|
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: 1080938-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 on April 27, 2024, just after a staff person’s (SP’s) shift at the facility, a vulnerable adult (VA) seemed lethargic and told a staff person (P1) that s/he got “high” using a glass pipe earlier that day. The SP had left a marijuana pipe at the facility on an unspecified date prior to the incident, and there were concerns that the SP provided the VA with a substance and a pipe. Date of Incident(s): April 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 June 17, 2024; from documentation at the facility; and through interviews conducted with facility staff persons (P1, P2, and the SP) and the VA. This investigator met the VA and talked with him/her regarding living at the facility, but the VA declined to provide information about this report. Facility documentation showed that the VA was diagnosed with bipolar disorder and anxiety disorder and had a history of providing inaccurate information. When the VA was emotionally and/or behaviorally dysregulated, s/he might appear to have memory or cognitive impairments, and s/he sometimes declined to have medical procedures recommended by his/her physician. The VA used a manual wheelchair for mobility and needed assistance from staff persons to complete some tasks of daily living. Living as independently as possible was important to the VA and staff persons and the VA’s guardian encouraged him/her to accept assistance to reach his/her goals. However, the VA had a history of substance use and was not able to meet his/her needs on a consistent basis. A good sense of humor and an ability to be a strong self-advocate were two of the VA’s strengths. Interviews with this investigator, facility documentation, and the facility’s Internal Review, provided the following: · P1 said that on April 27, 2024, s/he arrived at about 10 p.m. just as the SP was leaving after his/her shift. The VA was in the kitchen and asked for assistance to go outside to smoke a cigarette. The VA had difficulty lighting the cigarette and dropped it. P1 asked the VA whether s/he was okay, and the VA replied that s/he had gotten “high on marijuana” earlier in the day using a pipe. The VA had not left the facility on the date of the incident and when s/he did leave, staff persons provided him/her with transportation and assistance. The SP had worked with the VA on the shift prior to P1’s, so P1 thought that the SP might have given the VA marijuana or that the VA obtained marijuana during the SP’s shift. · During P1’s shift, the VA dropped a cup of coffee, fell asleep twice in his/her wheelchair, and had slurred speech which was difficult to understand. P1 assisted the VA into his/her bed for the night and checked on him/her several times during the shift. The VA required more assistance and needed additional help to complete tasks that s/he usually did him/herself. The next morning shortly before 6:15 a.m., the VA awoke and had coffee, then listened to the radio. When P2, a supervisory staff person, arrived at the facility just before 8 a.m., P1 told P2 what s/he had observed about the VA during the overnight shift. P1 did not call 9-1-1 because s/he thought the VA did not need emergency care. Nothing about the SP seemed off the night before and P1 did not think that the SP was under the influence of a substance. · P2 and P3, (P3 was also a supervisory staff person), each stated that P1 described his/her concerns to P2 regarding the VA on the morning of April 28, 2024. P2 immediately observed the VA and thought that s/he was his/her “normal self.” P2 notified P3 and then searched the facility for substances and paraphernalia but found nothing. P2 was concerned about the VA’s statements because the SP had previously left a pipe at the facility like pipes that were often used to smoke marijuana. No information showed that the VA required medical care and s/he was at baseline level the next morning. P2 and P3 instructed staff persons to be vigilant and monitor the VA for any changes. · The SP provided consistent information to this investigator and in the facility Internal Review that s/he had a marijuana pipe in his/her pocket at the facility the previous month, that fell from his/her pocket while s/he was on shift. The pipe was found by a staff person and supervisory staff persons talked with the SP about the pipe. After that, the SP did not bring substances or paraphernalia to the facility with him/her. The SP denied that s/he used substances prior to his/her shifts or while at the facility and did not know where the VA might obtain marijuana because the VA did not often leave the facility. The SP was aware that the VA previously used marijuana but denied that s/he gave marijuana or paraphernalia to smoke it with, to the VA. The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procedures prior to the incident. Conclusion: P1 said that on April 27, 2024, the VA told P1 that s/he had used marijuana earlier that day and was “high.” The VA’s speech was slurred, s/he seemed lethargic, dropped his/her coffee, and needed assistance to complete tasks that s/he usually did independently. P1 thought that the SP, who worked the shift prior to his/hers, might have given marijuana to the VA, or that the VA might have obtained marijuana while the SP was on shift, because the VA did not leave the facility without staff person supervision/assistance. P1 assisted the VA into his/her bed and checked on him/her but did not call 9-1-1 because the VA did not require emergency care. The next morning, P2 and P3 became aware of P1’s concerns, and P2 observed the VA, who appeared to be at his/her baseline. P2 searched the facility for substances or paraphernalia but found nothing. The SP acknowledged that s/he previously left a marijuana pipe at the facility when the pipe fell unnoticed from his/her pocket. After a discussion with supervisory staff persons, the SP agreed not to bring substances or paraphernalia to the facility in the future. The SP was aware of the VA’s previous substance use and denied that s/he gave marijuana or paraphernalia to the VA. Although P1 thought that the SP might have given marijuana to the VA which the VA said that s/he used to get “high” and the VA appeared to be lethargic, given that it was unknown whether the VA used marijuana, that the SP denied that s/he provided the VA with a pipe or marijuana, and that the VA did not require emergency care, there was not a preponderance of the evidence whether there was a failure to provide the VA with care and supervision that was reasonable and 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 stated that its policies and procedures were adequate and were followed. The incident was similar to previous incidents because the VA had made prior statements that s/he used marijuana with staff persons. The facility retrained staff persons at the VA’s residence on the Drug and Alcohol Policy and the VA’s plans were updated to “reflect the risk of alcohol and drug” misuse. P1 was retrained on the reporting of maltreatment timelines and received corrective action. The SP was no longer employed at the facility when this report was written. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
