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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: 1071033-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070961-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was initially reported (202300323) a vulnerable adult (VA) was not being provided basic cares; the VA was observed in saturated absorbent undergarments, not being bathed or groomed, and not being provided food. Additional concerns were reported (202304748) that the facility/staff persons continued to not provide the above-mentioned cares/services. Date of Incident(s): On going concern since January 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 two site visits conducted on February 16, and July 20, 2023; from documentation at the facility; and through interviews conducted with facility staff persons (P1-P4), facility supervisors (P5-P7), the VA’s case manager (CM), and the VA’s guardian (G). An interview with the VA was attempted, however the VA chose not to engage in a conversation with this investigator. Facility documentation showed that the VA enjoyed being busy and frequently attended outings in the community. Some of the activities the VA liked included going to parades, shopping, and having coffee and/or breakfast at a restaurant. The VA’s diagnosis included mood disturbance, memory disturbance, cerebrovascular accident, depression, anxiety, constipation, incontinence, history of urinary tract infections (UTI), and psoriasis. The VA had experienced severe depressive episodes, and a daily routine was important for the VA. The VA preferred to wake up in the morning and take a bath. The VA had a brain injury and dementia, and experienced delusions and paranoia. The VA was provided 24-hour supervision and did not have any unsupervised time in the community. The VA was not able to manage his/her health independently. The VA’s client specific documentation provided the following information: · The VA was on a regular diet, and “at times refuses to eat when prompted for meals.” The VA had recent weight loss, and staff persons would prompt the VA to eat at mealtimes and offer the VA higher calorie snacks, including a high calorie shake option. If the VA did not want to come out of his/her room to eat, staff persons would offer to bring the meal in to the VA’s bedroom. A facility supervisor would contact the CM and/or the G for further instruction if the VA continued to refuse meals and/or lost weight. · Staff persons would complete daily skin checks and apply the topical cream that was prescribed. Staff persons would monitor the VA’s health conditions and seek medical attention if there were signs or symptoms of the VA having a UTI or other illness. · The VA spent the majority of his/her time in his/her bedroom, and had a history of refusing to get out of bed. Staff person were to use a positive attitude to prompt the VA to get out of bed in the morning. Staff persons could offer the VA flavored coffee as well as breakfast items s/he enjoyed eating. Additionally, staff persons could offer the VA the opportunity to do some sort of activity after s/he completed his/her morning routine. · The VA had a history of incontinence and would often refuse to change clothing and absorbent undergarments. The VA would also refuse staff persons assistance with soiled clothing, bedding, and bathing. It was important that the VA bathed often due to his/her incontinence. If the VA continued to refuse to get out of bed, staff person would leave and come back after a little bit to prompt the VA again. After the VA got out of bed, staff persons would change the VA’s bedding, and wash the soiled bedding and laundry. Staff persons should contact a supervisor if the VA repeatedly refused, and the supervisor would contact the VA’s team. o It was noted the VA “generally refuses to bathe when prompted by staff [persons].” Staff persons could get the VA’s bath ready and use good smelling bubble bath, soaps, shampoo and conditioner. The VA required hand over hand assistance to complete his/her bathing. If the VA refused to bathe in the morning, staff persons would continue to prompt the VA throughout the day to take a bath. o Staff persons would also prompt the VA to use the bathroom every two hours. The VA was to have a dry absorbent undergarment and dry clothes on. Staff person would ensure the VA had a dry absorbent undergarment and dry clothes before going out in the community. o If the VA continued to refuse any of the above tasks/hygiene staff persons would document the refusal and inform a supervisor, thereafter the supervisor would contact the VA’s team for further instruction. The facility’s Home & Community- Based Services – Service Recipient Right showed the following: · The VA had a right to refuse or terminate services and be informed of the consequences of refusing or terminating services. · The VA would have access to three nutritionally balance meals and nutritious snack between meals each day. · The VA could have personal privacy, including the right to lock his/her bedroom door. · A right restriction required justification based on an assessment of what made the VA vulnerable to harm or maltreatment if s/he was allowed to exercise the right without a restriction, objective measures for ending the restriction, and a schedule to review the restriction. There was no information from the facility, the VA’s documentation, or from the CM, and/or the G that the VA had any rights restrictions. A review of a sample of the VA’s progress notes showed during the week of January 7 to 12, 2023, the VA refused to do personal hygiene tasks on multiple days, but according to the notes the VA did have food and something to drink. Documentation showed staff persons prompted the VA to complete the hygiene tasks, offered/provided assistance with changing clothing, gave the VA magazines, put music on, and offered to make food and/or brought food items to the VA. The CM and G expressed on-going concerns of a lack of engagement and care/services provided to the VA. Regarding the initial allegation received by the Department of Humas Services (DHS) on January 11, 2023: The VA was not provided basic care and services such as cleaning clothing, bathing, and meals. The G provided the following information: · The G arrived at the facility on January 10, 2023, at 11:30 a.m. The G said upon his/her arrival s/he noticed a strong odor of urine in the VA’s bedroom, and the VA was wearing clothing, including a coat, while lying in bed. The G said the VA immediately responded to him/her when the VA was told the G had brought the VA a coffee. The VA got up and the G observed the back of the VA’s clothing was saturated and the VA smelled “horrible.” The G assisted the VA to the bathroom and helped the VA bathe. · Prior to the bath, the G took photos of the VA’s absorbent undergarment because the absorbent undergarment was saturated, falling apart, and sticking to the VA’s skin. The G did not believe the VA had been assisted for a long period of time. The G believed the lack of care would lead to a breakdown of the VA’s skin, and observed the VA scratching his/her groin area. The G also noted the VA’s toenails were long. · After the bath was completed, the G assisted the VA to change clothing. A staff person had food for the VA sitting on the counter, however the G believed the spot was not a good place for the VA, and also had the staff person re-warm the food for the VA. The VA did not want the food. The G continued to interact with the VA and discussed other food options, specifically ice cream which was on sale according to an advertisement. The VA was provided an ice cream sandwich, and after eating one, the G motioned to the staff person to provide the VA with a second ice cream sandwich. · During the above interaction between the G and the VA, the G had music playing, and the VA was singing along. The VA allowed the G to comb his/her hair. The G believed the VA was not being provided the care and services s/he needed, and the staff persons were not using the techniques s/he and the CM suggested/recommended. · The G and the CM had multiple meetings with a facility supervisor regarding the on-going concerns with the lack of care provided to the VA, but the G said there were no changes or improvements. The G said the next step may be for the VA to move from the facility. The CM provided the following information: · The VA did not have any skin breakdown, or hospital visits due to the alleged maltreatment on January 10, 2023. However, the CM said the issues with the lack of care for the VA dated back months, and it had not improved. The CM said s/he was involved in meetings regarding the on-going concerns with the VA’s care and services. The CM felt the facility was “going downhill for years,” and staff persons decided they did not need to do anything. The concerns of a lack of care had been discussed with multiple levels of leadership at the facility, and also expressed concern related to how staff persons approached and prompted the VA. The CM said the VA’s team was trying to get staff persons/the facility to get the VA engaged to complete hygiene tasks and community outings. · The CM expected the facility to get the VA cleaned and bathed daily. The G had communicated the above concerns from January 10, 2023, and said the CM said the VA did better when engaged in things s/he liked. However, the CM also said the VA was not an easy person to support. The CM said the facility supervisors said the VA refused care and services, but the CM believed staff persons needed to use a “certain approach.” The CM and the G both offered to assist the facility in training staff persons on how to interact with the VA, as the VA was willing to engage with the G and CM when the right approach was used. The CM believed staff persons would prompt the VA, but walked away if the VA did not respond. · The CM said there was a plan for the VA to be moved to a different facility. P7 provided the following information: · P7 believed prior to January 10, 2023, the facility was making progress with the VA. P7 said the G and the CM expressed concerns of on-going issues with the care the facility was providing to the VA. P7 described the issues as an “important to and important for” as they related to the care of the VA. P7 said s/he, and the staff persons all wanted to support the VA with his/her “rights to live the way [s/he] wants to live.” P7 said all staff persons tried to provide care to the VA, but the VA often refused to get out of bed and/or engage in activities. P7 added the G did not have “unrealistic expectations,” and the G wanted staff persons to get the VA up, bathed, and engaged in activities daily. P7 believed staff persons tried their best to complete the cares and services the VA required, but at times the VA would not “budge,” and there was not a lot staff persons can do “legally.” P7 said, “We [as a facility] are not allowed to do the things [the G] wants us to do.” P7 provided an example of the G wanting staff persons to “roll” the VA around the bed while the bedding was changed. P7 said s/he would not put his/her “hands on the VA” when s/he was upset or refused cares/services. · P7 said when the VA refused to complete hygiene tasks staff persons would go into the VA’s room multiple times a day to prompt the VA, however, were unable to physically make the VA engage in the hygiene tasks. · P7 said the G had a long-standing relationship with the VA and the VA was more willing to engage with the G. P7 said the VA did not allow staff persons to build a relationship like that of the VA and the G, but staff persons tried building rapport. Even with the attempted rapport building the VA would not consistently allow staff persons to assist the VA in his/her daily tasks. · P7 had concerns with staff persons prompting the VA and then giving up easier than when P7 engaged the VA, but the VA was offered coffee and activities the VA liked and would still at times decline the activity or task. P7 said some staff persons did better than other staff persons, but the VA would still refuse care. P7 said the staff persons could do more, but pushing the VA to complete certain tasks could cause additional issues with the VA’s mental health. P7 said on the day this investigator completed the site visit, the VA was receptive to staff persons, but that was not always the outcome. P7 said sometimes the VA would say, “Get the hell out of here,” and refused all of staff persons’ prompting. · The facility had also purchased bath soaps, salts, shampoo, and had music on, but there were some days the VA would not complete the hygiene tasks. · P7 said there was a distinct smell in the VA’s room, but the facility was trying to problem solve the issue and take other steps to assist the VA with his/her incontinence issues. · P7 said there was no recent issues with skin breakdown, and the facility had a nurse complete a weekly check of the VA’s skin. · P7 said the VA had been maintaining his/her weight, and general health, but the G wanted additional calories added to the VA’s diet. The G suggested having the VA drink whole milk with chocolate added, and add cream cheese to the VA’s potatoes, but P7 was concerned that would affect the VA negatively. Staff persons would bring the VA food into the VA’s room if the VA refused to eat in the common area. P1 provided the following information: · P1 said on January 10, 2023, s/he had attempted to get the VA out of bed multiple times prior to the G’s arrival. After the G was able to get the VA out of bed, P1 changed the VA’s bedding, placed clean clothing out for the VA, and provided a towel for the VA’s bath. P1 said the overnight staff person had not been able to get the VA to change clothing or his/her absorbent undergarment from the previous day, and there was a strong smell of urine. · P1 said s/he would normally ask the VA if s/he would like breakfast, and if the VA declined, P1 would prompt the VA again after approximately 30 minutes. P1 said it “usually” took a few tries to get the VA out of bed. · P1 said it was typical for the VA to refuse completing tasks, but added that today (day the site visit) the VA had got up by him/herself, went into the bathroom, and had breakfast. P1 added that the previous day staff persons were unable to get the VA up all day. P1 said the VA was “kind of hit or miss” regarding the VA completing his/her daily tasks. · P1 said the VA liked music and s/he would play music to try and engage the VA. P1 said the VA usually “never” took a bath, but P1 would use cleansing wipes to clean the VA while changing his/her absorbent undergarment. P1 had not observed any skin breakdown, but P1 observed the VA having dry skin and itching him/herself. P1 would apply lotion to the VA’s body due to the dry skin. P1 did not observe any red marks or sores on the VA. · P1 said if the VA did not eat a meal in the common area the VA was provided food in his/her bedroom. P2 provided consistent information with that of P1; P2 said the VA refused assistance from staff persons with hygiene tasks and meals. P2 tried to utilize the suggested items like soaps, music, and certain foods/coffee as motivators for the VA, but “some days that didn’t work.” P2 said s/he was normally able to change the VA’s absorbent undergarments two times a day. P2 reiterated the VA had dry skin and lotion was used but was not aware of any sores. P2 said the VA loved the G and “lit up” when the G was around. P5 provided the following information: · P5 thought the facility was making “slow and steady progress” with the VA after the VA had developed negative behaviors related to refusing basic cares, but the process was not “as fast” as anyone would like. · P5 tried to work with staff persons to engage the VA, and there were times the VA would get up and have breakfast, but other times the VA refused. P5 said s/he would go “check” on the VA when s/he refused to get up and tried to get the VA’s bedding changed. · P5 also used the suggestion the G made regarding using music to motivate the VA and to use bubble bath to bathe the VA. P5 said the facility also tried to “entice” the VA with coffee, going out to breakfast or shopping, however those things only worked 50% of the time. · P5 said there were days the VA refused to change his/her absorbent undergarment. P5 said there were times s/he was worried as the VA seemed to be having seasonal depression and was not responding the staff persons prompting, and the VA slept all day. P5 said staff persons “nagged” the VA and the VA got “irritated” during those times. · P5 said the VA had dry itchy skin, but the VA did not have any skin breakdown. · P5 did not believe the VA was being neglected as staff persons were trying to complete the care and services, but the VA “refused a lot more than people think.” P5 said staff persons would prompt the VA after 10 to 15 minutes, but there were times the VA would “scream” at staff person that attempted to work with the VA. · P5 said the G loved the VA and wanted the best for the VA, but P5 believed the VA’s team had a “little bit higher of an expectation” of what the VA was able to do. Regarding the allegation received by DHS on July 3, 2023: There was an on-going concern with a lack of care being provided to the VA. The G and CM were “clear” that if the VA refused to complete his/her hygiene routine staff persons should give the VA a bed bath and change his/her undergarments as needed. Additionally, on June 27, 2023, the VA had developed “wounds” on his/her buttocks, however medical intervention was not sought until July 3, 2023. The VA was discharged from the hospital around July 10, 2023, and moved to different facility. The G provided the following information: · The G did not believe there was any improvement since the initial allegation, and the care of the VA got “worse.” The G said the VA and other vulnerable adults were “starving” for attention, and there was a “culture” issue at the facility. · The G went to the facility and met with the VA approximately once a month on average. The G said s/he could not “specifically” say the staff persons did not attempt to engage the VA, but his/her “perception” was that staff persons did not engage the VA because there was no improvement in the care of the VA. The G observed staff persons engage the VA, but that the engagement was “minimal.” The G said staff persons did not utilize the same techniques (music, coffee, food, verbal engagement) the G used to engage the VA. The G said the VA “never” said no to the G to complete a bath. The G said the care the VA received was apathic and it did not seem like the staff persons cared about the VA. · The G said s/he understood the VA had the right to refuse, but staff persons should not let the VA just lay in urine. The G said that “no one” was trying to have staff persons “force” the VA into completing tasks. · The G visited the VA at the facility on or around June 1, 2023, and observed some “darkening” of skin near the VA’s buttock but did not see any wounds or openings at that time. The G said on June 27, 2023, staff persons noticed “something going on” with the VA’s skin, and the facility nurse was contacted. The G was unsure if any person or medical professional observed the concern between June 27, and July 3, 2023. · The G said the VA moved to a different facility with a higher level of care after being hospitalized and was being provided 1:1 staffing 24 hours a day, which was an increased staffing rate. The CM provided the following information: · The CM provided consistent information of that from the G regarding the on-going concerns with the care and services the VA received. The CM felt the “upkeep” at the facility was lacking as there was a smell of urine in the facility. The CM described the smell as “very strong” in the VA’s room. The CM said the G and the CM communicated that if the VA refused to get up and complete hygiene tasks, staff persons should, on a daily basis, change the VA’s absorbent undergarment and wash the VA’s skin. · The CM had limited information related to the VA’s skin/sores in late June/early July. However, the CM believed the facility needed to ensure the VA’s health and safety, and due to a lack of care and services the VA had developed sores. The CM said the VA did not have a history of pressure sores. · The CM said the VA was older and believed the VA was declining cognitively and physically, however the “better relationship” a person had with the VA the more “cooperative” the VA was with the person. The CM said the VA never declined to complete activities with the CM or the G. P7 provided the following information: · The facility nurse was at the facility on a weekly basis. · The facility nurse observed the VA on June 21, 2023, and there was no redness or sores that were observed. · The facility nurse observed the VA on June 28, 2023, and observed redness/sores on the VA. A plan to monitor the sores was developed. · In the following days staff persons offered the VA assistance with cares, however the VA refused. The VA’s skin condition became worse, as s/he refused cares and would not get out of bed. The VA was seen at the hospital due to the sores on July 3, 2023. The MP said while the VA was hospitalized the VA had multiple wounds, including three that were larger in size. The MP did not provide a specific size, but said the wounds were located on the VA’s lower back/buttock. The MP described the wounds as “raw skin,” but added the wounds were not “tunneling.” The MP said the VA had to be “talked into completing cares” and did not “want a lot of cares” provided to him/her. P4 provided the following information: · P4 said the VA was incontinent and staff persons tried to get the VA out of his/her bed, however the VA refused P4’s assistance. P4 said staff persons were not able to “force” the VA to complete the hygiene task. P4 said s/he used techniques of playing music to get the VA engaged with staff persons. P4 added that s/he prompted the VA multiple times a day, but explained s/he had responsibility to care for the other individuals at the facility as well. · P4 said the VA’s bedding was clean most of the time, but the VA was “uncomfortable” with staff persons that were the opposite gender of the VA. · P4 said the facility nurse was contacted and informed by staff person the VA had an infection on his/her back. P4 believed the nurse was contacted a few days prior to the VA’s hospitalization, and P4 did not observe the sores for the first time until the nurse was at the facility on June 28, 2023. P4 said the nurse tried to assist the VA, but the VA refused the nurse’s care. · The VA was provided meal replacement options if s/he did not eat a meal. P3 provided the following information: · P3 said prior to the VA being hospitalized (July 3, 2023) s/he observed sores on the VA’s while assisting the VA with hygiene tasks. P3 provided the VA with a new absorbent undergarment, clean clothing, and clean bedding. P3 notified his/her supervisors and the facility nurse of the concern. P3 offered to apply barrier cream, however the VA refused the application of the barrier cream. P3 and another staff person tried to get the VA to go to urgent care, but the VA refused to go to urgent care. · P3 said between June 27, and July 3, 2023, the VA continued to refuse cares being provided, and the VA’s sores continued to get worse. The nurse and supervisors of the facility were notified of the concern. · P3 said the VA refused cares and meals but would encourage the VA during his/her shifts. P3 said that the VA would allow P4 to change the VA’s absorbent undergarment but refused to complete a shower/bath. P3 would play music for the VA, but the music did not increase the VA’s participation in hygiene tasks with P3. P3 felt the VA more often refused to complete hygiene tasks with staff person of the opposite gender. P5 and P7 provided consistent information related to the VA refusing care/services (as stated by other staff persons). Staff persons attempted to prompt the VA, and the VA refused treatment suggested by the facility nurse due to the sores. Moreover, the facility nurse observed the sores, and the facility attempted to mitigate the medical issue, until it became a concern in which the VA was seen at a medical facility. P1-P7 received training on the VA’s client specific information, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: There were on-going concerns with the facility providing the VA with care and services including basic cares related to hygiene and meals which was initially reported to DHS on January 11, 2023. Then, on July 3, 2023, DHS received an additional report that the VA’s care had not improved, and that the VA was hospitalized because of sores on his/her back and buttock. The VA moved to a different facility after being discharged from the hospital on July 10, 2023. The VA did not engage with this investigator during the investigation so did not provide information. However, the G and the CM said they had observed the VA’s wellness throughout the timeframe of the investigation, and described the VA was unkept, and the VA’s room having a strong smell of urine. The G was at the facility on January 10, 2023, and the VA’s cares had not been completed, his/her absorbent undergarment was saturated, and believed the care the VA was provided was not adequate. Furthermore, the CM and G believed that staff persons at the facility did not follow suggestions to engage the VA and did not see an improvement in the care of the VA over the past six to nine months. P1-P7 provided consistent information related to cares and services being offered to the VA that the VA often refused the prompts and/or assistance that was offered. P1-P7 stated they used the suggested techniques such as bubble baths, coffee, and food items as motivators. The VA developed sores on his/her back/buttock. The facility nurse and supervisors were contacted regarding the issue, however the VA refused to go to urgent care, and refused the application of barrier cream. The facility attempted to work with the VA for approximately a week, before it was determined the VA required medical treatment at a hospital. The VA was hospitalized and upon discharged moved to a new facility. The VA was provided a higher level of care and 1:1 staffing at the new facility. Based on the above information P1-P7 provided consistent information related to the staff person(s) attempting to engage the VA in care and services, but the VA consistently refused even when suggested motivators were used to entice the VA. Furthermore, it was reasonable for the facility to try and manage the sores that developed on the VA’s back/buttock in late June 2023. The facility offered to take the VA to a medical facility, however the VA declined, thereafter the facility nurse determined additional medical intervention was required the VA was seen at a medical facility. Throughout the six months included in this investigation, the facility was unable to fully support the VA in relation to his/her care due in part to the VA’s lack of engagement and his/her refusal of services, however given that staff persons consistently stated that they attempted to prompt the VA and when the VA refused would continue to prompt the VA, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services that were reasonable and necessary to 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 the policies and procedures were adequate, and followed. The report was similar to past events as the VA had a history of refusing care and services, but the facility did not complete any additional staff training or corrective action. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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