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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1070940-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns/Scott Brandt Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) gained over 50 pounds since moving into the facility due to staff persons not following the VA’s diet restrictions of 1200 calories daily or assisting the VA with exercising. Date of Incident(s): January 6 or 7, 2024 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 February 20, 2024; from documentation at the facility; and through 11 interviews conducted with two supervisory staff persons (P1 and P2), four facility staff persons (P3-P6), two facility clients (C1 and C2), the VA’s case manager (CM), the VA’s guardian (G) who was also a family member, and the VA. According to the VA’s plans, the VA enjoyed bowling, BINGO, and playing games on his/her tablet. The VA’s diagnoses included nearsightedness, a seizure disorder, and Prader-Willi (PW) syndrome, which was a genetic disorder resulting in a constant sense of hunger. It also was common for people diagnosed with PW to have a high pain tolerance. Individuals diagnosed with PW would constantly eat because they never felt full. As a result, extreme weight gain was often a concern. The VA lived at the facility since March 2023 with C1, C2, and another client who was unable to provide information. The main floor of the facility consisted of a front door, a rear door, a door leading to an attached garage, an office, a dining room, a kitchen, a living room, two bedrooms, and a bathroom. C2 and another client had bedrooms on the main floor. C1 and the VA had bedrooms in the lower level. There was a stairwell with a swinging gate-style door leading to the lower level. The lower level consisted of a bathroom, a laundry area, a utility room, two bedrooms, and a family room. The lower-level family room had two exercise bikes in it with a TV/DVD set up. During the facility tour with P1 and P2, this investigator was shown sensor alarms which had three settings: alarm, chime, and off. The VA knew how to silence the alarms and would sometimes do that so that they would not sound. “Child locks” were no longer in use since black combination style locks replaced those. The door from the interior of the facility to the garage had two sensors on the door while the front door had one sensor. The refrigerator and freezer doors in the kitchen each had combination locks in addition to sensors on each door. Kitchen cabinets containing food each had a combination lock and a sensor. The kitchen garbage only had a combination lock. The garage freezer had a combination lock and a sensor. At the time of this tour, there were no locks on the garbage or recycling bins, located inside the garage. A sensor was in place on the gate at the top of the stairway and a sensor was in place on the VA’s lower-level bedroom door. The G provided the following information: · The VA did not “feel pain,” would “constantly” eat, and would “literally eat [him/herself] to death if [s/he] could.” The VA was not at risk of eating cleaning chemicals but would eat “spoiled” foods. What techniques “worked” for one individual diagnosed with PW might not “work” for another. · Staff persons at the facility were “allowing” the VA to “[take] food” outside of the residence and were not watching the VA’s caloric intake. When out grocery shopping, the VA would have items like lunch meat and peanut butter jars “stuffed in” his/her clothing, with staff persons later finding empty food packaging. The G asked staff persons to “frisk” the VA when s/he left the store because the VA would have food items concealed. One change the facility made was that the VA was not allowed to wander the grocery store and had to push the cart when grocery shopping. The G also thought that facility management was “trying” but that staff persons were not properly trained. The VA was “quick” about taking food, and it even happened when the VA was with the G. · Staff persons were “ignoring facts” about the VA’s calorie intake and the VA had gained approximately 50 pounds since moving into the facility, which was becoming “life threatening.” An individual diagnosed with PW could die from a “perforated” stomach if too much was consumed in one setting. The stomach could “explode” or break open, causing sepsis and possibly death. The VA also had sleep apnea but experienced less “snoring” and “tiredness” when the VA’s weight was “down,” closer to the 150–160-pound range. · Staff persons were not “believing” the G or “paying attention” to the VA’s PW diagnosis. The VA was going into the cupboards in the middle of the night for food and would eat items out of the garbage at the home or in public settings. The VA was “pretty sharp” at what s/he could do. The VA was a “manipulator,” could “lie,” and was a “hoarder.” One time, the VA said that s/he was pushed by a staff person at another facility, but when video was reviewed, it was the VA who “rushed” at the staff person. Another time, the VA “took a crowbar” to the G’s refrigerator when it was locked. · Child locks were placed higher up on cabinets at one point, but the VA would move a chair to access the locks. An alarm was also placed on the VA’s bed, which was supposed to go off when the VA woke up, but either “wasn’t hooked up” or staff persons were not hearing it when the VA got out of bed. Speakers made a “beep, beep, beep” sound but they were not “real loud” especially if a staff person was sleeping. The G brought in the alarm that s/he used at his/her own home. That alarm went “boom, boom, boom” with a flashing light component, but another client in the home was “obsessed” with it and would take that alarm. · At first, P1 was “doubting” the G about how serious weight gain was for the VA, but eventually the facility believed the G, and was taking active steps to resolve this after the facility brought in someone from a facility where the VA used to live, who specialized in caring for individuals with PW. This was a “mandatory training” for staff persons with specific instructions given to managing the VA’s diet with an emphasis that PW could be “life-threatening.” One thing the facility implemented was using a frozen meal delivery program to help the VA with meals, but currently, the VA had to pay $180 per week for that him/herself as the facility would not. The G said that the facility “allowed” the VA to get to the higher weight and that the facility “should be responsible for losing [the weight].” · Some other things implemented by the facility included writing down daily calorie intake and involving the VA into the meal planning process. Prior to the training, staff persons were not writing down the VA’s daily caloric intake and the VA’s intake was to be 1200 calories per day. Staff persons thought that “smaller portions” would help the VA, but the VA was supposed to have certain food items, not just smaller portions. At one point, the VA weighed 277 pounds, but was down to 259 pounds at the time of this interview, which was “significant progress,” and things were “on the right track” now. · The VA was supposed to exercise for 30 minutes at a time, twice per day, but when the VA refused three times, staff persons were not allowed to ask the VA a fourth time to exercise. Recently, “significant changes” had been made at the facility and the G felt like the facility was heading in the “right direction” including putting combination locks on the refrigerator, freezer, and cupboards about a month prior to this interview. Prior to this, there were only alarms on the bedroom doors and cupboards, and night staff persons were “sleeping through” the alarms. The CM provided the following information: · The VA should have been exercising 30 minutes at a time, twice per day since the VA moved in. The VA’s daily caloric intake was set by a physician for 1200 calories per day for the last five years. · The facility the VA previously resided at used a bed pad sensor, motion sensors, and contact sensors that would sound if the contact between two sides of the door and frame were separated. These items had to be reconfigured for the facility and were placed on the VA’s bedroom door, cabinet doors that held food and spices, including the garbage door, and the doors to refrigerator and freezer. The sensor would “announce” when doors were opened where sensors were placed. The VA was “very honest” but was observed by an overnight staff person, standing on a chair, trying to get into food cabinets. · One example of concerns about the VA’s lack of exercise and calorie issues for the VA included a staff person allowing the VA to eat a “Big Mac” from McDonald’s. · An outside company that specialized in helping individuals diagnosed with PW went to the facility to provide training on January 11, 2024. On January 31, 2024, the VA’s weight was down to 259. P1 provided the following information: · P1 worked with the VA at a facility the VA lived at previously and knew that the facility would have to have sensors on cabinets. There was an installation delay due to scheduling issues, so the facility used store-bought sensors that were installed prior to the VA moving into the facility. The sensors made a “woo woo” sound and were placed on the refrigerator and other doors. Shortly thereafter, a security system was installed. This had a central unit in the staff person office with additional sensors on the fridge door and garage door, and would alert when the VA came out of his/her main floor bedroom, including a motion detection component in the main floor hallway (Investigator’s note: The VA’s bedroom was on the main level when s/he first moved into the facility and was later moved to the lower level after the team met in December 2023, to discuss the VA’s food intake and weight gain). That component was currently “missing” at the time of this interview as one of the other clients tended to take it. There was currently a “ticket” in to get it replaced and it would be relocated to the lower level where the VA’s bedroom was now located. After the security system was installed, the VA was still getting food additional to the food the VA was planned to have, evident by food wrappers found in his/her bedroom, so “child locks” were then placed high up on cabinets. P1 was “not familiar with dates,” but thought that the “child locks” were placed during the summer of 2023. It was later discovered that the VA was moving chairs to access the cabinets. After that, locks were placed throughout the facility after specialized PW training which occurred on January 11, 2024, for all staff persons because “no other measures were successful.” (Investigator’s note: All staff persons interviewed for this report attended the January 11, 2024, PW training. P1, P2, P3, and P6 each mentioned this training at some point during their interview.) · One concern, for the facility, was that locks “restricted” the rights of other clients in the facility so the facility tried the “least restrictive measures” first which was why locks were not placed right away. “Formal rights restrictions” were eventually incorporated after emails of approval were received from the other clients’ teams agreeing to locks. This delayed the process by several weeks. Chimes on the cabinet were not considered a “rights restriction.” An example of a rights restriction was when locks were placed on places that stored food. The VA’s team felt that locks were the “best” option and wanted it included in the VA’s rights restrictions. C1 and C2 knew the lock combination but the third client did not, however, his/her team agreed to those restrictions. The numerical code could be “spun” on the locks after opening, so that the VA could not see the code. Staff persons, C1, and C2 were told to “spin” the code on the lock after using it. · When the VA moved into the facility, his/her weight was being tracked, but it was not being done daily and the VA did not have a “formal” exercise schedule in place. In October 2023, P1 was concerned about the VA’s weight after observing that it had “jumped” from 240 to 280 pounds and then s/he began to see that the facility needed to start tracking better. P1 wrote an incident report and began to “ask more questions” as to what the facility was doing and decided that they needed to track calories on a tablet. P1 suggested downloading a calorie tracker on a tablet for staff persons to document meals like the facility the VA previously resided at did. The facility had the tracker but that was “never enforced” and staff persons were not mandated to track it until P1 created sheets to document calorie intake. Daily weight tracking began after the VA’s team met in December 2023, and P1 thought that P2 had recently increased the VA’s exercise workouts from one time per day to two. The VA’s calorie intake was to be 1200 calories daily. Meal tracking was implemented for the VA in January 2024, and prior to that, staff persons were trained on the VA’s plans including the VA’s diagnoses of PW and having a “sensational appetite.” The facility was aware of the VA’s diagnoses, and no one could “100% guarantee” that the VA was not going to take food additional to what s/he was supposed to have. · P1 thought that locks and food tracking could have been implemented sooner to prevent the VA from gaining weight. P1 also “wondered” if the facility was an “appropriate” location for the VA’s needs as the facility could not guarantee one-on-one staffing. The VA’s team, including the CM and the G were aware of this when the VA moved into the facility. The VA’s team had given the facility some “tools” however, the facility was unable to do things that the G could do at his/her home. For example, the staff persons at the facility could not “tell [the VA] to go to [his/her] room” when helping another client with cares and the facility could not “force” the VA to exercise. The facility’s goal was to “train, coach, [and] educate” the VA but could not “enforce” certain things. · P1 learned on February 19, 2024, that over the previous weekend, the VA went outside at the facility, took two bags of garbage from the garbage cans, and put the garbage in his/her bedroom closet. Two staff persons were on shift at the time; one staff person was on an outing with another client and the other staff person was using the restroom when the VA likely obtained the garbage. P3 weighed the VA one morning over the weekend and found that the VA had gained a few pounds. P3 conducted a room check and found the garbage bags in the VA’s closet. P2 had the VA call the G to tell the G what happened. The VA was not sick after this incident and the facility was “actively” trying to come up with a plan to see if the garbage company could alter the cans. Otherwise, the facility would have to put in additional locks and sensors on the front and back doors. The garbage cans were in the garage when the VA accessed them. The VA had not accessed the outside garbage cans before. A General Event Report from February 16, 2024, showed that the facility would increase the volume of the garage alarm so that staff persons could hear it while using the bathroom. P2, P3, and P4 had worked at the facility prior to the VA moving in in March 2023. All three clients, including C1 and C2 were at the facility prior to the VA’s arrival. P5 and P6 started working at the facility several months after the VA arrived at the facility and were not aware of what practices were in place prior to their start dates. Interviews with P2, P3, P4, P5, and P6 and facility documentation provided the following information: · Regarding weighing the VA: o The VA had a Height/Weight Report, where staff persons could record the VA's weight but from March to December 2023, was not consistently recorded. The VA's weight fluctuated during that time from 209 on the day s/he moved into the facility to 275. On January 11, 2024, the facility implemented daily tracking of the VA's weight. From January to February 2024, 17 days the VA’s weight was not documented. o P2 stated that when the VA moved into the facility, the VA was weighed daily. P2 added that depending on how the VA stood on the scale, the scale would read out different weights. P2 also stated that after the PW training the facility began implementing “new stuff” and the VA was losing weight. o P3 and P4 were unsure if all staff persons were weighing the VA daily when s/he first arrived, but now the VA’s weight was taken every morning and recorded on an application on a tablet that was created on the Medication Administration Record (MAR). o When P5 began working at the facility, staff persons were weighing the VA daily in the morning and documenting it on the VA’s MAR. o P6 weighed the VA each morning after his/her overnight shift after making sure the VA was awake. o According to P3, the VA gained “a “big amount” of weight after s/he moved into the facility, which “stemmed” from the VA taking food from grocery stores, gas stations, and during day shifts and nights that P3 was not there. When the VA moved into the facility, staff persons did not have extensive knowledge of PW until the PW training occurred. The facility did not have alarms on the garbage and at times, the alarms would be “faulty” or “broken.” Sometimes they would continue to beep without stopping and other times, they would not work at all. When alarms would stop working, it would take days to get them working. Prior to the VA moving to the lower level, there was no sensor alarm on his/her bedroom door, providing him/her a “direct route” past the faulty alarms, which was at the “heart” of the VA’s weight gain. Now, the VA had to go through several areas that alerted staff persons, such as his/her own bedroom door, and the upstairs stairway gate. The facility had hired four new staff persons since the time that the VA moved into the facility so “getting on the same page wasn’t always happening.” Some of the newer staff persons were not using the “Teams” application, which updated each other on previous shifts’ events. P3 would arrive to his/her shift after many days off and there would not be consistent updates in this application. o According to P3, at some point, the facility had a meeting where staff persons brought ideas to “get rid of errors” and P3 suggested moving the VA’s bedroom to the lower level. Moving the VA to the lower level would mean that there were more alarms the VA had to pass to get to the kitchen and the VA would also get more exercise as a result of using stairs more often. o P2 and P4 stated that the VA moved to the lower level between Thanksgiving and Christmas 2023. o P4 estimated that the VA gained approximately 60 pounds from the time s/he moved into the facility to the VA’s highest weight and added that after the VA moved to the lower level, staff persons began doing daily checks in the VA’s bedroom. o P6 stated that since January 1, 2024, the VA’s weight had declined. P1, P2, P3, and P6 each stated that the overnight position was a sleeping position and P6 added that VA was usually asleep when P6 started his/her shift at 10 p.m. P6 checked on each client when s/he got to the facility and was up frequently during the overnight shift. · Regarding food intake/calorie limit: o P2 stated that when the VA first moved into the facility, the VA’s food intake was monitored by attempting to give him/her healthier options which had fewer calories, but it was not as “structured” as it was now. o P2 and P4 stated that staff persons measured out food portions now versus “doing it in their head” as they did prior. o According to P3, P4, and P5, as on January 11, 2024, staff persons now tracked meals and snacks by counting calories and documenting the calories. P5 stated that staff persons were “working hard” at this. P4 stated that prior to the VA moving in, the facility told staff persons that the VA had an “eating disorder” where s/he had “no control” overeating food, so if food was left out, the VA would eat it. The facility told staff persons to keep “an eye” on the VA to make sure s/he was not taking additional food. o P2 and P5 each stated that one day, P5 took the clients to a holiday lights event and stopped at McDonald’s for dinner. According to P2, the VA ate a “Big Mac” that s/he should not have been allowed to eat, however it was the “only thing” the VA ate on that outing. According to P5, the VA did not have a “Big Mac” and P5 made sure that the VA had only a cheeseburger, a small fry, and a soda pop. P5 later heard the VA talking to the G on the phone, telling him/her that s/he ate a Big Mac, had a large fry, and large drink. P5 could not recall if s/he told the G that the VA provided the G with incorrect information and that the VA only had a smaller-sized meal at McDonald’s. P5 was trying to bring the clients, including the VA, out for a “fun” night, “to make sure their life is great,” and “tried to do what I could” to put the McDonald’s meal “into the diet.” P5 stated that s/he could have maybe had the clients eat at the home instead, but they were on a tight time schedule to get to the event. (Investigator’s note: A McDonald’s receipt was later submitted, dated December 7, 2023, showing that C1 and C2 each had a “Big Mac” meal, but that the VA had a “[Quarter] Cheese meal” with a medium-sized drink. · Regarding alarms/locking mechanisms: o P2’s statement was like P1’s when describing the mechanisms put in place to prevent the VA from accessing food outside of mealtime and snacks. P2 stated that “chirping” sensor alarms were installed in April 2023. They then added a system installed by Simply Home in May 2023, which included adding motion sensors in the facility. This was initially supposed to be installed sooner, but due to licensing rules with adding technology to a facility, it had to be delayed. After that “child locks” were placed “up high” in October or November 2023, but P3 found the VA climbing on a chair to unlock them at night. The facility then moved to combination locks which were installed the day after the January 11, 2024, training. So far, the VA was unable to unlock them. The sensors were left in place as a “secondary system.” The facility “worked up” to using combination locks to be “fair” to the other clients in the facility. Some of the mechanisms the facility put in place were not effective. The sensor alarms were turned off by the VA at times. The VA also now had a lock on his/her bedroom door and a bed pad alarm (the bed pad was an electronic pad placed between the mattress and bedding). The bed pad triggered the alarm to sound in the office, but the bed alarm went off “all the time” because when the VA moved while sleeping or in bed, the pad would get “pushed” to the side. This could have been intentional or unintentional on the VA’s part, but if the VA rolled off the pad, the alarm would sound in the office even with the VA still in bed. Another issue with one of the alarm systems, was that another client at the facility had a “fascination” with objects that made noise, so that client would take the motion sensors. Currently, a work order was in with Simply Home for a motion sensor replacement because one was missing. o P3’s statement was consistent with P2’s regarding the combination locks. Locks were added to other areas, including the garbage, which had previously been unmonitored. This should have happened “months and months” ago. P3 always checked the locks at the start of his/her shift. When the VA moved into the facility, alarms were installed where food was kept, including the refrigerator and freezer. A speaker was placed in the office, where overnight staff persons slept so that they could hear it if the VA got up. The alarm would say, “Refrigerator door open.” Now there was also a sensor on the garage door, on the stairway gate at the top of the stairs, and on the VA’s bedroom door that said, “[VA’s] bedroom door open,” but when the VA’s bedroom door sounded, the alarm said, “Garbage door open,” when no one was in the kitchen, and that alarm was not even on the same floor as the garbage. The speaker volume was adjustable and could be set from zero to “very loud.” P3 kept the alarm on a “specific volume” so that it would wake him/her when sleeping. A bed alarm was placed on the VA’s bed, but alarms were not on everything that they needed to be on. The facility was not “properly equipped” and had no garbage locks until after the January 11, 2024, training when the trainers said that the facility needed a lock on the kitchen garbage. o P4 stated that when the VA first moved in, food was reorganized and “child safety” style locks were placed which did not work because the VA was able to unlock the locks. Now the facility used locks with a combination, which was working better. The VA told P4 that s/he was not able to get into the locks unless a staff person or client left them unlocked. Sometimes, staff persons forgot to lock the cabinets, including P4, but P4 was only there one day of the week with the VA. The week before this interview, P4 found an empty can of food in the VA’s room. The VA said that it was a “really old” can. o P5 and P6 each stated that “alarms” were in place when they began working at the facility. This included sensors that were on the gate at the top of the stairway and the alarms upstairs.” P5 could hear the sensors going off “most of the time” despite them sometimes being hard to hear in certain areas of the facility. P6 stated that s/he did not have difficulty hearing the alarms sound, unless the speakers were turned down or s/he was down in the lower level of the facility but added that there was a volume control in the staff person office and now the VA’s bedroom was in the lower level, further from the kitchen. o P5 and P6 each stated that combination locks were installed sometime in January 2024. According to P5, prior to this, the VA was still trying to “get in” and “take them apart.” P6 added that additional sensor alarms in the hallway, on cupboards, the VA’s bedroom door, the VA’s bed, and main floor bathroom were also added at this time. o According to P5, the facility sometimes did not have more than one person working per shift but staff persons would try to keep the cabinets locked “all the time” or keep “eyes on” the VA. P5 and P6 each stated that when they were working, food was always secured. P5 said that staff persons had been “trying our best” to keep things locked, but the VA could still get into things. P6 added that it was “okay” if locks were unlocked if staff persons were sitting in the dining room or kitchen and if staff persons or clients were using the garbage or refrigerator. · Regarding exercise: o According to P3, the VA did not exercise when s/he moved into the facility, but P3 now did “stretch routines” with the VA in the mornings, and then the VA would also exercise during the day and in the evening. Staff persons seemed to be adhering to the new exercising schedule, which started in January 2024. The VA was known to be “stubborn” sometimes but lately had been doing a “good job.” P5 added that the VA had “lots of behavior” when asked to exercise, which was generally an outside walk or walk at the mall. P5 said that staff persons encouraged the VA by telling the VA it was good for his/her health and reminding the VA that the VA’s family wanted the VA to exercise too. When the VA would refuse to exercise, P5 would call the G, or another family member and they would talk to the VA. The VA would then exercise. o P2 stated that the facility added a second 30 minutes of exercise to the VA’s schedule. At times, the VA choose to use his/her tablet and not exercise. Since the training on January 11, 2024, when the VA would exercise with P2, P2 would attempt to get the VA to exercise a little longer each time. The VA did not complain when exercising with P2 but did with other staff persons including complaining of leg, knee, and foot pain. If the VA declined to exercise, staff persons could not “force” him/her to exercise, and documented the refusal, and calls were made to the team, including to the CM, a medical support assistant, the G, and another family member to discuss the next steps should the VA continue to refuse. If staff persons were not encouraging the VA to exercise and or not documenting attempts, the facility addressed the expectations with those staff persons. o The G wanted the VA to have a YMCA gym membership. The facility brought in membership paperwork in December 2023 and was waiting to hear back from the YMCA to get the VA a reduced membership rate. In January 2024, another family member of the VA’s told the facility to sign the VA up without the reduced rate. o P4 and P5 each stated that the VA was exercising more frequently now compared to when s/he moved into the facility. The VA’s exercise and calories were now being documented using a computer application. o P6 stated that the VA was exercising using a DVD. P6 worked overnights so did not exercise with the VA. o The VA’s plans initially stated that staff persons were to wait until 9:30 a.m. to allow the VA to initiate exercise. If the VA had not done so by then, staff persons were to give the VA a “verbal prompt” asking the VA to pick what s/he wanted to do for exercise. After five minutes, staff persons were to give a second “verbal prompt.” After another five minutes, staff persons were to again, “prompt” the VA and let the VA know that after the exercise, it would be time for a snack. If the VA still did not wish to exercise, the “refusal” would be documented but staff persons were to continue to try to get the VA to exercise throughout the day. The VA provided the following information: · The VA had been living at the facility since March 2023 and enjoyed living there. The VA did exercise routines like the bike, walking, and Richard Simmons’ DVD workouts. The VA said that s/he was exercising two times per day, 30 minutes at a time and staff persons were tracking the workouts and it was also going well for the VA. The VA stated that s/he had been exercising twice per day since moving into the facility. Staff persons would chart it on a computer. · The VA’s bedroom used to be on the main level but was moved to the lower level. Alarms were placed in and on the VA’s bedroom and on the refrigerator, cupboards, and on the garage freezer so that the VA would not access items like food. The alarms had been working well and staff persons were supposed to keep them locked. · The VA would sometimes take food while out in the community. Staff persons were to check the VA’s pockets. The VA was now on a one-to-one ratio with staff persons when out in the community but did not remember when this was implemented. C1 and C2 provided the following information: · C1 stated that prior to having the black, combination-style locks placed on the cabinets, there were “child locks” placed on the cupboards, freezer door, refrigerator door, by the spice cabinet, and by the fruit and vegetables to prevent the VA from getting food overnight. They were designed that a person had to slide a mechanism left or right to get them to open. C1 was unsure when the “child locks” were placed on the food cabinets and appliances. The new locks had been working. Staff persons and clients would leave the cabinets unlocked if they were in the kitchen area, but if leaving that area, the locks had to be engaged and the numbers had to be changed. · The cabinets, refrigerators, freezers, and areas where food was kept were locked to prevent the VA from getting into food and both C1 and C2 knew the combination codes to the locks. Things were going better since the combination locks were placed around the facility. · Staff persons, along with C1 and C2 remembered to keep the locks locked. C1 would lock the locks if s/he found them to be left unlocked, but this mainly happened if people were still in the kitchen area. · The VA exercised one time per day in the evening hours, for about 30-45 minutes using a stationary bike, pre-recorded DVD workouts, or by going on walks with staff persons. C1 added that sometimes s/he joined the VA to exercise. C2 added that staff persons would “kinda-sorta” encourage the VA to exercise and liked when clients got outside for exercise, but that the VA would “sometimes” exercise and sometimes not, depending on the VA’s “mood.” · C2 added that the VA generally had one to two staff persons with him/her when out in the community. All staff persons interviewed for this investigation were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: The G was concerned that the VA was gaining weight and that the facility and staff persons were not following the VA’s diet restrictions of 1200 calories daily or assisting the VA with exercising. The G felt that staff persons were “allowing” the VA to “[take] food” outside of the residence and were not watching the VA’s caloric intake. The G wanted staff persons to “frisk” the VA. The G said that the VA had gained approximately 50 pounds since March 2023, when s/he moved into the facility. According to P1, P2, P3, P4, P5, P6, C1, and C2, the following information was mostly consistent: · When the VA first moved into the facility, there was a delay in getting sensors put on cabinets, so the facility used store-bought sensors prior to the VA moving in. Shortly thereafter, a security system was installed on doors, cabinets, the VA’s bedroom door, and motion sensors were placed in the hallways. The VA was turning off alarms and going into cupboards at night for food. · The VA was still getting food that was outside of his/her meal schedule, so “child locks” were placed on cabinets and alarms were added throughout the facility. The VA was moving chairs at night to unlock the cabinets. The VA’s bedroom was moved to the lower level of the facility so that staff persons would have extra time to hear the VA going up the steps, and using the steps would assist in burning more calories. A bed alarm and a door alarm were placed on the VA’s lower-level bedroom. · The facility next implemented combination locks on the garbage and cabinet doors where food was stored and had to get permission from and fill out rights restriction documents for the other clients. · The VA’s weight was not recorded consistently when s/he moved into the facility. Some staff persons weighed the VA during their shifts while some did not. The VA was being given “healthier options” when s/he moved into the facility, but it was not as structured as it was now. · After an outside company that specialized in supporting individuals diagnosed with PW trained staff persons on January 11, 2024, the VA began exercising approximately two times per day, 30 minutes at a time, and his/her caloric intake was better followed at 1200 calories per day, with a more comprehensive meal-planning set up, which was tracked using a calorie-tracking application. The VA also belonged to a local gym and was losing weight. On January 31, 2024, the VA’s weight was down to 259 pounds. On February 16, 2024, the VA went outside, took two bags of garbage from the garbage cans, and put the garbage in his/her bedroom closet. One staff person was on an outing with another client and the other staff person was using the restroom when the VA likely obtained the garbage. It was discovered that there were trash bags in the VA’s bedroom closet after P3 weighed the VA and found that the VA had gained a few pounds. The VA was not sick after eating food from the garbage and the facility was “actively” trying to come up with a plan to see if the garbage company could alter the cans. Otherwise, the facility would have to put in additional locks and sensors on the front and back doors. The garbage cans were in the garage when the VA accessed them and the VA had not done so before. A General Event Report form this incident showed that the facility would increase the volume of the garage alarm so that staff persons could hear it while using the restroom. Although there were concerns that the VA gained approximately 50 pounds, didn't exercise twice a day, and was eating food despite staff persons attempting to make “healthier” options and track calories, given that the facility continuously worked with the VA's team, staff persons, and the VA to find ways to support the VA, and that after the VA accessed the outside garbage cans the facility began working on a plan to prevent a reoccurrence, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate. There was no need for additional training and the incident was not similar to previous complaints. There was not a need for corrective action, however the facility was developing new plans to further support the VA. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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