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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: 1080284-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that a vulnerable adult’s (VA) tooth was broken. The facility did not get the VA in to see a dentist and the VA had increased self-injurious behaviors. Date of Incident(s): February 2024, prior and ongoing 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 April 11, 2024; from documentation at the facility; and through six interviews conducted with three facility staff persons (P1, P2, P3), the VA’s case manager (CM), the VA’s guardian (G), and a staff person at the VA’s vocational program (VP). Due to his/her diagnosis the VA was non-verbal and unable to provide any information about the incident. The VA enjoyed music and movies and was diagnosed with intellectual disabilities and cerebral palsy. The Individual Abuse Prevention Plan showed that the VA displayed self-injurious behaviors such as hitting him/herself, biting him/herself, head banging, and hitting his/her body against objects. The behaviors had resulted in injury. The Intensive Services Assessment showed that the VA was “generally agreeable” while seeing his/her medical and dental professionals for “short” periods of time. The VA might not have the cognitive ability to understand, recognize, or report any illness or injury to staff persons or medical professionals. The VP provided the following information: · On December 19, 2023, the VP reached out to the facility when they saw that the VA had a tooth that appeared to be partially missing. The VP reported the concern to the facility and did not hear back. At a team meeting the facility said that the VA had a dental appointment at the end of the month (January 2024). The VA’s self-injurious behaviors had also increased, and the VP felt the VA was in pain. The side of the VA’s face appeared swollen. · The VA never went to the dental appointment in January 2024. The VA typically did not have a lot of self-injurious behaviors at the vocational program, but since the VP noticed the VA’s tooth issue, the VA had more self-injurious behaviors including hitting that side of his/her face, putting his/her hand in his/her mouth, and digging with his/her hand in his/her mouth. The Internal Review of Alleged Maltreatment Report, P1, P2, and P3 provided the following information: · The VA was nonverbal and communicated through yelling. At times the VA displayed self-injurious behaviors such as hitting his/her hand on his/her face/head, biting his/her arm/wrist, thrashing around, and banging his/her arms/hands/elbows on his/her bed. · Staff persons brushed the VA’s teeth twice daily, but this was difficult as the VA would attempt to bite, thrash around, and/or not keep his/her mouth open. In the past the VA had bit down on toothbrushes and snapped them. At a dental appointment on April 13, 2023, the VA’s dentist referred him/her to a new dental facility because the VA needed general anesthesia for his/her appointments. An appointment with the new dental facility was scheduled for January 3, 2024. · On December 19, 2023, the VA’s vocational program reported that they thought the VA had a chipped back tooth on the lower left side. P1 and P3 came to the facility to look at the VA but did believe it looked like the tooth was broken. The VA had a dental appointment set up for January 3, 2024, so they felt it could be discussed with his/her dentist at this appointment. P3 did not see any evidence of a chipped tooth, swelling, or bleeding. · The VA went to his/her family’s home for New Year’s and his/her wheelchair ended up breaking while at the family home. The family “rigged” up the chair, but it was not safe for the VA to sit or be transported in the chair. The facility was able to reschedule the VA’s dental appointment for the end of January 2024. · Before his/her next appointment the facility’s van lift broke and the VA was not able to be transported to that appointment. The next available appointment was May 15, 2024. · P2 said that recently the VA received a new bed and his/her self-injurious behaviors had significantly decreased while in bed as s/he was not able to hit his/her elbows in the new bed. The only time P2 ever saw the VA hit his/her face/mouth was when the VA was in his/her wheelchair. At some point P2 thought the VA was having dental pain when she/he was hitting him/herself in the mouth, but P2 noticed that since the VA got new leg braces that fit his/her feet better, P2 had not seen the VA hit his/her mouth area. · On April 3, 2024, the VA went to urgent care for an unrelated issue and staff persons asked the medical provider (MP) to look in the VA’s mouth for a second opinion. The MP said that the VA had gingivitis (inflammation of the gums) and to schedule the VA for a dental appointment. P2 said the MP did not say it was an emergency. · P1 said that they had not noticed any changes in the VA’s self-injurious behaviors or any signs of infection. P2 never noticed an increase in the VA’s self-injurious behaviors or any symptoms that could indicate an infection. P3 said that the VA had a high pain tolerance but never showed any sign of pain. · The new dental facility was contacted, and they noted that the VA was referred in April 2023, due to needing IV sedation. The dental facility contacted the previous dentist but were unable to get the needed paperwork until September 9, 2023. There was still some additional information needed that was supplied by the G on September 14, 2023. A consult was scheduled for December 13, 2023, but was cancelled because staff persons were not able to bring the VA in for the appointment. On January 2, 2024, there was a call to reschedule an appointment (likely the January 3, 2023, appointment). On January 22, 2024, an appointment was scheduled for May 15, 2024. The facility inquired about a waiting list, but the dental facility said that was how far out the appointments were which was normal for a “specialty consult.” The G provided the following information: · It seemed as though the VA had missed a few medical appointments when there was not a staff person to take the VA, or the facility vehicle broke down. The VA need general anesthesia for his/her dental appointments, and s/he had an appointment scheduled for May 2024, but the G thought that was just a consultation and was unsure if there would be any work done on the VA’s teeth. · It was difficult to brush the VA’s teeth and s/he would bite down on the toothbrush. The VA’s teeth “look so bad” that the vocational program had been brushing the VA’s teeth when s/he was there. · On December 31, 2023, the VA’s wheelchair broke while s/he was at a family member’s home but had since been repaired. The facility also got a new van as the previous one kept breaking down. · The G felt the VA was possibly in pain from his/her teeth as s/he was hitting the side of his/her face and had a bruise. It seemed that the VA was “acting out a lot” and had bad breath. Health Visit Records and other medical paperwork showed the following information: · On April 3, 2024, the VA was seen at an urgent care clinic and diagnosed with gingival disease (causes inflammation of the gums) and poor dentition (teeth that are not present or in the correct amount/arrangement in the mouth). The VA was prescribed Augmentin (antibiotic) twice a day for 10 days and was to follow up with the dentist. · On May 2, 2023, the VA was seen by his/her dentist and the exam showed “many decay teeth.” It was recommended to go to the “hospital” to get them restored/fixed. · On April 13, 2023, the VA was seen by his/her dentist and examined “as able” due to cooperation. The VA had heavy plaque and several caries possibly/likely causing pain. There was no visible swelling or drainage. The VA needed a sedation/general anesthesia referral for dental work, radiographs, and possible extractions. · A referral form to a new dental office was filled out April 13, 2023, and it was noted that the VA seemed to have pain on his/her right side but was unable to communicate. There were many caries present and possible extractions were needed. · On November 28, 2022, the VA saw his/her dentist and heavy plaque throughout the teeth was noted. The VA was to brush three times a day and return in six months. Medication Treatment Records from December 2023-March 2024, showed that staff persons assisted the VA to brush his/her teeth three times daily and “assist with oral hygiene” three times daily. Behavior Tracking showed a consistent level of self-injury (biting arm/hitting head) from December 2023-March 2024. Facility documentation showed that all staff persons interviewed received training on the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Consistent information was provided that the VA had on-going dental issues and poor oral hygiene. The VA had self-injurious behaviors and other behaviors that were challenging for completing dental appointments and hygiene. On April 13, 2023, the VA’s dentist noted cavities that needed to be fixed and some possible extractions that were needed, but that the VA would need to be sedated. The dentist referred the VA to another dental facility that provided those services. The new dental facility noted that they received all the completed paperwork from the dentist and the G by September 2023, and scheduled the VA for an appointment on December 13, 2023. The VA missed this appointment, and it was likely rescheduled for January 3, 2023. The VA’s wheelchair broke, and s/he was unable to attend the appointment on January 3, 2023. The next available appointment was May 15, 2024. On April 3, 2024, the VA’s tooth was checked by a medical professional when s/he had an appointment for an unrelated issue. The medical professional noted that the VA had inflammation of his/her gums and prescribed an antibiotic. It was recommended that the VA should see a dentist. On December 19, 2023, the VP said that one of the VA’s teeth appeared to be partially missing and this was reported to the facility who said the VA had a dental appointment in January 2024. The side of the VA’s face appeared swollen, and the VA appeared to be in pain as s/he had increased self-injurious behaviors. P1-P3 each stated that they did not notice any increase in the VA’s self-injurious behaviors or any indications of infection. P1 and P3 both looked in the VA’s mouth in December 2023, and did not notice a chipped tooth, swelling, or bleeding. The VA had poor dental health and needed major dental work including fillings and possible extractions. This likely caused the VA pain. However, given that the VA was unable to have work completed by a regular dentist and needed to be treated under sedation; that staff persons obtained a referral for the sedation dentistry and set up an appointment; that although an appointment or two was missed due to staff person issues and/or wheelchair issues, staff persons rescheduled as needed; that the VA was rescheduled to be seen as soon as possible; and that in the meantime the VA was seen by a medical professional for evaluation; 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 policies were not followed. Staff persons were retained in Health Service Coordination and Care Policy, Maltreatment of Vulnerable Adults Policy and Procedure, and Employee Conduct and Discipline Policy. A new Program Coordinator was put in charge of the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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