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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: 1097945-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Alice Percy 651-431-3970 Suspected Maltreatment Reported: It was reported that there were concerns regarding the care and services provided to a vulnerable adult (VA): · On one occasion, the VA began to choke on a piece of food, but was able to “cough it up.” The VA was not taken to the hospital after the incident. Several days later, the VA was taken to the hospital and diagnosed with bronchitis; · Staff persons did not document the VA’s medication administration and on one occasion, the VA did not receive his/her requested pain medication; · The VA was not taken to all of his/her scheduled medical appointments by the staff persons; and · A staff person did not use a Hoyer lift correctly, resulting in a shoulder injury to the VA. Date of Incident(s): Ongoing, prior to June 14, 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 July 7, 2023; from documentation at the facility; and through eight interviews conducted with a facility supervisory staff person (P1), two staff persons (P2 and P3), the VA, three of the VA’s family members (FM1, FM2, and FM3), and the VA’s case manager (CM). The VA enjoyed listening to audio books, shopping, coloring, attending religious services, and spending time with his/her family members and friends. The VA’s diagnoses included muscular dystrophy, ataxia, blindness, and torticollis (neck condition). The VA used a wheelchair for mobility. The VA was not subject to guardianship. According to the VA’s ISSA Assessment Detail, the VA preferred to eat independently, but needed to have his/her food cut into bite-size pieces. The VA requested assistance when needed. The staff persons used a hoyer lift to transfer the VA between his/her bed and wheelchair. The VA was able to schedule his/her medical appointments, but the staff persons typically assisted the VA so as to ensure that a staff person was available to transport the VA to the appointments. The VA was experiencing some decline in his/her physical strength and abilities. The VA provided the following information: · In May 2023, the VA was eating fruit at the table, but the fruit was not cut up like it normally was. The VA tried to chew it, but it “slipped down” his/her throat, causing the VA to choke. A staff person (P6) patted the VA’s back until the VA coughed it up. P6 did not call an ambulance for the VA. The VA coughed “a lot” and went to the hospital “days later.” The VA’s physician did not find that the VA aspirated the food. On another occasion, P4 gave the VA a cup full of cookies while the VA was in his/her bed, but then left to assist another resident, even though the staff persons were supposed to watch the VA eat. · In May 2023, the VA had two asthma attacks and went to the hospital “a couple of days later” because of coughing. P4 was supposed to order a medication for the VA and told the VA’s physician that s/he ordered it, but did not actually order the medication. On one occasion, the staff persons ordered a pain medication for the VA, but the VA’s physician did not reply to their request to refill the prescription. · On one occasion, the VA was unable to go to his/her medical appointments because there was no staff person to take the VA to the appointment. On a second occasion, the physician cancelled the VA’s medical appointment. · On one occasion, the VA asked the staff persons if a gait belt was put in his/her bag prior to going to a medical appointment and was told that it was. However, when the VA used the bathroom at the medical appointment, there was no gait belt for the staff persons to use to assist the VA with toileting and the VA fell while in the bathroom. The staff persons did not complete an incident report for the incident. After the incident, it was required that two staff persons accompany the VA to medical appointments. On another occasion, P2 dropped the VA while assisting the VA in the bathroom. The VA’s hip was sore, but s/he did not want to go to the hospital and no incident report was completed for the incident. · On one occasion a staff person (P4) used a Hoyer lift to assist the VA with using the bathroom, but placed the sling on the VA incorrectly. The VA told P4 to “put me down,” but P4 told the VA that they were almost there. When they got to the bathroom, the VA’s right shoulder was in pain because the sling was placed incorrectly. · The VA stated that in March or April 2023, after his/her family members told the staff persons that other staff persons were smoking cigarettes in the facility’s garage and allowing smoke to enter the facility, P1 told the VA that “it doesn’t matter what you say or do.” FM1, FM2, and FM3 provided the following information: · On May 17, 2023, the VA choked on a piece of cucumber, but was not taken to the hospital until May 21, 2023. FM2 stated that s/he learned about the incident from the VA, not the staff persons. On May 18, 2023, a protocol requiring the staff persons to sit near the VA when s/he ate was implemented. On May 22, 2023, FM1 visited the VA and saw the VA sitting alone in his/her bedroom eating cookies. · FM1 stated that at times, the VA did not get his/her pain medication because “it wasn’t in the system.” FM3 stated that the staff persons did not always document the VA’s medication administration and did not keep the computer or paper copy of the medication administration record (MAR) current. The staff persons did not always document if the VA asked for more pain medications. · FM1 stated that on April 3, 2024, P4 used the Hoyer lift incorrectly when transferring the VA to the bathroom and the VA injured his/her shoulder. The VA had shoulder pain prior to the incident, but it was worse after the incident. In May 2023, the VA missed medical appointments involving his/her shoulder pain because there were no staff persons to transport the VA to the appointments. · When the VA told the administrative staff persons that they staff persons were not following the VA’s plans, the staff persons “retaliated” against the VA by not engaging with the VA, not assisting the VA when necessary, not taking the VA on community outings, and making derogatory comments about the VA in front of him/her. The staff persons did not always update the VA’s progress notes. P1, P2, P3, and the facility’s documentation provided the following information: · The staff persons were required to cut the VA’s food into bite-size pieces because the VA had a history of choking. When the VA began to choke, the staff persons encouraged the VA to cough. If the VA was unable to cough the food up, the staff persons were trained to use a LifeVac (anti-choking device) and then to call 9-1-1 to have the VA evaluated by the emergency medical technicians (EMTs). Based on the EMT’s evaluation, an incident report would be written and a 7-day watch started. On May 17, 2023, the VA began to choke on a piece of food, but was able to “cough it out.” The VA refused medical attention. After the incident, the staff persons completed an incident report and the VA was placed on a 7-day watch. The staff persons were trained to remain near the VA when the VA ate in case the VA began to choke. The VA had breathing problems prior to the incident and on May 21, 2023, was diagnosed with bronchitis. P2 stated that s/he was trained on using the LifeVac, but had never had to use it. P2 stated that when the VA choked on the food, s/he documented the incident in the progress notes. P1 did not immediately notify the VA’s case manager (CM) because s/he did not know s/he needed to report an incident where the VA coughed up a piece of food and did not require medical care. · P1 stated that all of the staff persons received training on administering and documenting medication administration. The staff persons were trained to document when they administered medications and to complete progress notes each day. P3 stated that the staff persons documented medication administration on the computer and occasionally on a paper MAR if the computer was “down.” The information was later transferred to the computer record. · P1 stated that on one occasion, the VA had an “as needed” prescription for Tramadol. The VA’s physician wrote the prescription for the VA to use the medication for 10 days. After the 10 day period, the VA had three pills remaining, but the staff persons were unable to administer those medications to the VA because it was past the 10 day prescription period. If a prescription period “ran out,” the pharmacy had to contact the physician to have the prescription renewed, which might take time to do. On one occasion, the staff persons had called and emailed the VA’s physician, but the physician did not renew the VA’s prescription until one of the VA’s family members contacted the physician. · P1 stated that the VA and his/her family members typically scheduled the VA’s medical appointments. On one occasion in May or June 2023, one of the VA’s medical appointments had to be rescheduled because the VA and the staff persons arrived at the clinic late. The VA had “a lot of appointments” and it was necessary to send two staff persons with the VA in case s/he needed to use the bathroom while at the appointments. The missed appointments were rescheduled. P1, P2, and P3 were each unaware of any time that the staff persons failed to take a gait belt with them when they accompanied the VA to medical appointments. · In May 2023, the VA told the staff persons that his/her shoulder hurt. The VA had shoulder pain previously and had been receiving cortisol shots in the shoulder. The VA had multiple MRIs and his/her physician told the VA that his/her shoulder was “fine,” but that s/he had arthritis in the shoulder. The VA received injections and physical therapy to help with the pain in his/her shoulder. On April 4, 2023, the VA told P1 that a staff person placed the Hoyer sling incorrectly, causing pain to the VA’s shoulder. When asked if s/he wanted to be seen by his/her physician, the VA declined to be seen by his/her physician, but an appointment was made for the VA to receive a cortisone shot. · P1 stated that the VA required a two-person transfer to his/her bed, shower chair, and wheelchair. P2 stated that on one occasion in February 2023, s/he was assisting the VA with toileting and the VA’s legs “gave out” so P2 lowered the VA to the floor “gently” so that s/he was not injured. The VA did not tell the staff persons s/he had any pain after the incident, did not want to go to the hospital, and did not require pain medication. The CM stated that on one occasion, after a choking incident, the VA was put on a seven-day choking watch, but the staff persons only documented five days. The VA was prescribed many medications and the prescriptions were frequently changed by the VA’s physician. The VA’s physician was located in Rochester, MN, rather than locally, so it took longer for the staff persons to drive to and from the VA’s clinic, which made it more difficult to schedule the appointments. The VA did not always work with the staff persons to schedule medical appointments when two staff persons were available to accompany the VA to his/her appointments. At times, the VA cancelled his/her medical appointments. A review of the VA’s medical appointments showed that the VA had 11 medical appointments in May 2023. One of those appointments was missed. In June 2023, the VA had 10 medical appointments. The VA’s physician cancelled one of those appointments. The VA was taken to all of the other appointments. A review of the VA’s MARs for May, June, and July 2023, showed that all of the VA’s prescribed medications were documented as administered. Facility documentation showed that P1, P2, and P3 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. Conclusion: On one occasion, the VA began to choke on a piece of food but was able to “cough it up.” After the incident, the VA refused medical attention, so a 7-day watch was implemented by the staff persons. Although the VA was taken to the hospital several days later and diagnosed with bronchitis, it was not determined whether the choking incident was related to the bronchitis diagnosis. While it was reported that the staff persons did not document the VA’s medication administration, P1 and P3 each stated that the staff persons documented medication administration on either the computer or paper copies of the MARs. A review of the MARs showed that the VA’s medications were documented as administered. In addition, no information was provided that the VA sustained any injury or adverse effects as a result of missing any of his/her medications. On one occasion, the staff persons were unable to administer the VA’s pain medication because the prescription time frame for the medication had passed and the VA’s physician had to provide a new prescription for the medication. The staff persons called and emailed the VA’s physician, but the physician did not renew the VA’s prescription until one of the VA’s family members contacted the physician. While it was reported that the VA was not taken to all of his/her scheduled medical appointments by the staff persons, information was provided that the VA sometimes made medical appointments without first ensuring that two staff persons would be available to take the VA to his/her appointments. On one occasion, because the clinic was a distance from the facility, the staff persons and VA arrived at the appointment late. On another occasion, the physician cancelled an appointment. Those appointments were rescheduled and documentation showed that no other appointments were missed. It was also reported that a staff person did not use a Hoyer lift correctly, resulting in a shoulder injury to the VA. When asked if s/he wanted to be seen by his/her physician, the VA declined to be seen by his/her physician, but an appointment was made for the VA to receive a cortisone shot. Information was provided that the VA had shoulder pain prior to the incident and had been routinely receiving cortisone shots in the shoulder. The VA had several MRIs over a period of time and his/her physician told the VA that his/her shoulder was “fine,” but that s/he had arthritis in the shoulder. Although several concerns involving the VA’s care were reported, given the aforementioned, 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 that the facility’s policies were adequate and were followed by the staff persons. After the incidents, the VA’s plans were updated and the staff persons received training on the updates. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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