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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: 1120603-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Alice Percy 651-431-3970 Suspected Maltreatment Reported: It was reported that when a supervisory staff person (SP) left a vulnerable adult (VA) unsupervised in the staff office, the VA accessed the facility’s medicine cabinet and swallowed “two handfuls” of 500 milligram (mg) pills of Tylenol. The VA informed staff persons of the incident and the VA was taken to the hospital. Date of Incident(s): September 28, 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 5, 2023; from documentation at the facility and medical records; and through four interviews conducted with a facility staff person (P1), the SP, the VA, and one of the VA’s guardians (G). Attempts were made to contact and interview the VA’s other guardian, but the attempts were unsuccessful. The VA enjoyed dancing, listening to music, watching football games, going to the YMCA, going shopping, and spending time with friends and family members. The VA’s diagnoses included major depressive disorder, anxiety disorder, borderline personality disorder, mild intellectual disabilities, autistic disorder, attention-deficit hyperactivity disorder (ADHD), and oppositional defiant disorder. According to the VA’s Coordinated Services and Support Plan (CSSP), on September 1, 2023, the VA moved into the facility. The VA had a history of swallowing batteries, medications, and other substances. All medications were stored in a locked cabinet in the staff office. The VA relied on the staff persons to provide for his/her health and safety needs. The VA had one hour of unsupervised time in the community at specific locations and no unsupervised time at the facility. The main living areas of the facility, including the kitchen and the living room, were on the upper level of the facility. There were two bedrooms and a staff office on the lower level. Inside the staff office, a filing cabinet was used as a medication cabinet. The office door locked automatically when it was closed. The medication cabinet needed to be locked with a key. Consistent information was provided that at the time of the incident the cabinet was unlocked. According to the facility’s General Event Report, dated September 28, 2023, and completed by P1, in the afternoon, the VA had an argument with another resident. The SP took the VA to the staff office to talk about the incident and to allow the VA to have privacy from the other residents while s/he used a computer to take part in his/her therapy meeting. The SP left the staff office to ask P1 to sit with the VA during his/her therapy meeting. When the SP left the office, the VA shut down the computer and closed the office door, which locked. When P1 asked the VA to open the door, the VA did so. The VA then told P1 that s/he “overdosed” on Tylenol pills. P1 took the bottle of medication from the VA and telephoned 9-1-1 and an administrative staff person (P3). The VA was taken to the hospital, where s/he was admitted. The VA stated that on the day of the incident, s/he was alone in the staff office and was feeling suicidal, but did not tell anyone that s/he was feeling suicidal. P1 and another staff person (P2) were working at the facility at the time but were not in the staff office with the VA because they allowed the VA to have privacy during his/her weekly virtual therapy meeting. The VA stated that the SP was not at the facility at the time of the incident. The staff persons checked on the VA periodically. While unsupervised, the VA took “two handfuls” of Tylenol/acetaminophen out of the unlocked medication cabinet and “almost passed out.” At approximately 5:30 p.m., P1 checked on the VA, found the VA “overdosing” and telephoned 9-1-1. The VA was taken to the hospital, where s/he remained for approximately three weeks. P1, the SP, and the facility’s Investigation Report and Summary provided the following information: · On September 28, 2023, the SP and P2 worked at the facility. At 3 p.m., P1 arrived at the facility at the beginning of his/her work shift. That afternoon, the VA was upset after having an argument with another resident so the SP took the VA to the staff office to talk about the incident. The SP stated that s/he let the VA use the staff computer to participate in his/her therapy session and logged the VA onto the computer. At 5 p.m., the SP’s work shift ended. The SP knew P1 and P2 were on the upper level of the facility “with the television blaring.” The SP stated that s/he left the staff office, went to the stairway, and called for P1 to “switch places” with the SP. As the SP “crossed paths” with P1, the SP gave the staff office key to P1 and left the facility. The SP believed that as P1 approached the office door, the VA closed the door. · P1 stated that s/he did not recall whether the SP asked P1 to stay with the VA in the office, but after the SP gave the office keys to P1 and left the facility, P1 waited briefly for the VA to walk upstairs. When P1 did not see the VA, s/he called the VA’s name and then heard the VA in the staff office. P1 went downstairs to the office but the office door was closed and locked, so P1 unlocked the office door and the VA “shut down” the staff computer. A set of office keys was on the desk next to the VA. The VA told P1 that s/he “did something bad” and took “a handful” of pills. P1 took the bottle of Tylenol from the VA and told P2 to telephone 9-1-1 while P1 calmed the VA and telephoned P3. The ambulance arrived at the facility and the VA was taken to the hospital. · P1 stated that staff persons had a set of keys, including the keys to the office and medications cabinet, and that a spare set of keys was kept in the staff office in a blue box next to the staff computer. · Later that day, the SP received two text messages from P3 telling the SP that after s/he left, the VA locked him/herself in the office and took acetaminophen, that 9-1-1 was called, and that the VA was taken to the hospital. · The SP stated that prior to the incident, s/he “was told” that the medication cabinet did not need to be locked as long as the office door was locked. At the time of the incident, the medication cabinet was not locked. When the office door was closed, it automatically locked. The SP did not believe that anyone counted the pills remaining in the medication bottle after the incident, but the SP believed there was “still a significant amount” left in the bottle after the VA took some of the pills. The SP stated that after the incident, staff persons were required to keep the medication cabinet locked at all times. · According to the facility’s Investigation Report and Summary, while the VA was at the hospital, a hospital nurse told P3 that the hospital lab results showed that when the VA was admitted to the hospital, s/he had elevated levels of acetaminophen in his/her system and was treated with medication to reverse the overdose. Hospital Records provided the following information: · The VA’s Tylenol level was 145.3; close to the 150 level at which N-acetylcysteine (NAC) course was recommended. Hospital staff persons administered pursuant to recommendation from Minnesota Poison Control. The VA was discharged on October 6, 2023. The G stated that s/he had no concerns about the care the facility provided for the VA. According to the facility’s Policy and Procedure on Medication Administration, the staff persons were responsible for the security of the medication cabinet key, the medication cabinet/storage area, and the medications. Medications were not to be left unattended by the staff persons and the medication cabinet was to be kept locked at all times. A physician’s order was required for all medications and treatments, including over-the-counter medications. Facility documentation showed that the SP and P1 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Conclusion: On the afternoon of September 28, 2023, the SP, P1, and P2 worked at the facility. After the VA became upset because of an argument with another resident, the SP took the VA to the staff office to talk about the incident. The SP then logged the VA in to the staff computer so that s/he could participate in his/her online therapy session while the SP remained in the office with the VA. At 5 p.m., the SP’s work shift ended, so s/he called for P1 to come to the lower level of the facility to sit with the VA. P1 told this investigator that s/he did not recall the SP telling him/her to sit with the VA in the staff office, and when the VA did not follow the SP upstairs, P1 went to the office and unlocked the door. However, P1 documented in the General Event Report the SP left the staff office to ask P1 to sit with the VA during his/her therapy meeting. The VA told P1 that s/he took “a handful” of Tylenol. P2 telephoned 9-1-1 and an ambulance arrived and took the VA to the hospital. Minnesota Statutes, section 626.5572, subdivision 17, paragraph (c), clause (5), states, a vulnerable adult is not neglected for the sole reason that an individual makes an error in the provision of therapeutic conduct to a vulnerable adult that results in injury or harm, which reasonably requires the care of a physician; and: (i) the necessary care is provided in a timely fashion as dictated by the condition of the vulnerable adult; (ii) after receiving care, the health status of the vulnerable adult can be reasonably expected, as determined by the attending physician, to be restored to the vulnerable adult's preexisting condition; (iii) the error is not part of a pattern of errors by the individual; (iv) if in a facility, the error is immediately reported as required under section 626.557, and recorded internally in the facility; (v) if in a facility, the facility identifies and takes corrective action and implements measures designed to reduce the risk of further occurrence of this error and similar errors; and (vi) if in a facility, the actions required under items (iv) and (v) are sufficiently documented for review and evaluation by the facility and any applicable licensing, certification, and ombudsman agency. Although the VA was able to access a bottle of acetaminophen and take an unknown number of pills, given that it was reasonable for the VA to use the staff office to participate in his/her online therapy session, that the SP stated that s/he asked P1 to stay with the VA in the staff office when the SP left the facility, and that P1 was aware that the VA was downstairs unsupervised and checked on the VA a short time after the SP left, the SP’s conduct constituted an error in the provision of therapeutic conduct rather than neglect for the following reasons: (i) When it was observed that the VA had taken acetaminophen pills, staff persons provided care to the VA by calling 9-1-1 and having the VA taken to the hospital, where s/he was admitted; (ii) The health status of the VA returned to normal and the VA had no lasting injury as a result of taking the pills; (iii) The SP did not have a pattern of errors; (iv) The facility reported the incident as required; (v) The facility completed an internal review and implemented corrective action. (See Action Taken by Facility); and (vi) The facility’s actions as required by (iv) and (v) were sufficiently documented for review.
Given the aforementioned, it was determined that the SP’s actions constituted an error in the provision of the therapeutic conduct and were not maltreatment. It was determined that neglect did not occur (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct.). Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate, but were not followed by the SP. After the incident, all of the staff persons were retrained on the facility’s medication storage policy and supervision requirements. Action Taken by Department of Human Services, Office of Inspector General: The SP was not substantiated as a perpetrator of maltreatment of the VA because the Department of Human Services found that the incident for which the SP was responsible met the criteria to be determined an error. The SP was notified by the Office of Inspector General that any future incident of possible neglect of a vulnerable adult for which the SP is responsible might not be considered an error.
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