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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: 1068637-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady 651-431-6557 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) did not see a dentist for more than four years and as a result needed four extractions due to tooth decay. Date of Incident(s): Ongoing, prior to November 29, 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 25, 2024; from documentation at the facility and dental records; and through interviews conducted with the VA, a facility supervisory staff person (P1), and a family member/guardian (FM) of the VA. The VA’s support plans stated that the VA’s diagnoses included a mild intellectual disorder. The VA enjoyed going to movies and spending time with family. The facility was to schedule and transport the VA to medical appointments. The VA’s dental records (provided by the facility) stated: · On March 28, 2019, the VA saw the dentist. The VA had decay in five teeth (the five teeth were identified by a standard numbering system). The VA was to floss once a day and brush his/her teeth two to three times a day. The VA was return for a “restorative” visit and in six months a “hygiene” visit. · On April 15, 2019, the VA was seen to discuss a restoration plan for four teeth (two of the teeth were upper teeth and two of the teeth were lower teeth) as well as for one tooth that needed extraction. The VA was to return on April 24, 2019. · On April 24, 2019, the VA had a tooth extracted. There next appointment was left blank. · On November 19, 2023 (which was the first dental appointment since April 24, 2019, and at a different dental provider) the VA was seen for a cleaning and dental exam. The record stated that the VA’s “oral hygiene is poor, plaque is moderate, tarter is slight, bleeding and gingivitis are moderate.” It was recommended that the VA floss daily and brush his/her teeth for two minutes twice a day, that the VA try an electric toothbrush, and that the VA have six month checkups. The examination showed that the VA had broken teeth and decay. The dentist recommended pulling some of the broken teeth and filling in some decay. In the future it would be “beneficial” to have the VA get upper and lower partials (dentures) to fix the missing teeth. · On November 29, 2023, the VA received two fillings on teeth in his/her upper right side and was to return for two more fillings on his/her upper front teeth. · On January 8, 2024, the VA received two fillings on his/her upper front teeth. (It should be noted that the four fillings that VA received at the above appointments were all in upper teeth and in March 2019, two of the decaying teeth were identified as being lower teeth.) P1 and P2 were each staff persons who had either worked at the facility in a lead, a supervisory, and/or an administrative role since 2020. P2 provided the following information in the internal review report: · In the year 2020, when P2 began working at the facility, P2 was aware that the VA’s last dental appointment was in 2019. At that time, the other consumers at the facility were scheduled for sedation dental appointments every two years so P2 assumed that was also true for the VA. In March 2021, P2 called to schedule the two year appointment for the VA at the dental clinic where the VA last went and was told that it had been too long since the VA was seen so they could no longer see him/her and that they were not taking new patients. P2 was aware of another dental provider that might take the VA and believed that in June or August 2021 or 2022 (P2 was not sure of the year) P1 or P2 called that provider. The provider was to send paperwork for the VA and “they went back and forth” in trying to get it. When they received the paperwork, they gave it to the FM and then returned it to the provider. At that time, the provider said they would call back. After time passed and they did not call back, P2 called the provider. The provider had a “really long waitlist” so when they did call, it took a long time to get the VA an appointment. · P2 said that in between appointments, the VA never showed signs of his/her teeth being in pain. P1 (the supervisory staff person since August 2022), provided the following information in an interview and in the internal review report: · In September 2023, P1 called the VA’s 2019 provider believing that the VA was on two year dental schedule and was to be seen in 2023. P1 found out that the VA had not been seen since 2019, that s/he was removed from their patient list, that they were not accepting new patients. P1 then talked to administrate staff persons and got the name of a dental provider that might take the VA. P1 was able to arrange an appointment for the VA at that provider on November 29, 2023. · At the dental appointment on November 29, 2023, it was discovered that the VA needed six or seven fillings, and it was recommended that some of the VA’s teeth be replaced with dentures. The FM did not want the VA to have dentures as s/he was concerned that the VA would not tolerate then and would keep removing them. Instead, the VA was to receive fillings and had appointments in January and February 2024 to work on fillings. After the fillings, a follow up appointment was scheduled on May 30, 2024, at which time it would be determined whether the VA would continue with six month or annual checkups. · The VA would show or tell staff persons if s/he was in pain, but never indicated to P1 that s/he had any mouth pain. P1 believed that the VA would him/her if his/her teeth hurt. · Going forward, P1 purchased the VA an electric toothbrush. The VA brushed his/her teeth independently, but needed prompting from staff persons to brush his/her teeth for two minutes. The VA also had a timer that was set for two minutes when the VA brushed his/her teeth. The VA stated that that his/her teeth hurt and that s/he had an upcoming dental appointment. The VA believed that s/he last had a dental appointment about four months ago. The VA’s teeth felt fine prior to him/her going to the dentist. After, the VA’s top right teeth hurt, but the VA did not want to have his/her teeth pulled. The FM stated that the facility provided care to the VA for 20 years and that s/he did not have concerns about the care that the VA received at the facility. The VA had issues with his/her teeth since the VA was young. If the VA had his/her teeth pulled and had dentures put in place, the VA would not want to keep the dentures in place. Facility documentation showed that P1 and P2 each received training specific to the VA and on the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rules and/or Statutes: Minnesota Statutes 245D.05, subdivision 1, paragraph (a), states the license holder is responsible for meeting health service needs assigned in the coordinated service and support plan or the coordinated service and support plan addendum, consistent with the person's health needs. Conclusion: Information obtained showed that the facility was responsible for scheduling and transporting the VA to medical appointments. After a routine dental appointment on March 28, 2019, the VA was to return in six months for another appointment (the VA did have appointments related to restoration of his/her teeth on April 15 and 24, 2019). However, after April 24, 2019, the VA was not seen by a dentist again until November 19, 2023, which was a violation of Minnesota Statutes 245D.05, subdivision 1, paragraph (a). On November 19, 2023, it was noted that the VA’s “oral hygiene is poor, plaque is moderate, tarter is slight, bleeding and gingivitis are moderate.” The examination showed that the VA had broken teeth and decay. The dentist recommended pulling some of the broken teeth and filling in some decay. In the future it would be “beneficial” to have the VA get upper and lower partials (dentures) to fix the missing teeth. After the November 29, 2023, the FM did not want the VA to have dentures, so in two follow up appointments, the dentist put fillings in four upper teeth (in March 2019, two of the four decaying teeth were identified as being bottom teeth). There was no information from staff persons, or the VA, that the VA had any issues with pain in his/her teeth between March 2019 and November 2023. Because the VA did not indicate any concerns regarding tooth pain and the VA needed the same amount of fillings in November 2023 as s/he did in November 2019 (although not all the same teeth), it was not determined whether failure to have regular checkups and cleanings between March 2019 and November 2023, resulted in decay that would have not otherwise occurred during that time. Given the above, there was not a preponderance of the evidence whether there was a failure to provide the VA with health care which was reasonable and necessary to obtain or maintain the VA’s physical health. 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, but not followed as the VA should have been scheduled for regular dental appointments between 2019 and 2023. An administrative staff person was to follow up to ensure all appointments were scheduled in a timely manner. Action Taken by Department of Human Services, Office of Inspector General: On April 10, 2024, the facility was issued a Correction Order for the violation outlined in this report.
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