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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: 1071461-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns Suspected Maltreatment Reported: Allegation One: It was reported that a staff person (SP) put food in a vulnerable adult’s (VA) mouth and then put his/her hand over the VA’s mouth. Allegation Two: It was reported that multiple staff persons were not giving the VA his/her prescribed two doses of 10 milligram (mg) Saphris daily, and instead were administering it on an as-needed (PRN) basis. Date of Incident(s): Allegation One: April 15, 2024; Allegation Two: Multiple dates from January to April 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 (2); 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: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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 30, 2024; from documentation at the facility and medical records; and through nine interviews conducted with three facility supervisors (P1, P2, and P6), three facility staff persons (P3, P4, and P5), the VA’s guardian (G), a client (C), and the SP. Although this investigator met with the VA, s/he was unable to provide any information for this investigation. The VA’s support plans stated that the VA was diagnosed with cerebral palsy, depression, and a developmental disability. The VA was mostly non-verbal, using some signs or single words to communicate. The VA enjoyed listening to audiobooks, especially the Harry Potter series, being outside, and going to movies and concerts. The VA used a wheelchair to ambulate. The VA’s plans stated that his/her food should be cut into one inch by one-inch pieces. The facility was a single-story residence with a basement and the VA lived there with three other clients. The C’s bedroom was in the basement, and the VA and two other facility clients had bedrooms on the first floor along with a kitchen, a living room, a dining room, and a bathroom. There were no cameras in the facility. All staff persons interviewed for this report were trained in the VA’s plans and the reporting of Maltreatment of Vulnerable Adults Act. Allegation One: It was reported that the SP put food in the VA’s mouth and then put his/her hand over the VA’s mouth. P3 provided the following information: · On April 15, 2024, the VA was eating dinner and the SP put a piece of food in the VA’s mouth and the SP put his/her hand over the VA’s mouth, approximately one inch from making contact with the VA’s lips as the VA was trying to spit the food out. The VA was “not happy.” The VA threw the plate on the floor and one bite of food was left. The SP kept telling the VA in a “monotone” voice, “You’re going to eat it,” and “I’m not going to let you spit this out.” After the SP “hovered” his/her hand over the VA’s mouth, the SP took the tray off the VA’s wheelchair and the VA went to his/her bedroom. The VA generally liked to go to his/her bedroom after eating dinner. The VA did not choke and P3 did not say anything to the SP. · P3 could not recall what the VA was eating for dinner that night, but thought it was maybe some sort of meat dish. The SP was not yelling and was speaking at maybe a volume of three out of ten with ten being the loudest. P3 had not seen the SP do this before. The VA was “predisposed” to choking and staff persons were to cut his/her food into “bite sized” pieces as the VA could choke more easily than others. · The C was sitting at the table that evening at dinner, but P3 did not think that the C saw anything due to the seating position of the SP, the VA, and the C. The VA was agitated before and after dinner. The next day, P3 told a supervisor what s/he saw. · P3 thought that the SP treated the VA differently than the other clients and was more easily “irritated” with the VA. The SP would repeatedly say, “No,” to the VA when s/he would ask to listen to music. The SP would often only give the VA soda after making sure s/he drank some water first. P1 provided the following information: · P3 approached P1 the day after the incident and said that the previous day, the VA was eating supper and was done eating. The VA was “shaking” his/her head saying “finished.” The SP “insisted” the VA needed to take another bite. The VA threw the plate of food on the floor and the SP took the remaining food from the tray and put it in the VA’s mouth, covering his/her mouth with his/her “entire palm.” The SP’s hand touched the skin of the VA’s face. The SP said that s/he wasn’t going to “allow” the VA to spit it out and that the VA needed to chew and swallow the food. The VA continued to “shake” his/her head, but eventually swallowed the food. The VA did not choke but had a “tendency” to choke. · P1 heard of another time when a different client was having a “behavior” and was “spitting” on staff persons. The SP “covered” the client’s mouth to “block” his/her face, and said, “Please do not spit on me,” but the SP’s hand did not make contact with that client’s skin at that time. · The C told P1 that s/he did not see anything. P6 provided the following information: · P2 told P6 that P3 stated that on April 15, 2024, around 5 to 5:30 p.m., the VA had been “upset and moody.” When the VA came to the dinner table, s/he threw his/her food on the ground and P3 went to go clean. While s/he was grabbing the broom, P3 saw the SP with “hands over [the VA’s] mouth” stating, “You’re going to finish this,” and, “You’re not going to spit it out.” P3 then “froze” and did not know what to do in the moment. After that, the VA was assisted to his/her bedroom. The next day at around 8 p.m., P3 told P1, who then told P2, who then told P6 the following morning, April 17, 2024. · P6 talked with P1 and P1 shared the same information that P3 had stated; that the SP “forced” the VA to eat with the SP’s hand over the VA’s mouth. · When P6 talked to the SP, who had worked at the facility and with the VA for years, the SP stated that the VA was “in a mood” and threw food on the floor. The SP felt as though the VA should eat something, so s/he said s/he did not force the VA’s mouth open, but did take the food left on the table, put it into the VA’s mouth, and then put his/her hand over the VA’s mouth so food did not come out of the VA’s mouth. The SP stated that s/he did this for two bites. The SP stated that s/he knew s/he should not have done it and had not done this before. The SP stated that s/he did not raise his/her voice when speaking to the VA and did not swear at the VA. The SP said that s/he thought s/he was doing what was “best” for the VA. · P1 also told P6 that on previous occasions, the SP made “snide” comments to the VA such as, “If you don’t [want to] help yourself, I can’t help you,” and “If you want to live your life depressed, you go ahead and do that.” · The SP was “removed” that day from working at the facility. P1 said that the VA seemed “more jumpy” on April 17, 2024, but that was the only “mood change” following the incident. The VA had a history of throwing food when s/he was “moody,” and was also more vocal and would sometimes “hit” him/herself with his/her hands. The VA did not “harm” others. The C provided the following information: · The SP was “not very good” for the C and had “shoved food” down the VA’s throat a couple times. If the C saw that, s/he would “throw a fit” because s/he was “very protective” of the VA. · The SP said a lot of things that were “mean,” but s/he did not provide additional details. The C did not want to say anything to the SP when this happened. · Sometimes if the VA was coughing or choking on food, the C would tell the VA to “relax” and to “breathe.” P2 provided the following information: · The VA was “thin” but due to his/her cerebral palsy diagnoses, burned many calories throughout the day and as a result, ate a lot during the day. P2 was not concerned about the VA not eating when s/he did not want to eat. · P2 heard that one day, after the VA spit out his/her food, the SP gave the VA two bites of food and covered the VA’s mouth until s/he swallowed it. P2 thought that the SP’s hand was covering the mouth and touching the VA’s skin. The VA was “mad” and was “thrashing” his/her head. The VA was done eating and did not want to eat anymore. Another staff person was present when it happened, but P2 could not recall the name of the staff person. · The VA did not choke and did not “have a tendency” to choke. The VA had “swallowing studies” done. According to P4, the VA sometimes would “shake” his/her head or spit out food and about a month prior to this interview, P4 heard one night that P3 was working, and the VA was doing that, and the SP covered the VA’s mouth to keep the food in and the VA had “no choice but to swallow it.” P4 did not think the VA “choked” that night. P4 had also heard the SP “raise [his/her] voice in an uncomfortable way.” One example was when the VA would repeat him/herself, asking for something over and over, and the SP would “cut off” the VA and say, “No. No. No,” so that s/he could not get his/her words out. P4 described the volume as a seven out of ten loudness and the SP had a “deep voice.” P5 provided the following information: · The SP would “get in [the VA’s] face,” and was not a “very nice person” to the C. Sometimes, the SP would bring another client to the table when s/he did not want to eat and had “forced” another individual to eat. The VA would say, “Finish,” and the SP would “scoop up” the food and “stuff it” in the VA’s mouth and say, “You’re going to finish [the] food on your plate.” P5 would tell the SP to stop and on numerous times told P2 about it. P1 was also aware of these incidents and let facility administration know and they responded that they would “talk” to the SP. P5 never observed the SP place his/her hand over the VA’s mouth, but the SP’s hand would be “a couple [of] inches” from the VA’s face. · The SP acted like his/her gender was “higher than” the opposite gender and would “act like we didn’t know what we were doing.” Sometimes the VA would ask for soda and the SP would say, “You’re not getting [soda]. You’re getting water.” The VA did not have a “[soda] limit,” and technically, staff persons could not refuse the VA a soda if s/he requested it. The SP would say that the VA needed water. · The VA drank two to three cans of Mountain Dew daily, which had “a lot” of caffeine and P5 felt that when caffeine or soda was withheld, the VA might get headaches. The SP provided the following information: · On April 15, 2024, the SP began his/her shift at 3 p.m. When the VA was not happy, s/he would be verbal, but it would be “impossible” to have a conversation with the VA. The VA was in a state of “instability” the day of the incident where s/he had “mood swings.” · The SP was in another room and heard the VA “yell” and then heard his/her plate of food hit the floor. Normally, food would be placed in front of the VA, and s/he would reach down and eat independently. When the SP entered the kitchen, there were about three bites of food on the VA’s wheelchair tray. The SP was unsure if the VA had eaten any of his/her food that was on the floor. The SP had learned from the G that if the VA had a behavior when eating at a restaurant, the SP could say, “That’s enough, young [wo/man],” and the VA would “retreat” from his/her behaviors most of the time and the situation would “dissolve.” In the same “spirit” of telling the VA, “That’s enough,” the SP said to the VA, “That’s enough, oh no you don’t, young [wo/man].” While saying this, the SP took a bite of food, one bite at a time, cupped his/her own hand, and held the food up to the VA’s mouth for the VA to eat, one bite at a time. The VA would open his/her mouth and took the first two bites. The VA spat out the third bite. · The SP described placing the food in the SP’s “cupped” hand and that touched the VA’s lower lip. The VA opened his/her mouth and took two bites. The third bite the VA resisted and spat it out. The SP’s hand was “over” the VA’s mouth because of the 45-degree angle that the VA’s head was at with an open mouth. However, the SP did not cover the VA’s mouth with the SP’s hand. The VA was freely able to spit out the food, which s/he did on the third bite. · The SP next cleaned the VA’s face and took him/her to his/her room, which was “normal procedure” if s/he was in that sort of “mood.” · Several years back, the SP had arrived to work a shift at the facility and the VA had six empty Mountain Dew cans next to him/her. The VA was in a “violent mood” that day and asked the supervisory staff person working that day, who no longer worked at the facility, what the VA had that day to drink. The supervisory staff person replied that the VA had six cans of soda. The SP shared that in his/her own experience, when a person was dehydrated from drinking soda, there could be pain in his/her genital region that was a ten out of ten on the pain scale. The supervisory staff person did not know when the last time the VA had consumed water and so the SP brought the VA a glass of water and within 30 minutes, the VA drank two full glasses of water and shortly thereafter, stopped “screaming.” The SP said s/he “restricted” the VA from having soda, but after the VA drank water each day, the SP would give the VA soda. It was the SP’s and staff persons’ position to take care of the VA and do what was best for the VA. The VA did not have the “ability to decide what is good” for him/herself. After several days of the SP giving the VA water more regularly, the VA’s bowel movements were more regular. The previous supervisory staff person and P1 were okay with how the SP handled the soda and water situation.
· The SP stated that s/he thought s/he was being retaliated against and the information regarding April 15,2024, was being embellished. The G provided the following information: · A few weeks prior to this interview, the G was told about an incident involving food, the VA, and the SP. It occurred in April 2024, on a Monday. The G was told that the SP put his/her hand over the VA’s mouth so that the VA would swallow the food. The G was “upset” because the VA could have “choked.” The G thought that if the VA threw his/her food or spit his/her food out, s/he either did not like the food or was “done” eating. · The VA had a “predisposition” to choking if s/he did not chew his/her food but could eat independently. The VA had not required hospitalization for choking at any time. · The VA did not talk much and would not carry on a conversation. Facility documentation from shift notes on April 15, 2024, written by the SP stated the following: [The VA] got up for med[ication]s. [The VA] was very impatient demanding many different things. [The VA] was given [his/her] food and tried hitting [him/herself] and immediately after hitting [him/herself] threw [his/her] food on the floor. [The VA] was hand fed the small amount of food on [his/her] table and then [the VA] laid down. After receiving [his/her] PRN [as needed medication], [the VA] cried, yelled, screamed for 20 minutes. [The VA] calmed down. [The G] called. [The VA] said a few words with [the G]. [The VA] laid peacefully the rest of the evening. Conclusion for Allegation One: It was alleged that the SP put his/her hand over the VA’s mouth while eating, that the SP raised his/her voice at the VA, and that the SP did not allow the VA to have soda. Although P1, P2, P4, P5, and P6 understood that the SP put his/her hand over the VA’s mouth while feeding the VA, they did not witness it. P5 had witnessed the SP on other occasions “scoop up” food and put it in the VA’s mouth, saying, “You’re going to finish [the] food on your plate.” P3, who witnessed the incident on April 15, 2024, and the SP both stated that the SP did not place his/her hand on the VA’s mouth, nor did s/he cover the VA’s mouth. The VA took and swallowed two bites and spit out the third bite, with the food landing on his/her tray. The VA did not choke. There was conflicting information regarding the SP’s tone of voice. P1 thought the SP made “snide” comments to the VA, P3 stated the SP did not yell, P4 stated the VA had a loud “deep” voice, P5 stated the SP would “get in” the VA’s face and was not a “very nice person,” and the C stated the SP said “mean” things but did not provide details. The SP would often only give the VA soda after making sure s/he drank some water first. Sometimes the VA would ask for soda and the SP would say, “You’re not getting [soda]. You’re getting water.” According to the SP, s/he “restricted” the VA from having soda, because the SP felt that the VA needed to also drink more than Mountain Dew, but after the VA drank water each day, the SP would give the VA soda. The SP stated that it was the SP’s and staff persons’ position to take care of the VA and do what was best for the VA. The VA likely indicated s/he was finished eating and the SP put three more bites in the VA's mouth and the SP allegedly used a loud tone of voice, both of which were behavior that was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. However, given that P3 and the SP each stated that the SP's hand did not touch the VA's mouth but hovered over it, that the VA was able to spit the food out, that the SP was attempting to ensure the VA ate food which the VA ate the first two bites and spat out the third, and that there was conflicting information regarding the SP’s tone of voice and no further details regarding specific incidents, there was not a preponderance of the evidence whether the SP’s conduct would reasonable cause the VA emotional distress or whether there was a failure to provide the VA with reasonable and necessary care and services. It was not determined whether emotional 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: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening; 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). Allegation Two: It was reported that multiple staff persons were not giving the VA his/her prescribed two doses of 10 mg Saphris daily, and instead were administering it on an as-needed (PRN) basis. On May 9, 2024, during the facility’s internal investigation for Allegation One, it was discovered that the VA’s order for Saphris was not being administered as written. Prior to January 9, 2024, the VA’s Saphris order was two 10 mg tablets twice daily PRN for agitation and anxiety. A Psychiatric Referral Form dated January 9, 2024, showed the VA was prescribed Saphris 10 mg tablets twice per day for anxiety or agitation changing from a PRN to twice daily scheduled. The VA’s medical record dated January 9, 2024, stated that staff persons told the provider that with the facility’s new medication documentation system, it was “easier” if the VA’s Saphris order was written as scheduled and then Saphris administration could be held when the VA did not need it rather than documenting as a PRN. The provider was told that the VA did not need Saphris often. “We decided not to change [the VA’s] drug regimen.” In the “current medication” list, Saphris was listed as 10 mg tablet twice daily PRN for anxiety or agitation. The “plan” section stated, “Renew: Saphris 10 mg sublingual tablet,” one under the tongue twice daily. The VA’s Saphris Protocol (the document did not have a date), stated that staff persons could administer the VA’s PRN Saphris 10mg if s/he met the following criteria for anxiety or agitation: · The VA had been moaning or screaming for a period of 5 minutes or longer. · The VA was causing self- harm such as biting him/herself or hitting him/herself repeatedly. · All of the VA’s reasonable requests had been met. Staff persons were to try to give the VA choices of activities and make him/her use words to choose. Staff persons were not to “just give” the VA things because s/her was upset. · Staff persons were to “hold” Saphris administration if the VA was having a “good day.” Staff persons were to chart in Extended Care Professional (ECP,) and document “hold” if Saphris was not given. The “reason” for the “hold” was “hold per” the VA’s health care provider. Saphris could only be given every six hours, and only twice daily maximum. The facility’s Internal Review provided the following information: · P2 stated that s/he attended the January 9, 2024, appointment and told the VA’s provider that staff persons were “struggling” with their electronic documentation system with Saphris as a PRN. P2 discussed with the provider that it would be easier to order the VA to have Saphris scheduled twice per day with the ability to hold Saphris when the VA did not need it. The provider agreed and stated that s/he did not want the VA to receive Saphris if it was not needed. After the appointment, P2 informed staff persons and said if the VA was having a “good” day, Saphris could be held, not administered to the VA. · Stated that “ultimately” the goal was to not “overmedicate” the VA with Saphris. The Saphris order form January 9, 2024, was not written like s/he originally thought it was. The purpose was for the VA to have Saphris when s/he needed it with the option to hold the second dose if it was not necessary. · In January 2024, starting on January 10, 2024, the VA received 21 doses of Saphris. In February 2024, the VA received 29 doses of Saphris. In March 2024, the VA received 17 doses of Saphris, and in April 2024, the VA received 20 doses of Saphris. · A review of “shift notes” from January to May 2024, showed that several staff persons documented that they administered a “PRN” to the VA. A PRN Psychotropic Administration Protocol and Documentation form dated May 23, 2024, showed that the VA was prescribed Saphris 10 mg as a PRN with a maximum dose of 20 mg per day. Facility documentation and interviews with staff persons showed the following: · Prior to January 9, 2024, the VA was prescribed Saphris 10 mg PRN up to two times daily when s/he was “aggravated” to “calm” the VA and prevent the VA from causing self-harm. Staff persons documented when they administered Saphris to the VA. · On January 9, 2024, the VA had a virtual medical appointment that P2 attended. At that visit, the VA’s provider changed the way the prescription was written so that there would be enough medication each month for the VA to have up to two doses of Saphris daily, if needed. The way the prescription was written caused the MAR to be changed to the VA receiving Saphris twice daily scheduled at 7 a.m., and 3 p.m. However, instead of documenting only when the VA was given Saphris, staff persons were to also document “hold” on the MAR when the VA did not need Saphris at 7 a.m. or 3 p.m. It was discovered that staff persons sometimes forgot to document when Saphris was not given. The VA received Saphris when the protocol criteria for the VA’s behaviors was met. P1, P2, P3, P4, P5, and the SP provided the following consistent information with when, why, and how Saphris was to be given and documented: · Saphris was given for agitation and anxiety, “aggravation,” and for its “calm[ing]” effect when the VA was yelling and causing “self-harm” such as biting him/herself, sometimes drawing blood, or “repeating” words in an “agitated tone.” Sometimes, this included hitting and swinging at staff persons and other clients. On “good days” the VA would not need to be given Saphris. On days when the VA “could not cope,” s/he would be administered Saphris. When P2 and the VA’s provider spoke, they did not want the VA to be medicated twice daily with Saphris if it was not needed and if the VA was having a “good day.” · The VA’s provider did not intend for the VA to always be given Saphris at 7 a.m. and 3 p.m. each day but while discussing how the ECP documentation worked, the provider and P2 decided to change the Saphris order from PRN in the system to scheduled two times daily with the “hold” option if the VA did not need Saphris. The VA’s provider did not want the medication given twice per day on a regular basis. It would have been “way too much” for the VA. When the VA got “too much” Saphris, s/he would not eat anything, would be lethargic or sleepy, “out of it,” and would be difficult to transfer. · P1 and P2 communicated to staff persons how to document Saphris administration as “hold” if the VA did not need it. However, it was “easy” for staff persons to miss marking the Saphris as “HOLD” when Saphris was not given. When Saphris was not marked in the ECP, that meant it was not given. Staff persons would forget to use the “hold” dropdown and instead left the box blank. · The VA was not given Saphris when s/he did not need it. The VA not receiving Saphris two times a day did not cause the VA adverse side effects. · On May 23, 2024, the VA’s Saphris order was changed back to being documented under the “PRN” section of the VA’s medication tab in the ECP rather than in the daily medications. On May 24, 2024, the Saphris Protocol was updated to reflect this change. The G provided the following information: · The VA would bite him/herself on the hand and arm to the point of “drawing blood.” When this behavior would begin, staff persons gave the VA a PRN which helped “calm” him/her, made him/her “sleepy,” and stopped the biting. · The SP would sometimes not give the PRN to the VA, saying, “Oh, [the VA] will come out of it.” The G told P2 that this was happening. The G wanted facility staff persons to give the PRN to the VA when s/he needed it. If the VA was biting, screaming, or self-harming, s/he would be given Saphris. P2, P3, P5 and the SP provided the following information regarding the SP administering Saphris to the VA: · P2 stated that the SP told P2 that s/he felt that s/he could work through things with the VA without giving him/her Saphris. The SP thought that s/he was helping the VA, but P2 told the SP that s/he needed to give the VA Saphris if s/he needed it. · P3 stated that the VA was given Saphris when s/he needed it otherwise his/her “aggression” would carry over to other shifts. The SP did not always give the VA Saphris when the VA needed it because the SP felt Saphris “altered [the VA’s] personality.” The SP never “prevented” P3 from giving the VA the medication. · P5 stated that s/he felt like the SP wanted the VA to “suffer through” the “outrages.” Some days, one dose of Saphris would “wipe out” the VA, and other times it would just “calm” the VA. It was for everyone’s “safety” that the VA was given Saphris when s/he started to get upset. Staff persons, including P5 talked to P2 about these concerns. · The SP stated that the VA was not negatively affected when s/he did not receive Saphris twice per day, every day. The VA was given Saphris when needed with exception to sometimes the SP would allow the VA to “work through” it and the G would call the VA and the facility and tell the SP that the VA needed to be given Saphris because s/he could tell over the phone when the VA needed it. The SP felt like the VA should have been able to “work through” the agitation and aggression. · The SP stated that when the VA was given Saphris, s/he would lay in bed, “flat as a pancake,” and awake, “conscious for eight hours.” The SP thought that staff persons did not feel that giving Saphris to the VA on a daily basis was doing the best for the VA. Staff persons “fought” to keep the medication as a PRN. The VA had a good personality and was a good person to get to know and Saphris would take that away. · The SP stated that s/he had no personal beliefs against administering Saphris and had been “scolded” by P2 for not giving it to the VA. The SP would talk and communicate with the VA, trying to figure out what the VA’s “core issue” was that was “aggravating” him/her. The SP would try to work through the situations and figure out was wrong. The SP did not have “any kind of conviction” toward not giving Saphris to the VA. Relevant Rules and/or Statutes Minnesota Statutes, section 245D.05, subdivision 2, paragraphs (b) and (c) stated in part that if responsibility for medication administration is assigned to the license holder in the support plan or support plan addendum, the license holder must implement medication administration procedures to ensure a person takes medications and treatment as prescribed. The license holder must ensure information is documented in the person’s medication administration record that is needed to safely and correctly administer the medication including if a dose of medication is not administered as prescribed. Conclusion for Allegation Two: Information showed that the VA was prescribed Saphris for agitation and anxiety. Prior to January 9, 2024, the VA’s order was Saphris 10 mg twice daily PRN. On January 9, 2024, P2 attended a virtual appointment with the VA and discussed changing the VA’s Saphris order to regularly scheduled with the option for staff persons to “hold” Saphris and not give it to the VA if the VA did not need it. The provider agreed so s/he wrote the order for Saphris 10 mg twice daily and did not intend for the VA to receive two doses daily unless it was needed. This information was communicated to staff persons and the VA’s documentation was updated to show that Saphris was ordered twice daily, at 7 a.m. and 3 p.m. Staff persons were to document when Saphris was not given to the VA rather than how staff persons previously documented only when Saphris was given. In May 2024, it was discovered that staff persons continued to give the VA Saphris as a PRN according to the VA’s Saphris Protocol when the VA needed it. However, staff persons were not documenting when Saphris was held/not administered and were not administering Saphris twice daily at 7 a.m. and 3 p.m., both of which were a violation of Minnesota Statutes, section 245D.05, subdivision 2, paragraphs (b) and (c). There was no information that the VA had adverse effects from not receiving Saphris two times each day or that the VA did not receive Saphris when s/he needed it. Information was consistent that staff persons knew the Saphris Protocol and gave the VA Saphris as specified in the protocol. The G stated that the SP might not give the VA Saphris when s/he needed it. The SP stated that s/he wanted to help the VA and sometimes waited to administer Saphris because it altered the VA’s personality. There was no information that the SP did not give the VA Saphris when the VA needed it. Although the VA’s provider’s January 9, 2024, order for Saphris was not administered as written, given that the Saphris Protocol showed staff persons were to give the VA Saphris when s/he needed it, that the provider and P2 discussed this change for ease of the facility’s documentation program but that the VA did not need always Saphris twice daily, and that staff persons had the option to hold Saphris if the VA did not need it, that there was no information that the VA was harmed by not receiving Saphris twice daily, and that there was no information that the SP or any other staff person did not give the VA Saphris when s/he needed it, 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 completed two internal reviews, one for each allegation. Regarding Allegation One, the facility determined that policies and procedures were adequate, but that policies and the VA’s support plan were not followed. Staff persons were retrained, and the SP no longer worked at the facility. Regarding Allegation Two, the facility determined that policies and procedures were adequate but not followed. The facility’s corrective action was for the VA’s Saphris orders to be clarified with the provider and orders were to be outlined correctly in ECP. Staff persons were to be retrained on documenting correctly in ECP and supervisors were to be retrained on the scheduling of medications in the ECP system. Action Taken by Department of Human Services, Office of Inspector General: On December 30, 2024, the facility was issued a Correction Order for the violation outlined in this report.
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