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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: 1070710-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: Allegation one: It was reported that when a vulnerable adult (VA) arrived at an appointment, the VA “smelled” like urine and was wet with urine. Allegation two: It was reported that the VA was not seen by a dentist for about three years and when the VA saw the dentist, the exam showed significant decay on the VA’s teeth, which might lead to the VA having most of his/her teeth removed. Date of Incident(s): Allegation one: January 29, 2025 Allegation two: Ongoing between March 2022 and January 2025 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 February 7, 2025; from documentation at the facility and the VA’s dental records; and through eight interviews conducted with the VA, a dental employee (DE), a supervisory staff person (SP), two facility management staff persons (P1 and P2), two facility staff persons (P3) and P4), and the VA’s case manager (CM). The VA was not subject to guardianship. The VA’s Care Plan showed that the VA enjoyed doing “word searches” and watching the “shopping network.” The VA had a mild developmental disability and was diagnosed with cerebral palsy and “other schizophrenia.” The VA was not subject to guardianship. The VA’s Self-Management Assessment showed that the VA was also diagnosed with post-traumatic stress disorder, depression, and sleep apnea. The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans. Allegation one: It was reported that when the VA arrived at an appointment, the VA “smelled” like urine and was wet with urine. The VA’s Care Plan showed that the VA used adult undergarments and was independent with using the bathroom but needed some verbal reminders to use the bathroom and to change his/her adult undergarment. The VA’s Individual Abuse Prevention Plan showed that s/he was a “private person” and “does not like people to be in [his/her] personal space.” The VA “wants to remain as independent as possible” and “tends to have more fear and anxiety around people being in the bathroom with [him/her].” The VA was independent with showering. The VA had a “history of soiling” him/herself and it “typically happens when [s/he] does not want to go somewhere.” When the VA went into the community, the VA packed a “change of clothes and carry a bag.” Staff persons were to provide verbal reminders to take the bag into the community. The VA “will not tell staff that was incontinent. The VA’s Self-Management Assessment showed that the VA “does not like to go to the doctor,” except for the “eye doctor,” and “when [s/he] has an appointment that [s/he] does not want to go to, [s/he] has a history of soiling [his/her] pants.” Because of that, staff persons “allow enough time to leave the house, ask [him/her] to use the restroom and then attempt to leave.” The DE provided the following information: · On January 29, 2025, the VA was at his/her primary dental clinic. While the DE and the VA walked to the examination room, the DE was in front of the VA when one of the DE’s co-workers “tapped” the DE on the shoulder to tell him/her that the VA was “wet.” The DE then moved and walked behind the VA and noticed that the VA had soiled his/her clothing. · When the VA was in the exam room, the DE went to the waiting room and talked to P1, who brought the VA to the appointment. P1 told the DE that one of the VA’s “behaviors” was soiling him/herself because the VA did not like going to the dentist. When the DE asked P1 if s/he had another adult undergarment and extra clothing for the VA to change into, P1 told the DE that s/he did not bring along extra supplies and that they “ran out” of the facility and P1 “totally forgot to grab those.” The DE and the VA continued with the appointment. The VA stated that when s/he was incontinent, staff persons asked the VA to change his/her clothes and told the VA they would “report you to the police.” The VA also stated that some staff help him/her, but that others do not. The VA was not able to provide additional information. P1 provided the following information: · When the VA got ready to bathe, the VA liked to pick out his/her clean clothing to wear after. The VA preferred to have privacy when s/he showered/bathed. The VA was independent with using the bathroom and changing his/her adult undergarment. There were times that the VA soiled his/her adult undergarment and at times the VA changed it on his/her own, without guidance from staff. Other times the VA refused to change, and staff provided verbal prompts to the VA to do so. This happened when the VA was in a “really bad mood” or was “angry.” · On the day of the VA’s dental appointment (P1 did not remember the date), P1 went to the facility “early” because s/he knew that the VA needed additional time to get ready because the VA did not like going to the dentist. When P1 asked the VA to use the bathroom before they left, the VA did so, but when the VA was done, the VA went to his/her bedroom instead of going outside and getting into the van. P1 went to the VA’s bedroom and verbally prompted the VA to the van so they could leave, and the VA eventually did so. · While riding to the appointment, the VA was “very very quiet.” When they got to the appointment, the VA and P1 walked into the clinic. P1 waited in the waiting room when the VA went back for the exam. At that time, P1 did not notice that the VA soiled his/her clothing until s/he was told by the DE after the VA’s exam was completed. P1 and other staff typically brought extra undergarments and clothing for the VA, but that morning, P1 “forgot” to bring them because they were in a “rush” to get to the appointment. After the appointment P1 and the VA returned to the facility and the VA changed his/her clothing. The SP, and P3-P5 provided information that was consistent with the information provided by P1. The SP added that if staff “drew attention” to the VA when the VA was incontinent, the VA “will refuse to change for the entire day” and “will go from being a tiny bit wet to soaked.” The CM stated that the VA was independent using the bathroom but may be incontinent and “stubborn” about changing his/her clothes afterwards. When that happened, staff persons were to “encourage” the VA to change his/her adult undergarment and clothing if needed. Conclusion for Allegation one: The VA’s Individual Abuse Prevention Plan showed that the VA had a “history of soiling” him/herself and that it “typically happens when [the VA] does not want to go somewhere.” When the VA went into the community, the VA was to pack a “change of clothes and carry a bag,” that staff persons were remind the VA to bring. In addition, the VA would not tell staff if s/he had been incontinent. Information from all sources was consistent that the VA was independent using the bathroom and changing his/her adult undergarment and that the VA did not like going to the dentist. On January 29, 2025, P1 took the VA to a dental appointment. P1 stated that s/he arrived at the facility early to allow additional time for the VA to get ready for his/her appointment. The VA used the bathroom before they left, but rather than getting in the van afterwards, the VA went into his/her bedroom and required verbal prompts to go to the van, which caused them to need to “rush” to the appointment. As a result, P1 “forgot” to bring the VA’s bag of extra clothing to the appointment. The DE stated that after the VA went back to the exam room, the DE went to the waiting room and told P1 that the VA soiled his/her clothing. However, P1 stated s/he was not told that the VA had been incontinent until after the VA’s appointment. Although the VA was incontinent and P1 forgot a change of clothes for the VA, given that that VA used the bathroom shortly before leaving the facility for the appointment, that P1 did not notice the VA had been incontinent prior to the VA going back to the exam room, and that the VA could have soiled him/herself as s/he walked back to the exam room, there was not a preponderance of the evidence whether there was a failure to supply the VA with reasonable and necessary care or 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). Allegation two: It was reported that the VA was not seen by a dentist for about three years and when the VA saw the dentist, the exam showed significant decay on the VA’s teeth, which might lead to the VA having most of his/her teeth removed. The VA’s Care Plan showed that the VA was to brush his/her teeth and floss two times daily and that “staff will place toothpaste on [his/her] toothbrush each morning and night. Once the bathroom is set up for [the VA], the staff will let [him/her] know the bathroom is ready when [s/he] is. [The VA] will go into the bathroom and complete [his/her] routine on [his/her] own.” The VA’s Health Needs Record stated that “staff will coordinate and transport [the VA] to all necessary dental appointments.” There was no information regarding the frequency of those appointments. The VA’s Individual Abuse Prevention Plan showed that staff persons assisted the VA with setting up his/her toothbrush twice daily. The DE provided the following information: · On March 15, 2022, the VA was seen at the primary dental clinic, and two teeth needed to be extracted. Since the primary dental clinic did not offer sedation services, the VA was referred to a dental clinic that offered sedation services. The DE did not remember who brought the VA to the appointment. · The next time the VA was at the primary dental clinic was on January 29, 2025. During that appointment, the DE noted that the two extractions noted at the March 15, 2022, appointment had not been completed. In addition, the condition of the VA’s teeth was “really terrible” and there was “decay on nearly every single tooth, very deep decay” which caused the VA “pain.” The DE described the progression of the VA’s teeth from March 2022 until January 2025 as being “severe progression.” Pictures, taken by the DE on January 29, 2025, show significant tarter and plaque on the VA’s teeth and black areas. The VA’s dental records from the primary dental clinic were requested to include 2019 through 2025. The records provided the following information: · The VA was seen at the primary dental clinic on January 6, February 1, March 9, June 1 and 9, 2020, and December 1, 2020; June 3, 2021; March 15, 2022; and January 29, 2025. (Note: The facility maintained a listing of dates that the VA went to the primary dental clinic and for the most part, those dates coincided with information from the primary dental clinics data base, but the facility’s list included July 20 and November 16, 2023, with notes that said, “No med action found requested records.” There was no information from the primary dental clinic that the VA was seen at any time in 2023 or between March 15, 2022, and January 19, 2025.) · On March 15, 2022, the VA had “heavy plaque throughout” and “generalized moderate chronic periodontal disease.” The VA “had a hard time tolerating all procedures today” and the unnamed staff person accompanying the VA to the appointment stated that the VA “brushes [his/her] own teeth.” The dentist, “recommended [the VA] having help with homecare due to dexterity and the amount of debris present throughout” and that two teeth (#19 and #15), which “previously tested necrotic” (defined below) be extracted “when symptomatic.” The notes documented a referral to a dental clinic that offered sedation services. There was no documentation in the notes as to when the VA should return to the primary dental clinic. · At the next appointment, January 29, 2025, approximately three years later, the VA was seen at the primary dental clinic. At this time, the VA had “very heavy and globular plaque throughout, very heavy calculus throughout” and there was “heavy bleeding upon probing.” In addition, the VA had “severe periodontitis with potential for additional tooth loss.” The VA said s/he does not brush or floss his/her teeth. The VA was referred to a dental clinic that offered sedation services for further evaluation and care. The notes indicated that the VA had “pain with eating,” but that the VA was “not able to specify where it hurts.” According to www.truedentalcare.us, necrotic teeth is defined as “dead teeth-dead because the nerve at the root is dead.” A “necrotic tooth is potentially dangerous because the bacterial colonization within the dead pulp gains access to the blood supply.” The VA stated s/he “scrubbed” his/her teeth with “Crest toothpaste” and s/he went to the dentist every six months. The VA also stated that s/he did not need assistance from staff persons with brushing or flossing his/her teeth. The VA remembered that P1 took the VA to the dentist the last time and thought that the appointment was “in the spring.” On the day of the VA’s interview with the investigator, the VA stated that s/he did not have tooth pain. P1, P2, and P4 each stated that the SP was the staff person responsible for ensuring that dental appointments were set up for the VA. P3 stated that either the SP or P1 were responsible for setting up dental appointments for the VA. The SP’s job description stated that the SP “oversees the supervision and daily management of the staff and residents of more than one residential program site” and his/her responsibilities included managing “health services as assigned for individuals served ensuring effective and timely delivery” and “coordinates appointments for all health or consultant related services including physicians, psychologists, and all other consultants ensuring resolution of outstanding issues and preventative health care needs.” P2 provided the following information: · Appointments were tracked on a spread sheet. Annually, the sheets were given to the SP, and other persons in the same position, with the intention that they were supposed to fill out the sheets “as they go” and it was P2’s responsibility to oversee, at least annually, that the appointments were scheduled, and that the clients attended the appointments. Appointments were also tracked in a calendar in “Outlook” and P2 had access to the SP’s calendar. When P2 reviewed the SP’s Outlook calendar in October or November 2024, s/he noted that the SP’s outlook documented that the VA had a dental appointment in 2023, but P2 learned that the VA did not go to that appointment and P2 did not know why. As a result, P2 told the SP to schedule the VA with a dental appointment. If appointments were documented in Outlook, but not attended, it was the responsibility of the person that made that documentation to “delete” it from the Outlook calendar. · When P2 was asked for a reason as to why the VA missed dental appointments for over two years, s/he stated, “I just missed it” and “I didn’t catch it when reviewing documents.” · P2 was only aware of one dental clinic that the VA went to, which was the primary dental clinic. The Annual Appointment/Meeting Schedule stated that the “frequency” of when the VA was supposed to see the dentist was “annually” and that the VA saw the dentist on June 3, 2021; March 15, 2022, July 20and November 16, 2023; and May 16, 2024 (there was a note that the “dentist cancelled”), and January 29, 2025. [Note: P2 stated that although s/he looked, s/he was “unable to locate the med actions for those appointments in 2023.” In addition, there was no information from the primary dental clinic that the VA was seen at any time in 2023 or between March 15, 2022, and January 19, 2025.] P1 provided the following information: · The VA had past “trauma,” was “very private,” and “wants to do [his/her] own thing.” Staff persons did not assist the VA with brushing his/her teeth but provided verbal direction to do so. The VA brushed his/her teeth twice a day with staff persons assisting the VA with putting toothpaste on the VA’s toothbrush. The VA “doesn’t allow” staff persons to be in the bathroom when s/he brushes his/her teeth. After the VA brushed his/her teeth, P1 asked the VA if s/he brushed his/her teeth and the VA “always says, ‘Yes.’” P1 did not check the inside of the VA’s mouth to ensure that the VA brushed his/her teeth. The VA had dental floss but P1 did not know if the VA used it. · P1 took the VA to the VA’s primary dental clinic appointment on January 29, 2025, where the VA’s teeth were cleaned. At that time P1 was told that the VA had a “lot of buildup.” · P1 did not remember when the VA’s last dental appointment was prior to the January 29, 2025, appointment. P1 was not aware of a time when the VA complained of tooth pain. P1 said that s/he did not know how the condition of the VA’s teeth may have changed over the past three years, because s/he does not “get in [the VA’s] face” because the VA “doesn’t like people in [his/her] face.” P1 said once the dental appointments were made, any staff person could accompany the VA to those appointments. P1 did not know how often the VA was supposed to see the dentist. P3 provided information that was consistent with the information provided by P1. P3 also stated that s/he “prompted” the VA “quite a lot” to brush his/her teeth twice a day. A “couple [of] times” when P3 “walked by” the bathroom when the VA was brushing his/her teeth, the VA appeared to “be doing okay.” P3 was not aware of any time the VA complained of tooth pain and did not notice any changes in how the VA ate. P3 did not know when the VA last saw the dentist, prior to January 2025 or the frequency of how regularly the VA should see the dentist. P4 provided information that was consistent with the information provided by P1 and P3. P4 did not know how often the VA was supposed to see the dentist. The CM stated that s/he typically saw the VA two to three times a year and was not aware of any possible concerns related to the VA’s dental care. The CM stated that although the VA did not need assistance with brushing his/her teeth, the VA needed verbal reminders to do so. The CM did not know who the staff person was that set up dental appointments and even though it was “not” in the VA’s plans, the CM thought that it was “typical” that clients would see the dentist every six months. Documentation of the VA brushing his/her teeth showed that between January 1, 2024, and February 13, 2025, the VA brushed his/her teeth independently 42 percent of the time and needed “verbal prompts” 58 percent of the time. The SP provided the following information: · On some occasions, the VA “refused” to brush his/her teeth even after staff persons put toothpaste on the VA’s toothbrush and provide verbal reminders to brush his/her teeth. The VA typically did not ask for assistance with brushing his/her teeth because the VA was a “very private person” and “does not like [his/her] space invaded.” Although the SP could not remember the date, the facility purchased toothpaste for the VA that was specifically for sensitive teeth, but the VA did not like it and did not use it. As a result, a different type of toothpaste was purchased that the VA used. · The SP said s/he “usually” set up all appointments, including dental appointments, for the VA and staff persons took the VA to those appointments. The SP believed that the VA saw the dentist on a yearly basis. The SP used a “paper planner” to record appointments. · The SP stated that s/he took the VA to a dental appointment in March 2022 at the primary dental clinic, but the SP did not remember the date. At the end of the appointment, the SP was told that the VA, who “hates the dentist,” needed to be seen by a “specialty dentist,” but the SP was not given a reason and was not told that the VA needed two teeth extracted. The SP “assumed” that the VA “needed better, more care done than” the primary dental clinic could provide. The SP stated that after the appointment, the SP attempted to make an appointment for the VA with the referred dental clinic, but “never” got the VA an appointment at that clinic. When the SP was asked why that happened, s/he stated, “I don’t know,” and “I can’t imagine that I would miss a dental, but I’m human and I make mistakes.” The SP also stated, “There’s no reason to ever miss an appointment, but if I did, then that’s on me.” · When the SP was asked whether s/he made alternative arrangements when s/he did not get an appointment for the VA with the referred dental clinic, the SP stated that the primary dental clinic “is the one that I keep bringing [him/her] to.” The SP thought that the VA was supposed to be seen by his/her dentist on a “yearly” basis. · The SP s/he did not know the condition of the VA’s teeth because the VA “doesn’t let us look in [his/her] mouth.” In addition, the VA had not complained of teeth pain. · Attempts were made to contact the SP for additional information, but the SP did not respond to those requests. The facility’s Incident Report and Internal Review provided information that was consistent with the information from the VA’s dental records from the primary dental clinic. The review provided the following additional information: · “The residents 4-18-2024, annual meeting paperwork indicated dental appointments were completed on 7-20-2023, and 11-16-2023, although there are no dental med actions that match those dates and [the primary dental clinic did not provide these as treatment dates.” The notes also stated, “We have been unable to ascertain if these appointments were completed and by whom, or if they were intended appointments that were cancelled for some reason.” [Note: According to the dental records from the primary dental clinic, the VA did not have an appointment and/or was not seen at any time at their clinic in 2023.] · On October 14, 2024, “the RM (regional manager) was reviewing the 2024 appointment tracker, which listed dental care as scheduled annually with [the VA’s primary dental clinic] stating that the appointment would be due in November [2024], but also indicated that the resident was also placed on the cancellation list for a possible sooner appointment” and that “an appointment was completed” on January 29, 2025. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (a), states in part that the license holder is responsible for meeting health service needs assigned in the support plan or the support plan addendum, consistent with the person's health needs. Minnesota Statutes, section 245D.081, subdivision 2 and 3, states in part that delivery and evaluation of services provided by the license holder must be coordinated by a designated staff person and the designated coordinator must provide supervision, support and evaluation of the program. The license holder must also designate a managerial staff person or persons (designated manager) to provide program management and oversight of the services provided by the license holder. Conclusion for Allegation two: A. Maltreatment: Information from all sources was consistent that the VA did not require or want staff persons help with brushing his/her teeth, therefore, it was reasonable that staff persons did not assist the VA with brushing and might not know the condition of the VA’s teeth. In addition, information showed that staff persons prompted and encouraged the VA to brush his/her even at times the VA refused to do so. On March 15, 2022, the VA was seen at his/her primary dental clinic. The records noted that the VA had “heavy plaque throughout” and “generalized moderate chronic periodontal disease” and the DE stated that the VA needed to have two teeth extracted. The SP stated s/he accompanied the VA to that appointment and was not told anything about teeth needing extraction. In addition, the dental records stated that the two teeth should be extracted “when symptomatic.” A referral was made to the referred dental clinic who offered sedation services. The SP stated s/he attempted to make the VA an appointment at the referred dental clinic, but “never” got the VA an appointment and s/he did not know why. However, information from staff persons was consistent that the VA did not have dental pain and therefore, was not likely “symptomatic” so it was reasonable that no appointment was made at that time for the referral dental clinic. The VA’s Health Needs Record stated that “staff will coordinate and transport [the VA] to all necessary dental appointments.” Although the VA’s plans did not provide information regarding how often the VA was to be seen by a dentist, the CM stated that it was “typical” that clients would see the dentist every six months. In addition, the VA’s dental records from the primary dental clinic showed that the VA was seen at the primary dental clinic, six times in 2020; one time in 2021; one time in 2022; and one time in 2025. The VA went approximately two years 10 months (between March 15, 2022, and January 29, 2025) without being seen by a dentist, which was a violation of Minnesota Statutes, section 245D.05, subdivision 1. On January 29, 2025, the VA was seen again at the primary dental clinic (two years, ten months later) and the notes stated that the VA had “very heavy and globular plaque throughout, very heavy calculus throughout,” “heavy bleeding upon probing” and “severe periodontitis with potential for additional tooth loss.” The dental records stated that the VA had “pain with eating,” but that the VA was “not able to specify where it hurts” and that the VA was referred to a dental clinic that offered sedation. Although information was consistent from interviews that the VA did not demonstrate dental pain and that the VA’s plans did not provide information regarding how often the VA was to be seen by a dentist, the CM stated that it was “typical” that clients would see the dentist every six months and the SP stated that the VA was supposed to be seen by his/her dentist on a “yearly” basis. In addition, the VA’s Health Needs Record stated that “staff will coordinate and transport [the VA] to all necessary dental appointments.” Given that staff persons were responsible for coordinating and transporting the VA to all dental appointments, that the VA was not seen by a dentist for approximately two years ten months, and that when the VA was seen the VA’s diagnoses included “severe periodontitis with potential for additional tooth loss,” it would have been both reasonable and necessary for the VA to have not waited almost three years between appointments. Therefore, there was a preponderance of the evidence that there was a failure to supply the VA with reasonable and necessary health care. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. In their roles, P2 and the SP each had significant administrative and supervisory authority over the operation of the facility and ensuring compliance with Minnesota Statutes. When P2 was asked for a reason as to why the VA missed dental appointments for over two years, s/he stated, “I just missed it” and “I didn’t catch it when reviewing documents.” When the SP was asked why an appointment was not made for the VA, the SP stated, “I don’t know,” and “I can’t imagine that I would miss a dental, but I’m human and I make mistakes.” The SP also stated, “There’s no reason to ever miss an appointment, but if I did, then that’s on me.” The failure to ensure coordination and evaluation of the VA’s service delivery and program management and evaluation were violations of Minnesota Statutes, section 245D.081, subdivision 2 and 3. Given that staff persons at multiple levels of authority failed to ensure that the VA was seen by a dentist for almost three years, the facility was responsible for the maltreatment of the VA. However, this did not mitigate the SP’s individual responsibility. The SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans. Information from interviews, including the SP, showed that the SP had responsibility for ensuring that the VA attended appointments. The SP’s job description showed that s/he “oversees the supervision and daily management” and managing “health services as assigned for individuals served ensuring effective and timely delivery” and “coordinates appointments for all health or consultant related services including physicians, psychologists, and all other consultants ensuring resolution of outstanding issues and preventative health care needs.” Therefore, the SP was also responsible for neglect of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” The Office of Inspector General is also required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the SP and the facility was responsible did not meet statutory criteria to be determined as recurring or serious because failing to schedule an appointment was considered a single incident and it was unknown whether the care the VA required would have been different had the VA been seen in a timelier manner. Action Taken by Facility: The facility completed an Internal Review and determined that policies and procedures were adequate, but not followed (the review did not say what was not followed) and that additional training was provided to staff, specifically to the SP and P1. In addition, the facility trained all staff to “encourage dental care completed at the kitchen since the resident does not like others in the bathroom with [him/her].” Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. On June 18, 2025, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal.
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