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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: 1072157-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was confused and walking into walls, but the facility did not act. The following day the VA was found lying on the floor and was transported to the hospital where s/he was diagnosed with a systemic infection from Legionnaires disease. Date of Incident(s): May 9-10, 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 May 29, 2024; from documentation at the facility, medical records; and through 11 interviews conducted with six facility staff persons (P1, P2, P3, P4, P5, P6), two case managers (CM1, CM2), two mental health workers (MH1, MH2), and the VA’s guardian (G). Due to the VA’s hospitalization and treatment, s/he was unable to provide any information about the incident. The facility was a split-level home. The upper level contained an open concept living and dining area. There was a hallway that contained three bedrooms including the VA’s and a bathroom. Downstairs there was another bedroom, a living area, a bathroom, and a staff office.
The VA enjoyed spending time with his/her family. The VA was diagnosed with anxiety, delusional disorder, emphysema (lung disease resulting in shortness of breath), chronic obstructive pulmonary disease (COPD- inflammatory lung disease), sleep apnea (sleep disorder where breathing stops and starts), and tremors. The Support Plan Addendum provided the following information: · The VA experienced akathisia (feeling of restlessness with a strong uncontrollable need to move, nervousness and inability to relax) which presented very similar to anxiety. Usually, the VA identified the akathisia and requested an as needed medication (PRN). The VA had paranoia and delusions. · The VA was diagnosed with sleep apnea but refused to use a continuous positive airway pressure (CPAP) machine prescribed by his/her medical provider. Since the VA declined to use the CPAP machine, the medical provider prescribed the VA oxygen at night which the VA only occasionally used. The VA had weakness in his/her legs. The VA’s Care Plans & Protocol stated that the VA had back pain and leg weakness. The VA had COPD and used a PRN rescue inhaler. The VA was prescribed oxygen via a nasal canula at night. The G provided the following information: · The G lived over two hours from the VA, but the VA called and text the G multiple times a day. On May 9, 2024, the VA did not call the G. Later in the evening the G noticed the VA had sent some text messages that did not make sense. The G called the VA, but s/he did not answer. · On May 10, 2024, at approximately 5:30 a.m., the G called the facility to remind them that s/he was coming to pick up the VA that morning. The staff person said that the previous day the VA had been confused and walking into walls. The G and the staff person hung up and the staff person called back after s/he checked on the VA. The staff person said that s/he found the VA laying on the floor covered in urine. · The VA was taken to the hospital and diagnosed with a systemic infection from Legionaries disease (severe form of pneumonia caused by inhaling legionella bacteria from water or soil). The VA was put on a ventilator as his/her lungs were “so bad.” The VA’s mobility, speech, and ability to eat were compromised due to being intubated. · The G had a previous concern with the facility when they did not get medical attention for the VA when his/her medication change appeared to cause the VA to fall down and become confused. The VA had five hours of one-to-one staffing a day. The G felt that if the facility had gotten the VA medical attention sooner the VA’s illness would not have become as serious. P1-P6 who each worked at the facility on May 8 and/or 9, 2024, provided the following information: · The VA had some delusional thinking that was often hard to redirect. When the VA felt anxious, s/he reported to staff persons and asked for a prn medication. The VA had akathisia which also came with some confusion. The VA normally had some weakness if his/her legs. · The VA had an oxygen tank for his/her COPD that s/he was to use each night in place of a CPAP machine (the VA declined a medical provider prescribed CPAP machine). The VA almost always refused to use his/her oxygen even after staff persons prompts. · During the day the VA smoked a filter less pipe every 30 minutes to an hour. The VA had emphysema and a chronic cough. In January and April of 2023, the VA saw his/her medical professional about his/her cough. During one of these appointments a sleep study was recommended that showed the VA had sleep apnea and s/he was prescribed an additional inhaler. · P2, P3, P4, P5, and P6 each said that the VA had a typical day on May 8, 2024. P6 said the VA sat outside and joked with staff persons throughout the day. · On the overnight shift of May 8-9, 2024, the VA was a “little quieter.” The VA “might” have gone outside once during the night to smoke his/her pipe but remained in his/her bedroom as usual. · On May 9, 2024, the VA complained of being anxious several times. The VA had prn medications for anxiousness that s/he requested. P2 said that VA requested his/her prn Ativan that day and slept more during the shift which was typical when s/he took the prn. The VA seemed to be talking less. P2 and P3 each said they noticed a cough but only when the VA went out to smoke which was also typical. · P3 said that the VA seemed to be a little sleepier than normal. At some point, the VA was shaky and spilled some coffee. The VA usually acknowledged if s/he spilled something but this time s/he just rubbed the coffee with his/her foot. P3 asked the VA if anything was wrong, and the VA said it was his/her akathisia and anxiety. · P4 said that the VA reported anxiety but had just had a prn so s/he was given his/her second prn for anxiety (gabapentin) and later the VA reported that his/her anxiety was mildly relieved. At times during the evening the VA was “wobbly” when standing up. The VA asked P4 things throughout the evening like how to send a text or locate a contact which P4 felt the VA should know, but P4 attributed that the high anxiety the VA reported. The VA also reported that s/he was having akathisia. · P5 said that the VA was “kind of quiet” and seemed sleepy. The VA did not eat as well as usual, but did occasionally say that s/he did not want to eat dinner and then asked for it later around 9 p.m. The VA did not display any signs or symptoms of illness or change to his/her chronic cough. · P1 worked the overnight shift on May 9-10, 2024. When P1 arrived for his/her shift, the VA was asleep on the couch. P1 woke the VA and asked if s/he wanted some dinner as the VA had skipped his/her dinner (this was not uncommon as the VA at times refused food at typical mealtimes but then ate later). The VA looked sleepy and “dazed” and did not respond. P1 asked the VA if s/he was okay, and the VA said yes but that s/he did not want any food. The VA to his/her bedroom. · Approximately 45 minutes later, the VA came out of his/her bedroom. The VA stood in the hallway and looked like s/he was reaching for a doorknob. The VA said that s/he had akathisia. P1 told the VA that his/her bedroom was the other way. The VA went back to his/her bedroom and closed the door. · About a half an hour later, the VA went to the bathroom and P1 heard what sounded like some urine hitting the floor. This was not uncommon as the VA at times went into the bathroom half asleep and got urine on the seat of the toilet or the floor. The VA went back to his/her bedroom. P1 checked the VA, and s/he was not wet so P1 cleaned up the bathroom and went back to his/her other cleaning tasks. · At approximately 5:30-6 a.m., the G called the house to remind P1 that the G would be coming to pick up the VA early that morning. Approximately 20-25 minutes after that, the VA came out of his/her bedroom and was soaked with urine. P1 told the VA that s/he needed to get changed so P1 went with the VA to his/her bedroom. There was a puddle of urine on the floor. P1 had the VA sit on his/her bed while P1 went to get supplies to get the VA cleaned up. The VA was looking at P1 but not responding to anything P1 said. P1 wanted to get the VA’s vitals and a mop. P1 took a couple steps out the door and the VA rolled off the bed. · P1 went to the VA and asked if the VA was okay and if the VA could hear P1. The VA did not respond so P1 ran to get the phone and called 9-1-1. Paramedics arrived and took the VA’s vitals and temperature. The VA had a temperature of 102 F. P1 said the VA did not look hot and did not seem warm. The paramedics were concerned about possible seizure activity. P1 heard the VA tell the paramedics that the s/he had akathisia. The paramedics took the VA to the hospital. MH1 and MH2 met with the VA on May 6 and 7, 2024, respectively, each said that they had no concerns with the VA’s physical health at that time. CM1 met with the VA on May 8, 2024, and did not have any concerns with the VA’s physical health. The VA did not mention feeling ill or report anything outside of his/her typical concerns. Shift Notes indicated the following: · On May 8, 2024, the VA talked to family members and went offsite with a visitor (likely CM1). The VA was in “a great mood.” The VA was observed pacing and restless throughout the shift. · On the overnight of May 8-9, 2024, the VA appeared to be sleeping sound and did not get up for any reason. · On May 9, 2024, the VA stated that s/he was “severely” anxious and “disorientated” through the shift but could not determine why. The VA was observed shaking, falling asleep/drooling during conversations or when taking medications, and staggering while standing up. The VA’s affect was “blunted/flat,” and movements appeared fidgety, restless, and abnormally slowed due to high anxiety. · On the overnight of May 9-10, 2024, when P1 arrived at the facility the VA was sitting on the couch sleeping. P1 woke the VA, and the VA was very lethargic, drooling and could not really focus. P1 asked the VA if s/he was okay, and the VA said yes and that s/he was having akathisia. The VA went to bed but got up a few times throughout the night “not knowing what [the VA] was doing.” When asked what the VA was doing, the VA stated that s/he was having akathisia and then went back to bed. An Incident Report dated May 10, 2024, indicated that at 6:20 a.m., the VA came out of his/her bedroom and was soiled with urine. P1 told the VA to come back into his/her bedroom so s/he could change. The VA was not responding or understanding P1. The VA crawled back into bed and P1 went to get a mop. The VA then rolled out of his/her bed onto the floor. P1 called 9-1-1 and the VA was taken to the hospital. Medication administration records from May 2024, showed that on May 8 and 9, 2024, the VA was given ibuprofen for back pain. On May 9, 2024, the VA was given Ativan at 8:02 a.m. and again at 2:12 p.m. for anxiety. At 3:34 p.m., the VA received gabapentin for anxiety. Medical Records showed that on May 10, 2024, the VA was brought by ambulance to the hospital at approximately 7:18 a.m. The VA said s/he did not feel well but was not able to answer more questions. Staff persons told emergency medical providers that the VA did not seem like him/herself yesterday. This morning the VA walked out of his/her bedroom and was actively incontinent as s/he walked down the hall. The VA seemed “out of it” and the staff person wondered if the VA had a seizure. The VA’s temperature was over 101 degrees Fahrenheit and his/her oxygen was 90%. The VA was diagnosed with sepsis (blood infection), due to unspecified organism, pneumonia of the right lower lobe due to infectious organism, cognitive dysfunction, and Legionella pneumonia. On the morning of May 12, 2024, the VA’s fever improved but s/he developed hypoxia (low oxygen in the blood) in the afternoon. The VA was transferred to the intensive care unit (ICU). Overnight the VA required more oxygen and was intubated. On May 13, 2024, the VA was transferred to another hospital. According to www.mayoclinic.org/disease-conditions-causes/syc-20351747, Legionnaires’ disease is a severe form of pneumonia-lung inflammation usually caused by infection. Most people caught Legionnaires’ disease by inhaling the bacteria from water or soil. Older adults, smokers, and people with weakened immune systems were particularly susceptible to Legionnaires’ disease. Symptoms usually developed two to ten days after exposure and included headache, muscle aches, and a fever that may be 104 F or higher. By the second or third day, other symptoms developed including a cough, which might bring up mucus and sometimes blood, shortness of breath, chest pain, gastrointestinal symptoms such as nausea, vomiting, and diarrhea, and confusion or other mental changes. Facility documentation showed that all staff persons interviewed received training on the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Each P1-P6 all stated that on May 8, 2024, the VA had a normal day with no signs or symptoms of illness. CM1 also met with the VA on May 8, 2024, and did not notice any signs of illness. On May 9, 2024, the VA stated to multiple staff persons that s/he was anxious and had akathisia. Staff persons noticed the VA talking less and sleeping more with some unsteadiness on his/her feet and general confusion, but staff persons did not notice any signs of physical illness. During the overnight of May 9-10, 2024, the VA again appeared sleepy but reported that s/he was okay but had akathisia. The VA came out of his/her bedroom a couple times and once seemed to be confused but was directed back to his/her bedroom. Early that morning, s/he came out of the bedroom soaked in urine and shortly after fell out of bed. P1 called 9-1-1 and the VA was taken to the hospital. Although there were concerns that staff persons did not seek medical assistance in a timely manner, given that documentation and staff interviews showed that the VA was acting normally two days prior to the hospitalization and that although the VA appeared tired and confused the day before which staff persons attributed to the VA’s anxiety/akathisia and/or the result of the VA’s prn medications that s/he had taken, that staff persons did not notice any signs or symptoms of illness, and that when staff persons saw the VA’s odd behaviors and lack of response on May 10, 2024, they immediately called 9-1-1 to get the VA medical assistance, there was not a preponderance of the evidence whether staff persons failed to provide the VA with health care that was reasonable and necessary to maintain the VA’s physical health or safety. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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