|
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: 1068638-H_CRS (Home and Community-Based Services-Community Residential Setting) 1068630-HCBS (Home and Community-Based Services) Investigator(s): Christine Cavanaugh/Alice Percy 651-431-3444 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) did not receive dental care as required. Although the VA was to be seen by his/her dentist every three months, the VA was not seen by his/her dentist for over a year, resulting in several cavities, extensive plaque, and a recommendation for a root canal and tooth extraction. Date of Incident(s): Ongoing, prior to March 21, 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 April 3, 2024; from documentation at the facility and dental records; and through seven interviews conducted with three administrative staff persons (P1 – P3) a facility staff person (P4), the VA, the VA’s guardian (G), and the dental director (DD) of a dental practice. The VA enjoyed listening to music, watching television, bowling, working on art projects, going on community outings, and spending time with friends and family members. The VA’s diagnoses included autism spectrum disorder, binge eating disorder, diabetes, asthma, mild intellectual disability, attention-deficit hyperactivity disorder (ADHD), and depression. According to the VA’s Intensive Support Services Assessment, the staff persons were to schedule the VA’s medical and dental appointments and also provide transportation to the appointments. The staff persons were also to update the VA’s interdisciplinary team (IDT) of any of the VA’s changing medical needs. The VA stated that P1 typically scheduled the VA’s dental appointments. The VA did not recall the last time s/he went to the dentist and did not know why s/he had not gone to the dentist. When the VA went to the dentist, the G also had to attend the VA’s dental appointments because it was the clinic’s requirement. In March 2024, some of the VA’s teeth began to hurt and the VA told the G about the pain. The G updated the VA’s dental insurance and the VA went to a new dentist. The VA needed four fillings and two teeth needed to be extracted. The staff persons “sometimes” reminded the VA to brush his/her teeth but the VA brushed his/her teeth independently. The G stated that s/he was required to attend the VA’s dental appointments by the dental clinic and typically met the VA and a staff person at the dental clinic. The VA went to a dental clinic (one) in 2022 and 2023. When that clinic stopped taking the VA’s insurance, the VA had to transfer to another clinic (two). The G believed that the VA went to a dental appointment in the spring of 2024 and was not aware that the VA missed any dental appointments in 2024. When the staff persons became aware that the VA had not seen a dentist every three months as recommended, the G changed the VA’s dental insurance and the VA was taken to a new clinic (three). The VA needed some fillings and possibly a tooth extraction. The staff persons gave the VA reminders to brush his/her teeth but did not assist the VA with brushing his/her teeth. The staff persons began to use a timer to remind the VA to brush his/her teeth adequately and provided a new mouthwash for the VA to use. The G did not have any concerns with the care the VA received at the facility. The VA had not complained to the G about tooth pain. P1, P2, P3, and P4, and the facility’s documentation provided the following information: · P1 stated that the VA had dental appointments in June, July, and November 2022. The G took the VA to his/her dental appointments because the clinic required that guardians attend the appointments. P1 stated that it was easier for the G to schedule the VA’s dental appointments because s/he needed to schedule them around his/her work schedule. P2 stated that while the supervisory staff persons were typically responsible for scheduling the VA’s appointments, the G “had a fair say in all that stuff” and communicated with P1 about scheduling the appointments. The G told P1 that the VA had gone to a dental appointment in the spring of 2023. P1 was not provided with information on when the VA was scheduled for other dental appointments in 2023. · P3 stated that during the Covid epidemic, many of the residents “were off track” on their dental and physical appointments, so the facility audited the residents’ records to ensure that all of the appointments were current. In December 2023, P2 did an audit of all the client records and found that the VA had no documentation for dental appointments since November 2022. P1 talked to the G, who told P1 that s/he believed the VA had a dental appointment in the spring 2023. When P1 checked with the clinic about when the VA last had a dental appointment, s/he was told that the VA cancelled a May 24, 2023 appointment and neither attended nor cancelled a June 7, 2023 appointment. The clinic also told P1 that they contacted the VA with reminders about the appointments. P1 did not know why the clinic contacted the VA with appointment reminders instead of the G or P1. P3 stated that while the VA could cancel appointments, the facility staff persons were responsible to reschedule the VA’s dental appointments. P3 believed that in the past, the VA was involved in scheduling his/her own medical and dental appointments. · The VA’s dental clinic was unable to immediately schedule an appointment for the VA, so a second clinic was found for the VA. In March 2024, the VA went to the second dental clinic and it was determined that the VA had between eight and twelve cavities and needed to either have two teeth extracted or have root canal work done. The VA did not like going to that clinic. On April 3, 2024, the VA went to a third dental clinic and five appointments for dental treatment were scheduled. It was recommended at both clinics that the VA “do a better job” of brushing his/her teeth. · In the past, the staff persons did not assist the VA with brushing his/her teeth. The VA had a token-based program where s/he earned a token when s/he brushed his/her teeth. The staff persons documented when the VA told them that s/he brushed his/her teeth, but the staff persons did not observe the VA brush his/her teeth. P4 stated that after it was found that the VA needed extensive dental work, staff persons were trained to watch the VA brush his/her teeth to ensure that the VA was doing so adequately. P1 believed that the VA’s dental clinic typically scheduled dental appointments for the VA twice a year. P1 stated that there was no documentation that the VA complained of tooth pain at any time. · From October 2023 to February 2024, the VA did not live at the facility, but instead lived with the G and returned to the facility in February 2024. The DD and the VA’s first dental clinic’s Appointment Summary and Supporting Documents provided the following consistent information: · On November 18, 2022, the VA and the G attended the VA’s dental appointment. Periodontal maintenance and a fluoride varnish treatment were completed. The VA was scheduled for two appointments on May 24 and June 7, 2023. · On May 23, 2023, the VA was contacted by telephone and email reminding him/her of the first appointment. The VA cancelled the appointment. · On June 6, 2023, the VA was contacted by telephone and email about his/her second appointment, but did not cancel the appointment or appear for the appointment. The clinic sent a dismissal letter to the VA because of his/her two missed appointments. According to the VA’s third dentist’s Chart Progress Notes dated April 3, 2024, the VA required two tooth extractions and had cavities in five teeth. Treatment was planned for the VA and it was recommended that in the future the VA be seen by the dentist every six months. Facility documentation showed that P1 – P4 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. Conclusion: On November 18, 2022, the G accompanied the VA to his/her dental appointment. In May and June 2023, the dental clinic reminded the VA of two dental appointments, but did not contact the facility or the G with the reminders about the appointments. The VA cancelled the first appointment and did not cancel or go to the second appointment. Although the VA’s Intensive Support Services Assessment showed that the staff persons were to schedule the VA’s medical and dental appointments and provide transportation to the appointments, given that the VA’s dental clinic required the G’s attendance at the appointments with the VA, the G “had a fair say” in scheduling the appointments and typically communicated with P1 about scheduling the appointments. In December 2023, P2 audited the client records and found that the VA had no documentation for dental appointments since November 2022. Since the VA’s dental clinic was unable to immediately schedule an appointment for the VA, a new clinic was found for the VA. In March 2024, the VA went to a second dental clinic, where it was determined that the VA had between eight and twelve cavities and needed to either have two teeth extracted or have root canal work done. The VA did not like the second clinic and on April 3, 2024, the VA went to a third dental clinic, where five future appointments for dental treatment were scheduled. Although the facility did not ensure that the VA was seen by his/her dentist every six months as recommended, which likely contributed to the VA needing two tooth extractions and fillings in five teeth, given that the G typically was a large part of the scheduling process and also accompanied the VA to his/her dental appointments; that the G did not realize that the VA did not have any dental appointments in 2023; that the VA cancelled two appointments in 2023 without informing a staff person or the G; and that a dental appointment was scheduled as soon as the facility realized the VA was not seen by a dentist in 2023, there was not a preponderance of the evidence as to whether there was a failure to provide care or services to the VA which were reasonable and necessary 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 the facility’s policies were adequate but were not followed by the staff persons. After the incident, P1 was retrained on staying current with all medical and dental appointments for the residents. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
