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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: 1070849-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that a vulnerable adult’s (VA’s) bowel protocol was not followed resulting in a twisted colon causing bowel obstruction that required surgery. Date of Incident(s): Prior to August 15, 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 for this investigation was obtained remotely, including documentation from the facility and/or hospital medical records; and through six interviews conducted with a guardian (G), a facility staff person (P1), a facility health care professional (HCP1), day program staff persons (DP1 and DP2), and a case manager (CM). Due to the VA’s diagnoses, s/he was not able to participate in an interview regarding the incident. The VA’s family was very important to him/her. The VA liked parades, fast food, van rides, and fireworks. The VA’s diagnoses included severe intellectual disability, anxiety disorder, and constipation. The VA was incontinent and wore disposable adult absorbent undergarments. The VA’s Annual Plan stated that s/he was not able to independently administer his/her medications and required assistance. The VA “will attend appointments that [the G] has scheduled and will accompany [the G] to the appointments.” The VA’s Bowel Protocol, dated November 18, 2019, stated that s/he was administered specific medications for constipation throughout the day (linaclotide, MiraLAX, and Senna) and his/her bowel movements (BMs) were documented daily. If the VA had no BM within a 24-hour period, staff persons were supposed to place the palm of their hand over the VA’s belly button region and gently press inward. If the VA’s belly felt firm/hard, as needed (PRN) bowel medications were to be administered (milk of magnesia twice daily for one day). If the VA had no BM in 48 hours, a Dulcolax suppository was inserted into the VA’s rectum. The following was reported to the Department of Human Services: · On Sunday, August 11, 2024, an unidentified facility staff person told the G that they “didn’t know” about the VA’s BM protocol. The protocol was located, and staff persons began implementing it. · On Tuesday, August 13, 2024, a day program staff person (determined to be DP1) contacted the CM and said that the VA was exhibiting low energy/affect, loss of appetite, and irregular BMs. · On Wednesday, August 14, 2024, the VA had his/her annual meeting in the afternoon, and the CM, P1, and DP1 met along with the G who joined via telephone and the VA’s bowel protocol was reviewed. The G requested the facility’s heath care professional (HCP1) contact the VA’s medical doctor (MD) since the MD was involved in the establishment of the VA’s initial bowel protocol and because the VA did not do well in “urgent care” instances, and it was hoped that could be avoided. The team agreed that a medical professional needed to be involved “no later than Friday, August 16, 2024.” During the meeting it was also noted that the VA’s “typical” facility staff persons (determined to be P1 and P4) had been on vacation and less familiar staff persons had been caring for the VA. On Wednesday evening, an unidentified facility staff person contacted the G stating they believed the VA should go to the hospital; however, the G was out of town and staff persons were not able to remain with the VA if s/he was admitted. (Documentation from that day stated the VA’s stomach was “very big,” the VA was not feeling comfortable, and his/her bowel PRN medications were administered without results.) The G declined sending the VA to the hospital. · On Thursday morning, August 15, 2024, the VA was transported to his/her day program and arrived with a “distended abdomen” and a day program health care professional (HCP2) recommended the VA go to a hospital. P1 was contacted and went to the day program and transported the VA to a hospital and waited for the G to arrive. The VA was admitted to the hospital that evening, with initial plans for a colonoscopy on Friday morning. However, on Friday, August 15, 2024, the VA required emergency surgery due to a twisted colon causing a bowel obstruction. The G provided the following information:
· On Sunday, August 11, 2024, the G saw the VA and was concerned about his/her stomach “distention” and asked unidentified facility staff persons (determined to be P2) to contact a facility health care professional because the G requested a deviation from the VA’s bowel protocol by requesting Milk of Magnesia be administered to the VA. (This was considered a deviation because Milk of Magnesia was administered if the VA did not have a BM, however, the VA had a BM that day.) · On Tuesday, August 13, 2024, a staff person (P4) contacted the VA’s physician (MD). (No further information was provided regarding the outcome of the contact.) · On Wednesday, August 14, 2024, the G was called, and it was his/her understanding that the VA was constipated; however, no one told the G about the changes in the size of the VA’s abdomen. · The G said that the VA had regular check ups and had a bowel protocol so s/he did not know if anything could have been done differently to prevent the bowel surgery given the VA’s long-term use of laxatives and specific fiber diet. · The G had “no reservations” about the VA returning to the facility. Regarding the VA attending the day program on Thursday, August 15, 2024, and not going to the hospital until later that day, the G did not believe “an hour or two” made a difference. · After the VA’s discharge from the hospital on August 27, 2024, the G was concerned that staff persons were not documenting the VA’s BMs. The VA’s hospital records showed that s/he was admitted to the hospital on Thursday, August 15, 2024. The VA had abdominal distention and pain and was diagnosed with a “sigmoid volvulus” (twisted colon causing obstruction) that required decompression (deflating the abdomen by removing gas and stool) that same day. On August 16, 2024, the VA had a “sigmoid resection” (removal of the last section of the colon) to “prevent recurrence.” While hospitalized, the VA had issues with taking in liquids, cooperating with oral or bowel medications, and emesis. The VA was discharged back to the facility on August 27, 2024. The following information was obtained from interviews with P1, DP1, and DP2, as well as from the facility’s internal review and/or documentation: · On Sunday, August 11, 2024, a staff person (P5) worked with the VA in the morning when the VA ate breakfast. The VA left the facility with the G in the afternoon. Two staff persons (P2 and P7) worked together later that day. P2 previously worked full-time at the facility; however, on this date s/he worked as a “fill-in” staff person. P2 had not worked at the facility “in a while” but was trained regarding the VA’s protocol. P2 and P7 were present when the VA and the G returned to the facility, and each said that the VA’s stomach looked “big” that day. The G requested that the VA be administered medication to promote a bowel movement. However, P2 and P7 each confirmed the VA had a BM after returning with the G to the facility that required a shower/change of clothing. P2 explained to the G that the VA already received medications daily to promote BMs; however, the G wanted P2 to administer “more.” P2 said that the VA had a PRN order for Milk of Magnesia if s/he did not have a BM, but because the VA “just had a BM,” P2 was not able to administer more. P2 also checked documentation and saw that the VA had been having regular BMs. P2 and P7 were each aware of the VA’s bowel protocol. · On Monday, August 12, 2024, the VA had a normal, large bowel movement. · On Tuesday, August 13, 2024, the VA refused to eat breakfast, ate all his/her lunch, and ate “a little bit” of his/her dinner. The VA declined a van ride (a preferred activity). A staff person (P6) called P5 to say that the VA was “still not eating well.” When P5 arrived at the facility s/he observed the VA’s stomach was “very big and hard to the touch.” P5 called P1 and told P1 that the VA’s stomach “had not been this big before” and a suppository was administered. · On Wednesday, August 14, 2024, P1 went to the VA’s day program for a previously scheduled meeting and saw that the VA was “not looking good.” P1 telephoned the G prior to the meeting and said that s/he believed the VA should go to a hospital. The G suggested waiting until the weekend. According to P1, the VA’s protocol stated to administer Milk of Magnesia if the did not have a BM in 24 hours; however, the VA had a BM “every day” from August 5-14, 2024. DP1 said that during the meeting there was discussion about the VA’s stomach distension and that the G said that medical attention should be sought if the VA was still exhibiting concerns “by the weekend.” In the afternoon of Wednesday, August 14, 2024, P4 told P5 that if the VA did not have a BM by morning, P4 believed P1 should be called, and the VA should go to the hospital. That evening, a staff person (P3) administered the VA’s PRN medication (a suppository); however, there were no results. The VA’s temperature was taken three times that evening and was either 98.2- or 98.4-degrees Fahrenheit each time. · Between 10 p.m. on August 14, 2024, and 6 a.m. on August 15, 2024, the VA’s temperature was taken five times before the VA left for his/her day program. The VA’s temperature never exceeded 98.4 degrees Fahrenheit. · On Thursday, August 15, 2024, DP1 said that the VA arrived at the day program “still not well.” A day program health care professional (HCP2) unsuccessfully attempted to listen to the VA’s stomach for bowel sounds. Either DP1 or DP2 called the facility and learned that a suppository was attempted with no success the previous evening, and a call to the G determined the G was “not comfortable” with the VA being unsupervised at the hospital and asked that P1 be contacted to remain with the VA until the G arrived at the hospital. DP1 and DP2 did not believe an ambulance was warranted so P1 was contacted and transported the VA to the hospital. · All staff persons who worked at the facility were trained on the VA’s Bowel Protocol. · Information showed that after the VA’s hospital discharge following his/her surgery, staff persons (P5, P6, and P7) each implemented the VA’s BM protocol; however, between August 30 and September 1, 2024, they did not document on the Medication Administration Records (MARs) the results after administering Milk of Magnesia and a suppository. (However, documentation on the VA’s August 2024 T-Log and/or BM record each showed that staff persons documented when the VA had a BM, and the “amount” and “type” of stool.) There was no evidence that failure to document the outcome of those treatments on the MARs caused the VA harm. · HCP1 said that s/he was involved in “training” staff persons if there was some specific need for a client, however, staff persons were supposed to call a clinic health care professional if medical assistance or direction was needed. The CM provided the following information: · The CM heard that unidentified staff persons did not know about the VA’s bowel protocol when P1 and P4 were on vacation. However, when the CM spoke to P1, a management person, P1 said that the VA’s protocol was followed, and bowel movements and medications were documented. · The CM did not know if anything could have been done differently to prevent the surgery given that the VA used laxatives on a long-term basis and surgery may have been required whether or not “regular” staff persons were on vacation.
According to the National Institute of Diabetes and Digestive and Kidney Diseases, information regarding colonic volvulus showed that the diagnosis was more common in individuals with chronic constipation and frequent use of laxatives. Staff persons were trained regarding the VA’s program plans and on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information showed that the VA had a history of constipation for which s/he received daily medications and had a Bowel Protocol to address constipation if the daily medications were not successful. Documentation showed the medications and protocol were implemented as ordered. Despite the VA having daily BMs from August 5-14, 2024, the VA’s stomach gradually distended from August 11-15, 2024, at which time the VA required hospitalization and surgery for a twisted colon and removal of a section of his/her colon. Although there were concerns that facility staff persons did not know about the VA’s bowel protocol, information showed that all staff persons were trained regarding the protocol and implemented it as ordered. Although the VA was not hospitalized until after several days of stomach distention were observed, given that the VA had a history of constipation, that his/her protocol was followed, that the VA had regular BMs on those dates, and staff persons were in conversation with the G those days regarding whether the VA should receive medical attention or be hospitalized, there was a not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services 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 policies and procedures were adequate but were not followed regarding the correct place to document outcomes of the VA’s bowel protocol following his/her hospitalization. Staff persons received further training regarding that documentation. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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