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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: 1079435-H_CRS (Home and Community-Based Services-Community Residential Setting) 1068807-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a staff person (SP1) provided a vulnerable adult (VA) with spoiled food, and the VA had to be seen at an emergency room. After being discharged from the hospital a staff person (SP2) did not secure prescribed medications. A bottle of liquid antacid (Maalox) was found in the VA’s bedroom along with two unopened pill bottles. Additionally, it was also reported SP2 did not lock the staff office, and the VA obtained food from inside the staff office. Date of Incident(s): January 1, 2025 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on January 22, 2025; from documentation at the facility; and through five interviews conducted with the VA, a facility supervisor (P), the VA’s guardian (G), and SP1-SP2. Facility documentation showed the VA enjoyed going to the movie theater, walking in the community, playing basketball, bowling, and attending church. The VA had a good relationship with his/her family and talked with a family member almost every day. The VA valued being independent, and staff persons supported the VA by assisting him/her in making good decisions. Staff persons provided medications to the VA and ensured his/her safety. The VA advocated for him/herself and was “good” at requesting assistance from staff persons. The VA’s Self-Management Assessment provided the following: · Staff persons completed daily room checks to ensure the VA did not have or store food items in his/her bedroom. · The VA was diagnosed with anxiety and Prader-Willi syndrome. Due to the diagnosis the VA was on a diet plan of 1100 calories per day. The diet included “specific soft diet” due to prior bowel obstruction surgeries. · According to www.mayoclinic.org, Prader-Willi syndrome was a rare genetic condition that led to physical, mental and behavioral symptoms. A key feature of Prader-Willi syndrome was a sense of being hungry all the time, and people diagnosed with Prader-Willi Syndrome wanted to eat all the time because they never felt full. The VA’s Support Plan Addendum – Intense Services and Self-Management Assessment provided the following consistent information: · The VA was provided 1:1 staff person supervision, and the facility was responsible for the VA’s medication administration. The medications were located in a locked closet which was inside of the staff office. The VA required staff persons monitoring when using the stove, the microwave, and other potentially dangerous equipment. The VA did not have any community or facility unsupervised time, and the VA required staff persons supervision at all times. The VA was to be “visible to and monitored by staff” persons, including when s/he was taking a shower. Staff persons would complete routine bedroom checks when the VA was in his/her bedroom. The bedroom checks included “night checks.” · The VA had a history of bowel obstruction, was hospitalized several times in the past with partial bowel obstruction, and was “always a risk for surgery.” The VA had a restriction of rights related to food to ensure the VA’s health and safety; all food at the facility was kept in a locked area due to the VA’s diagnoses of Prader-Willi syndrome. Staff persons checked the VA’s bedroom daily to ensure the VA did not have or store food items in his/her bedroom. The VA’s Individual Abuse Prevention Plan showed the VA was susceptible to self-abuse due to behaviors associated with his/her diagnosis of Prader-Willi syndrome. Staff persons needed to be in proximity of the VA “except in [his/her] home’s bedroom, bathroom, and common areas.” The facility staff person schedule showed that SP2 worked from 3 to 11 p.m., on January 1, 2025 and from 3 to 11 p.m., on January 5, 2025. The VA provided the following information: · The VA said there was a day s/he ate salmon and vomited thereafter. The VA said s/he cooked the salmon, and believed it was cooked thoroughly. The VA added that a staff person checked the salmon to ensure it was fully cooked. The VA did not share any information that s/he consumed spoiled food. · The VA said SP2 took him/her to the emergency room visit and after returning to the facility the VA obtained medications that SP2 did not put away that were left on a counter. The VA said s/he hid the pill medications in his/her bedroom near his/her dresser and later drank half of the bottle of liquid antacid. The VA added that after consuming the liquid antacid s/he did not require any medical intervention. · The VA said SP2 did not lock the staff office, and s/he obtained oatmeal, pudding, pickles, and crackers without SP2’s knowledge. The VA said SP2 was on his/her phone in the living room when s/he obtained the food. The VA said s/he hid the food in his/her bedroom and ate the food during an overnight. · The VA was unable to provide a clear timeline of the alleged incidents and did not know the dates. Medical records provided the following information: · The VA was seen at an emergency room on January 1, 2025, at 5:45 p.m., due to an episode of nausea and vomiting. The VA informed medical professionals s/he had vomited three times, and had “burning pain” in his/her chest. The VA’s vitals were reviewed and were within normal limits. The VA was observed, and it was noted the VA did not appear to be in distress, or ill. While at the medical facility the VA was provided medication intervention of oral Pepcid, Zofran, and a “GI cocktail,” and discharged from the medical facility. It was noted the VA was diagnosed with nausea, vomiting, mild dehydration, “burning in the chest,” and gastrointestinal symptoms. The VA was prescribed Famotidine (Pepcid) tablet, Ondansetron (Zofran) tablet, and Aluminum-magnesium hydroxide-simethicone (Maalox Plus) liquid. It was noted the prescribed medications were “as needed for the next few days.” · The VA was admitted to a medical facility on January 6, 2025, due to abdominal pain and nausea. It was noted the VA was “typically on a mechanical soft diet,” but had consumed “a number of snacks, including chocolate, crackers, and chips, as well as about half a bottle of Mintox antacid.” The VA allegedly consumed the food around midnight, and had abdominal pain when s/he woke up at 8 a.m. The VA was admitted to the medical facility for further management and observation due to ongoing pain, complex medical history, and cognitive impairment limiting home monitoring. While hospitalized the VA had “several large bowel movements,” and did not experience nausea or abdominal pain. The VA was discharged on January 9, 2025, and was prescribed an increase of “frequency of Milk of Magnesia to every day and doubling the dose of Senna.” The VA’s Medication Administration Record (MAR) showed the VA started taking the prescribed medications on January 11, 2025. The facility completed an Internal Review, which provided the following: · On January 1, 2025, SP1 was working 1:1 with the VA. The VA ate lunch and after eating s/he worked on artwork. While doing a craft some beads fell to the floor in the living room, and the VA attempted to pick up the beads. The VA vomited while picking up the beads, and requested to contact the G. Thereafter, it was determined the VA would be seen at an emergency room. SP2 arrived at the facility at 3 p.m. and was instructed the VA needed to go to an emergency room. · SP2 transported the VA to the emergency room, the VA was seen by a medical professional and discharged with prescribed medications. · Upon returning to the facility SP2 told the VA to bring the medication inside the facility, and the VA said SP2 forgot to take the medication from the VA after they were inside. The VA said s/he kept the medications and hid the medication from SP2. The VA also said SP2 was on his/her phone and had left the staff office door open at which time the VA accessed the food inside the staff office. · The P said s/he spoke with SP2 after s/he arrived back to the facility with the VA, and they discussed the emergency visit, and SP2 said there was not a medication prescription. · On January 6, 2025, at 7 a.m., an overnight staff person observed the VA had food on his/her face and clothing. The staff person found food wrappers, and medications on the VA’s bed. Thereafter the VA was seen at an emergency room. During a conversation the VA told the G that s/he had ate spoiled food for dinner, as the food had been in the fridge for days and the food had not been checked by staff person to ensure it was properly cooked. The VA also told the G that s/he told SP1 that his/her food was spoiled, but SP1 told him/her to eat the food. The P said after the incident, s/he spoke with SP2, and SP2 said s/he forgot the VA had been prescribed medications during the emergency room visit. · SP1 denied providing the VA with spoiled food for dinner at any time. The P provided the following information: · The P said the VA was seen at an emergency room twice in early January 2025, due to issues with food. The P did not believe the VA was provided with spoiled or under cooked food, and did not have concerns with the care and services SP1 provided to the VA. · The P spoke with SP2 on January 1, 2025, after SP2 and the VA went to an emergency room. SP2 told the P there was no medication changes. However, the P said on January 6, 2025, a liquid antacid, and two unopened bottles containing pills were found in the VA’s bedroom. The P said the VA drank half of the liquid antacid, and there was no additional information about the unopened containers of pills. The P spoke with SP2 after the items were found, and SP2 stated s/he had asked the VA to hold the medications, and thereafter SP2 forget about the medication. · Additionally, the P believed SP2 had left the staff office door open, and the VA was able to obtain chips, oatmeal, and crackers. The P said the VA had difficulty digesting those types of foods, and the VA ended up being hospitalized for three days due to the incident on January 6, 2025. The P did not provide a timeline of when the VA obtained the food. The P said staff persons completed room checks on a daily basis. SP1 provided the following information: · SP1 denied providing the VA with any spoiled or undercooked food. On January 1, 2025, SP1 observed the VA picking up his/her beads, and the VA vomited. SP1 did not believe the vomit was due to the food the VA had for lunch. · SP1 did not have any firsthand knowledge of the VA obtaining medication or food from the office. SP2 provided the following information: · SP2 said s/he took the VA to an emergency room and obtained medications which were pills from the hospital. SP2 said s/he kept the medications in his/her pocket as s/he was not sure what to do with the medications after returning to the facility. SP2 said they arrived back to the facility around 8:30 p.m., and the VA ate food before going to bed. Prior to leaving the facility SP2 put the medications on a table in the living room and asked an overnight staff person to put the medications away. SP2 was unable to provide the overnight staff person’s name and said s/he only worked at the facility for a few days. (There was no other information obtained which showed an overnight staff was aware of the medications.) · SP2 said s/he was only employed at the facility for a few days, but had access to the P’s cell phone number, but did not ask him/her where to put the medications. SP2 said s/he talked with P, and SP2 told the P the VA did not take any items while SP2 was working. · SP2 said s/he was aware the food at the facility was kept in the locked staff office due to issues with the VA eating. SP2 said s/he always had the staff office keys on his/her person, made sure the staff office door was locked, and the VA did not go inside the staff office while SP2 was working. · SP2 was not aware of the VA eating spoiled or undercooked food at the facility. The G provided the following information: · The G said the VA told him/her that s/he ate some salmon that was not fully cooked. Thereafter, the VA got sick and was seen at an emergency room. · The G said the VA told him/her after being discharged from the emergency room SP2 gave the VA the prescribed medications which included two bottles of pills, and a bottle of liquid antacid. The VA later drank some of the liquid antacid. · The VA also told the G that SP2 had left the staff office door open, and the VA obtained food from the staff office. The VA was hospitalized as a result of incident. The P, SP1, and SP2 were each trained on Reporting of Maltreatment of Vulnerable Adults Act, and the VA’s client specific documentation. The training included a review of the VA’s rights, and current and relevant medical history, as well as information related to contacting supervisors, the location of keys to the medical cabinet. Conclusion: A. Maltreatment:
Regarding the VA consuming spoiled or under cooked food: The VA informed the G that s/he ate salmon that was not fully cooked, however, during the interview with this investigator the VA said s/he cooked the salmon and it was cooked thoroughly, and did not provide any information s/he had consumed spoiled food. SP1 denied providing the VA with spoiled food, and did not believe the VA had eaten undercooked food. There was no other information the VA ate spoiled or undercooked food. Given the above it was not determined why the VA vomited or whether it was related to food not being fully cooked. Therefore, there was not a preponderance of the evidence whether SP1 failed to provide the VA with reasonable and necessary care. 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). Regarding the VA obtaining food that was stored in the staff office: According to the VA, SP2 did not lock the staff office, and the VA obtained oatmeal, pudding, pickles, and crackers without SP2’s knowledge. The VA said SP2 was on his/her phone in the living room when s/he obtained the food, and the VA hid the food in his/her bedroom but the VA did not know which date this occurred. Sometime overnight on January 5 and 6, 2025, the VA consumed the food and required hospitalization. SP2 denied leaving the staff office unlocked, and did not believe the VA accessed the food inside of the staff office while s/he was working. Although the VA stated SP2 left the office door open so that the VA could obtain food items which s/he consumed and subsequently was hospitalized, the VA did not know when the door was left unlocked so it was not able to be determined when the door was unlocked and when the VA accessed the food so it was not known if other staff persons were working at the time who could have also been responsible for locking the door. Given it was not able to be determined who was responsible for locking the door at the time the VA accessed the food, there was not a preponderance of the evidence whether SP2 failed to provide the VA with reasonable and necessary care 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). Regarding the VA obtaining medications: On January 1, 2025, the VA was seen at an emergency room as s/he had vomited. SP2 was present during the emergency room visit, and the VA was prescribed medication. On January 6, 2025, these medications were found in the VA’s bedroom. SP2 said s/he was not aware of what to do with the medications upon returning to the facility, and kept the medications on him/her until the VA went to bed. SP2 said s/he put the medications on a table in the living room, and asked an unknown staff person to put them away. The P spoke with SP2 after the emergency room visit, and SP2 did not inform the P about any new medications. Additionally, the P said s/he was informed SP2 had the VA hold onto the medications. The VA said SP2 did not put away the medications, and left the medications on a counter. The VA said after s/he obtained the medications s/he hid them in his/her bedroom, and later drank half of the bottle of liquid antacid. There were also two unopened bottles pills of found in the VA’s bedroom. There was no medical intervention required after the VA ingested the medication. Given SP2 did not properly store the VA’s medications so the VA had them in his/her bedroom and consumed half a bottle of liquid antacid and was at risk of consuming more of the liquid and the two bottles of pills, there was a preponderance of the evidence that SP2 failed to provide the VA with reasonable and necessary care and services to maintain the VA’s physical health or 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. SP2 was trained on the VA’s client specific documentation, was aware of the VA’s supervision requirements, and was responsible for the care and supervision of the VA on January 1, 2025. Therefore, SP2 was responsible for the maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which SP2 was responsible was not “recurring” maltreatment because it was a single incident and was not “serious” because the VA did not require the care of a physician. Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, but not followed. The report was not similar to past events. SP2 no longer worked at the facility. The facility retrained all staff persons on working with the VA, and no further corrective action was taken to ensure the safety of the individuals. Action Taken by Department of Human Services, Office of Inspector General: SP2 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP2 was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of SP2. The determination that SP2 was responsible for maltreatment is subject to appeal.
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