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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: 1121144-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh 651-431-3444 Suspected Maltreatment Reported: Allegation One: It was reported that a vulnerable adult (VA1) missed three wound care appointments and that staff persons did not adequately care for VA1’s wounds. As a result, the wounds became infected, and VA1 was hospitalized. Allegation Two: It was reported that staff persons did not provide adequate care to a vulnerable adult (VA2) including not repositioning VA2 and not getting VA2 out of bed. Date of Incident(s): Ongoing prior to June 11, 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 July 7, 2024; from documentation at the facility, medical records; and through 11 interviews conducted with three facility staff persons (P1, P2, and P3), one hospital social worker (SW1), VA1’s and VA2’s case managers (CM1 and CM2), a facility health care professional (HCP1) who was also an administrative staff person, a facility health care professional (HCP2), a community person who worked with VA2 outside of the facility (CP), VA1, and VA2. Two additional clients living in the home were interviewed but did not provide information for the investigation. This investigator attempted to contact and interview via phone and email an additional community person who worked with VA1 through another licensed facility, but s/he did not respond to the request. Information obtained showed that HCP1 was a controlling individual on the license prior to the allegations in this report. However, HCP1 said s/he was not allowed access to and did not provide direct contact services between approximately March 2023 and the end of May 2024. Facility documentation showed a “formal notice” stating HCP1’s dismissal from the company took effect on May 22, 2023. On either May 23 or 25, 2024, HCP1 obtained sole ownership. HCP1 stated that after this, s/he did not initially have access to the electronic system which contained client and personnel files. Once HCP1 gained access, s/he was still unable to obtain/find some of the clients’ and personnel documents, including VA1’s and VA2’s Support Plans and Support Plan Addendums, which were required to be maintained. This was a violation of Minnesota Statute, section 259D.095, subdivision 3, which states in part that the license holder must maintain record of current services provided to each person at the facility where services are provided or coordinated. HCP1 created client plans after the alleged incidents in this report. Facility records showed P1 was trained on VA1’s and VA2’s plans prior to the incidents in this report, however, there was no documentation to show that HCP1, HCP2, P2, and P3 were trained on VA1’s or VA2’s plans prior to the incidents in this report. This was a violation of Minnesota Statute 245D.095 subdivision 5, which states in part, the facility must maintain documentation of orientation and training of staff personnel records. Facility records showed that P1 was trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incidents in this report. Although facility records showed P2 and HCP1 were trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incidents in this report, the training was not completed within the year prior to the incidents; and there was no documentation maintained by the facility to show P2, P3, and HCP2 were trained on the Reporting of Maltreatment of Vulnerable Adults Act. These were a violation of Minnesota Statutes, section 245A.65, subdivision 3, that states in part, the license holder shall ensure that each new mandated reporter receives orientation of the mandated reporting requirements (626.557 and 626.5572—The Reporting of Maltreatment of Vulnerable Adults Act) within 72 hours of first providing direct contact and annually thereafter. Allegation One: It was reported that VA1 missed three wound care appointments and that staff persons did not adequately care for VA1’s wounds. As a result, the wounds became infected, and VA1 was hospitalized. The facility was a single-level home with a finished basement where VA1’s bedroom was located. VA1 used a wheelchair, and at the time of the site visit, VA1 was unable to access the upper level of the home from the inside and used an outdoor ramp. This was a violation of Minnesota Statutes, section 245D.04, subdivision, 3, that states in part, that a person’s protection-related rights include the right to have use of and free access to common areas in the residence. VA1’s Resident Record-Face Sheet stated VA1 was diagnosed with flaccid hemiplegia (lack of voluntary movement) primarily affecting the right dominant side, traumatic brain injury, schizophrenia, major depressive disorder, muscle spasms, nerve pain, and unspecified disorder of adult personality and behavior. VA1 was not subject to guardianship. VA1’s MnCHOICES Assessment (February 13, 2024) from the facility provided the following information: · VA1 valued his/her independence and spending time in the community going to the Mall of America, Walmart, and thrift stores. · At times, due to VA1’s diagnoses, s/he was difficult to understand and had communication difficulties such as finishing his/her thoughts. However, if prompted or given time, VA1 was able to finish his/her statements. VA1 also had “severe” short-term memory issues/confusion. · VA1 was able to call and set up transportation rides through a transportation service; however, VA1 had a history of not sharing that information with staff persons and would forget that s/he scheduled a ride. In the past, his/her transportation service was suspended due to “no shows” but was recently reactivated. · VA1’s doctor prescribed a “wheelchair with tilt” to “help remove the pressure off” a “wound.” Additionally, VA1 went to a wound clinic monthly. Staff persons were to “assist with monitoring the condition” of VA1’s wound and “provide cares to prevent skin deterioration.” (Note: There was no information regarding the location of the wound.) · VA1 needed staff persons to wheel him/her up/down a ramp at the facility to enter/exit the basement entrance. However, VA1 was able to wheel him/herself short distances. VA1’s Customized Living Rates Worksheet (March 7, 2024), provided by CM1, stated VA1 was “forgetful,” and the facility should schedule and coordinate VA1’s appointments. Staff persons were to help set up all of VA1’s appointments due to “poor concentration” and “lack of follow through.” VA1 had nursing to “monitor pressure points and a pressure sore daily.” VA1’s Individual Abuse Prevention Plan (April 15, 2024), stated VA1 was unable to walk and needed help getting from downstairs to upstairs at the facility in his/her wheelchair by staff persons. VA1 could self-wheel him/herself short distances but needed help for longer ones. VA1 needed help from staff persons to arrange and coordinate transportation and used a transportation service. As previously stated, VA1’s plans in place at the time of the incidents were not available. However, VA1’s Coordinated Service and Support Plan Addendum – Intensive Services developed August 14, 2024, after the allegations in this report, stated VA1 liked to be involved in his/her appointments and make appointments for him/herself. However, VA1 did not remember when s/he was due for a medical/dental appointment and needed staff to be present to help advocate for him/her.) VA1 said that the staff persons “do good things for me” and had no concerns with any of them. VA1 had three or four pressure sores (wounds) on his/her buttocks but did not know how long s/he had them. Unnamed persons looked at the wounds “regularly” at the facility, but VA1 did not know what kind of treatment or care was provided for them. Information obtained showed that VA1 had multiple pressure sores (wounds). In 2024, at various points, VA1 was seen by a wound care clinic and had wound care completed by facility health care professionals (HCPs). Although persons interviewed stated that prior to VA1’s hospitalization, VA1 received in-home wound care from a provider outside of the facility, there were no records found of those services between January 1 and June 1, 2024. The facility’s Incident Report Summary and HCP1 provided the following consistent information: · HCP1 said that a change of ownership/management occurred at the facility on May 25, 2024, and from that date and prior other HCPs, including HCP2, were responsible for providing wound care to VA1. HCP2 resigned on May 23, 2024, and the other HCPs were no longer working at the facility after May 25, 2024. HCP1 stated s/he did not know if staff persons had anything to do with VA1’s wound cares and HCP1 did not initially know how often VA1’s wounds needed to be checked because s/he did not have documentation regarding VA1’s plans/health needs at that time. · When HCP1 started providing direct care around the end of May 2024, the condition of VA1’s wounds were “raw” and “bleeding.” There was ointment and dressings at the facility so HCP1 cared for VA1’s wounds. However, HCP1 was concerned and called VA1’s primary doctor to let him/her know about the condition of VA1’s wounds. The primary doctor’s office said that VA1’s wound care was addressed through a wound clinic. Additionally, HCP1 learned that VA1 was “dropped” from the wound clinic because s/he was not going to his/her appointments. However, HCP1 thought it was a “misunderstanding” regarding the missed appointments and that HCP2 scheduled them, but VA1 wanted to be involved in the scheduling, and then VA1 either cancelled the appointments or cancelled the transportation rides to them. · In the morning, on June 4, 2024, VA1 was not at the facility, and HCP1 did not know where VA1 was. HCP1 attempted to locate VA1 by visiting VA1’s frequented places in the community and eventually found VA1 at an eye appointment in Champlain after calling his/her transportation service. After the eye appointment, HCP1 brought VA1 to a different Allina clinic in Coon Rapids to get a glasses prescription. At that time, HCP1 saw that VA1 was “slumped down” in his/her chair in the vehicle and HCP1 thought VA1 “fainted.” HCP1 called VA1’s name, but VA1 did not respond. Since they were already at an Allina clinic, VA1 went to urgent care at that location and was later transferred by ambulance to an emergency room and then admitted at a hospital for a wound infection. After VA1 was discharged from the hospital, VA1 received in-home wound care three to four times a week. Wound clinic records showed that VA1 received wound care beginning at least February 1, 2022. VA1’s wound clinic (WC) records dated 2024 and facility Resident Notes included nursing notes (RN/NN) provided the following information: · WC- On January 18, 2024, VA1 was seen at the wound clinic for a wound check. The visit diagnoses stated dermatitis associated with moisture from incontinence and pressure injury of left ischium (stage three). Significant improvement was noted and the RLE (right lower extremity) was healed and the remaining left IT (ischial tuberosities- sitting bones) stage three wound was healing. The After Visit Summary gave the following recommendations: o Left ischial tuberosity and buttock area: cleanse with soap and water and pat dry. Apply calmoseptine ointment or any zinc-based barrier cream to open wounds. Stop ABD (abdominal) pads—they hold moisture against the skin. o Right lower leg: daily cleanse with soap and water, then pat dry. Apply 10% urea cream moisturizer or equivalent available to the entire lower leg. Reapply the medium edema wear (extra pair sent with patient). Follow up four to six weeks. o Follow up was to be four to six weeks or sooner if any issues/concerns. A follow up appointment was made for February 22, 2024, at 10:45 a.m. · WC- On February 22, 2024, VA1 missed the appointment. The appointment was confirmed the day prior, but cancelled the morning of the appointment due to VA1 being in the emergency room “last night” for an unrelated issue. On February 23, 2024, a letter was sent to the VA stating, “This letter is written in regards to your first failed appointment and we are now concerned that you may not be receiving the care you need.” It was recommended to cancel in advance if s/he was unable to keep a future appointment. Additionally, the letter stated the clinic would send a letter after each failed appointment and that future appointments may be suspended if there are three failed appointments within a six-month period. A copy of the policy was included.
· WC- On February 29, 2024, VA1 was seen for a wound check. The After Visit Summary stated VA1 was seen for irritant contact dermatitis, pressure injury if right thigh (stage three), pressure injury of left thigh (stage three), venous stasis dermatitis of right lower extremity, psoriasis, open wound of right lower extremity (subsequent encounter), and pressure injury of left buttock (stage two). The After Visit Summary gave the following recommendations: o For VA1’s left buttock, thigh, and bilateral IT (sitting bones) areas: Cleanse with soap and water and patted dry. Apply calmoseptine ointment or any zinc-based barrier cream to open wounds. Stop use of ABD (abdominal) pads (they hold moisture against the skin). o For right lower leg: Three times per week remove old dressing and discard; wash with soap and water or wound cleanser, pat dry; to all reddened areas, apply a small steroid cream and rub in; to posterior leg wound, cut piece of alginate and apply a small bead and lodosorb, place lodosorb side to wound bed; cover 5X5 Zetuvit silicome border dressing or similar dressing; apply tubigrip to right leg for compression, use on left leg also. Try to limit time in a chair to one to three hours at a time, three times per day for meals. Follow up in wound clinic in four weeks. A prescription for steroid cream was give. o The right lower extremity was intact with one remaining wound to left IT (sitting bones). Follow up four to six weeks or sooner for any issues/concerns. o A follow up appointment was made for March 28, 2024, at 1 p.m. · WC- On March 28, 2024, clinic notes stated “checked in” at 1:36 p.m. (36 minutes late) but “left without seen.” An appointment was made for April 19, 2024, at 10:15 a.m. · WC- On March 29, 2024, the wound care clinic mailed VA1 a letter stating VA1 had two failed appointments, and the clinic was “concerned” that VA1 may not be “receiving the care [VA1] needed.” The letter also stated that VA1’s ability to schedule future appointments “may be suspended” if there were three failed appointments within a six-month period. A copy of the policy was included with the letter. · WC- On April 15, 2024, the clinic confirmed VA1’s appointment for April 19, 2024, at 10: 15 a.m. However, on April 18, 2024, at 2:49 p.m., the appointment was cancelled. Notes stated that “patient has been suspended” from the wound clinic for six months and “may return” on December 1, 2024. · WC- Although information showed VA1 was suspended from the wound clinic, on May 3, 2024, VA1 was seen for a wound check. o VA1 had edema and cellulitis of his/her right lower extremity. VA1 had an enlarging stage three pressure ulcer on the left hip, a deep tissue injury on the right hip, a stage three pressure injury on his/her left medial buttock with a mirror image on the right medial buttock, and stage two intact fluid-filled blister on the right medial buttock. Topical lidocaine was applied to the wounds and a follow up appointment was to be scheduled in four weeks or sooner if there were any issues/concerns. At that time, there was also a concern that VA1 may have a blood clot in his/her right lower leg so an ultrasound was ordered to be done that same day; however, VA1 did not get the ultrasound done that day, and instead an unnamed staff person (later determined to be HCP2) took VA1 to the lab and had a lipid panel drawn. Later that day, when it was learned VA1 did not have the ultrasound, a clinic nurse (N) called the facility, spoke to HCP2 and instructed him/her that the VA1 needed to return for the ultrasound to ensure VA1 did not have a blood clot in his/her leg. The N instructed HCP2 and VA1 to “go to admitting” at the hospital who would direct them to the ultrasound lab and if positive, VA1 would go to the emergency department for further care because the wound care clinic would be closed and there was no one on-call. o Follow up was to be four to six weeks or sooner if any issues/concerns. o In addition, on May 3, 2024, wound care instructions were given to HCP2 and VA1 which stated the following: (Emphasis in Original) Wound Location: right lower leg wounds Dressing Change Frequency: Daily 1. Wash Hands. Remove Old Dressing and Discard. Rewash Hands. 2. Cleanse wound with wound cleanser, pat dry. 3. To wound beds, cover with calcium alginate 4. Cover with ABD (abdominal) pads, secure with roll gauze and tape 5. Apply 2 layer short stretch for compression HOW TO APPLY SHORT STRETCH – Apply short stretch wraps. Start just below toes; wrap two loops around the foot, then figure 8 the ankle twice being sure to cover the heel. Then wrap in a spiral up the leg in approximately 1 inch increments. Start the second wrap in the opposite direction, just above the ankle. Wrap in a spiral, approximately 2 inches apart, to just below the bend in the knee. Apply in the morning as soon as possible after arising. Remove at bedtime when legs are elevated. May leave on overnight if desired. May wash with warm water and soap, since thoroughly, and air dry. Wound Location: Left IT (sitting bones) Wound Dressing Change Frequency: Daily 1. Wash Hands. Remove Old Dressing and Discard. Rewash Hands. 2. Cleanse wound with Wound cleanser, pat dry 3. Cut calcium alginate to about the size of the wound, paint one side with iodosorb then apply to wound bed iososorb side down. 4. Cover with zetuvit silicone border dressing ABD (abdominal) pads. Wound Location: Right posterior thigh, skin breakdown on bilateral buttocks, and small wounds on medial left buttock. Apply zinc oxide barrier cream 2x daily and as needed. · RN/NN- On May 3, 2024, a facility healthcare professional wrote that a staff person took VA1 to a clinic for a consultation with his/her primary provider and had routine lab work done. VA1’s provider had a “concern” that VA1 had a blood clot in his/her lower right leg and wanted VA1 to have an ultrasound. VA1’s legs were “seeping fluid,” swollen, and red. The clinic called the facility and said that VA1 needed to “immediately” go to the hospital for an ultrasound to rule out a blood clot. The staff person contacted an ambulance service who later arrived at the facility and took VA1 to a hospital for the ultrasound. When VA1 returned to the facility, VA1 had been prescribed doxycycline 100 mgs twice a day for 14 days for infection. Staff were updated on new orders. An order was also faxed to the facility for an air mattress for VA1 due to VA1’s skin breakdown on his/her buttocks. VA1 also returned home from the clinic with some wound dressings for the facility to use until the medical company was able to deliver dressings. VA1 was also prescribed a post-op shoe for his/her right foot to reduce inflammation, alleviate pain, and facilitate movement. · RN/NN- May 4 and 5, 2024, VA1 was checked on and “okay.” · WC- On May 6, 2024, an appointment for May 31, 2024, at 11:15 a.m. was made. On May 27, 2024, that appointment was “confirmed.” On May 31, 2024, at 11:42 a.m. that appointment was canceled and clinic notes stated, “late cancellation.”
· RN/NN- On May 6, 2024, HCP2 wrote that VA1 was sitting in his/her wheelchair “24/7” causing a recurrence of the wounds on his/her buttocks, and both legs were swollen. The order for an air mattress was sent to a medical supply company. HCP2 wrote that VA1 should be in his/her wheelchair for one hour and was to then go back to bed. VA1’s wounds needed to be dressed every day and as needed. All the wounds were dressed with clean dressing—right leg wound dressing changed with clean/dry dressing as pre order and vital signs were within normal range VA1 was “refusing to follow the doctor instructions.” (Note: There was no additional information regarding what instructions VA1 was not following.) The ultrasound for a blood clot was negative.
· RN/NN- May 7, 2024, VA1 was “okay” and was showered. May 8, 2024, VA1’s cares “were done according to [VA1’s] plan.” May 10, 2024, VA1 was “okay.” · RN/NN- On May 11, 2024, a staff person wrote that VA1 needed to go to the hospital for a “better treatment” for the “sore” on his/her buttocks. (Note: No additional information was provided.) · RN/NN- On May 15, 2024, HCP2 wrote that VA1 had a bed bath and his/her skin was clean, dry, and “intact.” Lotion was applied to the “whole skin” and “cream” to groin area. VA1’s right leg wound dressing was changed with clean/dry dressing and the wounds on VA1’s buttocks were dressed with clean dressing. VA1’s vital signs were in normal range. · RN/NN- May 16 through May 20, 2024, VA1 was “okay” and “checked” on. (Note: No additional information was provided.) · RN/NN- On May 21, 2024, HCP2 wrote VA1 had a bed bath and his/her skin was clean, dry, and intact. VA1’s buttocks were “getting bad” because VA1 stayed in his/her wheelchair “24/7” and declined staff persons directions to get out of his/her wheelchair every hour. VA1 had three wounds that were cleaned/dressed per orders. · RN/NN- On May 23, 2024, HCP2 wrote that VA1 had a shower in the morning and skin was clean, dry, and intact. VA1’s right leg dressing was changed per order and vitals were within normal range. VA1’s next wound appointment was on May 31, 2024, at 11 a.m. · RN/NN- On May 24, 2024, at 5:32 a.m., P1 wrote that VA1 “was okay.” (Note: No additional information was provided.) · RN/NN- On May 25, 2024, at 8:15 a.m., HCP1 wrote that s/he visited the facility at 8 a.m. to assess the residents. Upon arrival, HCP1 was informed by a staff person, that HCP2 resigned two days prior and there was no available paperwork or reports documenting the current status of the residents. Attempts to contact the “previous owners” were “unsuccessful.” (Note: At that time, HCP1 did not have access to the electronic system that had the previous care notes.) At 11:11 a.m. HCP1 wrote that during his/her interaction with VA1, s/he observed VA1’s bedroom and the bathroom VA1 used and there was an “offensive odor” coming from the bathroom. VA1 was assisted with a shower and provided clean clothing. At 7:51 p.m., VA1 complained of severe pain in the buttocks, rating it a 10/10. P2 told HCP1 that “dark red blood was observed oozing from both subgluteal regions, with bright red blood streaks present in the right groin region.” VA1 also had “rashes” on the “mid-distal part of the left leg.” Due to a lack of wound care supplies at the facility and unsuccessful attempts to secure an immediate appointment for VA1, an unnamed staff person obtained supplies from HCP1’s home to provide wound care. Additionally, HCP1 wrote the following instructions for VA1’s “Immediate Plan of Care”: (Emphasis in original) 1. Hygiene: [VA1 was to] shower twice daily. 2. Wound Care: Wound dressing to be conducted twice daily until a medical appointment [was] secured. 3. Brief Changed: Change briefs three times daily to maintain hygiene. 4. Mobility: Encourage ambulation and elevate the feet to improve circulation and reduce swelling. 5. Hydration: Promote abundant fluid intake to prevent dehydration. 6. Nutrition: Provide a well-balanced diet, emphasizing high-protein meals, along with [VA1’s] preferred juice. 7. Appointments: Expedite securing appointments at the wound care and pain management clinics. 8. Pain Reliver: Provide [VA1] with ibuprofen 3x a day at 8hrs interval. · RN/NN- On May 26, 2024, at 6:12 a.m., a staff person wrote that VA1 was checked on at night and was changed in the morning. VA1 was “doing good” at the end of shift. · RN/NN- On May 26, 2024, at 8:59 a.m., HCP1 wrote that VA1 was seen outside the facility “boarded a mobility van without informing staff” of his/her destination. “A quick check” of VA1’s “usual frequented locations” including a bank, grocery store, and smoke shop, “did not yield” any information on VA1’s location. At 6:28 p.m., HCP1 wrote that at approximately 5 p.m., VA1 returned to the facility s/he stated s/he went to an appointment but did not provide additional details. VA1 “exhibited agitation” including swearing and using inappropriate language toward a staff person. VA1 was assisted with a shower and his/her wound was dressed. VA1 ate a meal and later “settled comfortably in bed.” At 9:35 p.m., HCP1 wrote that VA1 was “progressing well” and engaging in “social interactions” with staff persons and residents. “Oozing has ceased, and pain has diminished slightly.” VA1 had no additional complaints and was exhibiting no concerning behaviors and continued to be “closely monitored.” The care plan remained “unchanged” and the approval for an appointment with the wound care clinic was still “pending.” At 11:40 p.m., HCP1 wrote VA1 had a “calm and uneventful” shift and enjoyed snacks. VA1 was currently “resting peacefully” in his/her room and “monitoring [was] ongoing.” · RN/NN- On May 27, 2024, at 2:45 a.m., HCP1 wrote that VA1 “appeared” to be in “good general condition today.” VA1 reported “mild pain” localized to his/her right leg. VA1 was “reassured” regarding his/her ongoing care plan, including scheduled appointments with the pain management center and the wound are clinic for further evaluation and treatment. “Monitoring [VA1’s] condition will continue to ensure appropriate management of symptoms and overall well-being.” At 1:52 p.m., HCP1 wrote that VA1 was stable and had no complaints. At 11:36 p.m. HCP1 wrote VA1 had a “stable day” and exhibited “no signs of distress.” VA1’s vital signs were monitored and remained within normal limits throughout the shift. VA1’s pain levels were assessed and VA1 reported “mild,” localized discomfort in the affected leg, which was “managed per protocol.” VA1 had “no signs of worsening symptoms, such as increased swelling, redness, or warmth in the limb … monitoring [would] continue for any signs of complications, such as worsening pain, changes in skin color, or shortness of breath, and emergency protocols [wer]e in place if needed.” · RN/NN- On May 28, 2024, at 5:48 a.m., P1 wrote that VA1 was “okay.” At 7: 32.a.m., HCP1 wrote that VA1 was “stable” and had “no complaints.” VA1’s vital signs were within normal range and VA1 was relaxing in his/her room. Staff persons continued to “monitor” VA1. At 11:09 a.m., HCP1 wrote that VA1 was informed of an upcoming appointment on June 4, 2024, with the “wound care clinic.” At 11:20 p.m., VA1 had no complaints. The wound dressings were “successfully changed by the registered nurse (RN) without complication” and VA1’s pain levels “decreased.” VA1’s care plan remained unchanged and staff persons were to continue monitoring VA1 and caring for VA1’s wounds per the established plan. · RN/NN- On May 29, 2024, at 7:29 a.m., HCP1 wrote that VA1 was “feeling improved” and requested breakfast. VA1’s wound dressings remained “clean and dry” indicating no signs of infection or complications. At 11:44 p.m., HCP1 wrote that VA1 had a “stable shift,” with care provided by HCP1 and an unnamed staff person. “Monitoring” of VA1’s condition was “ongoing.” · RN/NN- HCP1 was unable to be at the facility for two days so s/he had a temporary HCP care for VA1. On May 30, 2024, at 6:53 p.m., HCP1 was told that VA1 was “doing well” but had “mild pain” in his/her right leg. VA1 showered twice and his/her wound dressing were changed per the care plan. VA1 received “continuous care and monitoring.” · RN/NN- On May 31, 2024, at 6:50 a.m., P1 wrote that VA1 was “okay.” VA1’s wound dressings were changed according to the care plan. · RN/NN- On June 1, 2024, at 5:03 a.m., P1 wrote that VA1 was “okay.” At 7:51 a.m., HCP1 and another staff person assessed VA1 in his/her room. VA1 said s/he was “feeling great” and had a “significant reduction in pain levels” and “appeared in good health.” VA1’s vital signs were within normal range. At 1:52 p.m. VA1 “appeared cheerful” and was enjoying lunch at the dining table. At 10:58 p.m., VA1’s briefs were changed and s/he was showered in accordance with the immediate care plan. VA1 had no complaints. · RN/NN- On June 2, 2024, at 6:06 a.m., a staff person wrote that VA1 was checked on at night and was changed in the morning. VA1 was “doing good” at the end of shift. At 8:16 a.m., HCP1 wrote that VA1 reported “feeling well” and VA1 had no concerns. VA1 took a shower and his/her pain level was “tolerable.” Staff persons continued to monitor VA1. At 10:36 p.m., HCP1 wrote VA1 appeared calm and expressed no concerns. · RN/NN- On June 3, 2024, at 6:42 a.m., a staff person wrote VA1 was checked on at night and changed in the morning. VA1 was “doing good” at the end of shift. At 8:54 a.m., HCP1 wrote that an unnamed staff person asked about a “wound care appointment” for VA1 but was told that it was scheduled for the next day. VA1 “appeared well.” VA1 wore “TED stockings” on the right foot, which was clean, dry, and free of odor. VA1’s wounds showed no signs of infection and VA1 reported “minimal pain, similar to the previous day,” and had no significant discomfort when his/her foot was elevated. “Monitoring and routine care will continue as planned.” At 10:53 p.m., HCP1 wrote that VA1 was reminded about the wound care appointment for the following day. The wounds were assessed and they appeared clean. VA1 had no complaints pain. VA1 took two showers. Care and monitoring of VA1 would continue as planned and the overnight staff was asked to get VA1 ready tomorrow morning for his/her appointment. · WC- On June 4, 2024, the clinic mailed the VA a letter regarding three missed appointments: February 22; March 28; and May 31, 2024. The letter stated that “based on repeated failed appointments, which are necessary for your medical care, the [wound care clinic] has concluded it will no longer be able to provide medical services to you, for a period of six months. This is in accordance with the Failed Appointment Policy that was previously provided to you.” Once the six-month period ended on December 1, 2024, VA1 or a referring provider may contact the wound clinic to re-establish care. The letter also provided recommendations for different wound care clinics. · WC- On June 4, 2024, VA1 was seen at an urgent care for “lethargy.” On that date, a nurse practitioner from the urgent care facility called the wound care clinic regarding VA1’s condition and wound care clinic suspension. Notes stated the suspension remained implemented “per protocol.” · RN/NN- On June 4, 2024, at 5:45 a.m. P1 wrote that VA1 was “okay” and had a shower that morning. At 9:54 a.m., HCP1 wrote that VA1 was not at the facility. A call to a transportation company confirmed VA1 was picked up and transported to his/her “appointment” without staff accompaniment. An unnamed staff person “followed up” with the “clinic” to inquire about VA1’s condition. Although the clinic staff were “somewhat evasive,” some information “was obtained.” VA1 attended an eye center for a check-up. (Note: There was no information as to why VA1 was at an eye appointment when previously a wound care appointment was discussed.) At 1:31 p.m. HCP1 wrote that while enroute to pick up VA1’s eye prescription, VA1 reported “feeling unwell.” VA1 was immediately transported to urgent care for evaluation and treatment. HCP1 wrote information in the resident notes that was from the urgent care visit notes which included some of the following information: o VA1 presented to urgent care with “worsening pain and drainage from known deep tissue on the right ischium and other stage three wounds.” VA1 was dropped from the wound care clinic due to late cancellation of appointments. o The new manager started Friday and was trying to get him/her caught up on appointments. VA1’s wounds were “draining more” and were “worsening.” The facility ran out of dressing supplies. VA1 was transported to an emergency department for a “higher level of care.” · RN/NN- On June 5 and 6, 2024, HCP1 visited VA1 at the hospital. The current plan appeared to be effective and VA1 was continually monitored. · WC- On June 6, 2024, during the time VA1 was hospitalized following the urgent care visit, a care coordinator called the wound clinic to discuss lifting the wound clinic’s suspension for VA1. However, correspondence notes stated the suspension would not be lifted per policy. · RN/NN- On June 7 and 8, 2024, HCP1 visited VA1 in the hospital and observed VA1 to be “doing well.” It was anticipated that VA1 be ready for discharge in the “next few days.” Urgent care and hospital records provided the following information: · On June 4, 2024, VA1 was seen at urgent care for “lethargy” and pain related to “deep tissue wounds” and “worsening pain and drainage” from deep tissue injury on right ischium and other stage three wounds. VA1 had wounds on his/her “bottom” and “peri area.” HCP1 told urgent care staff that s/he started caring for VA1 “four days ago” when s/he “took over” the nursing care at the facility. The facility had “issues with staffing” and was “without nursing staff prior for a period of time.” VA1 was transferred from urgent care to a local hospital for further care. · When VA1 arrived at the hospital, the hospital did not have any beds available, so VA1 was transported to a different local hospital where s/he was then admitted for an infection in his/her legs, “cellulitis with infection of decubitus ulcers.” VA1 had a medical history of decubitus ulcers (chronic wounds) and psoriasis. HCP1 told hospital personnel that VA1 had wounds on lower extremities for several months but the wounds “look better now than they have previously.” · VA1 was treated for wounds on both of his/her lower legs (more prominent on right) and worsening of the chronic decubitus ulcers. VA1 was administered IV antibiotics. VA1 also had cellulitis over his/her sacral wounds as well as in the right lower extremity. VA1 had a CT (computed tomography) scan of his/her pelvis which did not show any deep space infection, fluid collections, or gas. On June 8, 2024, VA1 was discharged and prescribed cefdinir 300 milligram (mg) capsules and doxycycline 100 mg capsules, each an antibiotic, for six days. · Because VA1 had been dropped from the wound care clinic due to missed appointments, the hospital care management found a different wound clinic for VA1, but the first appointment was not until four weeks. HCP1 said s/he would do the wounds cares until then. · There were additional concerns that facility staff persons were “not routinely” changing VA1’s dressings because they “ran out” of dressing supplies. The hospital records included a current medication list which included a hook and loop garment for wound and edema management, a wheelchair cushion, gauze bandage for pressure sore and dressing changes, mupirocin ointment to apply topically to affected area for VA1’s pressure injury of skin unspecified location, triamcinolone .025% ointment for venous stasis dermatitis of right lower extremity, and Desitin ointment for right ischial pressure sore. · On June 8, 2024, VA1 was discharged from the hospital back to the facility. The facility’s medication administration records showed that from May 1 to June 4, 2024, VA1’s Mupirocin 2% ointment and Triamcinolone .1% cream was applied by staff persons as prescribed with the exception of when VA1 refused and on June 2, 2024, when the medications were “out of stock.” However, HCP1 was notified and they were applied later that same day. SW1 provided information that was consistent with the information in VA1’s hospital records. SW1 was part of the team at the hospital who helped find a new wound clinic for VA1 since s/he was terminated from the previous one for repeated missed appointments. SW1 said there was some confusion as to why VA1 was not attending the wound care appointments—according to VA1, it was the responsibility of the facility, but the facility said that VA1 had cancelled his/her transportation rides to go to the appointments. CM1 said s/he was VA1’s case manager since May 2022, and that VA1 had a history of a buttocks wound/pressure sore since at least then. On June 7, 2024, during the time VA1 was hospitalized, a social worker at the hospital (SW2) called CM1 with concerns regarding VA1’s hospitalization and wound care. SW2 said VA1 was supposed to go to a wound care clinic but had missed some appointments. CM1 was not aware of VA1 needing to go to a wound care clinic and after learning that information, CM1 was unsure if VA1 was not going to the wound care appointments because VA1 declined to go or if the facility staff was not taking VA1. However, CM1 said a home health nurse from outside the facility came to the facility approximately two times a week to check on the wound and in between those visits HCP2 would daily monitor VA1’s wound. [Note: The home health company identified by CM1 did not have records for VA1 from January 1, through June 1, 2024.] SW2 told CM1 that after the hospitalization, VA1 would continue to have a nurse from outside the facility go to the facility to care for VA1’s wounds and VA1 would also go to wound care appointments. CM1 did not know which clinic or if it was the same clinic as before. CM1 said the facility was under “new management” and that “a lot of things weren’t done” and had “fallen through,” but they were “getting things in order.” HCP2 worked fulltime typically two to three days a week and every other weekend until May 25, 2024. HCP2 took VA1 to his/her wound care clinic appointments every month and dressed the wounds every day at the facility and documented them under “nurse notes” electronically. If HCP2 was not working, two other facility health care professionals provided VA1’s wound care. Staff persons were not responsible for VA1’s wound care. During the time HCP2 worked at the facility, the condition of VA1’s wounds varied, and his/her care changed based off each wound care appointment. Appointment dates were written on a white board at the facility so staff persons could see when the appointments were. The wound care clinic scheduled the monthly appointments for VA1 and HCP2 scheduled VA1’s public transportation rides to/from them. HCP2 or another staff person rode with VA1 to the appointments but sometimes VA1 canceled the transportation without staff persons knowledge because VA1 wanted to go somewhere else. When that happened, the appointment needed to be rescheduled. HCP2 did not remember if VA1 went to the wound clinic in May 2024, but s/he recalled taking VA1 to an appointment in April 2024. Sometime prior to April 2024, VA1 received in-home wound care at the facility from an outside provider, but insurance only covered a certain number of visits so at some point, they stopped coming. The wound care clinic instructed that VA1 should not sit in his/her wheelchair all day and should get out of the chair at least once every two hours; however, VA1 refused to do so. VA1 was unable to always provide accurate information due to his/her diagnoses and would get “confused” at times. VA1 was able to say if s/he was in pain or had discomfort. P1 said s/he typically worked the awake overnight from 7 p.m. to 7 a.m. VA1 had chronic wounds on his/her buttocks and legs from “always sitting.” P1 was trained to give VA1 a shower, but the HCPs dressed and cared for the wounds. P1 heard VA1 was recently in the hospital but did not know the reason. P1 had no concerns with VA1’s wound care not being done and did not have information about VA1’s wound care clinic/appointments. P2 said s/he worked overnight the awake overnight from 7 p.m. to 7 a.m. HCP1 was responsible for VA1’s wound care and P2 was not trained to do VA1’s wound care. P2 had no concerns with HCP1’s care for VA1’s wounds. P2 knew VA1 went to a wound care clinic but did not have information about him/her not going anymore. P3 said that s/he worked 7 a.m. to 7 p.m. shifts and that only the HCPs at the facility were responsible for wound care for VA1. P3 did not know how often wound care needed to be completed but thought it was done every other day or every two days. P3 did not work every day so s/he was unsure of the frequency. Additionally, the nurse charting was separate from the staff charting so P3 did not see nurses’ notes. P3 had no concerns regarding VA1’s wound care or with any of the HCPs. The HCPs scheduled appointments and would attend the appointments with VA1. If they were unavailable, a staff person could take VA1, but P3 had never done so. There was a calendar board at the facility that had appointments listed. P3 knew VA1 had a history of cancelling his/her transportation to places. Relevant Rules and/or Statutes: Minnesota Statutes 245D.05, subdivision 1, paragraph (a), states 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. Conclusion for Allegation One: VA1 had a history of wounds that varied in stages of healing and was seen regularly at a wound clinic, and the HCPs and/or home health care were responsible for VA1’s wound care/dressing changes. In addition, VA1 often refused to reposition or change where s/he was sitting as directed by the wound clinic and offered by staff persons. VA1’s Coordinated Service and Support Plan Addendum which was in place at the time of the incidents was not available, but VA1’s Customized Living Rates Worksheet, provided by CM1 stated that the facility was responsible for scheduling and coordinating VA1’s appointments. VA1 missed wound care appointments on February 22, March 28, April 19, and May 31, 2024, for varying reasons, and was therefore dropped from the wound care clinic’s care “based on repeated failed appointments.” However, there was a lack of information regarding the details regarding why the appointments were either cancelled or rescheduled and no information provided that VA1’s wounds worsened as a result of any missed appointment. VA1 was seen at the wound care clinic on January 18, February 29, and May 3, 2024.
Given that VA1 missed several wound care appointments and that the facility was responsible for ensuring VA1 attended appointments, the missed appointments were a violation of Minnesota Statutes 245D.05, subdivision 1, paragraph (a). Although there were concerns regarding the condition of VA1’s wounds and care at the facility prior to his/her hospitalization on June 4, 2024, given that VA1 had a history of wounds; that HCPs monitored and cared for VA1’s wounds; that there was no information provided regarding why VA1 missed appointments; that the transition in administrative and supervisory functions prevented HCP1’s access to VA1’s plan information for a period of time; and that when necessary, HCP1 took action and brought VA1 to urgent care when VA1’s condition worsened, there was not a preponderance of evidence whether there was a failure to supply VA1 with 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 staff persons did not provide adequate care to a vulnerable adult (VA2) including not repositioning VA2 and not getting VA2 out of bed. VA2’s Resident Record-Face Sheet stated that VA2 was non-ambulatory and required continuous nursing care and observation. VA2’s had multiple diagnoses that included inherited muscle weakness due to spinal cord deterioration (primary), low bone density, skin inflammation, generalized anxiety disorder, major depressive disorder, disorder of nervous system, sleep disorder, skin breakdown, quadriplegia, and recurrent urinary tract infections (UTI). VA2’s Support Plan (June 13, 2024) stated that VA2 was an independent thinker and was very good at directing his/her cares and expressing his/her needs. VA2 had strong communication and computer skills. VA2 was a good self-advocate and advocate for those with disabilities. VA2 would like to see his/her health improve especially with decreasing UTIs and some healing from somewhat recent joint injuries. VA2 was a “late-night” sort of person and generally stayed up until about 2 a.m. When VA2 woke up, s/he had his/her medications and ate lunch with assistance from staff persons. VA2’s Individual Abuse Prevention Plan (March 3, 2024), stated VA2 was unable to walk due to tetraplegia (quadriplegia) and used a power wheelchair for all mobility. Due to VA2’s diagnoses s/he required assistance with turning and repositioning every two hours when VA2 was in his/her bed. VA2 was to “offload” (get out of his/her chair) every one hour when VA2 was in his/her wheelchair and “as requested.” Additionally, a Hoyer lift was used for daily transfers and two staff persons were needed to assist in transfers including into and out of bed. VA2 had an indwelling catheter due to neurogenic bladder and urinary retention. The facility managed the indwelling foley catheter daily. Staff persons were to remind VA2 when it was time for his/her medication administration and a nurse would ensure that medication was ordered in a timely manner and set up according to schedule. VA2 was not subject to guardianship. VA2 provided the following information in his/her interview and in a document s/he provided: · VA2 was concerned about a lack of staffing at the facility and said that there were a “few occasions” when there were not “at least two trained and capable staff members available to provide timely assistance for residents’ health, safety, and dignity needs.” VA2 recalled two approximate dates when that occurred: June 6 and 9, 2024, when there were not enough staff persons available. VA2 was concerned that s/he was not notified of staffing shortages in a timely manner so s/he could plan ahead and work with staff persons to “accommodate the satisfaction of each other’s needs.” · VA2 required repositioning approximately every one to two hours when awake and approximately every three hours when s/he was sleeping. If VA2 needed repositioning, s/he called staff persons for assistance using a voice activated speaker. Even though two persons were supposed to reposition VA2, one staff person could do it if the staff person had “a lot” of upper body strength, but some staff persons were unable to reposition VA2 without help. VA2 also said s/he was “not extremely” concerned about the staff shortage, because at the time, s/he had no open pressure sores and only some pain/discomfort that was “difficult to resolve.” On June 6 and 9, 2024, VA2’s significant other came to the facility to help VA2 out of his/her bed because HCP1 was the only staff person working. Shortly after June 9, 2024, staffing started to “stabilize.” · VA2 did not remember any specific dates but there were “a lot of days” when VA2 “stayed in bed all day” due to feeing “frustrated,” “depressed,” “having headaches,” and/or “hip pain.” VA2 said it was his/her choice. When asked if s/he was ever in bed all day when it was not his/her choice, VA2 said, “No,” only if one staff person was at the facility it might be delayed by a couple hours until another staff came or VA2’s significant other could come help, but VA2 had “never been denied” the opportunity to get out of his/her bed and into his/her wheelchair. The CP said VA2 moved into the facility sometime around May 2023 and at some point, VA2 told the CP that s/he was being positioned inappropriately and spending too much time in bed due to not enough staffing. VA2 relied on staff persons to position his/her body and two staff persons were required to lift VA2 out of bed. HCP1 said that the end of May beginning of June 2024, hiring staff was “very difficult” and HCP1 worked to onboard new staff persons. Two staff persons were needed at the facility “at all times.” During that time, HCP1 was at the facility “8 to 10 hours almost every day” as the “second staff.” Although two staff persons were scheduled to work at a time, due to staffing challenges, there were times when there was only one staff. VA1 required two staff persons for a “total turn” for repositioning. HCP1 had no concerns with staff persons not repositioning VA2 when needed. On July 7, 2024, one staff person who was scheduled to work called in so HCP1 was the sole staff person at the facility. HCP1 called in another staff person, who then came to the facility to help reposition VA2. HCP1 was not aware of any injury to VA2 due to lack of staffing/repositioning and since HCP1 began providing direct care (May 2024). HCP2 said “every part” of VA2’s body had pain and VA2 required two staff persons at the facility. VA2 required repositioning every two hours or when s/he requested. During the time HCP2 worked at the facility (prior to May 23, 2024), there were always two staff persons working unless someone called in and then a backup staff person was called to come in and did so.
P1 said VA2 “instructed” staff persons on “everything” and VA2 knew what s/he wanted and called for assistance when needed. P1 always worked with another staff person and had no concerns that staff persons were not repositioning VA2 when needed. If VA2 did not “trust” someone, s/he would not let that person do his/her care. P2 said VA2 needed “total cares” and needed to be repositioned every two hours. At times, VA2 called for staff persons to reposition him/her more frequently than every two hours. Two staff persons were needed to reposition VA2 when s/he was in his/her bed, but only one staff person was needed to reposition VA2 in his/her wheelchair. If P2 was alone at the facility, s/he waited until another staff person arrived to reposition VA2. P3 said that two staff persons “always” worked at the facility and s/he had no concerns with a lack of staffing during the time s/he worked. VA2 needed repositioning every two hours by two staff persons. VA2 also notified staff persons when s/he needed care including repositioning. CM2 said started working with VA2 on approximately May 22, 2024. CM2 was aware of a concern that sometime around the end of May 2024 or the beginning of June there was a lack of staffing that impacted VA2’s cares and repositioning. Sometime prior to August 19, 2024, VA2 told CM2 that that the staffing was “now okay,” and that lack of staff was no longer a concern. VA2 needed two staff persons to assist with transferring but only one staff person to reposition when VA2 was in his/her wheelchair. VA2 was “really good” at “directing” his/her own care and made sure to let staff persons know what s/he needed and how s/he needed it. Facility staff schedules for May 1, to July 31, 2024, showed that two staff persons were scheduled at all times with two shifts, one from 7 a.m. to 7 p.m. and one from 7 p.m. to 7 a.m., with the exception of June 8, 2024. On June 8, 2024, HCP1 was scheduled 7 a.m. to 7 p.m., P2 was scheduled “(1-7),” and two staff persons were scheduled from 7 p.m. until 7 a.m. the following day. HCP2 and another staff person were scheduled 7 a.m. to 7 p.m. on May 28, May 31, June 1, and June 2, 2024. However, May 28, 31, June 1, and June 2, 2024, were dates when HCP2 no longer worked at the facility. The schedule did not reflect HCP1’s hours. Facility time entry records from May 1 through June 10, 2024, showed that at least two staff persons were at the facility except for the following dates/times: (Note: HCP1 stated that the end of May/June 2024, hiring staff was “very difficult” and s/he worked to onboard new staff persons. During that time, HCP1 was at the facility “8 to 10 hours almost every day” as the “second staff” and the time entries below do not include all the dates/times when HCP1 was at the facility.) · On May 25, 27, and 28, 2024, two staff person worked at the facility; however, there was no information to show what time P3 clocked out (clock-out time was blank). · On May 29, 2024, one staff person worked from 7:03 a.m. to 7:05 p.m. · On June 1, 2024, one staff person worked from 7:22 a.m. until 6:46 p.m. · On June 2, one staff person worked from 8 a.m. until 2:44 p.m. · On June 3, 2024, one staff person worked form 8:08 a.m. until 6:44 p.m. · On June 4, 2024, one staff person worked from 7:01 a.m. until 2:23 p.m. · On June 5, 2024, one staff person worked from 7:07 a.m. until 6:58 p.m. · On June 6, 2024, one staff person clocked-out at 8:07 a.m. and another staff person did not clock-in until 2:46 p.m. · On June 7, 2024, one staff person worked from 7:09 a.m. until 6:22 p.m. · On June 8, 2024, one staff person clocked out at 9:31 a.m. and another staff person did not clock-in until 12:58 p.m. · On June 9, 2024, one staff person worked from 7:17 a.m. until 7:10 p.m. · On June 10, 2024, one staff person worked from 7:25 a.m. until 2:43 p.m. Conclusion for Allegation Two: Information from all sources was consistent that VA2 required two staff persons to reposition and/or transfer him/her but one staff person could reposition VA2 when s/he was in his/her wheelchair. There were concerns which were verified by time records that on occasion from May 1 through June 10, 2024, there was only one staff person working. HCP1 stated that during that time hiring staff was “very difficult” and HCP1 worked to onboard new staff persons. In addition, during that time, HCP1 was at the facility “8 to 10 hours almost every day” as the “second staff.” Although there were likely occasions when only one staff person worked, given that VA2 said s/he was never in bed all day unless it was his/her choice; that if there was only one staff person working, VA2’s repositioning/transferring was delayed by a couple hours or VA2’s significant other came and assisted; that HCP1 stated s/he was at the facility “8 to 10 hours almost every day” as the “second staff;” and that there were no injuries to VA2 as a result of a lack of staffing, there was a not a preponderance of evidence whether there was a failure or omission to supply VA2 with the care that were reasonable and necessary to maintain his/her physical or mental health or 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 stated that their policies and procedures were adequate and followed. All staff persons underwent comprehensive retraining that encompassed the facility’s policies and procedures, the Reporting of Maltreatment of Vulnerable Adult’s Act, and the clients plans/medical needs. Action Taken by Department of Human Services, Office of Inspector General: On August 20, 2025, a Correction Order was issued for violations outlined in this report.
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