|
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: 1070424-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that staff persons did not bring a vulnerable adult (VA) to medical appointments, that staff persons did not offer medications to the VA, and that staff persons did not give the correct medications to the VA. Date of Incident(s): Prior to May 17, 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, from the VA’s medical records, and from law enforcement records; and through six interviews conducted with the VA’s family member (FM), three facility management staff persons (P1-P3), the VA’s social worker (SW), and the VA’s nurse practitioner (NP). Although this investigator attempted to contact the VA several times, the VA was unable to provide information in an interview. Attempts were made to contact two medical professionals (MP1 and MP2) for information regarding the allegations were unsuccessful. However, MP1 and MP2 provided information to the Department of Human Services so that information was included below. The VA’s support plan showed that s/he enjoyed going for walks, reading, writing poetry, and going out for lunch. The plan showed that the VA had mental health concerns and needed assistance with scheduling and attending medical appointments as well as “medication oversight.” The VA’s Coordinated Services Support Plan Addendum showed that some of the VA’s diagnosis included anxiety, depression, schizoaffective disorder, and asthma. The plan further showed that the VA’s “team has requested that the [facility] supervisor report all medication changes, medication refusals, and behavior/symptomatic concerns to [the VA’s] team in order to monitor [his/her] mental health status and progress.” The VA was not subject to guardianship. The SW provided the following information: · On or around May 15, 2024, the VA called the SW and stated that s/he had not received one of his/her medications, Geodon (a medication used to treat various mental health symptoms), for four to five days. The SW was aware that the VA had a history of refusing to take some medications. · The following day, the SW talked to the VA again and the VA was “out of sorts.” As a result, the SW called P3 because the SW believed that the VA needed to be hospitalized. P3 told the SW that although law enforcement was called because the VA’s mental health “appeared to be going downhill,” the VA refused to go to a hospital. · On May 21, 2024, P3 left a message with the SW that the “community response team” came to the facility and took the VA to the hospital for evaluation. MP1, who was involved in the VA’s treatment at the hospital, stated that staff persons did not bring the VA for medical appointments, did not offer medications to the VA, and that the VA’s medication list was inconsistent. MP1 did not provide further information or details. MP2, who also was involved in the VA’s treatment at the hospital, stated that when s/he talked to the VA on an unspecified date, the VA stated that s/he had not received the “correct medications” for three months and an unspecified staff person stated that there were times that the VA refused to take the medications when they were offered to the VA. MP2 did not provide further information or details. Law enforcement was called to the facility due to the VA’s mental health and those records provided the following information: · On May 16, 2024, law enforcement was called to the facility. The VA “was able to answer questions even though [his/her] answers were not necessarily appropriate and [s/he] had fanciful ideas and seemed confused.” Law enforcement took no further action and left the facility. · On May 21, 2024, law enforcement was again called to the facility. The VA was “able to answer questions coherently and started rambling about all sorts of different topics.” After that, a law enforcement officer talked to a staff person who stated that the VA was “not making any sense.” Also, the officer reviewed the VA’s medication chart and noted that although the VA was supposed to take four medications that morning, the VA had only taken one of the medications and there was no documentation to show that the VA received the other three medications. The VA was taken to the hospital for evaluation. The VA’s admission records to the hospital, dated May 21, 2024, stated that the VA “reportedly missed psychiatry appointments and it is presumed that [s/he] had not been taking [his/her] medications for some time.” The notes also documented that the “records of medication administration were disorganized and irreconcilable,” and that the VA said, “I need name brands (medications).” The facility’s VA/MOMA Report Form provided the following information: · The VA had a “known history of noncompliance with taking medications.” · When the facility reviewed the VA’s medication administration records (MAR), “The client was offered medications daily as prescribed but was either refusing to take them because [s/he] did not like them or [s/he] did not want the side effects and if [s/he] did take them for some staff, [s/he] was observed to then throw them up,” and that this was “reported” to the VA’s interdisciplinary team. · The facility reviewed email communication from P3, who was, on a “weekly” basis, communicating that the VA was “consistently refusing” to take medications beginning around March 2024. · The review also showed that P3 regularly communicated with the VA’s team that the VA was refusing to attend some appointments even though they were offered to the VA. The VA’s MAR showed that the VA was prescribed 50 milligrams (mg) of Geodon twice daily. In April 2024, there were four instances and in May 2024, there were six instances in which the administration of Geodon was not documented as given to the VA and there were no notes to indicate that the VA received or did not receive Geodon those days. The VA was prescribed olanzapine (used to treat mental health symptoms) which was to be administered once daily. In April 2024, the VA refused olanzapine 22 times and in in May 2024 the VA refused olanzapine 18 times. The VA was prescribed lurasidone (used to treat mental health symptoms) which was to be administered once daily. In April 2024, the VA refused lurasidone 20 times and in May 2024, the VA refused lurasidone 18 times. Review of documentation from the facility showed that P3 sent emails related to the VA’s medication compliance and refusals to the VA’s interdisciplinary team on March 15, 21, and 22, April 15, 16, and 25, and May 15, 2024. P1 provided the following information: · P1 did not remember the specific date but stated that the VA began to refuse some of his/her medications in March 2024. When that happened, P1 contacted the VA’s doctor, who made some medication changes. After those medication changes occurred, the VA seemed to do a little better with taking the medications and the VA appeared to be “normal.”
· At some point in April 2024, the VA began to refuse some of his/her medications again and when that happened, staff persons were encouraged to reapproach the VA at a later point to offer the medications again. Some of those times the VA complied, and some the VA did not. P1 noticed that the VA was sometimes in a “manic state” and “constantly on the move.” P1 noted that there were days in April 2024 that the VA appeared to be “social” and compliant with taking medications. · There were times the VA attended appointments, times the VA refused to attend the appointments, and times that the clinic the VA was supposed to go to cancelled appointments for various reasons. · Between the time when law enforcement was first called (May 16, 2024) and when law enforcement took the VA to the hospital (May 21, 2024), the VA had good days in which s/he participated like normal and then there were days that the VA did not participate in programming. · P1 acknowledged that there were times that medication refusals were not documented and when that happened, P1 called the staff person that worked the shift when the medication was not documented to confirm whether the VA took the medication or if s/he refused it. When medications were refused, staff persons were told to document a refusal on the MAR. In addition, P1 provided additional training to staff persons. P1 was not aware of a time that the VA received incorrect dosing of his/her medications or of a time that staff persons did not offer the medications to the VA. P2 and P3 provided information that was mostly like the information provided by P1. P2 said that although the VA refused medications in May 2024, the VA was generally receptive to taking the Geodon. P2 said that when the VA refused medications, s/he told P1. P2 also stated that s/he worked with the VA in the days leading up to the VA’s hospitalization and that there were times the VA seemed to be doing okay and would go on walks with P2, but times that the VA refused. The FM stated that the VA previously had a history of taking some or all his/her medications and when that happened “years ago,” the VA was hospitalized. In the three to four weeks before the VA’s May 2024 hospitalization, the FM talked to the VA frequently and noted that although the VA seemed to be “okay,” the VA was “slipping” and would “say things a little bit outlandish.” The VA had a history of wanting to take only name brand medications and refused generic medication provided by the pharmacy. The NP that treated the VA in the hospital stated that if a patient stopped taking medications that could mental health symptoms, but the timeline varied. The NP stated that even if a patient took medications as prescribed, hospitalization was possible because medication dosages could “no longer” be an “effective dose.” The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment Act and on the VA’s care plans prior to May 21, 2024. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.05, subdivision 2, stated that the license holder was to document administration of medications or the reason for not administering the medication. Conclusion: Information from the investigation showed that in April 2024, the VA began refusing some of his/her medications prescribed for mental health symptoms and the VA’s mental health began to decline. The VA had a history of refusing medications sometimes because they were generic and had a history of refusing to attend medical appointments. In April 2024, the VA refused olanzapine 22 times and refused lurasidone 20 times. In May 2024, the VA refused olanzapine 18 times and refused lurasidone 18 times. In April 2024, there were four instances and in May 2024, there were six instances in which the administration of Geodon was not documented as given to the VA and there were no notes to indicate that the VA received, did not receive, or refused Geodon those days which was a violation of Minnesota Statute 245D.05, subdivision 2. On May 16, 2024, law enforcement was called to the facility because of the VA’s symptoms but no action was taken until law enforcement was again called to the facility on May 21, 2024, when the VA’s mental health continued to decline, which resulted in the VA being hospitalized. Although the VA’s refusal to take some of his/her medications likely contributed to the VA’s decline, the NP stated that a timeline could not be established as to when a patient would decline if they did not take medications as prescribed. P1 acknowledged that there were times that medication refusals were not documented and when that happened, P1 called the staff person that worked the shift when the medication was not documented to confirm whether the VA was administered the medication or s/he refused it. When medications were refused, staff persons were told to document a refusal on the MAR. In addition, P1 provided additional training to staff persons. P1 was not aware of a time that the VA received incorrect dosing of his/her medications or of a time that staff persons did not offer the medications to the VA. Although there were concerns that the VA missed medications and appointments, and that there were some days where administration or refusal of Goedon was not documented, given that the VA had a history of refusing medications sometimes because a medication was not name brand, and refusing to go to appointments, that the facility communicated the VA’s decline in mental health to the VA’s team regularly, and that the facility took action by calling law enforcement when it was determined assistance was needed, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. 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’s VA/MOMA Report Form showed that policies and procedures were adequate, followed, and that no additional training was needed. The plan further stated that an “agreement with the team of what would be a reasonable and doable timeline of notification of client’s medication refusal should [s/he] stabilize and return to the home.” Action Taken by Department of Human Services, Office of Inspector General: On October 2, 2024, the facility was issued a correction order for the violations outlined in this report.
|
