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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: 801558-RMI (Residential Treatment and Services for Adults with Mental Illness) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that a staff person (P1) did a “walk-through” to survey a courtyard before a vulnerable adult had access. Later that same day, when another staff person (P2) was providing 1:1 supervision, the VA went into the courtyard and accessed several feet of weather stripping from around the courtyard door frame and hid the weather stripping under his/her clothing without P2’s knowledge. Later that day the VA turned over some pieces of the weather stripping but retained others and inhaled them resulting in the VA being sent to the hospital for a bronchoscopy. Date of Incident(s): June 27, 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 August 2, 2023; from documentation at the facility; and through three interviews conducted with the VA, a facility staff person (P3) and a medical professional (MP). Two staff persons (P1 and P2) declined an interview with this investigator. The VA was admitted to the facility on February 28, 2022. The VA’s diagnoses included borderline personality disorder, oppositional defiant disorder, major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder. The VA’s history included ingestion of foreign bodies. The VA enjoyed writing, playing cards, coloring, doing crafts, and listening to music. At the time of the incident, the VA resided on Willow Unit and was the only client on that unit. Facility documentation showed that the VA had a long-standing history of “disruptive and self-injurious behaviors.” Prior to his/her admission to the facility, the VA resided at Anoka Metro Regional Treatment Center (AMRTC) due to “unmanageable self-harm” primarily by means of swallowing inedible items, requiring medical intervention on multiple occasions. While at AMRTC, the VA had a 4:1 staff ratio at all times and was able to acquire items to ingest while staff persons were present at his/her side. It was determined that staffing ratio or proximity to the VA at all times was not determined to impact his/her ability to swallow inedible items. On the contrary, staff person proximity to the VA added exposure to items s/he could swallow (face masks, name badges, keys, eyeglasses, etc.). Information also showed the VA’s history included a plethora of psychotropic medications and electro convulsive therapy, all of which were thought to be ineffective in managing his/her self-harm behaviors. When the VA was first admitted to the facility, his/her behaviors related to swallowing inedible items progressed to “inhaling” items, with either method often requiring him/her to be sent to a hospital for medical intervention (bronchoscopy/endoscopy). The VA’s Individual Abuse Prevention Plan stated that s/he said on multiple occasions that his/her self-harm was an attempt to “kill [him/her] self.” Risk measures to prevent the VA from obtaining items included restricting items and modifying his/her environment. The VA had tear-proof blankets, pillows, and gowns. When the VA obtained items that placed him/her at imminent risk, verbal redirection and encouragement to surrender the items were attempted. Due to a history of sexual assault/trauma, when the VA stored items within his/her body cavities, “unclothed body searches would not be considered.” Likewise, items were not forcibly removed from the VA due to physical aggression and assaultive behaviors resulting. At the time of the incident, the VA’s supervision order was for “1:1 Observation” that allowed a “barrier” (such as a glass window) while on the unit. The order also stated that staff persons “may utilize camera” while the VA was in his/her room. When showering, the staff person stood outside of the shower and maintained verbal contact every two minutes. Hygiene items were to be poured into the VA’s hand, s/he did not have access to towels or washcloths, and s/he dried with a tear proof gown or tear proof blanket. A tour of the Willow unit showed that observation of the VA was provided from inside the unit’s office by looking out large windows that allowed visibility of the entire unit. The Willow unit also had various cameras that displayed on computer monitors inside the office. When ordered and/or when needed, a camera inside the VA’s bedroom also provided additional supervision. From the unit station, staff persons were able to see a common area, two doors that lead to bedrooms along one wall of the unit, and a door that lead out to the courtyard. The courtyard door had a window in the upper half of the door. Another window, approximately 18 inches wide, was located against the right side of the door frame and went from the top to the bottom of the door. Information from the MP, P3, facility documentation, and/or a review of video coverage around the time of the incident provided the following information: · Facility documentation showed that prior to the incident, the facility attempted to provide a “sterile” environment for the VA; however, that was determined to be unsuccessful as there was an increase in physical aggression as the VA attempted to enter the unit station to obtain items to swallow. It was also “virtually impossible to successfully limit all items in an environment and is not sustainable over time.” (For example, toilet paper was routinely needed and although amounts were rationed/limited, the VA obtained and ingested/inhaled toilet paper numerous times.) · The MP described the VA as “crafty and fast” and said that the VA hid items on and in him/herself. Given the VA’s trauma history, staff persons did not conduct unclothed body searches or body cavity searches when the VA obtained items to ingest/inhale. The MP said there were times when negotiation with the VA lasted “hours” when attempts were made to get items back from the VA. The MP wrote the VA’s “1:1 Observation” and said there needed to be a “direct line of sight” between the VA and a staff person. The VA’s entire body did not need to be visible, but staff persons needed to visually see where VA was located. At the time of the incident, the order did not necessarily “prevent [the VA] from getting things” it was to “render aid in the time of respiratory distress.” · On the morning of June 27, 2023, the Willow courtyard remained locked until a “walk-through” was completed. P1 completed the “walk-through” of the courtyard that day. · P3 said that a “walk-through” included visual observation of the courtyard. The courtyard did not have a solid roof so outside items blew into the courtyard through the overhead grates or from the roof attached to unit. Although there was no specific checklist identifying what staff persons were to look for, staff persons were trained to look for “contraband” or any items that the VA could use to harm him/herself. In the afternoon, after the “walk-through” was completed, P3 and the VA spent approximately 30 minutes outside in the courtyard while P1 and P2 observed the VA from the unit station. P3 said there were no concerns with the VA’s presentation and no identified items in the courtyard that could be used for self-harm. · After P3 and the VA went back inside, P3 left the unit and P1 and P2 continued to observe the VA from the unit station and via camera. P2 was assigned as the VA’s 1:1.
· A review of the camera footage after P3 left the unit showed the VA was in the common area making verbal contact at the unit station window. (P1 and P2 were in the unit station.) The VA then opened the courtyard door and held it open with his/her body. Only part of the VA’s body was visible given the lower half of the door did not have a window. The VA appeared to bend over for a few seconds and came back inside the unit within 15 seconds. After coming back inside, the VA again had a brief verbal interaction at the unit station window and walked around the unit. · P4 said that the unit courtyard search did not include visualization or any check of the integrity of the rubber stripping around the door frame because that was not a concern at that time and that was “not a normal part of the search for contraband." Staff person visually supervised the VA when s/he stepped into the courtyard and had no reason to believe the VA obtained anything knowing the courtyard was “clear” due to the walk-through that occurred earlier that day. · An Incident Report dated June 27, 2023, stated that at approximately 5:25 p.m., the VA “turned in” approximately three feet of weather stripping she said she obtained from the courtyard door. The VA reported inhaling several pieces and said that she had more weatherstripping in his/her genital area and was unwilling to give the remaining pieces to staff persons. · Unidentified health care professionals observed the VA for acute distress and monitored his/her vitals. Negotiation with the VA was unsuccessful as the VA sat in front of the Willow office and inhaled more rubber. The VA was closely monitored and was transported via ambulance to a hospital for further evaluation where s/he was intubated and bronchoscopy was performed to remove five “pieces” of weather stripping, each measuring two to three centimeters, a “small piece of fibrinous hair like material,” and a “small white foreign body that appeared to be a silicone.”
Conclusion: Information was consistent that on June 27, 2023, the VA had 1:1 staffing while residing on Willow Unit. Supervision was provided from inside the unit office that allowed visualization of the unit in conjunction with cameras that displayed on monitors that also showed various areas on the unit. That morning, a “walk-through” of the courtyard was completed that consisted of looking for contraband items or items the VA could use for self-harm. Around lunchtime, P3 and the VA spent approximately 30 minutes together in the courtyard and according to P3, there were no concerns with the VA and no identified items in the courtyard that could be used for self-harm. After P3 and the VA returned inside on Willow unit, P3 left. The VA made visual and verbal contact with P1 and P2 via the office window before s/he walked back to the courtyard door that was directly in front of the unit station. The VA held the courtyard door open with his/her body and bent down. The VA’s actions while bent over were not visible given the lower part of the door did not have a window. Within 15 seconds the VA obtained weather stripping, concealed it under his/her gown, and returned inside the unit. The VA later admitted concealing weather stripping and swallowing some of it. The VA was monitored and transported to a hospital for removal of five pieces via bronchoscopy. Although the VA was able to obtain and swallow weather stripping, given s/he had an extensive history of self-injurious behaviors, that staff persons followed the 1:1 observation orders as required by keeping the VA within visual contact, that staff persons conducted a “walk-through” of the courtyard as required, and that staff persons provided observation and medical services when it was made known the VA swallowed some weather stripping, there was not a preponderance of the evidence that there was a failure to provide the VA with supervision that was reasonable and necessary to maintain the physical health of the VA. 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. There was no need for additional staff person training. Follow-up to the incident included a review of the VA’s observation level, the camera angles for when camera observation was used, and the process to “clear” the courtyard. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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