MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

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:

1081068-H_CRS (Home and Community-Based Services-Community Residential Setting)
1072182-HCBS (Home and Community-Based Services)

Investigator(s):

Lindsay Arth
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
lindsay.arth@state.mn.us

651-431-6537

Suspected Maltreatment Reported:

It was reported that there were multiple concerns regarding the care a vulnerable adult (VA) received at the facility. This included that the VA lost 50 pounds (lbs) over a six-month period and that the VA had multiple worsening pressure injuries. There were also concerns regarding the staffing at the facility and that staff persons were not trained on the VA’s plans.

Date of Incident(s): Ongoing and prior to July 23, 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 June 6, 2023; from documentation at the facility, law enforcement records, and medical records; and through 13 interviews conducted with the VA, two facility supervisory staff persons (P1 and P4), two staff persons (P2 and P3), the VA’s case manager (CM), the VA’s family member (FM), the facility registered nurse (RN1), four health care professionals (HCP1, HCP2, HCP3, and HCP5) who were registered nurses and worked for a company that provided in home nursing services, and a registered nurse (RN2) from a local hospital. Additionally, a supervisory staff person (P5) and a temp staff person (T1) communicated with this investigator via email and that information is provided below. Attempts were also made via phone to contact and interview a health care professional (HCP4) who provided in home nursing services, but the attempts were not successful. Attempts were also made to contact HCP1, HCP2, HCP5, the CM, P2, and P3 for follow up of additional information but the attempts were not successful).

The VA’s support plans provided the following information:

· The VA moved into the facility on January 20, 2022, and was not subject to guardianship. The VA was diagnosed with multiple sclerosis (MS) and was non-ambulatory. The VA had “complex health issues” and had an “established medical care team.” As of March 10, 2022, the VA received wound care, in-home skilled nursing visits, physical therapy, occupational therapy, and speech therapy. At some point, the VA also consulted with hospice but requested not to move forward with those supports.

· The VA enjoyed spending time with his/her family members. The VA wanted to “stabilize” his/her health so that the VA could spend more time with his/her housemates.

· The VA was “bedridden” and “prone to wounds” due to limited mobility. The VA received “skilled” and “intensive” nursing to assist with wound care and to “maintain” his/her health. When the VA first moved into the facility, s/he had a large pressure wound on his/her upper buttocks and two open pressure wounds on his/her back. The VA’s “team” expressed concern regarding the amount of time the VA spent in bed because the VA was “at risk” for getting decubitus (pressure) ulcers. Staff persons were to assist the VA with repositioning every two hours, including during the night, due to the pressure wounds.

· The VA wore adult undergarments. The VA also had a catheter and was “prone” to getting urinary tract infections (UTI’s) that became “septic.” The VA had “numerous hospitalizations due to complications” from his/her catheter and pressure wounds. The VA also had “bowel incontinence” that could cause “accidental leakage” and when that occurred, the VA needed his/her clothing changed to prevent skin breakdown. Because of this, the VA “most likely,” at some point in the future, would have an operation for a colostomy bag.

· At “times of the day [which were not noted],” the VA required “two if not three” staff person’s assistance to meet the VA’s needs for transfers, turning and repositioning, and hygiene cares.

· Staff persons were “trained at a higher level” to ensure that the VA was able to remain out of the hospital and have “nursing level of care” at the facility.

· Due to the VA’s diagnoses, the VA had difficulty communicating and was difficult to understand. There was a “desire” to get the VA additional services to “support” the VA’s communication. The VA followed medical direction with the assistance of staff persons. The VA did not typically complain of pain. The VA’s family was to “check in and be involved” with the VA’s health. Staff persons were to follow the VA’s doctors’ orders and “regime” and report all concerns in facility “logs,” to the VA’s doctors, and to the VA’s “care team.” Additional supplies and equipment were to be purchased to support improving the VA’s overall health.

· The VA’s Master Care Plan updated on March 5, 2023, said that the VA’s diet was “mechanically altered.” [Note: According to Medicalnewstoday.com, a mechanically altered diet was a diet that consisted of soft textured foods that were pureed, mashed, or blended.] Additionally, the VA’s food was to be “minced and moist.” Around May 1, 2023, the VA was admitted to a local hospital and a feeding tube was placed to meet the VA’s needs because it was “not safe” for the VA to ingest anything orally due to MS. The VA returned home from the hospital on May 10, 2023, with “home care and therapy services.”

· Staff persons were “required” to complete daily progress notes each shift and document whether services were completed or if the VA “complied.”

HCP1, HCP2, HCP3, emails from HCP1 to the VA’s team, and the Home Care Visit in Allina Health Home Health provided the following information:

· Starting on April 24, 2023, the VA received in-home nursing visits from nurses including HCP1- HCP3. Prior to April 24, 2023, the VA received in-home nursing services from another company, including with HCP5. The in-home nurses, including HCP1- HCP3, provided “wound care,” “monitored” the VA’s feeding tube, changed the VA’s catheter, checked the VA’s vital signs, screened the VA for sepsis, and provided “some education” to staff persons. HCP1 typically worked with the VA but when HCP1 was “busy,” other nursing staff such as HCP2 and HCP3 worked with the VA. The in-home nursing typically met with the VA two to three times a week and HCP1 said that due to the VA having “so much going on” medically, s/he met with the VA for approximately two hours each visit.

· The VA was not able to communicate effectively due to his/her diagnoses which resulted in “increased vulnerability.” HCP2 said that the VA was “barely able to speak.” However, the VA was able to “understand” and moved his/her head to indicate yes or no.

· The VA was “dependent” on staff persons and was non-ambulatory due to MS. The VA was always in bed when the in-home nursing saw the VA (Note: The Home Health Communication Note dated February 8, 2023, and completed by HCP4, stated that it was “requested” that the VA’s doctor “clarify” if the VA could be out of bed during the day. However, there was no follow-up regarding if the VA’s doctor was spoken to about this, either by the facility or the in-home staff). However, the VA had a wheelchair to use for appointments. Staff persons told the in-home nursing they did not get the VA out of bed due to the VA’s pressure injuries. HCP3 did not know “how long” the VA was not getting out of bed.

· HCP3 said that staff persons were to reposition the VA “at least every two hours if not hourly.” The VA required two staff persons to reposition him/her. HCP3 always saw two staff persons during his/her visits but did not work with the VA as often as HCP1. HCP1 said that s/he saw between one and four staff persons at a time at the facility. This included that on one date, HCP1 was at the facility working with the VA and there was a single staff person, when HCP1 heard a “big thump” in another client’s bedroom. When HCP1 went into that client’s bedroom, the client was on the floor with his/her head “wedged” under his/her bed. HCP1 went into the living room to tell the staff person, who was a temp staff person, and the temp staff person was on his/her phone and not aware that the client had fallen. After HCP1 told the temp staff person about the fall, the temp staff person assisted the client. HCP1 said that in general, the temp staff persons did not have any “connect” with the clients and were “just there as a body.” HCP3 worked with the VA including on April 27 and May 17 and 31, 2023 and during those times, s/he observed staff persons “lying on the couch” and “watching TV.” HCP1 said that there were a “couple” staff persons who were “wonderful” regarding the VA’s care. However, those staff persons were not always at the facility.

· The VA had “multiple” and “worsening” pressure “injuries” on his/her sacrum (end of the spine near the pelvic area), both hips, knees, and on his/her feet and heels. At some point, HCP3 recommended that the VA go to a wound clinic but HCP3 did not know if the facility set that up (Note: The facility Nurse Visit Record showed that on June 16, 2023, the VA went to the wound clinic but there was no additional information provided regarding this). Normally, the wound clinic told the in-home nursing what “restrictions” a client would need for things such the amount of time spent in bed. The VA was in “a lot worse shape” than other clients HCP3 typically saw. HCP3 had seen “worse wounds” but the VA had “so many” wounds which HCP3 did not typically see. It was a “very sad situation.”

· HCP3 said that on April 27 and May 17 and 31, 2023, when s/he arrived at the facility, the VA was “soiled” and “full of stool.” HCP3 notified the staff persons working to assist HCP3 with “cleaning [the VA].” HCP3 had concerns that the VA was “sitting in a soiled brief” that was “soaked down to [the VA’s] mattress.”

· HCP1 said that between April 24 and June 2, 2023, the VA was hospitalized five times. During a hospitalization from May 20 to 25, 2023, for a UTI, the VA’s “sacral pressure injury” improved “dramatically.” However, shortly after the VA returned home to the facility, in-home nursing observed that the VA’s sacral wound had “deteriorated beyond pre-hospital status,” which HCP1-HCP3 “suspected to be the result of suboptimal care.”

· The Home Care Visit in Allina Health Home Health dated May 30, 2023, said that the VA needed “wound clinic ASAP [as soon as possible] due to complexity.” [Note: The facility Nurse Visit Record showed that the VA went to the wound clinic on June 16, 2023.] The VA’s sacral wound had “significantly decreased” (worsened) since being home likely due to “suboptimal care in group home.” HCP1- HCP3 had concerns that staff persons were not “turning” the VA as they were trained to do. Additionally, at some point after the VA returned from the hospital, HCP1 told P1 that the VA’s wound was “worse,” including that it was “deep purple,” which HCP1 said was “pressure related.” P1 was “defensive” when talking to HCP1 and told HCP1 that staff persons “repositioned” the VA but that the VA “moved” him/herself back to the position s/he had been in previously.

· The Home Care Visit in Allina Health Home Health dated May 31, 2023, said that wound care was not being provided as ordered and the VA was not being repositioned. There were concerns that the staff persons were “not consistent” including because there were temp staff. The “plan” was to “identify” a facility registered nurse who was “overseeing” the facility to be present for home care visits as the facility registered nurse was “responsible to update group home care plans and teach [staff] cares.”

· Because the VA’s wounds were “very concerning,” starting at some point after May 25, 2023, the in-home nursing went to the facility daily (instead of two to three times per week) to “ensure [the VA] was getting taken care of.” However, the VA could only receive daily care for 10 days and then the VA returned to the previous schedule. After that, the CM was going to work with staff persons at the facility, including P1 and the “main nurse,” who HCP1 said was P5. (Note: P5 was not a nurse but was a supervisory staff person.)

· The Home Care Visit in Allina Health Home Health dated June 1, 2023, said that there was a “high risk for skin breakdown and neglect due to [the VA] not being repositioned.” Staff persons were “instructed” that the VA needed to be repositioned every two hours at minimum, and that the VA could not be on his/her left hip for longer than 10 minutes at a time. It was “okay” for the VA to go onto his/her back and right hip but that needed to be “monitored closely.” On this date, it was also noted that the CM was going to talk to RN1 to “determine care plans, orders, and who was responsible for educating staff” on the VA’s “orders” and care plans.

· The Home Care Visit in Allina Health Home Health dated June 2, 2023, said that there was a “decline to [the VA’s] wound noted,” including some “bleeding to peri-wound.” Staff persons were “instructed” change the VA’s bandage after any incontinence or “saturation.” The VA’s bandage was to be “mostly dry” as damp dressing would break down healthy skin. Additionally, the VA was to be repositioned “every two hours minimum.” The staff person working (who was not identified) “verbalized understanding.”

· Additionally, the Home Care Visit in Allina Health Home Health dated June 2, 2023, said that a staff person (who was not identified) told the Allina nursing staff that s/he had “concerns” that “temp staff” were scheduled at the facility “all weekend.” The staff person “fears that [the VA] will not be cared for” as the temp staff “just sit out there” and the staff person was “not sure what they do.” The staff person said that s/he felt that s/he took “three steps forward” with the VA each week but then five steps back “after a weekend with temp [staff].” The Allina nursing staff asked the staff person if the temp staff could do the VA’s cares including “free water flushes, meds, cath [sic] care, [and] wound care” and the staff person said that s/he “did not know.” The staff person said that s/he was “not sure” what the temp staff were trained or “allowed to do.” The Allina nursing staff said that the CM was “working on this information” and in the meantime, the in-home nursing staff would “be in daily to assess and complete wound cares.”

· HCP1 said that at some point, the VA had a physical therapist. However, due to the frequent hospitalizations, the VA’s physical therapist was not able to work with the VA. This was because the physical therapist needed to do an “evaluation” each time the VA returned home and then do a “restart.” Additionally, the Home Care Visit in Allina Health Home Health dated June 5, 2023, noted that a physical therapist asked HCP1 what his/her “thoughts” were on having the VA up one hour daily in his/her wheelchair as the VA’s “fragile status of coccyx wounds” required further consult with HCP1. It was also noted that staff persons did not do the VA’s range of motion exercises per the VA’s physical therapist “over the weekend” as there were “float staff.” However, the VA did his/her range of motion exercises on June 5, 2023, and said that they felt “very good.”

· On June 10 and 11, 2023, HCP2 changed the VA’s dressings because the VA’s wounds were “so severe” and “concerning.” When HCP2 met with the VA, the VA was sitting in a “warm” bedroom, on his/her back, and there was “no way” for the VA to “help” him/herself. This gave HCP2 some “red flags.”

· The Home Care Visit in Allina Health Home Health dated June 11, 2023, stated that the VA “ran out of tube feeding” at some point between 3:29 and 4:30 p.m., while HCP2 was at the facility. HCP2 also said that the VA kept pointing to his/her nutrition bag on the feeding tube and was shaking his/her head, “No.” HCP2 then saw that the VA’s bag of food had “run out.” HCP2 then called his/her supervisor to ask if the tube feeding was “managed” by the facility or by in-home nursing. HCP2 was told by his/her supervisor that the facility managed the feeding. The VA was supposed to have 24/7 nutrition through his/her feeding tube, which was changed “every 24 hours” per the “order.” HCP2 then spoke to a staff person (who was not identified) who said that they did “not know how” to administer the tube feedings but “believed” that P1 replaced the bags. HCP2 then notified P1 who was “one” of the staff persons who “managed” the VA’s nutrition. P1 told HCP2 that they typically changed the food in the morning so P1 was “surprised” that it was “empty.” P1 said that s/he would be at the facility in 20 minutes to change the bag, which P1 did. P1 also said that s/he planned to train another staff person so that it was “not just [P1]” who was trained on the VA’s feeding tube (Note: A document from the facility showed that on May 10 (no year listed), P1, P2, P3, and P7 were trained on a document titled Feeding Tube. This investigator asked P5 to send additional information regarding what this training entailed but P5 did not send it).

· The Home Care Visit in Allina Health Home Health dated June 12, 2023, said that the VA’s catheter was “clogged again” and the VA’s bed was “soaked with urine.” There was a “new staff” at the facility (who was not identified by name) who said that s/he was trained on “catheter flushes.” However, the in-home nurse “educated” staff persons on the VA’s catheter, including “when to flush.” The in-home nursing also left a message with the VA’s urologist to change the VA’s orders on his/her catheter to daily instead of as needed (PRN). There were also “concerns” noted by nursing due to “lack of off-loading and repositioning,” including because the VA was on his/her left side.

· The Home Care Visit in Allina Health Home Health dated June 14, 2023, said that there was a “large amount of urine-soaked gauze” around the VA’s “insertion site.” Staff persons were “instructed” that wet or damp gauze could not be placed on good skin and “left there for any considerable amount of time.” Staff persons were told to call “Allina” if they were not able to flush the VA’s catheter. Additionally, the VA’s left hip wound appeared to be “worsening” and staff persons were reminded that the VA was not to be placed on his/her left side for longer than 10 minutes. Additionally, it was noted that physical therapy would “discharge” from in-home care services because the VA had an upcoming wound care clinic appointment which would determine “how much wheelchair” use the VA could do, due to “advanced sacral and left greater trochanter wounds.” There were to be new physical therapy orders once the VA’s wounds were “more stabilized,” and the VA could return to “more regular wheelchair use.”

· The Home Care Visit in Allina Health Home Health dated June 20, 2023, said that a staff person (who was not identified) told HCP1 that the temp staff do not complete “any” cares regarding the VA’s catheter or feeding tube on the weekends which HCP1 said “concludes” that the VA was not getting his/her free water flushes (for his/her feeding tube). Additionally, the VA said that s/he was thirsty and the staff person working said that the VA’s “liquid” for his/her tube feeding “ran out overnight” the night prior and that s/he had to wait until the morning staff arrived as s/he had not been “trained.” The VA was also “out of” fitted bed sheets, disposable “chux [disposable bed pads],” and gauze pads. HCP1 thought that the VA was out of these things due to the VA having “several loose [stools].” The staff person was told to notify the “house manager” to order the supplies needed “ASAP” because the VA sitting on wet bedding would “breakdown [the VA’s] skin very fast.”

· HCP1 also noted that on June 20, 2023, there was “concern” with the VA’s right “IT” wound and a “decline” of the VA’s left hip wound. However, “some wounds” showed “improvement.” The VA’s “sacrum was stable but not improving.” The unidentified staff person said that the wound clinic wanted to see the VA “more often,” but the staff person told HCP1 that it was “difficult without adequate staffing.” The VA’s next wound appointment was scheduled on July 12, 2023. Additionally, a team meeting between HCP1, RN1 (facility RN), and P1 was scheduled for June 22 or 23, 2023, to discuss the concerns, including the temp staff persons.

· According to an email dated June 26, 2023, from HCP1 to the CM, the FM, P1, P5, and RN1, HCP1 said that the temp staff told HCP1 that they were not able to “complete certain tasks” including the VA’s feeding tube cares and/or daily wound care. If it was only temp staff persons at the facility, HCP1 was “told” (HCP1 did not indicate who told him/her) that “none of these tasks were being done.” HCP1 said that his/her role (and the role of other in-home nursing) was to “teach things to the staff as we would any family member in a home” but that the in-home nursing could not do the “initial teaching or sign [staff person’s] off on a skill.” HCP1 said that the facility registered nurse needed to do the initial teaching and sign off. On June 27, 2023, P5 replied stating that s/he was “under the impression that temp agency staff can do what we train them on.” P5 said that s/he was going to “connect” with the temp agency and then “get back to the team on this.” P5 also stated that s/he “hoped” it was not the temp agency staff persons stating that they “can’t do certain things because they don’t want to.”

· The Home Care Visit in Allina Health Home Health dated June 30, 2023, said that HCP1 “instructed” P1 to schedule a wound clinic visit “ASAP” (prior to the scheduled July 12, 2023, appointment) due to a decline in “right IT wound and visible bone.” Additionally, HCP1 told staff persons that “repositioning was the most important for healing” the VA’s wounds. HCP1 noted “concerns” that temp staff were working on the weekend due to the “declining wounds.”

· The Home Care Visit in Allina Health Home Health dated July 3, 2023, said that there was “no update” from the facility “leaders” regarding “education” for temp staff persons. Additionally, there were no facility staff persons who worked on the weekend and only temp staff. Therefore, it was not able to be “verified” if the VA’s “wound care was completed.” There was also a “decline” to the VA’s sacral wound which indicated that the VA was “spending too much time on [his/her] back.”

· The Home Care Visit in Allina Health Home Health dated July 7, 2023, said that on June 29, 2023, the facility was “instructed” “ASAP” to make an appointment with the VA’s wound clinic due to “deteriorating status.” The wound clinic said that on June 29, 2023, there were “plenty of appointments available.” However, the facility did not call until July 5, 2023 “mid-day” and all appointments were “full for the week.” The VA had an appointment previously scheduled for July 12, 2023, but in-home nursing wanted the VA to go to the wound clinic “sooner” due to “declining IT wound.” The VA did not get an appointment until July 10, 2023.

· The Home Care Visit in Allina Health Home Health dated July 9, 2023, said that “several concerns” were noted about the “consistency of care” at the facility and the in-home nursing staff were “working closely” with the in-home staff to “improve [the VA’s] care,” quality of life, and “outcome.”

· Additionally, HCP3 said in October 2022, the VA weighed approximately 165 lbs but that as of June 2023, the VA weighed 114 lbs. The VA had an approximately 50-pound weight loss between October 2022 and June 2023. (Note: The VA’s feeding tube was place on May 1, 2023, and P5 said that as of August 2023, the VA weighed 140 lbs.) The Home Care Visit in Allina Health Home Health dated May 31, 2023, also said that the VA had a 50 lb weight loss since October (no year listed), due to “severe malnutrition.” The VA weighed “around 300 lbs” when s/he first moved to the facility (Note: The VA’s Annual Physical and Orders dated January 28, 2022, said that the VA weighted 215 lbs). HCP3 did not know why the VA lost so much weight. The VA had been hospitalized “a lot” over the past few months and each time the VA went to the hospital, the VA “lost more weight.” Prior to the feeding tube, the VA was “dependent” on feeding and was not able to feed him/herself. HCP3 “did not know if [staff persons] were feeding” the VA.

· At some point, HCP1 was told by staff persons that P4 changed the VA’s diet to “pureed” food but that it was “never clinically indicated [that the VA] needed pureed” food. HCP1 said that s/he heard “mixed information” regarding the VA needing pureed food. This included that the VA had difficulty swallowing and was aspirating food (prior to getting the feeding tube May 1, 2023) and that because of the difficulty, the VA was losing weight. HCP1 also said that the VA had such a “bad tremor” that the VA was not able to feed him/herself. HCP1 thought that it may have been easier for the VA to drink pureed food out of a straw.

· HCP2 also said that the VA had poor oral hygiene and was unable to do his/her hygiene care on his/her own. The VA had a “buildup of secretions” in his/her mouth which indicated “neglect of hygiene care.” The Home Care Visit in Allina Health Home Health dated May 29, 2023, said that the VA’s mouth was “back to poor condition.” Staff persons told the in-home nursing that the VA returned from the hospital recently with his/her “mouth in good condition” but that the temp staff did not perform mouth care “all weekend and [the VA was] back to poor condition.”

· According to HCP1, the VA had “all these doctor’s orders” but HCP1 did not know who was doing the VA’s cares and did not know “who was responsible for overseeing staff in the home to make sure these things were getting done.” P1 was HCP1’s “main contact” at the facility but HCP1 and HCP3 were told by staff persons that P1 was only at the facility once a week and as needed. HCP3 said that staffing at the facility was “inconsistent” and HCP3 had “concerns” that the VA’s care plans were not updated and/or followed. HCP3 also had concerns regarding who trained staff persons, including who trained on how to take care of the VA’s wounds. HCP1 said that s/he attempted to educate staff persons about the VA’s cares including the VA’s wound care and dressings. HCP1 “even wrote down” instructions for staff persons. However later, when HCP1 returned to the facility, “nothing had been done.” Staff persons were “not grasping” what was taught. Additionally, one staff person “stood at the [VA’s] door” and would not “come in the [VA’s] room” when HCP1 attempted to teach them. HCP1’s supervisor “finally” told HCP1 that the facility nurse was responsible for overseeing the “education” regarding the VA and that it was not HCP1’s “job.” HCP1 said that all s/he could do was “reinforce.”

· HCP3 said that in their role, the in-home nursing did not typically “educate” staff persons. However, HCP3 said that they typically educated the facility registered nurse (at other providers), who would then educate the staff. As of June 6, 2023, staff persons told HCP3 they had not seen a facility nurse in “over a year” and that they “did not receive education on a regular basis.” (Note: An email dated June 23, 2023, from HCP1 and sent to the CM, P1, P5, and RN1 said that on that date, RN1 and HCP1 “met” and that RN1 “got to experience first-hand the typical cares [the VA] required” and that HCP1 and RN1 spent “almost three hours” doing so.)

· Staff persons told the in-home nursing that the VA was “probably too complex of care” for staff persons. The staff persons said that they told P1 about this but that “nothing happened.” HCP3 said that the staff persons were not “getting the education they needed” from the facility to support the VA.

· HCP1 had concerns that due to the VA having a lot of medical needs and “many orders,” that the facility did not have a sign off book/sheet to document the VA’s cares. HCP1 had also been at the facility during shift change and there was never a “report” or communication given between staff persons regarding the VA’s cares, such as when the VA was last repositioned.

· HCP1 ”could not get a handle [regarding] who was responsible for overseeing the staff [at the facility] to make sure things were getting done” regarding the VA’s cares. If the in-home nursing did not meet with the VA, HCP1 did not know who staff persons would contact regarding the concerns.

· HCP1 also said that when the in-home nursing first began working with the VA in April 2023, the VA did not have any “supplies” including briefs and personal care items. HCP1 asked P1 if the VA had a “waiver” for these things and P1 “did not know.” HCP1 asked P1 if there was an “invoice” from prior orders and P1 was not aware. At some point, HCP1 talked to the CM who said it was a “weird billing thing” regarding personal care supplies. The CM thought that the prior in-home care company was providing these things as a “courtesy.” Additionally, the facility was using other clients supplies for the VA. HCP1 also had concerns that a staff person used a “mallet” to crush ice for the VA and said that the facility was “so broke” that they could not afford an ice maker.

HCP5 worked with the VA prior to HCP1, HCP2, and HCP3 and thought it was prior to December 2022. HCP5’s role included helping to “manage” the VA’s wound care and catheter. When HCP5 first began working with the VA, the facility had “consistent” staff persons and the wound was “getting better.” However, those staff persons “quit” so the facility had staff persons from a temp agency so there were “new people all the time.” HCP5 taught staff persons the VA’s wound care but then the next time HCP5 was at the facility, a new staff person would be working who was not trained. Because of the staffing, the VA’s wound got “worse” and “led to hospitalizations.” The VA also missed medical appointments due to “no staff.” HCP5 worked with the CM to find the VA a different facility to move to, but no one would take the VA as s/he was “too complex.” The VA had been “complex” since moving into the facility and the facility was “great” in the beginning. The facility had a nurse but HCP5 did not meet them. The VA had weight loss and “malnutrition” due to difficulty swallowing from MS. At some point, the VA had a hospice “consult” because of the difficulty swallowing but the VA “refused hospice.” The VA was on a “pureed” diet including “thin liquids.” The pureed diet was “recommended” by the VA’s speech therapist due to choking. HCP5 was not aware of the pureed diet causing the VA to lose weight. The VA did not have a feeding tube when HCP5 worked with the VA (December 2022 and prior).

RN2 said that on July 23, 2023, the VA had a “change” in his/her “behavioral status and level of cognition” and was taken to the hospital. When the VA arrived at the hospital, the VA smelled “strongly” of urine. The VA’s brief was “completely soaked” and the VA was “covered in feces.” The VA also only had “gauze” covering his/her wounds despite having “extensive wounds.” A “nurse report” also said that the VA had “very poor oral hygiene.”

The VA said that s/he did not have any concerns with the facility (Note: The VA was mostly non-verbal but was able to shake his/her head yes or no to questions). The VA thought his/her wounds were getting better and s/he was not in any pain. Staff persons repositioned the VA as they were trained to do and the VA did not think that staff persons should reposition him/her more. The VA had recent weight loss but the VA did not know the reason.

The VA did not have any difficulty eating. Staff persons assisted the VA with bathing and toileting. The VA could tell the FM if s/he had any concerns.

The CM, emails between the CM and P5, and photos of the VA’s wounds provided the following information:

· The CM worked with the VA since January or February 2020. The VA had “high needs” and had been “in and out” of the hospital. The VA’s health changed “quite often” so it was “hard to keep updating” the VA’s plans. The communication was “lacking” between the “management” at the facility and the in-home nursing staff persons. However, the CM said that the in-home nursing should communicate with the facility so the facility was aware of the “expectations” regarding the VA’s care. The communication was also difficult due to the facility not having a house supervisor. (Note: P1 was filling in as the house supervisor but worked at multiple homes, including the facility.) P1 was “trying to get things situated” for the VA. The CM also had concerns that the facility used multiple temp agencies which was an “ongoing issue” since the VA moved in. The CM did not know if all the temp staff persons could do the VA’s cares.

· The VA had difficulty communicating due to his/her diagnoses but “liked” living at the facility. The VA was not able to feel pain.

· The VA was not able to swallow properly due to MS and there was a concern with aspiration. Because of this, on May 10, 2023, the VA received a feeding tube. The CM was not aware of the VA’s food running out in the feeding tube. The hospital and in-home nursing staff were supposed to train facility staff persons on the feeding tube prior to the VA’s hospital discharge. The CM “could not remember” if the hospital then provided “directions” to the facility to “pass on” after that to train future staff persons. The CM had “no idea” if staff persons knew how to use the feeding tube. Additionally, the CM did not know if the facility had a nurse that “oversaw” the feeding tube to ensure all staff (including temp staff) were trained. A facility nurse (RN1) “did not come along” until after the VA received his/her feeding tube, around June 22, 2023.

· On April 19, 2021, the VA weighed 230 lbs. Staff persons at the facility, including P1, told the CM that the VA also weighed 230 lbs on March 16, 2023 (Note: P5 provided documentation that showed around April 21, 2023, the VA weighed 141 lbs). On June 22, 2022, the CM saw the VA and said that the VA lost a “significant” amount of weight but the CM did not know why. The CM also saw the VA on March 7, 2023, and the VA “looked a little rough” but “not anything” like the VA did on June 22, 2023. The CM was not aware of a supervisory staff person putting the VA on a pureed diet and said that as of around March 2023, the VA was eating sandwiches from Subway (that needed to be cut up).

· At times, it was difficult to get supplies for the VA, such as adult undergarments. However, this was due to many factors such as Medicare, the VA’s medical supply company, staffing at the facility which included multiple supervisory staff persons during the time the VA lived at the facility, and doctor’s orders. At times, the VA was not “well enough” to go to his/her doctor to get the orders. At some point, P1 and the CM both called the medical supply company together to get supplies for the VA and there was “continued difficulty” with getting the items.

· When this investigator asked the CM about the VA’s plans stating that staff persons were trained at a higher level of care, the CM said that the VA received a “rate exception for higher wages.” An email dated January 10, 2023, from P5 to the CM said that the facility was in the process of hiring, including paying a “higher rate” to “hopefully attract more staff.” An email dated January 5, 2023, from P5 to the CM said that the facility was “at least double staffed on every shift.” On March 21, 2023, P5 sent the CM an email stating that the facility wanted an “increase in our exceptions” (funds) because the VA had “some pretty extraordinary needs that have been difficult for some staff.”

· The facility “promised” the moon when the VA first moved in, but it had been “pretty rough ever since.” This included that the facility told the CM that there would be two staff persons “at the worst” and up to three staff persons at the facility at one time. However, around December 2022, the CM became aware that the facility was single staffed for periods of time (see Investigation Memorandum Report Number 202210601). At some point in the beginning of 2023, P5 said that the facility “might have to close down” due to lack of staffing. However, P5 “found” temp staff persons after that.

· On June 22, 2023, the CM met with the VA’s team, including RN1, HCP1, P1, and P5 and said that there needed to be staff persons for “just [the VA].” The CM also spoke to the VA’s team regarding what the temp staff persons could do but it was “never broken down” and the facility “never figured it out.” However, the temp staff persons could do the VA’s “repositioning cares and toileting cares.” The feeding tube and wound care were “questionable,” but the CM asked the facility to update their “protocols and documentation” so that “everyone was aware.” The CM also asked for the VA to have a “sign off” in his/her bedroom regarding repositioning every two hours.

· The VA had the wound on his/her back since the CM began working with the VA. That wound would “come and go” and get “better” and “worse.” After moving to the facility, the VA had additional wounds, including on his/her hip and tailbone.

· On May 20, 2023, the VA was admitted to the hospital for a UTI, which the VA had a history of due to his/her catheter. While in the hospital, the VA’s wounds, including the wound on the VA’s back, almost “completely healed.” The VA was discharged from the hospital on May 25, 2023. On May 29, 2023, the wounds were “very bad” again. The CM said that this “indicated” that staff persons were not repositioning the VA every two hours since the hospital had a “lot of improvement” with the wounds. Additionally, the CM did not know if the facility realized that the wounds got to a “really healthy spot” when the VA was in the hospital. If staff persons did the cares “correctly,” the wounds would “continue” to be “healthy.”

· The in-home nursing, including HCP1, took three photos of the wound on the VA’s back, near the VA’s tailbone, which they then sent to the CM. A photo taken of the wound when the VA went to the hospital, showed an approximately 10 centimeter red and purple wound, with some yellow/white along the edges, that was partially open. Another photo taken on May 25, 2023, when the VA was discharged from the hospital, showed an approximately 10 centimeter wound that was pink and mostly closed. A third photo taken on May 29, 2023, showed a 10-centimeter open wound that was red with a little purple and yellow/white.

· As of May 29, 2023, the in-home nursing company, including HCP1, began seeing the VA daily due to “how bad” the wounds had become.

T1 provided the following information:

· T1 worked for a temp agency and had worked at the facility three times, including on March 30 and 31, 2023. T1 did not receive any training on the facility or the clients. T1 did not read any of the clients plans and did not have access to the clients’ files as they were “in the computer system.” T1 did not receive any training on the VA’s wound care and if there were concerns, HCP1 “took care of it.” The only training T1 had was from being a certified nursing assistant (CNA) and working at a local hospital prior to the facility. When T1 worked, s/he “looked for something to do.”

· On March 30, 2023, at 7 a.m., T1 arrived at the facility for his/her scheduled shift. P3 had worked the overnight shift and P2 was the morning shift and was supposed to work with T1. However, at some point, P2 “walked out” on his/her shift. T1 told P3 to “stay” because s/he “did not know how the facility worked.” P3 stayed but said that s/he was “tired” and would not help T1 with any of the cares. Each client typically awoke at the same time so T1 was not able to assist any of the clients, including “lifting” them, until around 8 or 9 a.m. when P4 was able to come to the facility. One of the clients (whose name T1 did not recall but whose gender was the same as the VA) had a bowel movement (BM) that was “smeared” all over his/her bedding. T1 said that other clients needed help “at the same time” so s/he was not able to assist the client with the BM until P4 arrived.

· T1 said that P4 was “well educated” and would be helpful to talk to. P4 was “manipulated” by staff persons including P2 and P3. The “whole house was a mess” and the “whole facility needed to be watched.”

P2 provided the following information:

· P2 had worked at the facility since February 2023. When P2 first began working at the facility, P4 told P2 that the VA was “bedridden.” The VA typically listened to music or watched television while in bed. However, P2 had seen a “lot of different changes” since working at the facility. At some point after, staff persons got the VA out of bed each day and into his/her recliner for approximately one hour, because staff persons were also told that the VA was supposed to be out of bed. However, around June 6, 2023, due to the VA’s “wounds,” getting the VA out of bed was on “pause” and staff persons were waiting on direction from the VA’s in-home nursing staff.

· The VA had a history of wounds including a “huge” wound on his/her back near his/her tailbone that was “pretty deep.” The VA also had one on his/her left hip that was a “little bigger than a quarter” and a “little deep.” Staff person changed the bandages twice a day and more if there was any BM on them. The VA also had a “couple wounds” on his/her heels that staff persons changed the bandages on “weekly.” As of June 6, 2023, the VA had a “couple new” wounds near his/her genital area. Staff persons changed the bandages on those “as needed,” including when the bandage was “coming off.” Because of the wound on the VA’s left hip, the in-home nursing HCPs told staff persons not to “flip” the VA and only have the VA on “one side” so that VA was “never coming off” his/her hip. However, because of that, the VA ended up getting a “red mark” on his/her hip.

· Staff persons cleaned the wound on the VA’s back with “spray” and then “patted” the wound with “gauze.” Staff persons then use a “pad” and taped around it. For the wound on the VA’s hip, staff persons had to pull out gauze from the “hole” in the wound and then get new gauze and put “wound cleaner” on it and then “stuff” the gauze into the wound with a cotton swab. Staff persons then used a bandage and tape to cover it. The wound on the VA’s back was cleaned daily and the one on his/her hip was cleaned twice a day. Staff persons documented when they did this.

· When this investigator showed P2 the photos of the VA’s wounds taken by the in-home nursing around May 2023 (as described in the CM’s information), P2 said that s/he had not seen the wounds look “that bad” since P4 worked at the facility (prior to February 2023) when “nothing was being done.” This included that P4 would not do the VA’s wounds cares. However, P4 “sometimes” repositioned the VA. Since P4 left, the wounds looked “a lot better.” If P2 saw the VA’s wound look similar again, s/he would notify the nurse “right away.”

· Although P2 said that P4 did not do the VA’s wound cares, P2 also said that around February, March, or April 2023, P4 was using a “homemade” “powder,” each time s/he changed the VA’s wounds. P2 did not know what was in the powder or where P4 got the powder from. The powder was in a clear bottle and there was “no label” on the bottle. (Note: P4 told this investigator that it was not powder in the bottle but saline that the in-home nursing provided.) P2 did not see any other staff persons using this bottle. P4 told P2 not to “tell anyone” that s/he was using it because P4 knew that s/he “was not supposed to be [using] it.” P2 did not know the “impact” from P4 using the powder because P2 was “not allowed” to do wound care during that time because s/he was not trained, so P2 did not see the wound.

· Because of the wounds, staff persons also rotated/repositioned the VA every one to two hours which required two staff persons. Although the VA required two staff persons to reposition him/her, there were times when P4 was employed at the facility (Note: P4 stopped working at the facility on March 31, 2023), that P2 was the only staff person working at the facility. P4 “did not care” and would leave P2 alone. At some point, P2 told supervisory staff persons about this. (Note: P4 denied this and P5 was not aware of this) and the following day, P4 “quit.” When P2 was single staffed, s/he was still able to reposition the VA because the VA was “pretty good” at grabbing the bars on his/her bed and “rolling” to his/her side. Being single staff was “challenging,” including due to repositioning. Staff persons documented when they repositioned the VA.

· Some staff persons used a “wedge” for the VA when repositioning. However, the in-home nursing staff persons said that it was making the wounds “worse” and said to not use it.

· P2 said s/he was “never” trained to work with the VA when s/he first began working at the facility. The in-home nursing staff persons asked P2 why the wound care was not being done and P2 said that “no one ever showed me.” P2 also thought it was not done because other staff persons were also not trained. P2 did not know how to do the VA’s cares until P1 started working at the facility (which P1 said was March 31, 2023). Around this time (which HCP1 said was April 24, 2023), the Allina in-home nursing also began working with the VA and also trained staff persons on working with the VA, including how to use the VA’s feeding tube and do the VA’s wound care. Only staff persons who were “signed off” and trained by the nurses were “allowed” to do the wound care. P2 thought that “all” staff persons were not trained to do these things until P1 and the Allina in-home nurses began. Now, all the staff persons were trained.

· The VA wore “briefs” which were “usually” changed every two hours or when “wet.” Staff persons documented when they changed the VA’s adult undergarment.

· The VA was “sometimes” able to express pain, including at times, when changing the VA’s wounds, the VA “winced.”

· The VA had “significant weight loss” due to P4 switching the VA to a “pureed” diet because P4 said that it was “easier” to feed the VA that way. P4 said that it took staff persons “too long” to “sit there” and feed the VA, including cutting the VA’s food. P2 said that the VA “refuses [the pureed] meals” and only drank Ensure drinks, which P2 thought caused the weight loss. Prior to this, the VA ate solid food, including cheeseburgers, with no issue.

· Things were “very rough” when P2 first began working at the facility (February 2023) but when P1 began, things “tremendously improved.” (Note: Information showed that there were interpersonal conflicts between P2 and P3 and P4 and T1).

· Staff persons trained the temp staff as they “went.” However, at times there were only untrained temp staff persons at the facility. When this occurred, when a staff person next worked, they noticed things that were not done such as the VA’s oral hygiene care. P2 said that “little things added up.” Additionally, at times, the temp staff were on their phone or “lying there” so P2 had to do things on his/her own. P2 also heard the clients calling for assistance and the temp staff persons had headphones on and did not hear them. P2 told supervisory staff persons the concerns about “certain” staff but “forgot” to tell them about others.

· The in-home nurses did a “lot” with the VA and P2 would be “struggling” if the in-home nursing was not there. If the in-home nursing stopped coming to the facility, the VA’s health “declined” including that the VA’s “wounds” got a “lot worse.” This included because they were “cleaning [the wound] at a higher level” than staff persons knew how to do. Additionally, the facility did not have a “lot of supplies” and the in-home nursing staff had “better supplies.” However, P2 said that now that staff persons were trained, it was a “little better.” The facility just needed to ensure that “everyone knows [what] to do.”

· Between February and June 6, 2023, P2 had only seen the facility nurse “one time” and during that, the nurse just “looked” at the VA. P2 did not know the nurse’s name.

· P2 did not know who reviewed the health progress notes (where P2 said that staff persons were trained to document concerns) but thought that P1 did. Staff persons also reviewed progress notes from the prior shift. Additionally, staff persons “sometimes” called P1 if they had concerns.

P3 provided the following information:

· Staff persons helped the VA with “everything.” When the VA first moved to the facility (January 2022), the VA had one quarter sized “wound” above his/her buttocks on the VA’s spine. After the VA moved in, it got “progressively worse.” Around this time, staff persons started “quitting” and the facility began to use temp staff. In approximately May 2022, P3 also stopped working at the facility but began working there again in October 2022. When P3 returned, the VA had “wounds all over” and there were “too many to count.”

· At some point, P3 worked the overnight shifts. P3 told P4 that s/he was not doing the VA’s wound care overnight because s/he was not “trained for that” and day staff persons did it instead. However, P3 said that s/he should have been trained. At some point (later determined to be April 24, 2023), the new (Allina) in-home nurses began training staff persons. However, if the temp staff was at the facility, the VA’s wound care was not getting completed.

· Staff persons had no training from the facility on how to take care of the VA’s wounds and did “whatever the [in-home] nurses [told them].” P3 usually had the temp staff read over the client’s plans but there was “no specific training” for the temp staff persons. At some point, one of the Allina in-home nurses asked P3 if they had a facility nurse and how staff persons were trained on the VA’s care. P3 told the in-home nurse that s/he was “pretty sure” the facility did not have a nurse and that the only “training [that] was done [was] by [the Allina in-home nursing].” The in-home nurse said that was a “concern” and that the VA “deserved so much better.”

· At some point, P3 began working the day shift and began doing the VA’s wound care. Staff persons changed the bandages on the VA’s wounds on his/her “bottom” once daily and also when there was BM on it. The wound on the VA’s hip was changed once daily. The wound on the VA’s foot was changed weekly. The VA also had a tape allergy (which was documented in the VA’s plans) which impacted the VA’s wounds, including that the skin around the area would “break down.”

· When this investigator showed P3 a photo of the VA’s wounds that the in-home nursing took in May 2023 (as described in the CM’s information), P3 described it as the “worst” s/he had seen it. However, P3 also said that s/he saw the wounds look similar but did not recall when s/he saw that. When P3 saw the wounds look similar, P3 said that s/he could not “just leave [the VA] like that” so P3 cleaned the wound and put a bandage over it. Additionally, the in-home nursing was coming around that time to “take care of it.”

· When P3 started working at the facility, staff persons used to take the VA outside a lot, including in January 2020. (Note: Information showed that the VA did not move into the facility until January 20, 2022, but information also showed it might be 2019). However, at some point, the VA stayed in bed all day due to his/her wounds but “asked all the time” to get out of bed.

· The VA required two staff persons for most of his/her cares including two staff persons to reposition him/her. If the VA had a BM, it took two staff persons to change the VA. Additionally, there were three other clients at the facility who also needed assistance. Staff persons repositioned the VA every two hours and documented when they did so. When this investigator asked P3 why s/he thought the VA had the wounds, including that they worsened, P3 said that it was due to “not having staff.” There were times that staff persons, including P3, were single staffed and during that time, it was “difficult” to reposition the VA. The last time P3 recalled being single staffed was the week prior to June 6, 2023, where P3 was the only staff person for 30 minutes. P3 also said that the “majority” of the temp staff persons were “not doing their jobs.” The temp staff persons sat on the couch and facility staff persons had to ask them to do tasks.

· The VA used to be “chunky” but had recently lost weight. At some point, P4 told staff persons that they were to puree the VA’s food. P3 said that there were “no doctor’s orders” so staff persons should not do that. The VA, who “loved” food, was also “refusing” his/her food because it was pureed which P3 though was “weird.” P3 thought that the VA stopped eating because s/he did not want to eat the pureed food. P3 was not aware of supervisors (aside from P4) or the in-home nursing being aware that the VA’s food was pureed. Prior to the food being pureed, staff persons cut the VA’s food into small pieces and fed the VA remaining with the VA while s/he ate. The VA’s food was pureed for approximately one to two months prior to the VA getting a feeding tube.

· Staff persons were supposed to document in the health progress notes but P3 was the “only one doing notes.” However, P3 also said that a “few” staff persons documented “here and there.” P3 also told P1 when there were concerns and P1 was “pretty good” at addressing those concerns. All staff persons were to document a progress note for each shift, including for wound care. P2 told P3 that s/he “refused” to document in the health progress notes as s/he was “stuck charting” everything else.

· P1 was typically at the facility two to three times per week. However, P1 supervised other homes too. This included that the week prior to June 6, 2023, P1 was at another house the entire week. P5 was “never” at the facility.

P1 provided the following information:

· P1 began working at the facility, including with the VA, on March 31, 2023. P1 said that in a “perfect world,” the facility should have three staff persons during the morning/day/evenings shifts and two staff during the overnight. However, the facility was not always staffed like this, including that there were often only two staff in the evenings, which P1 said was manageable for staff persons.

· P1 supervised seven other homes so there were times that s/he was not at the facility. However, there should also be a “manager for every house” but the facility was short staffed so did not have a house manager. The facility also used temp staff and the “regular” facility staff, including P2 and P3, trained them. However, when this investigator asked P1 if the temp staff persons were trained on the VA’s plans, P1 said there was no documentation showing that the temp staff persons were trained. However, the temp staff had “access” to the client’s plans and P1 said there were no times when a temp staff person worked at the facility without a facility staff person.

· When P1 began working at the facility on March 31, 2023, staff persons pureed the VA’s food. P1 asked the staff persons why they were doing so and if there was a “doctor’s order.” Staff persons said that they “did not know” of a doctor’s order but were told by P4 to puree it, due to the VA “not wanting to eat much.” Once P1 became aware, they “immediately stopped pureeing” the VA’s food. Shortly after P1 stopped pureeing the food, the VA was hospitalized due to “over four gallons” of “bowel compaction.” P1 thought that once the “bowel compaction” was removed, this caused the VA to lose weight. Additionally, the “compaction” caused the VA to stop eating, although P1 said that the VA “did not completely stop,” which then caused the weight loss. P1 was also told that the VA was not eating when P4 pureed the VA’s food. At some point (P1 said that s/he did not recall when but was later determined to be May 1, 2023), the VA required a feeding tube due to being “hospitalized so much.” Prior to the feeding tube, staff persons hand fed the VA.

· In approximately May 2023, the VA was hospitalized due to having “wounds all over [his/her] back.” When the VA returned home from the hospital, the VA had “wounds everywhere,” including his/her knees, genital area, inner right thigh, right knee, finger, right ankle and foot, left foot in between his/her toes, and face. The VA also had a “body rash.” The VA did not have those wounds prior to going to the hospital. P1 had pictures of these which P5 sent to this investigator. Prior to going to the hospital in May 2023, the VA only had wounds on his/her heels, back, and hip.

· The VA also had in-home nursing for the wounds. P1 initially said there was “nothing” that staff persons could do to prevent the wounds. However, P1 later said that staff persons repositioned the VA “every hour” during the day and every two hours during the overnight. The in-home nursing typically wanted the VA repositioned on each side but the VA’s right side was starting to get a wound so the VA was not supposed to be on that side. Additionally, the VA did not like to be on his/her side and felt most comfortable on his/her back. There was a “tracking system” so staff persons knew when to rotate the VA. Two staff persons typically repositioned the VA but one staff person could do it. Staff persons also cleaned the wounds and bandaged them.

· The Allina in-home nursing wrote instructions regarding the VA’s care in a book in the VA’s bedroom. This included the VA’s “wound” care and that the nurses did not want temp staff to “touch” the VA’s feeding tube, including cleaning. The feeding tube was considered “medication” and temp staff did not administer “medication.” The VA’s feeding was “so slow,” and one container of food lasted the VA four hours. The VA was “always fed.”

· The VA was only out of his/her bed when s/he went to a medical appointment. The VA was not able to stand long or sit in a chair. P1 was trying to work with the VA’s in-home nursing to see if the VA could sit in a recliner but they said that a physical therapist needed to make that “decision.” At some point, it was decided that it was “too much pressure” on the VA’s wounds for the VA to sit, including in the VA’s recliner.

· There had “always” been concerns with the VA’s wounds. At some point, a doctor at the hospital told P1 that for the VA’s wounds to “clear,” the VA needed to be “off” them for “months.” However, because the VA was in bed most of the day, they would not clear up.

· When this investigator showed P1 photos of the VA’s wounds from the in-home nursing, including one prior to the VA going to the hospital, P1 said s/he was not aware of the wounds looking like that. However, P1 was aware that the wounds got worse at the facility. P1 said this was because the hospital had “all kinds of things” they could use to keep the VA “propped up” that the facility did not have. This included a “cheese wedge” so that the VA could not “roll” to his/her side. P1 later told this investigator

that the facility had the “cheese wedge” from the hospital but that staff persons “did not know how to use it” and there was no directive that staff persons were supposed to use it.

· The VA had suppositories and took a medication that caused him/her to have frequent BM’s so staff persons were “constantly” changing the VA’s adult undergarment. The frequent BM’s caused the wounds to get “infected.” It was recommended that the VA have a colostomy bag.

· The VA had a “bed bath” three days a week. However, staff persons did not document when they gave the VA one. When this investigator asked P1 how staff persons knew when to give it, P1 said that the “regular staff just do it.”

· The company At Home Living (AHL) had a nurse but s/he was not at the facility “at all” or only as “needed.” Because the VA had in-home nurses, the facility nurse was not needed.

· The VA was not able to communicate verbally due to MS but communicated using gestures. The only time the VA complained of pain was when staff persons “touched” the VA or “moved” the VA.

· Staff persons documented the status of the VA’s wounds in health progress notes but P1 did not know if they were being documented “properly.” Additionally, P1’s position was supposed to review the progress notes but P1 did not do so. This was because staff persons would verbally tell P1 “big concerns.” P1 would then do a “video” call or direct staff persons to call 9-1-1. P1 also used his/her “[motherly/fatherly] instinct” regarding how to direct staff persons.

· When this investigator asked P1 about the concerns that staff persons were watching TV, on their phone, or on the couch, P1 said that s/he could “not watch everyone” all the time. Additionally, there were times when there was “down time” at the facility and if staff persons did their job, they could be on their phones or watch TV.

P4 provided the following information:

· P4 was the supervisor of the facility from January 2021 to March 30, 2023. At times, the facility was “so short” staffed so P4 “advocated” for temp staff persons, which P5 got for the facility “instantly.”

· Regarding staff persons being trained, P4 said that “no one trained anyone.” If a staff person was “hired today,” they would start working at the facility “that evening.” P4 said that s/he “learned as [s/he] went.”

· The facility typically “always” had two staff persons at a time. However, P4 said that the facility should have had four staff persons at once due to the client’s plans and needs.

· In the two years P4 worked at the facility, s/he only saw a facility nurse one time and was always told the nurse was on “vacation.”

· HCP5 trained staff persons on the VA’s wound care. The VA needed a “lot of attention,” including being repositioned every two hours. At some point, P4 told staff persons to reposition the VA every hour which “helped a little.” However, the overnight staff persons were “very bad” with repositioning the VA and changing the VA. This included P3 who would “not get anything done.”

· P4 denied using a homemade power on the VA’s wounds but said that s/he used “saline” which was in a clear bottle that was provided by the VA’s “home care.”

· P4 was not aware of the VA losing weight and said that the VA was “always” fed. When P4 first began working at the facility, the VA ate “regular food.” However, due to MS, the VA began choking so the VA’s speech therapist recommended that the VA eat pureed food.

· There were interpersonal conflicts between P4 and staff persons at the facility, including P2, P3, and P7. This included that P4 “changed the culture of the whole house” and made the staff persons work which they were not used to. These staff persons called P4 a “crazy boss” and that P4 was “controlling.”

RN1 provided the following information:

· RN1 began working at AHL around September 2023, but there was a “delay,” so RN1 did most of his/her training at the “end” of October 2023. RN1 “never really got good training on what [s/he] was supposed to do.” However, when RN1 began, s/he became “familiar” with the client’s care plans. RN1 then went on a leave from approximately December 2022 to February 2023. RN1 did not “do anything [aside from a tour of the home]” with the facility until approximately May 2023. RN1 oversaw 16 sites, including the facility, which was “a lot.”

· RN1’s role with all the sites was that s/he did medication administration training for new staff persons. RN1 also did “quarterly assessments” to ensure things were “up to date” on the client’s medical forms.

RN1 did the assessments by reviewing what was in the computer “system.” When RN1 first started, there were “a lot of things out of date,” including standing order lists.

· Around May 2023, RN1 became aware that the VA had “a lot” of hospital visits which brought RN1’s “eye” to the facility. One of the hospital visits included that the VA had a “new” feeding tube so RN1 “double checked” the “orders” to ensure staff persons followed those. The in-home nursing initially trained “everyone” who worked at the facility to use the feeding tube. However, RN1 “did not know the answer” regarding if the temp staff were trained as it was “hard to keep track” of the temp staff since they “changed every time.” RN1 was not aware of any times that only temp staff persons were at the facility. Staff persons would “sign off” once they were trained.

· Additionally, around this time, RN1 told P5 that there should be a full-time nurse “working the floor” at the facility with the VA. This was because RN1 did not think that the facility should be taking care of a client with a feeding tube without a nursing staff person in the home “all day.” The feeding tube “involved a more skilled” “scope of practice of care” to ensure the “site” of the feeding tube was cleaned daily. RN1 oversaw multiple facilities and only worked 16 hours per week. In addition, between September 2022, and October 4, 2023, RN1 had been to the facility “maybe” six times. Additionally, the VA had in-home nursing staff but RN1 thought that the VA should have “regular” nursing staff who were at the facility “all day” instead. However, at some point, RN1 was told that the VA or the facility could “not afford” to have a nurse for the VA all day. Because of this, the facility and the CM began looking for different placement for the VA that was “better suitable for [the VA’s] needs.”

· Starting around May 2023, HCP1 would “update” RN1 with changes in the VA’s “care plans or orders.” If there were “any issues,” HCP1 would typically talk to P1 as P1 was “more involved.”

· RN1 did not do “anything” regarding the VA’s wound care and said that the in-home nursing did that. Staff persons were trained on the VA’s wound care via “videos,” “handouts” from the in-home nursing, and “hands on practice.”

· Staff persons were supposed to weigh the clients monthly. RN1 was not aware of the VA losing weight. The facility had a scale but staff persons “did not know where it was.” However, the VA had a “lot” of weights documented from hospital visits.

· RN1 was not aware of concerns with the VA’s oral hygiene or any concerns with the VA’s briefs being soiled. When RN1 was at the facility, there were typically three staff persons. RN1 never saw one staff person. RN1 only saw staff persons on the couch/on their phones/or watching TV when RN1 was at the facility in the “evening.” Normally, the house supervisor would talk to staff person’s if they did those things but there was not a house supervisor. The facility had been “hiring” for a “long time,” but the facility location was “pretty far away for most people.”

· The feeding tube food bag should be “changed” each day and a bag of food would typically last the VA for one day. Staff persons documented in the VA’s medication administration record or via a computer system when they administered the food via the feeding tube. RN1 was not aware of the food running out but said that it “clogged” a few times and that the VA was then seen by a medical professional for some “troubleshooting.” If the food ran out, all staff (in addition to P1) should have been trained to change it.

· RN1 did not have any concerns with the care staff persons provided to the VA, including with the feeding tube or repositioning (which staff persons documented) and said that s/he “trusted” staff persons and that they were “capable.” The only concern RN1 had regarding the VA’s care was the VA needing “nursing staff around the clock.” RN1 thought that a lot of the concerns regarding the VA could have been from the VA’s “worsening MS.” However, prior to RN1 working at the facility, s/he did not know who was training staff persons or “if they were being trained.” Additionally, prior to RN1, the facility had been “without a nurse for quite a while.”

· The facility house supervisor typically trained staff persons on clients plans. The facility did not have a house supervisor and P1 was “juggling” multiple homes, which RN1 did not think was manageable as P1 was “super busy.”

P5 provided the following information:

· P5 began his/her position around July 2022, and “oversaw” the supervisors of 36 AHL “sites,” including the facility. P5’s job requirement included that s/he visit each “site” at a “minimum” of one time per year. P5 had been to the facility three to four times, including when P4 was at the facility.

· P1 oversaw 8 sites, including the facility. Prior to P1 working at the facility, the facility did not have the “structure and supervision” it had with P1, as P1 was at the facility “almost daily.”

· P5 said that AHL sites, including the facility, used temp staff which they had done prior to P5 starting his/her role. The temp staff were “always second staff” and there was “always” an AHL staff there to “assist with questions” or “help with needs.” The temp staff persons were trained through the “temp agency prior to working” at AHL.

· RN1 oversaw 16 homes, including the facility. RN1 began working in September 2022 (and there was another RN prior) and did quarterly assessments at the facility. RN1 had “many concerns” that s/he “addressed” with P1, including that the VA needed “higher level of care” than the facility could provide. RN1 and P1 had “many discussions” regarding finding the VA a different placement. However, P1 had a “strong connection” with the VA and wanted to “try and do everything” s/he could do to help the VA “succeed” at the facility.

· At some point, the VA received a feeding tube during one of his/her hospital admissions. After that, the hospital sent a hospital staff person to the facility to train the facility staff on the VA’s feeding tube. This included that they showed “all” staff persons how to use the feeding tube and provided a phone number for staff persons to call if there were “any problems.” After that, RN1 trained and “tested out” on the feeding tube prior to staff persons using it (Note: RN1 said that the in-home nursing did this training). The temp staff persons were not trained on the feeding tube. P5 was not aware of the food in the feeding tube running out. When this investigator asked P5 who was responsible on June 11, 2023, to ensure the VA had food in his/her feeding tube, P5 said that P1 was “responsible for oversight.”

· When this investigator asked P5 about the VA’s weight loss, P5 said that it was “brought to [his/her] attention” that the facility scale had been broken for “some time” and that the VA’s weight was not being checked monthly, which was the facility “expectation.” As of September 1, 2023, the facility purchased a scale which would be “arriving soon.”

· Documentation (from medical records) showed that on April 21, 2023, the VA’s weight was 141lbs. On May 10, 2023, the VA’s weight was 119lbs and on July 20, 2023, the VA’s weight was 140lbs. There were no additional weights provided by the facility. P5 said that s/he would “try” to find information regarding the VA having a swallow study but P5 did not provide this investigator any information. However, P1 told P5 that P4 pureed the VA’s food because the VA “stopped wanting to eat.” The facility then “found out” that the VA had “issues with [his/her] bowels” which resulted in “several hospitalizations.”

· P5 said that there were “no orders” for the VA staying in bed but that “no one knew” that the VA could get out of bed due to his/her wounds. However, they then found out that the VA’s wheelchair was “making [the VA’s] wounds worse.”

· There was “online documentation” for staff persons to reposition the VA every two hours, which was implemented when the VA first moved to the facility.

· The VA had in-home nursing since January 25, 2022, to assist with his/her cares. However, P5 did not know specific dates that each company, including Allina, worked with the VA.

The FM provided the following information:

· Prior to the VA moving to the facility, the FM told the facility that the VA was “unable to do anything on [his/her] own” and the facility told the FM things such as “yup we got it.” The facility sounded “really good at first” but then “went in the tank.” The staff person (who the FM did not name) who told the FM these things was no longer at the facility. The “biggest issue” with the facility was that they had “no employees” and could not “maintain” their employees.

· The VA had a wound on his/her back that had been there for “years” and looked “painful.” The FM talked to the VA’s doctors about the wound and the doctor’s said there was nothing they could do as the VA was “bedridden.” The wound on the VA’s back was the “longest” wound the VA had but it kept getting bigger and “worse” while at the facility.

· The FM said that staff persons could reposition the VA but then the VA would get wounds on other parts of his/her body, including his/her sides. The FM had a “big” concern regarding the wound on the VA’s hip, which the VA got after moving to the facility. When the FM first saw the wound on the VA’s hip, it made the FM “mad” as it showed that staff persons were not “rotating” the VA as they should. At some point, the FM saw the wound and had concerns that there was not a “bigger Band-Aid” covering it and that it looked like the Band-Aid was “stuck inside the wound.” The FM was not aware of the VA ever going to a wound clinic for the wounds. The VA said that s/he did not feel the wounds on his/her hip, backside, or feet. However, the VA did not express concerns to the FM because the VA did not like to be a “burden.”

· At some point when the FM went to the facility unannounced, the VA had not been “rotated.” The FM knew the VA was not rotated as s/he was at the facility for more than two hours and no one came in to rotate the VA. The VA’s doctor said that the VA needed to be repositioned/rotated every two hours.

· The FM had seen staff persons change the VA’s adult undergarment while at the facility.

· When the FM went to the facility, there were typically two staff persons. However, around Christmas 2022, the facility was “struggling” and there was only one staff person but the facility later “fixed that issue.” The VA needed “at least” two staff persons to reposition him/her.

· The FM had concerns that each time s/he visited the VA at the facility, the VA was always “watching TV” in bed. The FM thought that the VA should be out of bed even if the VA’s doctors said it was “beneficial” for the VA to stay in bed. The VA was a “prisoner.”

· The VA had “definitely lost weight” but the FM was “not too concerned.” The VA had been in the hospital three to four times in approximately the spring of 2023, due to “extreme constipation.” The VA’s stomach looked like a “beach ball” and the VA’s doctors said that the VA’s “big belly” was from fecal matter. The VA went from having a “beach ball” in his/her stomach to a “flat” stomach due to getting medical help to remove the constipation.

· The hospital put in a feeding tube for the VA due to concerns with the MS and swallowing. Prior to the feeding tube, staff persons had to hand feed the VA “one scoop at a time.”

· The VA was “deteriorating.” The FM did not know if the deterioration was due to the VA’s MS diagnoses, the facility, or “both.”

The Sherburne County Sheriff law enforcement report provided the following information:

· P5 said that it was the facility policy to take a client’s weight “at least monthly.”

· There was a “core [in-home] nurse [HCP1]” that did care for the VA on a “regular basis.” However, each time a new nurse came in, they wanted the VA sent to the hospital.

· The LEO requested staff training regarding the VA’s plans from P5 but none of the documentation showed “wound care specifically stated in their course description.” The LEO asked P5 if staff persons were trained in “specific” cares such as wound care. P5 told the LEO that the medication administration training course “goes over all types of cares for an individual.” However, P5 also said that not all temp staff persons were trained on medication administration but that there were some temp staff persons who “consistently” picked up shifts who were trained on medication administration.

· The LEO received a document titled Feeding Sign off which staff persons signed between May 10 and June 26, 2023. The LEO said that all of the training s/he received from P5 were only for facility staff persons and not the temp staff persons, which the facility used “almost daily.” The LEO asked P5 if the temp staff persons repositioned clients, provided wound care, or provided feeding tube care. P5 stated that the facility could train temp staff persons on these cares but it was not “common” for them to do so due to the many different temp staff persons who worked at the facility and “inconsistences” regarding who worked.

· P5 also said that only staff persons that were trained on a client’s “skill” were able to “conduct the skill.” The facility house supervisor was to sign off on staff persons “skilled competency.”

· On July 18, 2023, the facility gave the VA a 60-day notice to move out as the VA needed a skilled nursing facility that was “better equipped” to handle the VA’s level of care.

· The LEO sent the report to the county attorney for review of charges who then sent it to the MN Attorney Generals office for “prosecution.”

Progress notes showed that staff persons documented when they did the VA’s wound cares, repositioned the VA, and when the VA’s “food bag” was replaced. Staff persons also documented when the wound nurses came to the facility to assist the VA with his/her wound care. On January 8, 2023, there were two times where staff persons documented that due to the “many” pressure wounds that the VA had, that it was “complicated” to reposition the VA. This included a “large” wound on the VA’s tailbone and on his/her left hip which prevented staff persons from “repositioning the other way.” On January 1, 2023, the VA “declined” to be “adjusted.”

Facility progress notes also showed that the VA had skin care daily at 8 a.m. and 12 p.m., including “preventative care” to his/her skin. Staff persons were to gently wash and dry the areas as needed. Facility documentation showed that staff persons signed off on doing this multiple times per day.

The After Visit Summary said that the VA was admitted to the hospital on April 28, 2023, and discharged on May 10, 2023, due to “constipation and wound care.” The VA was discharged with home health services, including wound assessment and care. The VA also had “new tube feeds” and education was to be provided to group home staff by “Fairview Home.” Additionally, the “Allina” in-home care nurse was to “reinforce teaching regarding tube feeds.” The VA was prescribed an “adult formula drip feeding continuous osmolyte 1.5.” The VA had wound care daily on his/her sacrum and left hip, which was to be cleaned with saline and gauze. The VA was to be “side lying only” and avoid “supine” unless the VA needed to eat. The VA also had wounds on bilateral heels, right lateral foot, and left lateral ankle which was to be cleaned every three days and as needed. The VA was to be repositioned and turned every two hours “side to side only.” The VA was to “resume” home care services.

Fairview Medical records provided the following additional information:

· On May 20, 2023, the VA was admitted to the hospital for systemic inflammatory response syndrome (SIRS). The VA weighed 121.8lbs and had “severe malnutrition” and cachexia (weight loss and muscle loss). The VA also had wounds, including a sacral wound that s/he had in August 2022. The sacral wound was “previously a stage three pressure injury.” The VA also had a hip wound and there were “no indicators” of the VA having the hip wound as of October 24, 2022.

· The VA also had a right gluteal would which was “incontinence associated dermatitis progressed into unstageable pressure injury.” A photo taken on May 23, 2023, showed a wound that was 7 centimeters in length, 4.5 centimeters wide, and 0.4 centimeters in depth.

· It was recommended that a wound nurse from the VA’s facility care team “follow” the VA after returning home. If the facility did not have a wound care nurse, then it was recommended that the VA see the “wound and Ostomy Clinic.” It was “challenging” for the VA to leave the facility but it was recommended that the VA come monthly if possible. The VA was to be repositioned every two hours, including lying on his/her left hip for five to ten minutes then returning to his/her right hip or back, which allowed the blood flow to return to the VA’s right hip. The VA was to use a gel pillow or other “offloading” device between his/her legs.

· On May 28, 2023, the VA was again seen in the emergency department due to bleeding sacral decubitus ulcer that happened while “trying wound care today.” When asked if the VA felt “worse than normal,” the VA shook his/her head no. The VA did not have any fever or any other symptoms. The wound did not appear infected and a new dressing was placed. The VA was discharged back to the facility.

P1, P2, P3, P4, and P5 were trained on the Reporting of Maltreatment of Vulnerable Adults Act. P1, P2, P3, and P5 were also trained on medication administration. P1, P2, P3, and P4 were also trained on the VA’s “Care Plans.” Additionally, as of May 10, 2023, P1, P2, and P3 were also trained on the VA’s feeding tube. There was no documentation to show that any of the temp staff persons received training on the facility policies and procedures and no documentation to show that facility or temp staff persons were trained on the VA’s programs plans which were violations of:

· Minnesota Statutes, section 245D.09, subdivision 4a, paragraphs (c) and (e), which states in part that the license holder will ensure that staff persons review and receive instruction on the person’s coordinated service and support plan (CSSP) and CSSP addendum and how to implement those plans; and the staff person must review and receive instruction on the safe and correct operation of medication equipment used by the person to sustain like including feeding tubes; and

· Minnesota Statutes, section 245D.095, subdivision 5, paragraph (a), which states in part the license holder must maintain a personnel record of each employee to document and verify staff qualifications, orientation, and training, including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor.

Relevant Rules and/or Statutes:

Minnesota Statutes section 245D.04, subdivision 2, clause (9) states that a person’s service-related rights include the right to receive services form an individual who is competent and trained, who has professional certification or license, as required, and who meets additional qualifications identified in the person’s support plan or support plan addendum.

Minnesota Statutes section 245D.05, states in part that the license holder is responsible for meeting health service needs assigned in the support pan or the support plan addendum consistent with the persons health needs. If responsibility for meeting the person’s health services needs has been assigned to the license holder in the support plan or the support plan addendum, the license holder must maintain documentation on how the person’s health needs will be met, including a description of the procedures the license holder will follow including use of medical equipment or devices safely and according to written instructions from a licensed health professional.

Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a) states that the license holder must ensure services were provided in response to a person's identified needs, interests, preferences, and desired outcomes as specified in the coordinated service and support plan and the coordinated service and support plan addendum, and in compliance with the requirements of this chapter. License holders providing intensive support services must also provide outcome-based services according to the requirements in section 245D.071.

Conclusion:

A. Maltreatment:

According to the VA’s plans, the VA was diagnosed with multiple sclerosis. The VA had in-home nurses who provided “wound care,” “monitored” the VA’s feeding tube, changed the VA’s catheter, checked the VA’s vitals, screened the VA for sepsis, and provided “some education” to staff persons.

Regarding the VA’s weight loss:

P2 and P3 said that the VA had recently lost weight and P2 described it as “significant” weight loss. HCP3 said in October 2022, the VA weighed approximately 165 lbs and that as of June 2023, the VA weighed 114 lbs. HCP3 said that the VA had an approximately 50-pound weight loss between October 2022 and June 2023.

Although P5 said that the facility scale was broken, P5 said that documentation from medical records showed that on April 21, 2023, the VA weighed 141 lbs. On May 10, 2023, the VA weighed 119lbs and on July 20, 2023, the VA weighed 140 lbs. There were no additional weights provided by the facility, including around October 2022.

P1 and the FM said that at some point, the VA was hospitalized due to “over four gallons” of “bowel compaction” and P1 thought that once the “bowel compaction” was removed, this caused the VA to lose weight. P1 also thought that constipation caused the VA to stop eating, which then caused the weight loss. The FM was “not too concerned” regarding the VA’s weight loss.

Additionally, although P1 and P3 had concerns that staff persons, including P4, were pureeing the VA’s food without doctors’ orders, which may have caused the weight loss, the VA’s Master Care Plan updated on March 5, 2023, said that the VA’s diet was “mechanically altered.” HCP5 and P4 also said that the VA was on a “pureed” diet which was “recommended” by the VA’s speech therapist due to choking.

HCP5 said that the VA lost weight due to difficulty swallowing due to MS and that because of this, the VA had a hospice “consult” but “refused hospice.” However, on May 10, 2023, the VA received a feeding tube because of the difficulty swallowing and after that, the VA began gaining weight.

Although the VA lost weight; that there were inconsistences regarding what the staff persons understanding was of what the VA was supposed to eat; and that the facility was not tracking the VA’s weight, which P5 and RN1 said should be done monthly, given that the VA’s weight loss was likely due to multiple things, including MS and constipation relief, and that during the time the VA lost weight, s/he was overseen by multiple health care providers, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services that were reasonable and necessary to obtain or maintain the VA’s 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).

Regarding the VA’s pressure injuries and concerns regarding the VA’s cares:

According to the VA’s plans, the VA was “bedridden” and “prone to wounds” due to limited mobility from MS. The VA was “dependent” on staff persons and also received “skilled” and “intensive” nursing to assist with wound care.

During a hospitalization between May 20 to 25, 2023, the VA’s “sacral pressure injury” improved “dramatically.” However, shortly after the VA returned home to the facility, in-home nursing observed that the VA’s sacral wound had “deteriorated beyond pre-hospital status,” which HCP1-HCP3 “suspected to be the result of suboptimal care.” HCP2 described wounds as “severe and concerning.” HCP1- HCP3 had concerns that staff persons were not “turning” the VA as they were trained to do. The CM said that this “indicated” that staff persons were not repositioning the VA every two hours since the hospital had a “lot of improvement” with the wounds.

According to HCP1, the VA had “all these doctor’s orders” but HCP1 did not know who was doing the VA’s cares and did not know “who was responsible for overseeing staff in the home to make sure these things were getting done.” HCP1 said that the role of the in-home nursing was to “teach these things to the staff as we would any family member in a home” but that they could not do the “initial teaching or sign [staff person’s] off of a skill.” HCP1 said that the facility registered nurse needed to do those things. As of June 6, 2023, staff persons told HCP3 they had not seen a facility nurse in “over a year” and that they “did not receive education on a regular basis.” P3 was “pretty sure” the facility did not have a nurse and that the only “training [that] was done [was] by [the in-home nursing].” HCP5 had not met RN1. In the two years P4 worked at the facility, P4 only saw the facility nurse one time. Between February and June 6, 2023, P2 had only seen the facility nurse “one time” and during that, the nurse just “looked” at the VA. P1 said that AHL had a nurse but s/he was not at the facility “at all” because the VA had in-home nurses.

Although RN1 worked at AHL since September 2022, RN1 did not start working with the VA until approximately May 2023. The CM said that RN1 “did not come along” until approximately June 22, 2023, due to the VA’s feeding tube.

Although the VA’s plans said that s/he required “two if not three” staff person’s assistance to meet the VA’s needs for transfers, turning and repositioning, and hygiene cares, HCP1 said that at times, s/he only saw one staff person at the facility. P3 said there were times that staff persons, including P3, were single staffed and when that occurred, it was “difficult” to reposition the VA.

The FM said that the VA was “deteriorating” but the FM did not know if it was due to the VA’s MS diagnoses, the facility, or “both.” RN1 thought that a lot of the concerns regarding the VA could have been from the VA’s “worsening MS.”

Although the VA’s medical issues were described as “complex,” “extraordinary,” and “high needs,” documentation in the VA’s plans said that staff persons were “trained at a higher level” to ensure that the VA was able to remain out of the hospital and have “nursing level of care” at the facility. However, there were multiple concerns expressed regarding the training the staff persons received regarding the VA’s care. HCP3 had “concerns” that the VA’s care plans were not updated and/or followed and concerns regarding who was training the staff on the VA’s plans. P4 said that “no one trained anyone.” P2 and P3 said at some point, they were not trained on the VA’s wound care. HCP1 said that s/he attempted to educate staff persons about the VA’s cares including the VA’s wound care but later, when HCP1 returned to the facility, “nothing had been done.” HCP3 said that staff persons were not “getting the education they needed” from the facility to support the VA.

The in-home nursing also had concerns regarding whether the temp staff were trained including that temp staff told HCP1 that they were not able to “complete certain tasks” including the VA’s feeding tube cares and daily wound care. If it was only temp staff persons at the facility, HCP1 was told that “none of these tasks were being done.” T1 was a temp staff and said that s/he was not trained on the clients plans. Although P1 said that the temp staff had “access” to the client’s plans, T1 said that the client’s plans were in the computer system which s/he did not have access to. Additionally, although P5 said that the temp staff persons would always be with a facility staff person, T1 said that s/he worked alone and P2 also said that at times there may only be untrained temp staff persons at the facility. When this occurred, staff persons noticed things that were not done such as the VA’s oral hygiene care and wound care. P3 also said that the “majority” of the temp staff persons were “not doing their jobs.” The failure to provide services in response to the VA’s identified needs and rights were violations of Minnesota Statutes section 245D.04, subdivision 2, clause (9); section 245D.05; and section 245D.07, subdivision 1a, paragraph (a).

Given that multiple health care professionals noted that the VA’s wounds “deteriorated beyond pre-hospital status,” which was “suspected to be the result of suboptimal care;” that P1 and other staff persons were not aware of the VA’s wounds looking as they did until this investigator showed them photos; and the multiple aforementioned concerns regarding the training, including on wound care, and staff persons failure to complete the VA’s wound care, repositioning, and tube feedings, there was a preponderance of the evidence that there was a failure to provide reasonable and necessary care to the VA.

It was determined that neglect occurred (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).

B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c):

When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors:

(1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care;

(2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and

(3) whether the facility or individual followed professional standards in exercising professional judgment.

Given that the facility was responsible for maintaining compliance with Minnesota Statutes including hiring and training staff persons and ensuring required staffing that met the individuals’ needs was maintained, but that this was not done consistently, and that information showed that the facility frequently used temp staff as part of their staffing pattern, yet the temp staff were not trained on the VA’s plans as shown by lack of documentation and information from in-home nursing staff persons and staff persons, the individual staff persons’ responsibilities were mitigated.

The facility was responsible for the neglect of the VA.

C. Serious Maltreatment:

The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.”

Minnesota Statutes, section 245C.02, subdivision 18, states:

"Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult.

It was determined that the substantiated neglect for which the facility was responsible did not meet statutory criteria to be determined as serious because although the VA had deteriorating wounds, there was no information that the VA sustained a serious injury which reasonably required the care of a physician whether or not the care of a physician was sought.

Action Taken by Facility:

The facility completed an internal review and determined that policies and procedures were adequate and followed. However, a staff person (who was not named) said that “not much training had been done” and that s/he was “doing the best [s/he] could.” P1 said that the VA had been to the hospital “a lot” since P1 began working on March 31, 2023, due to things the facility “could not control.” However, the staff persons and in-home nurses were doing the “best” they could, to keep the VA out of the hospital and back in the facility, where the VA would get the “most cares.” The facility provided additional training to staff persons and “more charting.” The VA no longer received services from the facility.

Action Taken by Department of Human Services, Office of Inspector General:

On June 5, 2024, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal.

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