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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: 1079598-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux carla.harvieux@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) gave a vulnerable adult (VA) a stretchy cloth headband. The VA had a history of swallowing non-edible items and swallowed part of the headband which obstructed his/her airway. Staff persons (P1, P2, and P3) attempted lifesaving measures, but the VA passed away. Date of Incident(s): February 27, 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 March 29, 2024; from documentation at the facility and the VA’s medical records; and through interviews conducted with facility staff persons (P1, P2, P3, P4, and the SP), and the VA’s guardian (G). The VA resided in the basement of the facility and his/her living area was composed of a bedroom, a bathroom, a living room, and a kitchen. An office was located across the hallway from the VA’s bedroom. Facility documentation showed that the VA’s diagnoses included fetal alcohol syndrome, borderline intellectual disability, and anxiety and mood disorder. The VA might require additional time to process verbal information and might be slow to respond to questions or instructions from staff persons. The VA had two to one staffing. If the VA was upset, s/he might decline to engage with staff persons, perseverate on various topics, or respond aggressively. Indicators that the VA was upset or becoming upset included having mood changes, using rapid/pressured speech, engaging in demanding behavior, and a decreasing ability to focus his/her attention. The VA might act impulsively, verbally or physically aggress toward others, destroy property, attempt to leave the facility without supervision, or have crying, yelling, or screaming outbursts. The VA had a history of wrapping cloth items around his/her neck to try to suffocate him/herself then hiding from staff persons and had attempted to swallow potentially dangerous items which might increase the likelihood that s/he be evaluated at or admitted to hospitals that provided care to persons with a mental illness. Staff persons were to ensure that the VA had no access to potentially dangerous objects that might be swallowed by removing the items from the VA and placing them in locked areas of the facility that were not accessible to the VA. A Rights Restriction for the VA, which was approved by his/her team, showed that the VA was not to have access to jewelry, pins, ceramic fragments, screws, tacks, earbuds, batteries, phone batteries, coins, wearable clothing that wrapped around the neck, or other property that might be potentially dangerous or require hospitalization if ingested. Staff persons were to keep the VA in their sight inside the facility and in the community unless the VA used the bathroom, then the bathroom door was open at least four inches so staff persons could hear the VA. The December 18, 2023, Use of Permitted Actions and Procedures for the VA showed that s/he made numerous attempts over the last 12 months to ingest inedible items. When staff persons attempted to remove or relocate possibly dangerous items away from the VA, s/he might become upset and hit or attempt to hit them. Staff persons were to block the VA’s hits and prevent the VA from ingesting dangerous items. If possible, staff persons were to avoid physical engagement with the VA while removing items that the VA might use to harm him/herself or others. Staff persons were to call 9-1-1 when all less intrusive strategies had been attempted or use the least restrictive manual restraint to protect the VA or others from harm. No information showed that the VA previously swallowed pieces of cloth that s/he ripped from items. The VA might have undesirable behaviors more frequently when non-preferred staff persons worked with the VA, when the VA wanted to be evaluated in the emergency department of a hospital or call a law enforcement agency but staff persons declined the VA’s requests to do so, when the VA wanted to leave the facility without supervision, or when s/he felt confused or did not understand something. The VA was kind and had a great sense of humor. Facility documentation, the VA’s medical records, information provided by P1, P2, P3, P4, the SP, and the G in interviews with this investigator, and the facility’s Internal Review, provided the following information: · On February 27, 2024, when the VA was upset in his/her bedroom, s/he obtained the cloth headband that the SP gave him/her from his/her dresser. The VA removed a piece of cloth from the headband, placed the cloth in his/her mouth, and attempted to swallow it. The VA was unable to swallow the cloth and it blocked his/her airway. · P1 and P2 provided consistent information that prior to the incident, the VA had been upset and breaking apart a plastic cabinet in his/her bedroom and attempting to remove a screw from a bedroom wall. P1 and P2 attempted to verbally de-escalate the VA and monitored him/her. The VA walked around the bedroom, opened a bedroom window which caused an alarm to sound, then obtained several items that s/he was permitted to have in his/her bedroom and attempted to swallow them, but the VA gave the items to P1 and P2 when s/he was redirected. · The VA then grabbed the headband from his/her dresser, ripped it, and quickly placed part of the cloth from the headband in his/her mouth then “instantly” looked like s/he wanted help according to P1. P1 asked the VA to cough up the cloth but the VA could not dislodge the cloth from his/her mouth/throat. P2 told the VA that s/he was going to give him/her the Heimlich maneuver and began to do the Heimlich maneuver on the VA while P1 called 9-1-1 and provided the facility address. The VA lost consciousness so P2 laid the VA on the floor, P1 looked in the VA’s mouth with a flashlight to try to remove the cloth but could not see anything, and P2 and P1 alternated giving the VA chest compressions. P3, who was upstairs with another individual, heard the activity downstairs, came downstairs, and assisted P1 and P2 to give the VA chest compressions. · Emergency medical technicians (EMTs) soon arrived, and took over lifesaving efforts from P1, P2, and P3, using a Lucas device (a machine that performed chest compressions) with the VA, and examining his/her airway for obstructions. EMTs removed the cloth from the VA’s airway using medical tools and took the VA to the emergency department of a hospital in an ambulance, followed by P1. · The VA’s medical records showed that at 6:56 p.m., on February 27, 2024, the VA was in cardiac arrest when EMTs brought him/her to the hospital. According to the records, the VA was unresponsive when the EMTs arrived at the facility, without respirations, and without a pulse. EMTs were able to remove a foreign body from the VA, and provided ventilation and used a Lucas device to give the VA chest compressions. At the hospital, the VA had no pulse, no respirations, and no responsiveness. A physician determined that the VA had passed away, and according to the VA’s death certificate, s/he died from accidental choking. · The SP said that s/he did not work with the VA on the evening that s/he passed away but had worked with him/her the day before. Swallowing inedible items was a newer issue for the VA that s/he engaged in when s/he was upset. Several weeks ago, the SP gave the VA the cloth headband to hold the VA’s hair back from his/her face when applying moisturizers and skin treatments to the face. The SP knew that staff persons were not to give gifts to individuals and that anything s/he gave to individuals at the facility was to be donated to the facility for everyone’s use, but other staff persons had given the VA gifts, and the SP thought that the VA could use the headband. The SP knew that the VA had a rights restriction preventing him/her from having small inedible objects, but the VA had ponytail holders to hold his/her hair back from his/her face and had not previously ripped fabric items apart to swallow them or attempted to swallow anything like cloth from a headband. · P4, who was a supervisory staff person, said that s/he was unaware that the SP gave the VA a headband until the day after the VA passed away. P4 thought that the VA having the headband itself did not violate the VA’s rights restriction because the rights restriction was to prevent the VA from having access to items with small or plastic parts, but the headband was larger and about the size of a sock. The VA had unsupervised access to his/her socks in his/her bedroom, so P4 thought it would have been okay for the VA to have unsupervised access to the headband. On the date of the incident, the VA was dysregulated and had attempted to swallow many items. P4 thought that P1 and P2 supervised the VA correctly and that they, and P3, took appropriate timely action when the VA ingested the cloth from the headband. However, giving the VA the headband was a violation of the facility’s policies and procedures because it was not given anonymously and was specifically for the VA. · The G said that s/he was pleased with the care that the VA received at the facility and thought the facility and its staff persons never gave up on the VA. The facility’s Gifts and Donations for Clients policy showed that gifts given to individuals who resided at the facility were to be for all residents and that gifts from staff persons were to be given anonymously. The facility’s personnel and training records showed that staff persons interviewed for this report were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes section 245A.04, subdivision 14, paragraph (b), clause (3) states that the license holder shall monitor implementation of policies and procedures by program staff. Conclusion: Information was consistent that the SP gave the VA a cloth stretchy headband prior to the incident that the VA might use when s/he applied facial care products. There was a rights restriction for the VA which showed that s/he was not to have access to small items including jewelry, pins, ceramic fragments, screws, tacks, earbuds, coins, clothing that wrapped around the neck, or other property that might be potentially dangerous or require hospitalization if ingested. No information showed that the VA had previously ripped cloth and ingested it. On February 27, 2024, the VA was upset, tore some cloth from the headband, and ingested it. The cloth blocked the VA’s airway, P1 attempted to remove the cloth from the VA’s mouth/throat but was unable to do so and the VA became unconscious. P1, P2, and P3 gave the VA chest compressions and P1 called 9-1-1. When EMTs arrived, they continued chest compressions on the VA with a Lucas device and used a tool to remove the cloth from the VA’s mouth/throat. The VA was taken via ambulance to a hospital where a physician determined that s/he had passed away. Medical records showed that the VA was in cardiac arrest when s/he arrived at hospital, had no pulse, was not breathing, and was unresponsive. The VA passed away from accidental choking. P4 thought that the VA could have the headband because the VA’s rights restriction was in place to prevent the VA from accessing items with small/plastic parts. The headband was approximately the size of a sock, and the VA kept socks in his/her bedroom. P1’s, P2’s, and P3’s actions with the VA were appropriate and timely, according to P4. However, the SP gave the VA the headband and knew that giving the VA a gift was a violation of the facility’s policies and procedures. Although the VA tore the headband and swallowed part of it, given that the VA’s rights restriction did not prohibit the VA from having sock-sized cloth items, that the VA had no history of swallowing pieces of cloth, and that P1 and P2 were supervising the VA according to his/her plans when the incident occurred, there was not a preponderance of the evidence whether there was a failure to provide the VA with care and supervision necessary to obtain or maintain the VA’s 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 which determined that its policies and procedures were adequate and were followed when P1, P2, and P3 responded to the VA when s/he placed the headband in his/her mouth and attempted to swallow it. However, the SP did not follow the facility’s policies/procedures or adhere to the VA’s plans when s/he gave the VA the headband. The SP was immediately retrained on the facility’s policies and procedures and given a formal letter of expectation. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate corrective action, the facility was not issued a correction order for the violation outlined in this report.
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