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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: 1075790-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Henne/Alice Percy Suspected Maltreatment Reported: It was reported that the staff persons did not follow nursing instructions to ensure that a vulnerable adult (VA) received medical care for a possible leg infection. The VA was later taken to the hospital, where s/he was diagnosed with sepsis. Date of Incident(s): Ongoing, prior to January 18, 2024 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 25, 2024; from documentation at the facility and medical records; and through eight interviews conducted with two facility supervisory staff persons (P1 and P2), three staff persons (P3 – P5), the facility’s health care professional (HCP), the VA, and the VA’s guardian (G). The VA enjoyed using technology, being active in the community, watching movies, going for walks, spending time with his/her friends and family members, and watching television. The VA’s diagnoses included schizoaffective disorder, mild intellectual disabilities, diabetes, anxiety, depression, and chronic diastolic congestive heart failure. According to the VA’s Coordinated Services and Supports Plan (CSSP), the staff persons assisted the VA with scheduling and attending all medical appointments. The staff persons were to follow up on any medical orders made by the VA’s physicians. The VA sometimes forgot to take his/her medications and the staff persons assisted the VA with medication administration. The VA stated that s/he liked living at the facility and had no concerns about the care s/he received from the staff persons. If the VA was not feeling well, s/he would tell the staff persons. The HCP provided the following information: · The HCP stated that the VA had high medical needs and was not always compliant with following his/her physician’s recommendations. The VA had lymphedema and had been hospitalized on numerous occasions. The VA frequently refused to elevate his/her legs, walk, clean his/her legs, or wear compression stockings, which had all been recommended by his/her physician. The VA also sometimes refused to allow the staff persons to clean or treat his/her legs. The VA was prescribed warfarin, which was a blood thinner. The VA preferred “telehealth” check-ins with his/her physicians rather than in-person visits. The HCP did not accompany the residents to their medical appointments, but s/he did make recommendations for the residents to be seen by their physicians and also ensured that the staff persons were aware of follow-up medical appointments for the residents. · On January 5, 2024, the HCP visited the VA at the facility. The VA had orthopedic “splints” on each of his/her legs. The splints were strapped on the VA’s lower legs with several straps. When the HCP asked the VA where s/he got the splints, the VA told the HCP that they belonged to the VA. The straps on the splints were so tight that the VA’s legs were “ballooning” over the edges of the splints. The VA’s left leg had an odor of infection, there were open areas on the leg, and there was a 3-inch area below the knee that looked like “postules.” The VA’s right leg was swollen and red, but the skin was intact. The HCP cleaned the VA’s legs and told him/her that s/he needed to wear his/her compression socks. The VA showed the HCP a package of new compression socks that s/he had. The HCP told P3 to continue to keep the VA’s legs clean and to apply a spray cleanser to the legs prior to wrapping the legs and putting compression socks on the VA’s legs. The HCP then telephoned P1 and described the condition of the VA’s legs and told P1 that the VA needed to see his/her physician. P1 told the HCP that the VA was being seen by his/her podiatrist on January 8, 2024. The HCP then told P1 that the VA also needed to be seen by his/her physician. The HCP stated that s/he believed it was clear that s/he wanted P1 to take the VA to Urgent Care when s/he first talked to him/her on January 5, 2024 · On January 8, 2024, the HCP texted P1 to ask about the VA. P1 sent a text to the HCP saying that the VA’s legs “looked a little better” and P1 was trying to get a refill for one of the VA’s medications. The HCP texted P1 to say that the VA still needed to be seen by his/her physician. On January 9, 2024, the HCP texted P1 and asked P1 to let him/her know what the Urgent Care physician said about the VA’s legs. · On January 16, 2024, the VA was taken to the hospital via ambulance. The HCP stated that the VA did not want to go to the hospital, but was told that s/he had a serious condition that had to be treated. The VA was diagnosed with sepsis. On January 17, 2024, a hospital staff person telephoned the HCP and talked about whether the VA was able to care for him/herself at the facility or needed a higher level of care. The HCP was uncertain whether the VA would have developed sepsis if s/he had been seen by his/her physician on January 5, 2024, as the HCP requested, since it was “up to [the VA]” to agree to go to the hospital and to be compliant with the physician’s recommendations and medications. The HCP stated that the staff persons could call him/her if they had concerns about any of the residents’ health. P1, P2, P3, P4, P5, the HCP, and the facility’s documentation provided the following information: · P1 and P2 each stated that the VA had on-going issues with his/her feet and legs due to the VA’s diabetes. P1 had taken him/her to numerous medical appointments. On January 8, 2024, the VA’s podiatrist went to the facility to check the VA’s feet. P5 stated that on January 14, 2024, s/he worked at the facility. At that time the VA’s legs were “good” and the VA did not need lotion applied to his/her feet. The staff persons were told to check on the VA’s legs each day and to let a supervisory staff person know if there was something “wrong” with the VA’s legs. P5 did not observe any sores or red spots on the VA’s legs that day. · On January 15, 2024, the VA had a telehealth appointment with his/her physician about the VA’s medication. The VA told the physician that his/her legs were “fine” and the physician told the VA to keep up with the prescribed treatment. P1 stated that s/he was unaware of any concerns about the condition of the VA’s legs and did not recall the HCP or any of the staff persons expressing any concerns about the VA’s legs. On January 12 and 15, 2024, P1 asked the VA to be seen by his/her physician because of his/her general health and hygiene, but the VA refused to go to a medical appointment. P4 stated that on January 15, 2024, the VA was “fine” during P4’s work shift. · P3 stated that on January 15, 2024, s/he worked the overnight shift at the facility. At 11 p.m., P3 arrived at the facility and the VA was in his/her bedroom watching television and was “good” when P3 checked on him/her. At 2 a.m., the VA was still watching television in his/her bedroom. At 4 a.m., when P3 checked on the VA, the VA was sitting in his/her bedroom chair and “did not look well” and P3 asked the VA if s/he was okay. The VA told P3 that s/he was okay, but s/he was cold, so P3 turned up the heat. P3 asked if the VA wanted any medications and the VA said no. At approximately 7 a.m., P3 administered the VA’s medications to the VA and gave breakfast to the VA, which the VA ate. When P4 arrived at the facility, P3 told him/her to check on the VA because s/he “was not like [s/he] usually was.” · P4 stated that on January 16, 2024, at 8 a.m., s/he began his/her work shift at the facility. P3 told P4 that the VA was “not looking good.” The VA was sitting in a chair in his/her bedroom and was weak and shaking and did not act as s/he usually did. When P4 asked the VA if s/he was okay, the VA had difficulty speaking and was unable to stand. P4 tested the VA’s blood sugar and blood pressure, which were normal. P4 telephoned P2, who was driving to the facility to drop off groceries and told him/her that the VA was “below borderline.” P2 arrived at the facility and checked on the VA, who was in his/her bedroom and was shivering. When P2 asked the VA how s/he was feeling, the VA said s/he was “fine,” but P2 told the VA that s/he needed to go to the hospital and be seen by his/her physician. P4 telephoned 9-1-1 and the VA was taken to the hospital via ambulance. P4 stated that s/he telephoned 9-1-1 because of the VA’s demeanor and not because of his/her legs. P2 stated that the VA typically did not want to go to the hospital, but would tell the staff persons when s/he was unwell and wanted to go to the hospital. · According to the facility’s Shift Notes, P4 documented that when the paramedics carried the VA out of the facility in a chair, the VA fell out of the chair. The paramedics contacted the fire department and the fire department staff persons arrived at the facility and assisted the VA into the ambulance. · P4 stated that the VA did not require the assistance of the staff persons with bathing or dressing, but the staff persons reminded the VA to bathe and change his/her clothing because the VA sometimes refused to bathe or change his/her clothing. The VA wore compression socks because of the swelling of his/her legs. On one occasion, P4 saw the VA wear a wrap on his/her leg that had straps holding it on his/her leg. P4 did not know where the VA got the wrap. P4 stated that the VA’s legs were “always swollen.” · P1 stated that s/he did not assist the residents with their personal cares, but scheduled appointments for the residents and took them to the appointments. P1 stated that s/he did not receive training on the residents’ plans or on their medical needs prior to the incident. The G stated that the VA frequently went to the hospital with sepsis when the wounds on his/her legs became infected. The G believed that the VA frequently did not comply with his/her physician’s orders and did not allow the staff persons to assist him/her with his/her medical issues. In 2023, the VA was hospitalized for sepsis on two occasions. The VA was able to communicate his/her needs and wants, but did not always want to go to the hospital. The G believed that the staff persons were not always trained on how to work with someone with the VA’s diagnoses. According to the VA’s physician’s Progress Notes, on January 15, 2024, the physician had a scheduled telephone visit with the VA to discuss the VA’s medications. According to the VA’s Hospital Discharge Summary, on January 16, 2024, the VA was admitted to the hospital and on January 29, 2024, the VA was discharged from the hospital. The VA was admitted for septic shock secondary to cellulitis. Facility documentation showed that P2 – P5 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. P1 received training on the Reporting of Maltreatment of Vulnerable Adults Act, but not on the VA’s plans. Relevant Rules and Statutes: Minnesota Statutes, section 245D.09, subdivision 4a, paragraph (a), state that the license holder is to provide training to the staff persons on the plans and procedures for the individuals served by the program prior to the staff persons having unsupervised direct contact with the individuals. Conclusion: Consistent information was provided that the VA had on-going issues with his/her feet and legs due to the VA’s diabetes. On January 5, 2024, the HCP told P1 that s/he was concerned about the swelling and sores on the VA’s legs and recommended that the VA be seen by his/her physician. On January 8, 2024, the VA’s podiatrist came to the facility and checked the VA’s feet. On January 12 and 15, 2024, P1 asked the VA to be seen by his/her physician because of his/her general health and hygiene, but the VA refused to go to a medical appointment. However, on January 15, 2024, the VA had a telehealth call with his/her physician and told the physician that his/her legs were “fine.” The physician told the VA to keep up with the prescribed treatment. P1 stated that s/he was unaware of any concerns about the condition of the VA’s legs and did not recall the HCP or any of the staff persons expressing any concerns about the VA’s legs. The staff persons did not have any concerns about the VA’s health until the early morning hours of January 16, 2024, when the VA appeared unwell. The staff persons telephoned 9-1-1 and the VA was taken to the hospital via ambulance, where s/he was diagnosed with sepsis. P1 stated that at the time of the incident, s/he had not completed training on the VA’s plans. In addition, the facility had no documentation to show that P1 received that training, which was a violation of Minnesota Statutes, section 245D.09, subdivision 4a. After the incident, when it was discovered that P1 did not have the training, P1 received training on the VA’s plans. Although the VA was not seen by his/her physician on January 5, 2024, as recommended by the HCP, and was subsequently hospitalized and diagnosed with sepsis on January 16, 2024, given that the VA was seen by his/her podiatrist on January 8, 2024; that the VA had a telehealth call with his/her physician on January 15, 2024; that P3 and P4 each stated that the VA was “fine” on January 15, 2024; and that when the VA began to appear unwell during the early morning hours of January 16, 2024, 9-1-1 was called and the VA was sent to the hospital, 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. After the incident, all of the staff persons reviewed the VA’s plans. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took corrective action regarding P1’s training on the VA’s plans, a corrective order was not issued.
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