the stander had declined. · In place of the stander, P1 stated that the VA would do physical therapy exercises and stretches with staff persons seven days per week, two times a day. Physical therapy exercises for the VA were posted in the VA’s bedroom, and if the VA was tolerating it, they would take about 20 minutes to stretch the VA’s body out. On certain days, the VA would refuse lower or upper body exercises if s/he could not tolerate it. For safety reasons, since the VA was “very tall,” there was not really a safe way to stretch the VA without using the stander. During this time frame, the VA continued to attend a fitness center twice per week (Tuesdays/Thursdays), and physical therapy on Wednesdays and Fridays.
· The VA would sometimes refuse to use the stander because when s/he would use it, the VA’s fists would be balled up in his/her face. Additionally, when the VA was in the stander, the VA would get “very, very upset to the point of like kicking, trying to hit” staff persons. The VA had been needing increased medical help and the facility no longer felt that they could provide that level of care. · The stander was broken for approximately six to eight months of the year and P2 thought the VA had used the stander, “three times at the max” in that time. The VA needed to be willing to go in the stander for them to train new staff persons and recently the VA refused to use the stander. Staff persons could not force the VA to use the stander. P2 added that recently CHPC1 put the use of the stander on hold. The SP provided the following information: · The SP stated that the VA had not used the stander aside from approximately four times for training purposes. The SP corroborated that the stander was not always working, that parts were backordered, and when the stander was finally fixed, it “didn’t fit [the VA]” and the SP had “never seen [the VA] in it where [the VA was] comfortable.” The stander was adjusted and/or fixed multiple times by the repair technicians to get it to fit the VA properly, and “because [the VA] deteriorated more,” it still did not fit. · The SP stated that the VA did exercises with staff persons in the morning and afternoon, unless the VA was in pain, or had already completed a portion of them that day at physical therapy. · Some noted changes to the VA’s physical condition from when the SP started at the facility in June 2022 to current were that the VA’s head was “more slouched,” both knees were more bent, his/her back was more curved, and more equipment was used to safely move the VA from location to location. · The SP was trained on the use of the stander by either CHCP1 or CHCP2. The SP stated that recently while s/he and another staff person were putting the VA into the stander, CHCP1 had them stop and said, “This isn’t safe for [the VA].” The PT provided the following information: · The PT could not remember when the doctor’s orders for the stander originated, but the VA had the stander for probably four or more years. When the stander was first being used with the PT, the VA used the stander daily. At that time, the VA was not able to tolerate it for very long but began to increase the time s/he spent on it. The PT was aware that there were concerns that the stander was no longer being used and thought that it was due to staff persons not being trained on how to use the stander. · The PT would see the VA twice per week and described that in the past year, the VA’s range of motion had decreased while his/her hypertonicity increased. The PT stated that this could be due to the stander not being used. When asked why the VA’s hypertonicity might have increased, the PT stated that the VA’s “progression of [his/her] medical condition,” could cause that. G2 stated that in the last year, the VA's condition was “deteriorating” and that s/he was rigid and tight, but that was “part of the disease.” Facility documentation showed that from August through December of 2021, the VA used the stander a total of 21 times. In 2022, the stander had been used a total of 24 times, and from January through August 2023, it was used 14 times. Facility documentation also showed that the stander was repaired and parts were ordered on several occasions. Conclusion for Allegation Two: Although G1 and G2 were concerned that stander was not being used over the past few years, information showed that during some of that time the stander was broken, that parts were on backorder, and that it was in various stages of repair, preventing its use. Other times, the VA refused to use the stander or did not fit properly in it, possibly due to decline in the VA’s posture and dexterity. Additionally, there was not always enough staff persons available to safely get the VA into the stander and some staff persons were not trained to help the VA into the stander. Despite the VA’s lack of regular use of the stander, when CHCP1 and CHCP2 got involved to assess the use of the stander, they both determined that the stander should not be used due to safety and possible injury concerns to the VA. Information also showed that over time, the VA’s health condition deteriorated, and it was not determined how the lack of use of the stander could have contributed to the VA’s decline. However, information showed that staff persons regularly completed physical therapy exercises with the VA and the VA attended physical therapy. Although G1 had concerns that the VA’s bedding was not changed on June 11, 2023, documentation showed that the VA had a fever that day, that G1 and G2 were at the facility and helped the VA with a shower, and that the VA’s cares were completed. Although the VA was not regularly using the stander and not having enough staff persons available who were trained on the stander was one contributing factor, given that some of the time the stander was not in working order, some of the time the VA refused to use the stander, and it was determined that the VA was no longer able to safety use the stander because of decline in his/her health, there was not a preponderance of evidence that there was a failure to provide the VA with reasonable and necessary care and services to obtain or maintain his/her physical 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 and determined that policies and procedures were adequate and followed. There were no similar events that occurred. The facility retrained staff persons on “professional conduct” related to “swear words” and continued stander training once the stander issues were resolved. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
