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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: 1069679-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady/Scout Peterson 651-431-6557 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had falls where staff persons did not assist the VA after the fall; that the VA had bruises from staff person grabbing him/her and another consumer hitting him/her; that the VA was not getting care related to his/her urinary incontinence; and that staff persons were not taking daily blood sugar checks as required. Date of Incident(s): Ongoing, prior to December 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 January 18, 2024; from documentation at the facility and medical records; and through interviews conducted with the VA, four facility staff persons (P1, P2, P3, and P4), the VA’s case manager, and a health care professional and a therapist from an outside agency. The VA’s support plans stated: · The VA’s diagnoses included cerebral palsy, a mild developmental disability, and personality disorder. The VA had an unsteady gait and used a walker to walk short distances and a wheelchair to go longer distances. · The VA was also diagnosed with type 2 diabetes. The VA checked his/her own blood sugar levels once a day and then showed the number to staff persons who were then to document it. Staff persons were to offer the VA foods that would raise his/her blood sugar as little as possible and too many carbohydrates were to be avoided. (There was no information that the VA took medications or had a prescribed diet based on the daily blood sugar levels). · The VA was not subject to guardianship. The VA stated that s/he enjoyed bowling, movies, and reading. Regarding the VA’s falls and injuries. Hospital records stated that on December 5, 2023, the VA was brought to the hospital after a fall off of the toilet. The VA did not hit his/her head. The VA had complaints of weakness for the past week. The VA also complained that another consumer hit him/her in the chest the prior night. A hospital staff person (H) stated that s/he contacted P1 about the consumer hitting the VA and P1 told the H that the VA was not hit by the consumer, but that the consumer did yell at the VA as well as other consumers. The VA stated that s/he needed a higher level of care that the facility was able to provide. P1 told the H that the VA may need a higher level of care if the recent home care services ordered for the VA did not result in the VA having improved mobility. The VA was discharged back to the facility with orders to continue home care including physical and occupational therapy as well as nursing services. Information from P1-P4 and the VA showed that the VA and another consumer did not always get along, but there was no information that there were physical altercations between the two. A health care professional (HCP) from an outside agency provided the following information: · On December 19, 2023, the HCP arrived at the facility to see the VA. The HCP went into the VA’s bedroom and found the VA on the floor, naked. The VA told the HCP that s/he lost his/her balance and fell while grabbing a towel off of his/her dresser to go take a shower. The VA told the HCP that s/he was not injured. Two staff persons were working (the HCP did not know their names) and one staff person said that s/he knew the VA fell and they were about to assist him/her up off the floor. The two staff persons were able to get the VA onto a chair and then the VA used his/her walker to transfer to a recliner chair. · After the VA was in the recliner, the HCP noticed that the VA had an open sore on his/her right leg (.5 by .5 centimeters [cm]), a bruise on his/her upper left arm (3 by 11 cm), and two bruises mid back (1 by 2.5 and 1 by 1.5 cm). The VA stood up and the HCP did not see any other issues with the VA’s skin. The VA was not aware of the bruises until the HCP asked the VA about them. The VA told the HCP that s/he got the bruise on his/her arm when staff persons grabbed him/her and mentioned that a staff person helped him/her up from a fall the prior week. The VA said that staff persons yelled at the VA and on that morning the VA wanted to stay in bed, but staff persons would not let the VA stay in bed. The VA added that s/he did not eat breakfast, but a staff person told the HCP that the VA did eat breakfast. A therapist (T) from an outside agency stated that the VA had frequent falls with minor injuries. The VA stated that s/he fell 30 times in a month. When the VA fell, staff persons came and checked the VA for injuries. The VA was able to get up by him/herself, but staff persons wanted to walk with the VA. The VA said that there were times when s/he fell and staff persons did not immediately come and help him/her. In those instances, staff persons might be working with another consumer before they could respond, but staff persons yelled and asked the VA if s/he was okay. The VA said that that there was another consumer who the VA did not get along with. P1, a supervisory staff person, provided the following information: · At some point, the VA started to have frequent falls. The VA did not trip, s/he just fell. If the VA fell, it was difficult for one or two staff persons to assist the VA back up after a fall. As a result of the falls, P1 made an appointment for the VA to be seen by his/her primary care physician. · The VA was involved in several 9-1-1 calls related to falls. Recently a staff person from an outside agency called 9-1-1 when the VA was on the ground but did not tell P3, who was working at the time. On another occasion, when the VA fell, P1 and P3 attempted to get the VA up off of the floor and called 9-1-1. When paramedics arrived, P1 and P3 had already assisted the VA into a chair. · Staff persons were trained to do body checks on the VA after a fall. On one occasion after a fall, a staff person from an outside agency noticed a bruise on the VA’s left arm. The VA told different stories about what happened to cause the bruise. The VA was not always accurate about events, so it was not known how s/he received the bruise. P3 provided the following information: · One time a staff person from the outside agency called 9-1-1 and said that the VA was “not okay” and needed to go to the hospital. P3 did not see anything wrong with the VA. Paramedics arrived and asked the VA some questions. The VA said that s/he was not going to go to the hospital. The VA’s vital signs were normal. The VA signed a document that s/he did not want to go to the hospital and P3 signed the document as a witness. · One day, P3 arrived at the facility and P1 and the VA were in the bathroom. P1 and a staff person from the outside agency tried to get the VA up off of the floor. The VA had feces in his/her mouth so the VA was taken to the hospital. · On another occasion, P3 was not sure of the date, a staff person from the outside agency saw a bruise on the VA’s leg. P3 assisted the VA with a shower earlier that day and did not notice the bruise and did not know how the VA received it. · The VA did not always give accurate information when asked questions such as information regarding dates and times. P2 stated that the VA would be walking and then look like s/he was going to fall. When it looked like the VA was going to fall, the VA usually just sat down on the floor. When the VA fell, staff persons checked the VA for injuries. Recently, the VA showed signs of being weaker so s/he went in for an appointment and therapy was ordered for the VA at the facility. P2 was not aware of the VA having injuries as a result of falling. P4 stated that one time in the morning during a shower, s/he noticed a quarter sized mark on the VA’s right thigh. It looked like a pinch mark. P4 was aware of one fall by the VA in November 2023 and was not aware of anytime the VA was transported for medical care as a result of a fall. Regarding the VA’s blood sugar levels The HCP stated that the VA was supposed to have his/her blood sugar levels checked once a day. One day, the HCP requested recent blood sugar levels, but the staff person working was only able to get the results from the day before as s/he could not get the prior results off of the computer where they were documented. The HCP looked at the VA’s glucometer readings and there was not a reading for everyday as required. The times on the glucometer showed that checks were completed at 1:30 a.m. The staff person told the HCP that the time was set wrong on the glucometer and that the blood sugar levels were tested in the evening. The VA stated that s/he tested his/her own blood sugar level once a day in the evening. After, staff persons documented the reading. According to documentation regarding the VA’s blood sugar levels from December 4, 2023, to January 18, 2024, the VA’s blood sugar levels were not documented on December 5, 6, 7, 10, 13, 14, 15, 17, 20, and 22, 2023. Most of the readings were documented in the evening between 6 and 10 p.m. P1 – P3 each stated (P4 did not work during the time that the VA checked his/her blood sugar levels) that once a day in the evening, the VA tested his/her own blood sugars, told staff persons the reading, and staff person documented it (electronic documentation). P1 stated that there were times where it was not documented. For a couple week period of time one of the staff persons was not able to access the computer program to document the VA’s blood sugar levels. P1 told the staff person to document a late entry when s/he was able to get into the program. Even after P1 and an administrative staff person worked on the computer issue, the staff person was still not able to access the computer program. Regarding the VA’s incontinence The T stated that the VA was incontinent and there was strong odor of urine on the VA and in the VA’s living area. On one occasion, the VA’s bed was statured with urine. P1-P3 each stated that the VA wore incontinence briefs and that they were checked every two hours. The VA did not always cooperate with having his/her brief changed. P4 worked the overnight shift and changed the VA’s brief in the morning and if P4 worked during the day s/he would change it three or four times if the VA needed to be changed. The CM stated that s/he did not have concerns about the care that the VA received at the facility. The VA lived at the facility for seven or eight years. Recently the VA began receiving occupational and physical therapy services from an outside agency and it appeared as a result that the VA’s overall strength was getting better. Facility documentation showed that P1-P4 each received training on the Reporting of Maltreatment of Vulnerable Adults Act and training specific to the VA. Relevant Statute Minnesota Statutes, section 245D.05 subdivision 1 paragraph (b) states that if responsibility for meeting a person’s health service needs has been assigned to license holder in the person’s support plan, the license holder must maintain documentation on how the person’s health needs will be met. Conclusion: Regarding the VA’s falls and injuries. Prior to the investigation, the VA had an increase in falls and as a result had physical and occupational therapy ordered to increase his/her strength. There were concerns that staff persons did not always respond to the VA’s falls, but the VA said that staff person generally responded when they knew s/he fell and if they did not, it was because they were helping other consumers. The VA had injuries that may have been related to the falls or to staff persons assisting the VA up off of the floor, but it was not determined whether staff persons caused any injuries to the VA other than in the provision of therapeutic conduct. Information showed that the VA and another consumer did not always get along, but there was no information that they had physical confrontations. Regarding the VA’s blood sugar levels The VA’s blood sugar levels were to be tested once a day. The VA did the procedure by him/herself and then staff persons were supposed to document the results on the computer. There were concerns that the blood sugar levels were not completed as required as the HCP looked at the VA’s glucometer readings and there was not a reading for everyday as required. In addition, the glucometer indicated that the readings were taken during the overnight as opposed to the evening. However, that could have been due to the correct time not being set on the glucometer. Documentation showed that there were multiple occasions where the VA’s readings were not documented as required which was a violation of Minnesota Statutes, section 245D.05. Despite the lack of documentation, information from the VA and staff persons showed that the VA tested his/her blood sugar levels once a day. In addition, the VA did not take a medication or on a prescribed diet that was based on his/her daily blood levels. Regarding the VA’s incontinence The T stated that the VA was incontinent and there was strong odor of urine on the VA and the VA living area. On one occasion, the VA’s bed was statured with urine. P1-P3 each stated that the VA wore incontinence briefs and that they were checked every two hours. The VA did not always cooperate with having his/her brief changed. P4 worked the overnight shift and changed the VA’s brief in the morning and if P4 worked during the day s/he would change three or four times if the VA needed to be changed. There was no information that there was any harm to the VA related to his/her incontinence. Given the above regarding falls and injuries, blood sugar levels, and incontinence, there was not a preponderance of the evidence whether there was a failure to provide the VA with care and services which were reasonable and necessary to obtain or maintain the VA’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). Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were adequate and followed. Action Taken by Department of Human Services, Office of Inspector General: On March 22, 2024, the facility was issued a Correction Order for the violations outlined in this report.
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