|
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: 1071998-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Alice Percy 651-431-2155 Suspected Maltreatment Reported: It was reported that when concerns were raised about a vulnerable adult’s (VA’s) catheter, a supervisory staff person (SP) took the VA to an emergency room but did not wait for the VA to be seen by a physician. The VA continued to have problems with his/her catheter for approximately three weeks. The VA was then taken to the hospital where s/he was diagnosed with “septic shock secondary to a urinary tract infection (UTI).” Date of Incident(s): Ongoing, prior to September 27, 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 October 20, 2023; from documentation at the facility and medical records; and through ten interviews conducted with a facility administrative staff person (P1), five staff persons (P2- P6), the facility’s health care professional (HCP), the SP, the VA, and the VA’s guardian (G). The VA enjoyed playing computer games, going to the movies, cooking, going out to eat, and spending time with his/her friends and family members. The VA’s diagnoses included Down syndrome, adjustment disorder, dementia, and mild intellectual disabilities. The VA used a walker or wheelchair for mobility. The VA attended a work program two days each week. According to the VA’s ISSA Assessment Detail, the staff persons administered the VA’s medications to the VA and ensured that the physician’s orders were followed. A staff person scheduled the VA’s medical appointments and accompanied the VA to his/her medical appointments. When the VA showed signs of illness, the VA was to be placed on a seven-day watch. The VA was unable to urinate on his/her own and had a catheter in place. The staff persons routinely emptied the catheter bag and provided care for the bag. According to the Physician Order Sheet, the staff persons were to empty the VA’s catheter bag during each shift and “as needed.” The staff persons were to document the amount of urine output and to inform the facility’s administrative staff persons or the HCP if there were any concerns regarding the VA’s catheter. The VA stated that s/he was recently very ill and went to the hospital in an ambulance, but was unable to provide additional information about the incident. P1, P2, P3, P4, P5, P6, the SP, the HCP, and the facility’s documentation provided the following information: · P1 stated that in the past, when the VA had a UTI, s/he became sick “very fast.” When the VA had a UTI, the VA’s urine was dark and had a strong odor and the VA felt unwell and did not want to participate in activities. P5 stated that the VA typically had a UTI once a month. The HCP stated that s/he typically changed the VA’s catheter monthly and the staff persons routinely irrigated the catheter. The HCP trained the staff persons on the residents’ medical cares and told them to telephone 9-1-1 without checking with the HCP or an administrative staff person if they felt that something was “seriously wrong” with a resident. P3 stated that the staff persons were trained to irrigate the VA’s catheter and to document the VA’s urine output. P4 and P6 each believed that the staff persons were caring for the VA’s catheter as they were trained to do and accurately documented the catheter care. P5 believed that the new staff persons were not always adequately trained on caring for the VA’s catheter care. · On the morning of September 7, 2023, the HCP changed the VA’s catheter. The HCP stated that the VA had “some irregular output” that day and the VA’s urine was “very thick.” That evening, P1 received a phone call from P2 because s/he saw blood and mucus in the VA’s underwear. The VA did not want to go to the hospital, so P1 called the SP and asked him/her to take the VA to the hospital. The SP then took the VA to the emergency room, where they waited until a nurse checked the VA’s vitals and asked the VA if s/he wanted to wait to see a physician. The SP encouraged the VA to stay at the hospital, but the VA was “insistent” that s/he wanted to go back to the facility and go to bed, so the SP took the VA back to the facility. The SP forgot to bring the medical referral form with him/her to the hospital. The nurse told the SP that the catheter was possibly put in “too roughly” earlier that day and would heal. · The SP later texted P1 and told him/her that the VA was seen by a nurse at the hospital, who “checked out” the VA and took his/her vitals. The SP told P1 that the nurse told the SP that it was “just trauma” from the new catheter. The VA did not want to remain at the hospital to see a physician, so the SP took the VA back to the facility. P5 stated that the VA and the SP were away from the facility for approximately one hour, even though the VA was typically at the emergency room for several hours. P5 did not see any paperwork from the emergency room visit and the SP did not document the visit. P6 stated that the SP was not trained on the process of documenting things like emergency room visits. The HCP believed that the VA should have been seen by a physician when s/he went to the emergency room. The HCP stated that the residents had the right to ask to leave a medical appointment, but that the staff person accompanying the resident should then let an administrative staff person know that the resident left the appointment. · P1 stated that after the VA was taken to the emergency room by the SP, the VA appeared to be “fine” and told the staff persons that s/he felt fine. P5 stated that the VA appeared to be tired the day after going to the emergency room, but that was not uncommon after an emergency room visit. Several new staff persons began working at the facility during that time and the VA was did not always want to do certain activities for them. P4 stated that the VA seemed fine after his/her visit to the emergency room and that s/he could tell when the VA felt ill because s/he would shake, look pale, and appear unwell. The VA sometimes had a small amount of blood after his/her catheter was changed. When the staff persons noticed blood at the catheter site, they were trained to contact the HCP or P1. · On September 11, 2023, the HCP talked to the SP about the VA’s emergency visit because there was no paperwork from the visit. The SP told the HCP that s/he forgot to take the medical referral form to the emergency room and had no paperwork from the emergency room visit. The HCP telephoned P1 and told him/her about the SP’s failure to get the paperwork filled out by a physician. P1 stated that s/he was told the SP did not bring any paperwork back from the hospital that showed the outcome from the VA’s emergency room visit, but P1 stated that it was not uncommon for the hospital nurses to forget to send the paperwork back to the facility or the staff persons to forget to bring the paperwork back. P1 talked to the SP about the lack of paperwork, but since the VA did not have any further signs of an infection or illness and there was no more mucus or blood, nothing further was done. · P6 stated that on September 27, 2023, the VA did not want to get out of bed, which was not uncommon for the VA. P6 administered medications to the VA and gave him/her something to drink. At approximately 9:30 a.m., when P6 attempted to irrigate the VA’s catheter tubing, it was clogged. P3 stated that the VA’s catheter was not “flowing” properly and the VA refused to get out of his/her bed so s/he telephoned the HCP and asked the HCP to check the VA’s catheter. The HCP went to the facility and checked the VA’s vitals, which were all stable. The HCP attempted to get the VA to eat and drink, but the VA told the HCP that s/he was not feeling well. The HCP changed the VA’s catheter and the VA’s urine was cloudy and bloody. P6 stated that the HCP and P1 had a long discussion about whether the VA needed to go to the hospital, even though the VA told them s/he wanted to go to the hospital. The HCP eventually telephoned 9-1-1 and the VA was taken to the hospital via ambulance. P3 accompanied the VA to the hospital. The HCP stated that none of the staff persons told him/her that the VA was feeling unwell prior to when s/he was asked to check the VA’s catheter. P4 stated that s/he worked with the VA on the day prior to his/her hospitalization and the VA “seemed fine.” P6 stated that in the days leading up to his/her hospitalization, the VA complained about an upset stomach “a couple of times,” but continued to eat and “seemed fine.” · P1 stated that in the past, the VA’s physician had the staff persons irrigate the VA’s catheter with an antibiotic solution twice a day. During the six weeks that the staff persons followed this procedure, the VA did not have any UTIs. Between the day when the SP took the VA to the emergency room and the day when the VA was hospitalized, the VA’s physician had the staff persons stop using the antibiotic solution and return to irrigating the VA’s catheter once a day without the antibiotic solution. P1 stated that the staff persons were “very proactive” in making sure the VA had medical care when s/he appeared ill. · The SP stated that s/he was not adequately trained while s/he worked at the facility and repeatedly asked P1 for training. P3 stated that the VA appeared to trust the SP and P3 had no concerns about the SP’s interactions with the residents. P6 stated that the SP was “good” with the residents and was “proactive” with them. P5 stated that the SP sometimes “declined to do cares” for the residents and sometimes had difficulty getting the residents to agree to his/her requests to do activities such as getting out of bed. The G stated that the VA had lived at the facility for 20 years and enjoyed living there. The G had no concerns about the VA’s care prior to the incident. The VA had three or four UTI’s in the previous 18 months. The G believed that one of the VA’s physicians changed the care order from having the staff persons clean the VA’s catheter bag and doing an antibiotic flush twice each day to only changing the bag once each day and not doing the antibiotic flush. After the VA’s hospitalization, the VA returned to the facility and was “doing good.” According to the facility’s Progress Notes: · On September 7, 2023, P5 documented that the VA had “pus/mucus” in his/her underwear and “light blood flow.” At 9 p.m., a staff person took the VA to the hospital and at 10 p.m., they returned to the facility. The staff person was told that it was a “normal reaction” to the catheter being changed that morning. · Between September 7 and September 19, 2023, the staff persons completed documentation about the VA. No concerns about the VA’s health were raised by the staff persons. · On September 20, 2023, P2 documented that the VA “seemed a little confused this morning waking up.” Later that day, P4 documented that the VA “seemed a little unsteady,” but told P4 that s/he was fine. P4 noticed a slight odor to the VA’s urine, which “might be the beginning of a UTI.” The VA slipped while getting into the van for a community outing, but P4 “caught” the VA by his/her arms and assisted him/her into his/her wheelchair. · On September 21, 2023, the VA refused to walk to the dining room table because s/he fell on his/her “butt” the previous day. The VA complained of back pain from the fall, but did not want medical care for his/her back pain. · On September 22, 2023, P4 documented that the VA told him/her that his/her back “hurt just a little.” · On September 23, 2023, the VA complained that his/her stomach hurt, but refused to go to the emergency room. The VA ate his/her meals and completed his/her physical therapy exercises. · On September 24, 2023, the VA refused to walk because s/he was afraid s/he might fall. · On September 25, 2023, the VA was seen by his/her neurologist and “everything looked normal.” · On September 26, 2023, the VA had an appointment and then returned to the facility. · On September 27, 2023, P6 documented that the VA did not want to get out of bed. At 10:20 a.m., P6 attempted to irrigate the VA’s catheter, but it was “completely clogged.” P6 contacted the HCP, who arrived at the facility, changed the VA’s catheter, and attempted to get the VA out of bed, but the VA was having dizzy spells. At approximately 12:05 p.m., 9-1-1 was telephoned and the VA was admitted to the hospital. · On October 3, 2023, the VA returned to the facility after being discharged from the hospital. According to the hospital’s Visit Information, on September 7, 2023, at 9:07 p.m., the VA arrived at the emergency room because the staff persons noted a “little bit of blood and mucus” in the VA’s underwear after a new catheter was put in earlier in the day. The VA’s catheter was “flowing with clear urine” and the VA denied being in pain. The VA left the emergency room because s/he was “tired of waiting.” The VA was advised to return should there be any worsening symptoms. According to the hospital’s Admission form, on September 27, 2023, the VA was admitted to the hospital for “septic shock secondary to UTI.” Facility documentation showed that P1 – P6, the HCP, and the SP each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. Conclusion: On September 7, 2023, the HCP changed the VA’s catheter. That evening, P2 saw mucus and blood in the VA’s underwear and the VA was taken to the emergency room by the SP. The SP forgot to bring medical referral paperwork to the emergency room and did not receive any documentation from the emergency room. According to the hospital’s Visit Information, the VA was seen by a nurse, who documented that the VA’s catheter was flowing with clear urine. The VA denied being in pain and wanted to return to the facility rather than wait to be seen by a physician so the SP took the VA back to the facility. On September 27, 2023, the VA’s catheter was clogged and the VA appeared unwell. The HCP checked on the VA and then telephoned 9-1-1. The VA was taken to the hospital, where s/he was admitted and diagnosed with septic shock secondary to UTI. According to the staff persons and the Progress Notes, the VA had no symptoms of feeling ill or having a UTI between September 7 and 27, 2023, beyond a slight odor to his/her urine on September 20, 2023, and some back pain after almost falling on September 20, 2023. Information was provided that in the past, when the VA had a UTI, s/he became sick “very fast.” While it was reported that the VA had problems with his/her catheter between September 7, 2023, when the SP took the VA to the emergency room, and September 27, 2023, when the VA was admitted to the hospital with a UTI, no information was provided that the failure of the VA being seen by a physician on September 7, 2023, resulted in the VA developing a UTI on September 27, 2023. The staff persons continued to check on and irrigate the VA’s catheter as required after the VA’s visit to the emergency room and contacted P1 and the HCP when the VA showed signs of being ill. While the SP did not follow the facility’s protocol and obtain medical referral paperwork from the emergency room, there was not a preponderance of the evidence whether there was a failure to provide care or services to the VA which were reasonable and necessary to maintain the VA’s physical health and 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 the facility’s policies were adequate, but were not followed by the staff persons. After the incident, the staff persons were retrained on the facility’s policies. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
