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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: 1071621-H_CRS (Home and Community-Based Services-Community Residential Setting) 1071617-HCBS (Home and Community-Based Services) Investigator(s): Thomas Nixon 651-431-2155 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was brought to the emergency room for an infected open baclofen pump site that was not properly monitored and cared for by a staff person (SP). Date of Incident(s): April 27 to June 26, 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 August 8, 2023; from documentation at the facility and medical records; and through nine interviews conducted with the VA, the VA’s guardian (G), a nurse (N), the facility health care professional (HCP), two supervisory staff persons (P1 and P2), and three staff persons (the SP, P3, and P4). The VA’s diagnoses included cerebral palsy with spastic quadriplegia, a traumatic brain injury, and scoliosis. The VA enjoyed watching anime and movies, playing video games, and using his/her tablet. The VA used limited verbal communication, was very soft spoken, and needed encouragement to finish statements. The VA used some American Sign Language and his/her tablet to type out short responses for others. The VA requested staff persons assistance with toileting and cleaning up after any accidents. The VA was assisted by staff persons for his/her medical needs including medication administration, diabetes and health monitoring, special diet preparation, and scheduling, attending, and following up on any medical appointments. The VA had an intrathecal baclofen pump to treat his/her spasticity and tetraplegia. According to the website WebMD, a baclofen pump is a metal disc-shaped device, about one inch thick and three inches around, surgically placed under the skin of the stomach near the waistline. The device releases medication into the spinal cord to treat muscle stiffness and spasms. Pumps are typically refilled every one to three months and surgically replaced every five to seven years based on the device battery life. Facility documentation and medical records showed that on April 26, 2023, the VA’s baclofen pump was surgically replaced. On June 23, 2023, the VA was seen for a medical appointment due to a decline in his/her health. The VA was diagnosed with a severe infection at the surgical site, and a health care professional documented, “It is obvious that the intrathecal baclofen pump reservoir pocket is infected severely. . . Given the degree of infection/physical appearance of the wound, it is my opinion that the infection has been going on for several weeks at least.” The VA was taken to the emergency room at the advice of the clinic. The VA was hospitalized, the pump was surgically removed, the VA received antibiotics, and the VA was put in a medically induced coma. The facility used a Seven Day Watch form to track “early signs of a change in medical condition/status so action can be taken sooner.” The reasons to start a Seven Day Watch included discharge from the hospital, discharge from urgent care or emergency room with a diagnosed condition and orders, noticing a physical change, and “when an individual is seen by a medical professional, resulting in ‘nothing wrong’ or no diagnosis, but staff observe a clear difference in the individual.” The form was used to document “vitals, observations, and actions taken as you provide care” and was to be “customized for each individual.” Documentation was to be done every four hours while the person was awake, the “manager and nurse (if applicable to the service site) must be updated daily,” and a health progress note was to be written to document any change in the person’s usual condition. The Seven Day Watch forms for the VA were requested for this investigation and the facility was not able to produce any. The G provided the following information during his/her interview: · The VA “might not always let [staff persons] do what needs to be done,” and often refused medical treatments and supports recommended by health care professionals. · When the G asked the VA how s/he was, the VA was “dismissive” of the question. If the VA was in pain s/he was able to tell a staff person what hurt. However, sometimes when asked if s/he was in pain, the VA pointed to the person that asked the question. · The facility did not pay attention to” medical things.” Staff persons did not “catch [concerns] as quick as they should,” and were “not trained to know what look for.” The G was concerned that when staff persons bathed and dressed the VA, they failed to address sores or other things that “did not look right” and “needed to be checked out.” Though the VA often declined a shower from staff persons, s/he completed a shower two times a week. The following is a summary of information obtained from P1, P2, P3, P4, the HCP, facility Progress Notes, text messages, emails, and the VA’s medical records: · The SP was responsible to schedule the VA’s appointments, to enter information and documents into the facility’s electronic recordkeeping system, and to follow up with the HCP and P2 on any health issues. · Incident reports were to be completed by P2 within a certain number of days based on the “level” of the report. If the incident report was not done by the due date, P1 completed it. For medical incidents, the HCP was to receive a copy of the incident report. · If the VA stayed in bed, it was an indication something was “off” with the VA and s/he might not feel well. Staff persons were to check and document the VA’s vitals and inform P2 and the HCP of the VA’s status. The HCP might order a Seven Day Watch to be started. · On April 26, 2023, the VA had baclofen pump replacement surgery. On April 27, 2023, the VA was discharged from a hospital to the care of the facility. The VA’s medical records stated the VA was to continue to use a “belly band” over the surgery site; do no bending, lifting, or twisting; start pain medications; and attend follow up appointments; with no instructions specific to monitoring the VA’s surgical site. There were no reported complications at this time. The HCP said the VA’s post-surgery recommendations were not sent to him/her by the SP. However, email showed the SP sent the discharge paperwork to the HCP and P2 on April 29, 2023. A Seven Day Watch form was supposed to be started, but the HCP was not able to locate it when s/he went to the facility. · On an unknown date, the HCP visited the VA at the facility. The HCP said the VA “seemed fine from what I know . . . I don’t work directly in the house,” the VA appeared to be “back to [his/her] baseline,” and the VA’s recovery was “smooth from what I knew.” · On May 10, 2023, the VA attended a follow up appointment and ten staples were removed from the surgery site. The clinic documented there were no concerns with the findings and no change in orders or recommendations. The HCP said another Seven Day Watch form should have been started on that date, but the HCP did not see one when s/he was at the facility. The SP was to inform the HCP and P2 of any changes in the VA’s condition. However, the HCP said there was “not much communication” from the SP about the VA’s surgical site after the May 10, 2023, appointment. · The VA’s progress notes dated May 11 to June 2, 2023, did not document any health concerns for the VA. · On June 3, 2023, the progress notes for the VA stated at an unspecified time between 7 a.m. to 1 p.m., the VA “didnt [sic] feel good last night some time [s/he] threw up so had some pop and tried a few soda crackers but threw that up also did not have any lunch.” · On June 4, 2023, the progress notes for the VA stated at 10:11 a.m., “[The VA] woke up having an accident and [his/her] lower back and left front of leg has a reddness [sic] to it. Staff washed and dryed [sic] area and [the VA] reused to go see the doctor in regards to this.” · On June 5 to June 6, 2023, the progress notes for the VA stated, “[The VA] has woken to having urine accidents on the overnight. [The VA] has been freshened up and staff applied hydroctrozone [sic] cream to the area. [The VA] is refusing to be seen by [his/her] primary doctor when asked if [s/he] is in pain [s/he] delines [sic]. Staff is observing as they can.” · P2 said that on an unknown date, P2 got a call from the SP that the VA did not feel well and refused to be seen by a doctor. P2 told the SP to “give [the VA] time” and have P3 attempt to get the VA to be seen. If the VA refused to be seen an incident report was to be done. Communication about the incident report was to be done by phone or email, not text. · On June 7, 2023, the progress notes for the VA stated that between 7 a.m. and 10:18 a.m., “[The VA] was repositioned and staff observed [his/her] redness from having an [sic] urine accident on the overnight. [The VA] was freshened up and declined to have any topical creams put onto it. [The VA] continues to refuse to be seen by [his/her] doctor when asked if it hurts [s/he] says no. Staff are encouraging [him/her] to drink fluids and to report any discomfort.” · P3 said the VA usually was a “big eater,” but on an unspecified date, the VA did not eat his/her normal amount, returned his/her bowl half full, and said s/he was not hungry. The VA usually did not wear absorbent undergarments and was able to inform staff persons s/he needed to use the toilet. The VA appeared “tired” and there was an “increase in accidents” of urine and bowel. P3 said s/he “and most of the staff” told the SP about the VA’s changes. P3 was to document this in the VA’s progress notes, but did not this time. P3 said, “At the time I wasn’t charting because I was working a lot, so I wouldn’t get it all done. I’d be like I’ll do it tomorrow when I go in and then I would forget.” P3 did not see nor was s/he aware of the VA’s vomiting at this time. · On June 8, 2023, the VA was seen at an urgent care walk-in clinic for vomiting and weakness. The VA’s baclofen pump surgical site was not evaluated. The After Visit Summary stated the VA was diagnosed with weakness, dehydration, and hypokalemia. (Note: According to the Mayo Clinic, hypokalemia refers to a lower-than-normal potassium level in your bloodstream. Potassium is critical to the proper functioning of nerve and muscles cells, particularly heart muscle cells.) The VA was prescribed twice daily potassium tablets for four days. The VA’s white blood cell count was slightly elevated. The physician documented that this “could be from infection or inflammation. I am unsure where the source may be if it is infection... [The VA] was coughing today and I recommended getting a chest x-ray to evaluate for pneumonia, however, [s/he] declined. Let me know if [s/he] agrees to this at least and we can make sure it’s not pneumonia contributing to [his/her] elevated WBC [white blood cell] and cough. If anything is worsening, please bring [The VA] back for evaluation.” · P2 said there were “a lot” of emails and calls between P2 and the SP when the VA “got sick and ended up in urgent care when [s/he] was refusing to go in” for the vomiting. P2 said the SP called him/her about the VA’s condition and “right away took [the VA] into urgent care.” P2 was not sure if the HCP was informed of the urgent care visit. P2 said P1 “was doing the incident reports” during this time. · On June 12, 2023, the VA was seen at a wound clinic for a sore on his/her heel and lethargy. There was no reference to the VA’s surgical site on the facility referral paperwork, nor in the VA’s medical record for this appointment. The VA’s progress notes for that day stated, “[The VA] was made [sic] a doctor appiontment [sic] as [s/he] still is not feeling good. [The VA] does not have a fever and going to Centra Care Redwood Clinic to see the doctor, it was found that [s/he] has a small cut on [his/her] toe and some skin breakdwon [sic] on [his/her] heel. [The VA] is to have the banadages [sic] changed daily. [The VA] refused to have an X-Ray while at the clinic.” · Between June 12 and 15, 2023, there were text messages between the SP and P2 which discussed the SP’s concerns for the VA’s health; the possibility of him/her needing to be seen at an urgent care; the results of the June 12, 2023, wound care clinic appointment; and the VA’s improved state afterwards. · For “a week or two” on unspecified dates, when P3 worked with the VA, s/he changed the surgical site bandage at least three times: in the morning, afternoon, and before bed. If the VA showered that day, s/he changed the bandage four times. P3 changed it “every three hours” when the VA’s bandage was “leaking pretty bad.” Sometimes the VA did not allow certain staff persons to change the bandage. · There was no documentation in the VA’s progress notes and/or Medication Administration Record by any staff person that the VA’s surgical site bandage was changed, nor that the VA refused to allow the bandage to be changed. · On June 19, 2023, a “couple weeks after [the VA] had gotten the staples out for the pump,” P3 and P4 worked an evening shift at the facility. P3 and P4 put the VA into his/her bed and saw blood on the VA’s bed pad that P4 said was smaller than a dime. P3 and P4 rolled the VA over onto his/her side to see where the blood was coming from. P4 saw an “open sore” at “probably the bottom corner of the [VA’s baclofen] pump.” P4 saw “a little bit of blood around the edges… [and] like a white spot or infection or something in the center.” P3 said the VA’s skin was “pulling apart” and “pulling further open.” P3 said it was “not a lot [of blood]” and was as if the spot “broke and [bled].” P3 asked the VA if s/he hurt, and the VA said, “No.” P3 and P4 called the SP about the VA’s condition. The SP said to “cover” the spot that night. The SP said s/he would look at the wound on June 20, 2023, and the VA had appointment scheduled at the wound care clinic for that day as well. P3 and P4 changed the VA bandage on the site. P3 said s/he told the overnight staff person who arrived about the situation and “forgot” to document in the VA’s file. · On June 20, 2023, the VA was seen at a wound clinic where s/he was diagnosed with surgical wound dehiscence (split open wound) with exposure of his/her baclofen pump, and an abdominal wall ulcer with exposed fat layer. The wounds were dressed with Aquacel AG dressing and Mepilex dressing. The orders stated for the VA’s right abdomen “clean with wound cleanser gauze, gently pack with aqua cell AG (sic), cover with adhesive foam bandage, change every two days,” and to follow up with the Mankato clinic about the wound dehiscence and pump exposure. The medical record noted that the VA and accompanying staff person were told that if [the VA] developed fever, increased redness, worsening drainage, or pain [s/he] should be seen “immediately.” · The VA’s progress notes dated June 21, 2023, did not document any health concerns for the VA. · On June 22, 2023, at 8:40 a.m., the SP contacted the Pain Management Center clinic as directed by the Wound Clinic. An appointment was scheduled for June 23, 2023, at 2:20 p.m. · On June 23, 2023, P3 returned to work after s/he was off for “a couple days” and when s/he returned s/he saw the VA “wasn’t acting like [him/herself].” P3 asked P4 how the VA was. P4 said the VA, “let me change [the bandage] out before [s/he] went to bed [on June 22, 2023].” · On June 23, 2023, at 2:20pm P3 took the VA to his/her Pain Management Center appointment. The VA’s surgical site was examined, and the dressing was “saturated with purulent and sanguineous drainage [blood and thick white pus].” When the dressing was removed, the pump was visible at the wound opening. The wound was “bleeding and had dead tissue” around it and appeared “infected severely”. P3 told the clinic s/he changed the bandage in the past when the wound was “barely starting to open,” but did not know when it was last been done or what the facility protocol for it changing it was. The clinic cleaned the wound and told P3 the VA needed to go to the emergency room. P3 called the SP to update him/her and that they were going to the emergency room. The SP met P3 and the VA at the emergency room and the VA was admitted to the hospital. · At the hospital, the VA’s baclofen pump was surgically removed and s/he was induced into a coma to prevent baclofen withdrawal symptoms. The VA was taken out of the coma, put on antibiotics, and used a feeding tube until a swallow study was completed. · The HCP said s/he did not know about the VA’s infection and surgery until P2 told him/her about it on June 26, 2023. The HCP called the SP, who said s/he “thought” the HCP was included on the group text messages with the G, P2, and the VA’s case manager with updates on the VA’s health. The HCP thought the SP said the VA’s initial appointment was on June 21, 2023, as staff persons had “noticed an issue;” that the SP was told the VA needed to be seen on June 23, 2023; and that at the June 23, 2023, appointment the SP was told the VA needed to go to the emergency room because the baclofen pump was “rejecting” and “coming out.” The VA underwent surgery on June 24, 2023, to remove the baclofen pump. · The HCP said s/he was not told the VA went through a period where s/he threw up, nor that the VA was diagnosed with weakness, dehydration, and low potassium; but that s/he should have been notified according to the facility’s policy. The HCP said s/he was also not informed via incident report or any other method that the VA went to urgent care on June 8, 2023, that there was concern about a possible infection of the VA’s surgical site, nor of the VA’s lab results. The HCP said the protocol was for the SP to email or call him/her about updates, and that this information should not be sent via text message. (Note: documentation showed that the HCP was informed via the facility’s electronic recordkeeping system that the VA went to urgent care on June 8, 2023, for a rash and dark urine.) The HCP did not have direct contact with any of the VA’s medical providers. The HCP said four Seven Day Watch forms should have been completed: one after the VA’s initial surgery, one after the VA’s the staples were removed, one at the onset of weakness and vomiting, and one after the VA’s urgent care visit. · On August 7, 2023, P1 retroactively completed the Incident Reports for June 8, 12, and 20, 2023. P1 used information provided by the SP to document on the incident reports whether P2 and/or the HCP were notified of the incidents. · P1 provided the DHS investigator with the progress notes for the VA and said that if there were entries missing, they were not completed by the staff persons. P1 said the facility was unable to locate Seven Day Watch forms for the dates in question. The VA provided the following information: · The VA said s/he “kind of” liked the facility, got along with staff persons, and they took good care of him/her. The VA said his/her baclofen pump surgery and recovery went “okay.” The VA did not recall any pain after the surgery or around the surgery site. The VA said a staff person saw the surgery site every day, usually when s/he was assisted to bathe or dress. The VA could not recall if the HCP came to look at the surgery site. · The VA provided inconsistent information about whether s/he informed a staff person s/he did not feel well prior to the hospitalization. Initially the VA denied telling staff persons s/he was unwell as s/he “didn’t even know” s/he was not at baseline. However, the VA also said s/he told a staff person s/he did not feel well, but did not recall who s/he told. The VA recalled feeling ill and vomiting, but s/he did not know if it was related to the surgery or something else. The VA said it was up to him/her to decide whether to see a doctor, but could not recall if s/he refused to be seen when s/he was unwell. The VA “doubt[ed]” if there was anything staff persons could have done to prevent the hospitalization. The SP provided the following information: · The VA moved into the facility in March of 2023. The SP had worked with the VA previously at a different facility. The VA was “hard to understand” and “soft spoken,” but the SP was able to understand the VA’s speech. The VA used some American Sign Language and might need encouragement to continue to speak if s/he “can’t get it all out.” · The VA’s baclofen pump expired and s/he underwent surgery to have it replaced. The next day the VA was discharged from the hospital to the facility. The VA wore a belly band for two weeks post-surgery, and staff persons did “bed baths” for him/her because the VA was not supposed to shower. The SP said a Seven Day Watch was completed after the surgery. · At a follow up appointment, the VA’s staples were removed. The progress showed the VA healed and everything post-surgery went “fine.” The VA was given “no restrictions” and there were no post appointment instructions for staff persons. The SP did not recall if another Seven Day Watch was started after the staples were removed. · On an unknown date after the staples were removed, the VA “wasn’t feeling good” and s/he “became sick with like a cold.” After a couple days the VA told the SP s/he did not want to be seen for his/her illness. The SP contacted the HCP and P2 by email or text about the VA’s health concerns and told them the VA was “not coming out [of his/her room], not joking.” P2 asked that the SP keep him/her updated. The SP contacted the G about the VA’s health concerns and refusal of medical attention, and told the G that s/he might be asked to encourage the VA to be seen and to “override” the VA if “push comes to shove” as a “last resort.” The SP said s/he was in “almost daily” contact with the G and P2 by email or text about the VA’s health. The SP thought the VA’s vitals were done during this time and were documented in the progress notes. · On June 7, 2023, the VA vomited on the overnight shift. On June 8, 2023, the VA agreed to go to urgent care. The SP prepared the referral form for urgent care, but s/he did not mention the recent surgery, only that the VA did not feel well. P3 took the VA to urgent care. · On June 8, 2023, at urgent care, a “head to toe” exam revealed a wound on the back of the VA’s heel. The VA usually wore thrombo–embolus deterrent stockings that helped reduce risk of developing blood clots due to his/her poor leg circulation. The VA also wore slip on shoes, and at the urgent care visit it was seen that s/he started to develop a sore on the back of his/her heel. The VA was directed to be seen at a wound clinic. The urgent care lab found the VA’s levels were “normal” except for low potassium levels. The SP was not aware the paperwork result stated the VA’s white blood cells count was increased possibly due to an infection. · The SP talked with P3 after the urgent care appointment and did not believe the surgery or baclofen pump was discussed as it was “two months after surgery.” The SP “believe[d]” s/he emailed the HCP about the urgent care appointment and that the VA received potassium four for days. The SP uploaded the paperwork from the appointment into the facility’s electronic recordkeeping system that the HCP could access. The SP called the G about the urgent care visit and called the HCP about the medication change. The SP thought a Seven Day Watch was started. The SP thought P2 completed an incident report for the urgent care visit and the HCP was included on it. The SP was not aware of any issues with the baclofen pump at the time of the urgent care visit and made an appointment at the wound care clinic for the VA’s heel as recommended. · The SP said “everything was still fine” with the VA until approximately two weeks after the urgent care appointment. The day before or the day of the second wound clinic appointment, the SP was told by a staff person that the VA showed “some leakage next to the baclofen pump” and there was a “small little incision.” The SP told the staff person s/he planned for the wound care clinic look at the pump site. The SP denied s/he was made aware of any issues with the surgical site prior to this. · The wound care clinic examination showed the VA’s baclofen pump was “pushed out of [the VA’s] side.” The clinic bandaged the surgical site and instructed the bandage was not to be changed for two days unless it bled through. The staff person was told the VA needed to be seen at a pain clinic. The SP did not know if a Seven Day Watch was started after the wound clinic appointment. · The SP was not working when the VA had his/her June 20, 2023, appointment. The SP returned to the facility on June 21, 2023, and called the pain clinic and set an appointment for the VA the next day. The SP was “pretty sure” s/he let the HCP and P3 know by text or email about the wound care clinic recommendation the same day s/he made the appointment at the pain clinic. The VA was “doing a lot better… not as tried” after the wound clinic appointment and ate more normally. · The SP and P3 took the VA to the pain clinic. At the appointment the SP was told to take the VA to an emergency room “right away.” The VA was taken to the emergency room and the baclofen pump was surgically removed. After the baclofen pump was removed, the VA received oral pain medications to compensate for the loss of baclofen. However, the VA’s body rejected the oral pain medications. The VA went into withdrawal and was put into an induced coma to help him/her safely recover. The SP was in contact with the HCP the day the VA went to the emergency room. The SP, the HCP, and P1-P4 were each trained on the Reporting of Maltreatment of Vulnerable Adults and on the VA’s support plans. Conclusion: Information was consistent that on April 26, 2023, the VA had baclofen pump replacement surgery. On April 27, 2023, the VA was discharged from a hospital to the facility. On May 10, 2023, the VA had the surgical staples removed. There were no reported issues, complications, or follow up care ordered at that time. About three weeks later, the VA started to become ill which included incontinence, vomiting, reduced appetite, and increased tiredness. Information was consistent that despite attempts by staff persons, the VA declined to be seen by a medical professional. On June 8, 2023, the VA went to urgent care and was found to be weak, dehydrated, and hypokalemic along with a slightly high white blood cell count. Urgent care completed an exam and advised that the VA be seen at a wound care clinic for a sore on his/her heel, but the VA’s baclofen pump surgical site was not evaluated. Around this time, staff persons noticed wounds at the VA’s surgical site. The wounds developed from an “open sore” to a “small spot on the incision,” and “blood around the edges” that were “smaller than an inch” and “just noticeable,” to multiple bandages changes a day and “leaking pretty bad.” There was insufficient information to determine whether the wounds developed before or after the urgent care visit. On June 20, 2023, the VA was seen at the wound clinic where the surgical site was rebandaged, and health care professionals instructed staff persons to change the dressing in two days; and according to P3, P4 told him/her s/he changed the VA’s wound dressing on June 22, 2023. On June 22, 2023, the SP scheduled an appointment for the VA to be seen at the pain clinic the following day. On June 23, 2023, at the pain clinic appointment, staff persons were advised to take the VA to the emergency room due to severe infection at the surgical site. From the emergency room, the VA was admitted to the hospital where the baclofen pump was surgically removed. Information was consistent that there were gaps in communication and documentation about the VA’s condition. However, the wound care clinic examined the VA’s surgical site on June 22, 2023, and did not identify any infection, nor indicate the VA needed emergency medical attention at that time. In addition, the instructions from that appointment were to wait two days before changing the dressing on the surgical site and to make an appointment with the VA’s pain clinic, and those orders were completed. Therefore, there was not a preponderance of the evidence that there was a failure to supply 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 an Internal Review and found their policies and procedures adequate, but not followed by staff persons. All staff persons were retrained on completion, documentation, and storage of Seven Day Watch forms. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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