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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: 1071595-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported that the facility did not obtain a vulnerable adult’s (VA’s) medical records and information about his/her diagnoses from the VA’s previous residential facility, so the VA had recommended medical appointments that were not completed, and suffered a medical emergency related to the diagnosis. Date of Incident(s): December 2023 and January 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 March 20, 2024; from documentation at the facility and medical records; and through three interviews conducted with a facility supervisor (P), the facility nurse (N), and the VA. Facility documentation showed the VA was described as easy going, respectful, and got along with people well. The VA’s heritage was important to him/her, and the VA enjoyed being peaceful. The VA like to feed birds, squirrels, deer, and chipmunks. The VA was diagnosed with schizoaffective disorder, traumatic brain injury, type II diabetes, and had a history of seizures. The VA’s physical health declined over the past few years, but the VA was not subject to guardianship. The VA’s medical history included hepatocellular carcinoma (liver cancer) on August 27, 2019, and the VA had a benign tumor in his/her kidney removed. The VA was unable to independently contact a medical professional or emergency services to obtain medical attention for routine or emergency services. The facility staff persons were responsible for scheduling routine medical, dental, and psychiatric appointments, as well as provide transportation and attend appointments with the VA. Staff persons should communicate with healthcare professionals to support continuity of services and provide insight regarding possible physical and mental health concerns. Staff persons would explain treatment provided and follow up care to the VA. The VA’s client specific documentation showed s/he was on a diabetic diet and staff persons encouraged the VA to consume healthy snack options and well-balanced meals. Staff persons would monitor portion sizes and provide the VA with corresponding amount of insulin predetermined by his physician to cover any carbohydrates consumed. The VA used a Freestyle Sensor Kit which allowed staff persons check the VA’s blood sugar levels four times daily to determine the amount of insulin to be given based on carbohydrates consumed. The VA self-administered insulin shots, and needed to use a blood glucose meter to double check his/her insulin level. The VA had a history of refusing to use the blood glucose meter to determine his/her insulin level. Staff persons would assist the VA by calculating the amount of insulin to cover carbohydrates consumed. The VA moved to the facility on January 23, 2024, in part to be closer to family. Prior to the move the VA lived at a different residential facility operated by the same provider. The VA’s medical records provided the following information: · Documentation showed the VA completed laboratory tests for stage 3a chronic kidney disease on February 1, 2023, and the results showed a normal “GFR” value of 79, and normal creatine level of 1.2. · The VA attended a medical appointment on August 18, 2023, without staff persons. There was no other pertinent information within the note. · An endocrinology department appointment was scheduled for September 14, 2023. However, there was no information indicating whether the VA attended the appointment. · On November 15, 2023, the VA’s medical records noted a plan of care for the VA’s pacemaker, which included remote follow-up three times a year and one in person visit each year. The plan did not include any information of endocrinology follow-up. The VA’s (ISSA) Assessment provided the following information: · The Chronic Medical Conditions section stated concerns with the VA diabetic condition, and the VA would at times refuse to test insulin levels. There was no information within the section related to the VA’s cancer treatment. · The Preventive Screening section stated the VA needed assistance from staff persons to schedule and attend appointments. · The Medical and Dental Appointments section stated the VA required staff support in presenting concerns to doctors, and following instructions. · The Community Survival sections stated the VA did not have a good memory. The VA’s Progress Notes showed the VA moved to the facility on January 23, 2024, and the N wrote a progress note on January 25, 2025, regarding the N’s initial assessment on the VA which occurred on January 23, 2025. The N noted the VA was “very forth coming about information,” and denied having any concerns with pain or discomfort. The N reviewed all upcoming medicals appointments that had previously been scheduled, and completed a physical check of the VA’s well-being. The VA disclosed that a scar was a result of “live cancer.” The N worked on creating a plan to ensure the VA had all diabetic needs met while the VA was at the facility. Administration and nursing from the VA’s previous residential facility and the facility exchanged emails which provided the following information: · The emails included information about the VA moving facilities, and questions regarding the VA. Part of the information shared was an attachment for upcoming appointments for the VA, and login information for the VA’s “My Chart” online healthcare dashboard. · On January 23, 2024, at 9:40 p.m., the N sent an email asking if the VA completed a DXA (bone density) scan on January 25, 2024, and asked for information about the VA having a scheduled CT scan of his/her abdomen on February 25, 2024. · The nurse from the previous residential facility responded that the VA had liver cancer, and had a “gastro visit” that provided information about his/her “cancer and hep[ititis] C.” The facility’s Incident Report and the VA’s Medication Administration Record (MAR) provided the following information: · On February 2, 2024, the VA’s blood sugar was tested four times throughout the day as stated in the VA’s MAR. The blood sugar ranged between 155-183 mg/dl, with the last reading (183 mg/dl) occurring around 8 p.m. · On February 2, 2024, at 10:30 p.m., the VA was being assisted by a staff person to his/her bedroom when s/he collapsed. The VA’s blood glucose was tested and measured at 23 mg/dl. (An internet search showed a normal range for blood glucose was 72 to 108 mg/dL. Additionally, based on the VA’s measurement s/he was in a “dangerously low” level.) · The N was contacted and instructed the staff person to provide the VA with glucose tablets and juice. 9-1-1 was contacted and an ambulance arrived at the facility. The VA’s blood glucose was tested after 15 minutes and measured at 179 mg/dl. · The ambulance arrived at the facility and completely checked the VA. The VA was transported to a medical facility, and a scan was completed. It was discovered the VA had blood in his/her abdomen. The VA was later transported to a different medical facility, and it was discovered the VA had a tumor burst. A surgery was completed, and the VA was hospitalized The VA provided the following information:
· The VA said s/he previous lived at a different residential facility and the staff persons at that facility attended appointments with him/her. The VA added that s/he had not had a follow-up appointment for liver cancer for two or three years. The VA said there was a scheduling mistake and believed the appointment was rescheduled. The VA was unable to provide any further information related to the specific details related to the missed appointment. · The VA was unable to provide any information related to the staff persons involved in assisting the VA with his/her appointment while at the previous residential facility. The VA said the staff persons at the previous residential facility tried their best to assist and provide services to the VA, and added that s/he liked being at this facility and did not express any concerns with the facility. The N provided the following information: · The N said s/he felt that when the VA moved into the facility there was inadequate information regarding the VA’s health and additional communication issues during the VA’s placement. The N said the VA’s medical records showed s/he needed a liver scan since December 2022, which had not been completed. After moving into the facility, the VA had a medical emergency, which resulted in the VA being hospitalized. The N said the VA’s health and medical appointments were stabilized after the hospitalization. · During the VA’s initial intake at the facility the N completed an assessment of the VA and noted the VA did not have any visible bruising, or sores on his/her upper torso. During the assessment the VA denied being in any pain or discomfort. The N noted the VA had multiple scars on his/her upper torso, and back, as well as scars on his/her abdomen. The VA informed the N a scar was from when s/he had “liver cancer.” · The N found the VA had scheduled appointments with cardiology, dentist, gastroenterology, endocrinology, and a primary doctor. The N also found scheduled appointments for the VA’s pacemaker, and problem solved the issues with the VA’s pacemaker. The P provided consistent information as stated above regarding the VA’s move to the facility, the VA’s medical records, and the VA’s health concerns. Additional medical records from medical providers were requested to determine past appointments the VA had or were to be scheduled but the records were not received. Facility records showed that the P and the N were trained on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information showed that the VA moved into the facility on January 23, 2024, and the VA had a medical emergency on February 2, 2024, when the VA’s blood glucose level was low. The VA was hospitalized after having a surgery for a bust tumor, but the VA’s health stabilized after the hospitalization and returned to the facility. On January 23, 2025, the N completed an initial medical assessment and noted the VA did not have any visible bruising, or sores on his/her upper torso. During the assessment the VA denied being in any pain or discomfort. The N noted the VA had multiple scars on his/her upper torso, and back, as well as scars on his/her abdomen. The VA informed the N a scar was from when s/he had “liver cancer.” The N said the VA’s medical records showed in December 2022, the VA was recommended a liver scan however there was no information which confirmed whether the appointment had been completed. There was information within the VA’s medical records which showed the VA had completed other medical appointments between December 2022 and January 2024, including appointments for hepatitis C and liver cancer, kidney failure, endocrinology, and pacemaker plan of care. The VA said staff persons at his/her previous residential facility had assisted him/her with medical appointments, but the VA had not had a follow-up appointment for liver cancer in two or three years. The VA said there was a scheduling mistake and believed the appointment was rescheduled. The VA was unable to provide any further information related to the specific related to the missed appointment. Based on the information the facility was not aware whether the previous liver scan appointment was completed or whether the facility needed to schedule one. The N reviewed the VA’s medical records, completed an assessment of the VA when the VA moved into the facility, and created a plan for the VA’s medical needs. Furthermore, the medical emergency that occurred on February 2, 2024, was unforeseen as there were no signs and symptoms from the VA, it was not able to be determined if further medical care prior would have prevented the VA’s condition, and the VA had seen multiple medical providers within the past two years. Therefore, without additional information there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary healthcare and 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) Action Taken by Facility: The facility completed an internal review and determined the policies and procedures were adequate, but not followed. The facility took corrective action to ensure the VA’s well-being by updating the VA’s health care needs and trained all staff persons on the changes. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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