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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: 1104320-RMI (Residential Treatment and Services for Adults with Mental Illness) Investigator(s): Sarah Schumacher Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) left the facility without supervision and obtained Tylenol PM which s/he later ingested. Date of Incident(s): July 12, 2022 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 August 18, 2022; from documentation at the facility and medical records; and through four interviews conducted with the VA, a staff person from the VA’s residence (P1), and two facility supervisors (P2 and P3). The facility provided crisis stabilization services. Clients with “aggressive behavior” were not to be admitted to the facility. Upon application, clients completed Crisis Assessments to determine eligibility for services. Criteria to receive crisis stabilization services included clients who: · Required further service to stabilize a crisis or emergency situation outside of their home, · Would benefit from short term supervised structed crisis stabilization services, · Were not actively violent or displaying poor impulse control, · Were not actively threatening suicide and agreed to contract for safety, and · Were able to manage their medical and personal hygiene needs. The facility had six secure external entrances, each requiring a key to gain access The facility had a courtyard that was enclosed by a fence. Clients went to the courtyard to smoke. There were two exits through the fence that could be opened from the inside of the courtyard. There were at least two staff persons working on each shift with a ratio of one staff person to nine clients. Staff persons were to monitor and perform eyes on checks of clients every hour to maintain an awareness of clients’ whereabouts. If a client required increased checks for their safety, it was to be documented on a “Eyes-on Checks” form and communicated verbally to staff persons from shift to shift. The VA’s diagnoses included anxiety, depression, post-traumatic stress disorder, bipolar disorder, schizoaffective disorder, and pica (compulsively eating nonfood items). The VA lived at a licensed community residential services facility. The VA enjoyed doing arts and crafts, drinking coffee, doing bead work, and being sociable. The VA was not subject to guardianship. On July 12, 2022, at 10:59 a.m., the VA conducted a phone screening with the facility. At 11:45 a.m., P2 was consulted, and the VA was “accepted” to be admitted to the facility with a note that the VA had a “swallowing risk.” Around 1:30 p.m., the VA arrived at the facility and was admitted. Upon admission, the VA “denied” suicidal ideation or intent, and stated s/he had a self-injurious behavior of “picking” two days prior. The VA reported having no safety or health concerns. The VA’s recommended length of stay was seven to ten days. The VA’s Crisis Assessment stated that the VA referred him/herself to the facility from his/her residential facility because his/her mental health was decompensating but s/he could not identify a trigger or stressor. Staff persons from the VA’s residential facility stated that a supervisor had some time off which was a trigger for an increase of the VA’s bipolar disorder symptoms and that the VA had a “recent history” of swallowing batteries, medications, and hand sanitizer. The VA reported an increase in anxiety, depression, and not being able to sleep. The VA stated that s/he had suicidal thoughts “about a year ago,” and a suicide attempt via overdosing on over-the-counter medications in December 2021. The VA denied current suicidal ideation and reported that s/he was feeling safe with no urges to swallow anything and was able to contract for safety. The VA’s Individual Abuse Prevention Plan stated staff persons were to perform hourly eyes on checks of the VA to ensure safety from all types of abuse. The VA was to report any increased thoughts of self-injurious behaviors or urges to swallow items. The VA provided the following information: · The VA had some mental health symptoms and “confusion” and did not feel like s/he was getting the support s/he needed at his/her residence. The VA did not have a psychiatrist at the time and was worried that his/her medications would run out without a psychiatrist to prescribe them to him/her. So, the VA called the facility and was accepted for admission. · Shortly after, residential staff persons transported the VA to the facility and dropped him/her off there. Staff persons at the facility told the VA they could support him/her, and the VA needed a “break” and a “vacation.” The VA did not think there would be an “issue” with the number of staff persons at the facility because when s/he arrived, there were several staff persons present. Later, there were only two staff persons working. · Around 6:30 p.m., the VA was “triggered” when “everyone was upstairs playing a game” including both staff persons. The VA left the facility and walked to a supermarket. The VA did not tell anyone s/he was leaving, and no one saw the VA leave. At the supermarket, the VA bought two bottles of “pills” and then went to a laundromat next door and ingested the pills around 7 p.m. Then, the VA walked back to the facility. · Around 9 p.m., the VA told staff persons that s/he ingested the pills, so a staff person called 9-1-1. The VA did not recall what happened after that. P1, a staff person at the VA’s residence, provided the following information: · The VA wanted to check him/herself into the facility so P1 talked to an intake staff person. P1 told the intake staff person that the VA had a two staff person ratio and a history of swallowing items. The intake staff person “assured” P1 that the facility could keep the VA “safe.” P1 did not ask the intake staff person if the facility was going to provide a two to one staff person ratio for the VA. The VA was not subject to guardianship so the VA’s residential staff persons “could not stop” the VA from going to the facility. · On July 12, 2022, at 10:33 p.m., P1 received a phone call and voice message from the intake staff person but because his/her phone was off, P1 did not see the call and listened to the message the next morning. The message stated that the VA had ingested Tylenol and was transported to the hospital. · Later, P1 asked the VA about the incident and the VA stated s/he had “no memory of that evening.” P1 stated that the VA was not an accurate reporter of information. Interviews with P2 and P3, and facility documentation provided the following information: · P2 and P3 each stated that when the VA called the facility for the phone screening, the VA reported that s/he live in his/her own apartment and did not disclose that s/he lived in a community residential services setting. · P3 stated that while the residential staff persons were driving the VA to the facility, they let the facility know that the VA was a “high risk” for ingesting chemicals and harming him/herself and that the VA had a two to one staff person ratio at the residence. P3 stated they informed the residence and the VA that the facility did not provide that staffing ratio and provided a ratio of one staff person to nine clients. P3 stated that a residential staff person dropped the VA off at the facility and then “left immediately.” · Around 1:30 p.m., the VA was admitted and completed the intake process including a belongings search, a tour, and a room walk through with staff persons. As a precaution, once the VA was at the facility, items such as dish soap and hand sanitizer which were typically unlocked around the facility were placed into locked areas so the VA could not access those items and ingest them. In addition, the VA’s lighter was collected and locked up as a safety precaution which was not typical of clients at the facility. The VA’s belongings were also thoroughly searched. · The VA spent the afternoon “in the milieu” with peers and staff persons. The VA attended relationship skills group, ate dinner, and then attended progress group. · The facility’s Incident Report stated that around 6:30 p.m., the VA was given his/her lighter to smoke and did not return within the approved period of time. Staff persons looked in the courtyard and in the VA’s room and all around the building but did not see the VA. Another staff person did a sweep and the VA eventually appeared in the courtyard. The VA returned the lighter and stated that s/he had not left the building. Staff persons asked the VA where s/he was, and the VA “refused” to provide details. Staff persons continued discussion with the VA and eventually the VA stated that s/he left the facility to go to the gas station where s/he purchased two bottles of Tylenol PM with 24 pills in each. The VA said s/he ingested both bottles and provided the location of the empty bottles in his/her room. 9-1-1 was called and the VA was transported to the hospital. · Rounds sheet showed that the VA was checked on and marked as “seen in facility awake” from 2 to 10 p.m. each hour. The VA left between hourly safety checks so was present during each check the day of the incident. · P2 stated that clients did not need to let staff persons know if they were going into the courtyard to smoke and that clients could be easily seen in the courtyard when conducting hourly eyes on checks. P2 stated that increasing the VA’s supervision level or placing the VA on 30-minute checks was not warranted because the VA did not have increased symptoms and was engaging in groups. · P3 stated that clients did not need to inform staff persons if they were going into the courtyard to smoke. The VA was not allowed to keep his/her lighter so needed to check it out with staff persons when s/he wanted to smoke. P3 stated that the VA’s residence was informed both via telephone and when a staff person dropped the VA off of the staff person ratio and supervision level the facility provided. P3 stated that the VA was very engaged in programing while s/he was at the facility and was seen in the milieu often. · Throughout the VA’s stay at the facility, the VA was provided with group options and staff person support for one-to-one interventions. The VA’s medical records were requested but were not received. Information from the VA’s team’s documentation showed that the VA was admitted to the hospital and then moved to a different hospital to the Intensive Care Unit. The VA was discharged back to the facility a few days later. Facility documentation showed that P2 and P3 were each trained on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information showed that on July 12, 2022, the VA, who was not subject to guardianship, called the facility because s/he wanted to be admitted for crisis support services. The facility completed a phone screen in which the VA denied current suicidal ideation and reported that s/he was feeling safe with no urges to swallow anything and was able to contract for safety. The VA was admitted, and residential staff persons dropped the VA off at 1:30 p.m. P1 stated that s/he told the intake staff person that the VA had a two staff person ratio and a history of swallowing items. The intake staff person “assured” P1 that the facility could keep the VA “safe.” P1 did not ask the intake staff person if the facility was going to provide a two to one staff person ratio for the VA. The VA was not subject to guardianship so the VA’s residential staff persons “could not stop” the VA from going to the facility. P3 stated that while the residential staff persons were driving the VA to the facility, they let the facility know that the VA was a “high risk” for ingesting chemicals and harming him/herself and that the VA had a two to one staff person ratio at the residence. P3 stated they informed the residence and the VA that the facility did not provide that staffing ratio and provided a ratio of one staff person to nine clients. P3 stated that a residential staff person dropped the VA off at the facility and then “left immediately.” Facility documentation showed that the VA spent the afternoon “in the milieu” with peers and staff persons. The VA attended relationship skills group, ate dinner, and then attended progress group. Then, around 6:30 p.m., the VA requested his/her lighter to smoke. When the VA did not return, staff persons began looking for the VA. Then, the VA appeared in the courtyard and stated that s/he did not leave the facility. Later, the VA told staff persons that s/he left the facility and went to a gas station where s/he obtained and ingested two bottles of Tylenol PM. 9-1-1 was called and the VA was taken to the hospital via ambulance. Although the VA who had a history of swallowing medications and was able to leave the facility without supervision to obtain Tylenol PM and then ingest two bottles of the medication, given that facility documentation showed that the VA was supervised as required at the facility with hourly checks conducted, that the facility took precautions upon the VA’s admission to lock up hand sanitizer and other things the VA could swallow, and that once the VA stated s/he ingested the medication the facility took immediate action to seek medical attention, 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 Review and determined that policies and procedures were adequate and were followed. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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