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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: 1111602-AFC (Adult Foster Care) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) lost 17 pounds since moving into the facility five months prior. In addition, there were concerns that someone pulled the VA’s arm or used force resulting in left shoulder pain. Date of Incident(s): Prior to June 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 2, paragraph (b), clause (1); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. 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 17, 2024; from documentation at the facility; and through five interviews conducted with three facility staff persons (P1, P2, and P3), a therapist (T), and a family member (FM). This investigator met the VA; however, due to the VA’s diagnoses, s/he was not able to provide information related to the report. Two attempts to obtain information from a primary care provider (PCP) were unsuccessful. The VA was 69 years old and was diagnosed with dementia. The VA’s verbal skills were limited, and s/he needed assistance with all activities of daily living. The VA enjoyed having company, going out for drives with family members, sitting outside, and going for walks. An Individual Abuse Prevention Plan and Mobility Assessment stated that the VA’s confusion resulted in “difficulty in swallowing” and that s/he needed “continuous cues and reminders to keep eating.” The VA was no longer able to dress him/herself and needed total assistance. Facility documentation showed that in December 2023, prior to the VA’s admission to the facility, s/he weighed 120 pounds. Starting in February 2024, the VA’s weight was tracked multiple times per month either on the facility’s scale, at two different clinics, or on a scale brought into the facility by a home health care agency staff person. On May 29, 2024, the VA weighed 100.9 pounds. Additional documentation at the facility showed: · An April 18, 2024, medical referral form showed that the VA was seen by his/her PCP for weight loss, depression, and anxiety. The PCP’s orders included taking weekly weights and providing Ensure (a nutritional drink) at least once a day. The VA was to “wean off Lexapro” and start Effexor XR 37.5 milligrams daily. In addition, Tylenol and muscle/joint cream were ordered twice per day. · An Incident Report Form dated April 24, 2024, stated that at 2 a.m., the VA was getting out of bed on his/her own. When a staff person (P4) was at the VA’s doorway, the VA’s feet touched the floor and s/he fell on his/her buttocks onto the floor. P4 documented that it was “not a hard fall.” P4 checked the VA and did not believe the VA was hurt. · An April 2024, “Family Notes” written by the FM stated that the VA needed “some help with eating” and that there was a 16-pound weight loss between December 2023 and April 2024. The VA experienced pain in his/her “upper left chest/shoulder” and the PCP ordered Tylenol and muscle/joint cream twice per day. · The PCP saw the VA on May 9, 2024, for weight loss and left arm pain. The medical referral form showed that the VA was supposed to increase Ensure to two drinks per day, continue current medications, and not lift his/her left shoulder due to pain. An x-ray of the shoulder was completed. (Although the referral form did not indicate the x-ray findings, P1 stated that the shoulder was “intact.”) The PCP ordered “physical therapy” and “homecare” from a home health care agency. · The VA’s daily notes from March 5 through June 8, 2024, were reviewed and showed multiple days where the VA cried without a known reason. The VA showed signs of confusion, anxiety, and paranoia. Although there were days and evenings the VA was uncooperative with dressing and/or undressing or did not know how to complete the task without assistance, there was no documentation to indicate when it began. The therapist (T) stated that the VA was seen for “shoulder pain with no known cause.” The T was concerned the pain was “staff related” based on the VA’s comments about staff persons “yelling” at the VA and saying, “If they pull on it, it will hurt.” Additionally, an unidentified staff person told the T on more than one occasion there was “difficulty with dressing” the VA some evenings. A review of the VA’s daily notes showed that occasionally the VA did not eat his/her entire meal. Interviews with P1-P3 showed that staff persons provided assistance to the VA when s/he did not eat on his/her own. In addition, the VA’s daily notes and Medication Schedule sheets, as well as information from P1-P3, showed that the VA was provided Ensure as ordered. P1-P3 provided the following additional information: · P1 said that the VA had “rapid dementia” and his/her abilities “deteriorated at a rapid rate.” The VA was easily distracted resulting in confusion when eating meals. Around the same time the VA complained of left shoulder pain, the VA also had a decrease in daily function as well as an increase in confusion. The VA was yelling and crying and displayed anxiety that was addressed by the PCP with medication changes. P1 said it was unknown what, if anything occurred to cause the VA’s shoulder pain. P1 said that although the VA fell in April 2024, it was “not a hard fall” and the VA was complaining about his/her shoulder prior to the fall. · P2 did not know what caused the VA’s arm/shoulder pain and did not have any concerns regarding staff persons interactions with the VA. · P3 said that when the VA started to complain about shoulder pain, s/he asked the VA if s/he “slept wrong;” however the VA did not know what caused the pain. Depending on what type of shirt the VA was wearing, the VA let P3 know when it hurt to bend his/her arm and P3 was careful when s/he undressed the VA. Staff persons interviewed confirmed they were trained regarding the Reporting of Maltreatment of Vulnerable Adults Act and were aware of the VA’s diagnoses and care needs. Conclusion: Regarding the VA’s weight loss: Information showed that between December 2023 and May 2024, the VA lost 19 pounds. During that period of time, the VA was seen by his/her PCP, his/her weight was regularly tracked, s/he was provided Ensure, and s/he was given assistance when unable to feed him/herself. Given the VA’s diagnoses and that staff persons at the facility were aware of the VA’s weight loss and were addressing it as ordered by the PCP, there was a preponderance of the evidence that there was not a failure to provide reasonable and necessary care to the VA. It was determined that neglect did not occur (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 left shoulder pain: An April 18, 2024, medical referral form and an April 2024, “Family Notes” indicated that the VA had left arm/shoulder pain. A review of facility records and interviews with the FM, P1-P3, and the T showed that while the VA complained of shoulder pain, an incident that started the pain was not known. When the VA saw the PCP, s/he was prescribed and administered both Tylenol and muscle/joint cream. Given that the VA already saw the PCP for his/her shoulder a week prior to falling out of bed on April 24, 2024, that incident was likely not the cause of his/her initial pain. The T was concerned that the VA’s pain was “staff related,” because the VA made comments to the T about staff persons “yelling” at him/her and said, “If they pull on it, it will hurt.” The VA did not provide additional information and documentation showed that due to his/her diagnoses, s/he showed signs of confusion, anxiety, and paranoia. Additionally, there was no information that a staff person caused harm to the VA while providing daily care. Given that it was not determined the circumstances that caused the pain in the VA’s shoulder/arm or when the pain started, there was not a preponderance of the evidence whether the VA’s pain or injury was caused by means other than during the provision of therapeutic conduct or whether it was caused by a failure to provide the VA reasonable and necessary supervision. It was not determined whether physical abuse or neglect occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; 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 adequate and were followed when the VA’s pain was addressed in a timely manner and the VA’s weight was tracked Ensure offered as prescribed. Additional training was provided to staff persons regarding how to put on and remove clothing to not stress the VA’s shoulder. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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