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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: 1071891-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 (VA) did not receive his/her prescribed long-acting insulin on December 9 and 10, 2023, because staff persons (SP1 and SP2) did not reorder the insulin. On December 11, 2023, the VA was transported to a hospital where his/her blood sugar was over 1000 milligrams per deciliter (mg/dL), and s/he was diagnosed with ketoacidosis. Date of Incident(s): December 8-11, 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 December 28, 2023; from documentation at the facility and hospital medical records; and through six interviews conducted with the VA, and four facility staff persons (P1, P2, SP1, and SP2), and a facility health care professional (HCP). The VA’s diagnoses included type 1 diabetes, an unspecified psychiatric disorder, depression, hyperlipidemia, and poly substance use disorder. The VA enjoyed being outdoors and playing basketball, ping pong, and frisbee golf. The VA moved into the facility on August 24, 2023, and was not subject to guardianship. The VA’s plans showed the following information: · A Community Support Plan (CSP) stated that the VA had “uncontrolled blood glucose.” The VA reported that s/he had trouble managing his/her medications, especially when s/he had a “bad day,” and his/her blood sugar was high. The VA said that s/he sometimes forgot to take his/her medication and needed help with “set up, reminders, and administration.” Within the five months prior to the VA’s admission to the facility, the VA was hospitalized two times for diabetic ketoacidosis. The VA was supposed to check his/her blood glucose three to four times per day, was insulin dependent, and took daily scheduled insulin (long-acting) as well as a sliding scale insulin (short-acting) with meals. · The VA’s Intensive Support Services Assessment (ISSA) stated that s/he needed to take long-acting insulin and needed to check his/her blood sugar four times per day. Staff persons were supposed to ask him/her for blood sugar numbers if the VA did not provide those numbers. The VA did not always take his/her medications on time. Staff persons prepared the VA’s medications with the exception of the short-acting insulin that the VA kept in his/her room. · A Medication Administration Record (MAR) showed that in December 2023, the VA was prescribed 40 units of Levemir (a long-acting insulin) delivered via FlexPen (injection) once daily at 11 a.m. The VA was also prescribed insulin aspart (also known as NovoLog/short-acting insulin). The VA was to administer two units for every 15 grams of carbohydrates eaten with a maximum of 15 units administered three times a day (total maximum of 45 units per day). · The VA had two diabetic protocols. The first protocol dated August 23, 2023, stated if the VA’s glucose level was “above 200 at any time,” staff persons were supposed to call the HCP and recheck the VA’s glucose as directed by the HCP. A newer Diabetic Management Protocol (undated, however, staff persons received training regarding it on December 8, 2023, so it was written prior to that date) stated that the VA was supposed to check his/her blood sugar “in front of staff 4x daily” and as needed. Staff persons were to record the reading on the MAR. The protocol identified what to do if the VA’s glucose levels were outside of specific high or low ranges and what the treatment was for each. Anytime the VA’s blood sugar was above 450, staff persons were supposed to call 9-1-1. (The newer protocol again said to call the HCP; however, the specific criteria of when to do so was not clear. In addition, the VA’s newer protocol did not indicate what staff persons were supposed to do if the VA did not check his/her blood sugar or administer insulin as prescribed.) On December 11, 2023, the VA’s hospital record stated s/he was first brought to a local emergency room with complaints of altered mental status and hyperglycemia (high blood glucose). Upon admission, the VA’s blood glucose was 1065 mg/dL after not receiving his/her prescribed long-acting insulin for two days and s/he was diagnosed with diabetic ketoacidosis. A facility staff person (determined to be P1) stated that staff persons were supposed to “remind” the VA to check his/her blood sugar and administer insulin; however, it was not unusual for the VA not to administer his/her regular insulin (short-acting) or check his/her blood sugar. Insulin infusion and fluid resuscitation was initiated, and the VA was transferred to a different hospital where s/he was admitted to an intensive care unit. On December 13, 2023, the VA was transferred to a general care floor at the hospital. On December 18, 2023, the VA was discharged back to the facility. According to a Mayo Clinic internet search, hyperglycemia did not cause symptoms until blood sugar levels were “above 180 to 200 mg/dL.” Early symptoms included frequent urination, increased thirst, blurred vision and feeling weak or unusually tired. If not treated, hypoglycemia could cause toxic acids, called ketones, to build up in the blood and urine, called ketoacidosis. Symptoms of ketoacidosis included dry mouth, fruity-smelling breath, abdominal pain, nausea and vomiting, confusion, and/or loss of consciousness. The facility’s internal review stated that after the VA was hospitalized on December 11, 2023, P1 and the HCP went to the VA’s room and observed four short-acting insulin pens (the VA kept these in his/her room) and four medication cups with “medication in them.” Observation of the VA’s long-acting insulin pen (kept upstairs in a medication cabinet) showed that 20 units remained. Information also showed that it was the facility’s policy to order refills for medications when there were seven or less days prior to running out. Multiple persons (P1, SP1, SP2, and another staff person, P3) documented that they gave the VA his/her long-acting insulin between December 4 and 10, 2023; however, none of those staff persons attempted to refill the VA’s insulin. P1 admitted s/he did not check the remaining units after the VA used the Levemir pen on December 4, 2023. P3 passed medications to the VA on December 5, 2023, and stated s/he did not know how to check the pen to see how many units of insulin were left. SP2 said on December 8, 2023, s/he was aware the VA had 20 units remaining and intended to reorder it, but there was “too much going on” and s/he forgot.
Interviews with this investigator and/or the facility’s internal review provided the following additional information: According to the HCP: · The VA’s insulin was not on automatic reorder “due to insurance” so when the VA had one or two insulin pens remaining, SP2, a supervisory staff person, was responsible for reordering; however, all staff persons were trained regarding how to reorder medications when necessary. · When the VA refused to follow his/her diabetes protocol, the HCP told staff persons to “reattempt” to get the VA to administer his/her insulin, but “if [the VA] does refuse, [s/he] is [his/her] own guardian and is allowed to refuse.” Staff persons were supposed to document that the VA refused. · On the weekend of December 9 and 10, 2023, the HCP was never notified about any concerns regarding the VA and/or not having enough Levemir to administer his/her prescribed daily amount. According to P1: · The VA was supposed to check his/her blood sugar in front of a staff person and report the number; however, the VA generally did not do that and only told staff persons a “number” to document.
· The VA refused to take his/her insulin “a lot.” P1 believed the VA refused his/her short-acting insulin up to two to three times a week and the long-acting insulin (that was administered once daily) a “couple times a month.” · The procedure for administration of the long-acting insulin included a staff person handing the VA the insulin pen and the VA “dialed” the correct dose and administered it in the presence of the staff person. While the staff person was supposed to observe the amount of insulin the VA “dialed,” for the most part, the VA “would not show” the amount to staff persons prior to injecting. · The VA “never” told staff persons when the pen was “running low” on insulin. P1 and P2 each said that all staff persons were responsible for reordering the VA’s insulin and were supposed to make sure it was ordered when seven days of insulin remained. The VA provided the following information: · The VA was able to identify each of his/her insulin by name and stated that Levemir was taken once a day. However, the VA said that s/he did not take Levemir “two days in a row” (determined to be December 9 and 10, 2023) because it was not reordered. The VA said that s/he did not know who was responsible for reordering medications. · The VA admitted that s/he did not always tell staff persons about his/her blood sugar readings, and did not always take his/her insulin as prescribed because “they [staff persons and the doctor] don’t know how much I am supposed to get.” The VA believed s/he knew how much insulin s/he needed to inject because s/he had “been doing this for 21 years.” SP2, a supervisory person, provided the following information: · SP2 worked during the day on Friday, December 8, 2023, and the VA was awake, talking, and eating. Around 11:50 a.m., SP2 gave the VA his/her oral medications and long-acting insulin pen. The VA was responsible for his/her insulin injections and after using the Levemir insulin pen, the VA told SP2 that there were only 20 units left (indicating the VA did not have enough units for his/her dose the next day.) However, SP2 was busy with other work tasks and “forgot” to order the insulin. That same day, a staff meeting was held and the VA’s “updated diabetic protocol” was reviewed with all staff persons who were present. · SP1 did not attend the staff meeting on December 8, 2023, so when SP1 arrived at the facility that afternoon, SP2 reviewed the VA’s “updated diabetic protocol” with him/her. SP2 told SP1 to call him/her if s/he had any questions. · Upon hire, all staff persons were trained regarding ordering medications through a specific pharmacy and the telephone number was readily available. · On Saturday, December 9, 2023, SP1 called SP2 and asked how to sign up for the “401” saving plan. SP1 did not report any client concerns to SP2 at that time. · SP2 was not aware of any medical concerns regarding the VA until P1 called SP2 on Monday, December 11, 2023, and told SP2 the VA was hospitalized. SP1 provided the following information: · On Friday, December 8, 2023, SP1 arrived at the facility “early” for a meeting with a “supervisor.” SP1 did not recall the supervisor’s name, nor the information provided at the meeting. When asked if the VA’s diabetic protocol was covered at the meeting, SP1 again said s/he did not recall but did remember a prior occasion when P1 reviewed the VA’s diabetic protocol. · SP1 was the only staff person working at the facility on the weekend of December 8-10, 2023. SP1 had to go downstairs to the VA’s room to give the VA his/her medication including his/her insulin pen that was stored upstairs because the VA “was not coming up like [s/he] normally would.” SP1 observed the VA “just down laying in the bed.” SP1 said that s/he checked on the VA “at least once a day,” and on one of the occasions when SP1 went to the VA’s room, SP1 observed some of the VA’s pills were still sitting there because the VA had not taken them. SP1 asked the VA to take them and the VA “appeared to.” SP1 admitted that s/he did not observe the VA administering either the short or long-acting insulin pens that weekend. · SP1 was aware that when medication refills were needed, the pharmacy was supposed to be called, and refills would be delivered to the facility. SP1 was not aware that the insulin pen s/he brought to the VA’s room did not have enough insulin so SP1 did not call for a refill. Information from the VA’s November and December 2023 MAR showed the VA was supposed to check his/her blood sugar four times per day: · From November 1-16, 2023, (with the exception of November 11 and 12, 2023, when no blood sugar was documented for either day), documentation showed specific numbers for the VA’s blood sugar or a note that the VA was either sleeping, gone, or refused. · From November 17-30, 2023, documentation of the VA’s blood sugar was more sporadic. There were multiple notations stating the VA was “sleeping” and no blood sugar was documented. On November 25, 2023, the VA’s blood sugar was documented as 324 in the morning and the VA slept or refused to check his/her blood sugar again until two days later, at 11 a.m. on November 27, 2023. There was no documentation that the HCP or a physician was called. The VA’s overall blood sugar readings in November 2023 ranged from 53 to 392. · Between December 1-10, 2023, documentation showed that the VA would not get up (documented as sleeping) or refused to check his/her blood sugar sixteen times. The VA was supposed to tell staff persons his/her blood sugar readings four times per day. December 2, 2023, was the only day where the VA’s blood sugar was documented four times. On December 1, 4, and 5, 2023, the VA’s blood sugar was only documented once each day. During those 10 days in December 2023, the VA’s blood sugar ranged from 43 to 329. · The VA “refused” to administer his/her insulin aspart (short-acting) or was sleeping and did not administer that insulin twice on December 1, once on December 3, twice on December 4, four times on December 5, once on December 7, three times on December 8, twice on December 9, and three times on December 10, 2023, for a total of 18 non-administered injections during that period. (According to P2, each time the VA missed or refused any medication, the HCP should have been notified; however, P2 did not know if that occurred.) · SP1 initialed the VA’s Levemir was administered on December 9 and 10, 2023. (It was determined there was only 20 units of Levemir insulin at the facility as of Saturday, December 9, 2023, therefore, the VA could not have administered it to him/herself when the SP1 brought him/her the insulin pen.) · SP1 documented the VA’s blood sugar was 120 on December 8, 2023, at 11:22 p.m. The following day, December 9, 2023, SP1 documented the VA’s blood sugar was 273 at 12:14 p.m., and 231 at 11:09 p.m. On Sunday, December 10, 2023, SP1 documented the VA’s blood sugar was 245 at 11:18 a.m. No further blood sugar notations were made that day because the VA was “sleeping” according the SP1’s documentation. (The internal review showed that when SP1 was asked about the VA’s blood sugar numbers recorded on the MAR, SP1 admitted they were “made up” by SP1.) The VA’s Note Summary Report (shift notes) for December 8-10, 2023, written by the SP1 showed that on December 8, 2023, between 4:30 p.m. and midnight, the VA “spent the entire shift in the basement in [his/her] bedroom.” (There was no documentation for December 9, 2023.) On December 10, 2023, documentation for 6 a.m. to midnight again stated that the VA “spent the entire time in the basement and did not come out of [his/her] room.” The facility’s Health Needs Coordination Policy stated that the facility was supposed to meet the health service needs of each person being served as defined and assigned in that person’s records. This included: 1) providing medication assistance or medication administration; 2) medication documentation and charting; and 3) coordination of medication refills. The facility’s Medication Administration Learner Materials stated that when staff persons “notice that medication stock is running low (7 or less days of pills, etc.)” it was staff persons “responsibility to take ACTION.” That action included contacting a supervisor or a pharmacy directly to reorder medications. Facility information showed that staff persons were trained regarding medication administration, the VA’s diabetic protocol, and the Reporting of Maltreatment of Vulnerable Adults Act. There was no documentation that SP1 was trained on the VA’s program plans. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.11, subdivision 2, clause (3), states that the license holder must establish policies and procedures that promote health and welfare by ensuring safe medication assistance and administration. Minnesota Statutes section 245D.05: · Subdivision 1, paragraph (a), states that the license holder is responsible for meeting health service needs assigned in the coordinated service and support plan or the coordinated service and support plan addendum, consistent with the person's health needs. · Subdivision 4, paragraph (a), states that when assigned responsibility for medication administration, the license holder must ensure that the information maintained in the medication administration record is current and is regularly reviewed to identify medication administration errors. At a minimum, the review must be conducted every three months, or more frequently as directed in the coordinated service and support plan or coordinated service and support plan addendum or as requested by the person or the person's legal representative. Based on the review, the license holder must develop and implement a plan to correct patterns of medication administration errors when identified. Minnesota Statutes section 245D.09, subdivision 4a, paragraphs (a) and (c), states that before having unsupervised direct contact with a person served by the program, or for whom the staff person has not previously provided direct support, or any time the plans or procedures are revised, the staff person must review and receive instruction on the requirements as they relate to the staff person's job functions for that person. The staff person must review and receive instruction on the person's coordinated service and support plan or coordinated service and support plan addendum as it relates to the responsibilities assigned to the license holder, and when applicable, the person's individual abuse prevention plan, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. Conclusion: A. Maltreatment: According to the VA’s Intensive Support Services Assessment (ISSA), the facility was responsible for administering and monitoring the VA’s medications. The VA needed to take long-acting insulin once per day, short-acting insulin three times per day, and the VA needed to check his/her blood sugar four times per day. Information showed that multiple staff persons did not follow the VA’s diabetic protocol, did not ensure that the VA administered his/her insulin as required, did not consistently document the VA’s blood sugar, and did not refill the VA’s insulin when required to do so, which was a violation of Minnesota Statutes section 245D.05, subdivision 1, paragraph (a). This overall failure to provide the VA with diabetes care was inconsistent with the standards of professional caregivers in a facility licensed by the Department of Human Services, and it also hindered the VA’s ability to receive appropriate healthcare. Information also showed that between December 8-10, 2023, the VA “refused” to administer his/her short-acting insulin or was sleeping and did not administer that insulin 8 out of 12 times. That, along with the VA not receiving his/her long-acting insulin during that same period because it was not filled resulted in the VA needing hospitalization and being diagnosed with ketoacidosis. Although the VA refused some insulin doses, given that the VA’s long acting insulin was not available because it was not refilled as it should have been, that the VA’s diabetic protocols were not consistently followed, and that as a result the VA was hospitalized and diagnosed with ketoacidosis, there was a preponderance of the evidence that there was a failure to supply the VA with care or services which were reasonable and necessary to maintain the VA’s health and safety. 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. Given the following, the individual staff persons’ responsibility was mitigated, and the facility was responsible for the maltreatment of the VA: · The facility lacked compliance with regulatory standards and lacked oversight of policies and procedures specifically the facility’s Implement their Health Needs Coordination/Safe Medication Assistance and Administration Policy which was in violation of Minnesota Statutes section 245D.11, subdivision 2, clause (3). Despite the VA’s ongoing issues with his/her diabetes management, there was no information that anyone at the facility followed up with the VA’s physician and/or the facility HCP regarding multiple missed blood sugar checks and/or insulin doses, the VA’s refusal to take insulin as prescribed, or concerns about the VA’s self-administration of insulin. · The VA’s blood sugar was not documented or addressed four times per day as outlined in his/her protocol. Between December 1-10, 2023, the VA’s blood sugar was only documented four times on one day (December 2, 2023). · Multiple staff persons (P1, P3, SP1 and SP2) did not ensure the VA’s long-acting insulin was refilled. The facility’s actions were in violation of Minnesota Statutes 245D.05, subdivision 1, paragraph (a) and subdivision 4, paragraph (a). · SP1 worked alone the entire weekend of December 8-10, 2023, with the VA and was not trained regarding the VA’s program plans which was a violation of Minnesota Statutes section 245D.09, subdivision 4a, paragraphs (a) and (c). C. 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.” 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 maltreatment for which the facility was responsible was “serious” maltreatment because the VA required the care of a physician that included insulin infusion and fluid resuscitation on an intensive care unit. The VA was hospitalization from December 11-18, 2023. Action Taken by Facility: The facility completed and submitted a Death or Serious Injury Report as required. The facility also completed an internal review and determined that policies and procedures were adequate but were not followed, and there was a need for additional staff person training regarding the VA’s plans and diabetic protocol as well as ordering and refilling medications in a timely manner. SP2 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On July 23, 2025, the license holder was ordered to forfeit a fine of $5000 as a result of the substantiated maltreatment for which the facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal.
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