|
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: 1120398-HCBS (Home and Community-Based Services) Investigator(s): Emily Kearns 651-431-6513 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) ingested an unknown amount of an unknown medication, that the VA had slurred speech and difficulty walking for several days, and that the VA refused to go to the hospital. It was also reported that staff persons did not contact emergency services to address the VA’s health concerns and did not report the incident. Date of Incident(s): April 18 to April 22, 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 May 7, 2025; from documentation at the facility and through six interviews conducted with a supervisory staff person (P1), two facility staff persons (P2 and P3), two of the VA’s case managers (CM1 and CM2), and the VA. The VA’s plans stated that s/he was diagnosed with schizoaffective disorder, bipolar disorder, unspecified mood disorder, and had a history of self-injurious behavior. The VA enjoyed being around his/her cat, going for walks, painting, listening to music, and being outdoors. The VA was not subject to guardianship, was over the age of 21, and lived in his/her own apartment unit in a building that was to be staffed 24/7 by staff persons. The VA’s plans stated that the VA “required a 24-hour on-site staff person.” The facility’s Program Abuse Prevention Plan stated that the facility “maintains a consistent staffing pattern designed to ensure adequate supervision and support 24 hours a day. The program operates with awake overnight staff and a rotating team of trained direct support professionals during daytime and evening shifts,” and “The program maintains 24/7 staffing with awake overnight coverage to ensure individuals are never left unsupervised in the facility.” The VA’s plans stated that if the VA needed medical or psychiatric care, staff persons were to call 9-1-1. The VA was at-risk for “cutting” him/herself when stressed and would sometimes “overtake medication” during a mental health crisis. The VA received Integrated Community Supports (ICS) services with five hours of in-person services and two hours of remote services, seven days per week. According to the VA’s support plan, staff persons assisted the VA with “instrumental activities of daily living,” such as transportation, shopping, medication management, financial management, health interventions, eating and meal preparation, cleaning, activities, and companionship. The VA provided the following information: · On Friday, April 18, 2025, the VA was with P2 and had been having a “good day.” At around 6 p.m., a few hours after P2 left, the VA began to get into a “depressive” state. Sometimes this happened “gradually” and sometimes, “it came on like a bull.” On that day, it came on “sudden[ly].” The VA was unable to get in touch with a family member and P1 was not available to come help the VA. The VA had bottles of medications that s/he brought from his/her prior living arrangement that staff persons were unaware of. The VA took a “whole bottle” of Klonopin (a medication to treat panic disorders) and a “whole bottle” of trazadone (a medication to treat depression) between 10:30 – 11 p.m. on Friday, April 18, 2025. The VA “came to” on Monday, April 21, 2025. The VA also described the ingested number of pills as “a handful.” The VA was unsure how many pills s/he ingested. · On Monday, April 21, 2025, the VA was still “a little bit wobbly” on his/her feet from taking the medications but was “feeling good.” The VA stated that s/he had been prescribed and taking medications his/her “whole life” and had a “high tolerance” to medications. · The VA stated that P1 and P2 checked on the VA over the weekend. The VA recalled answering the door and thought it was Saturday, April 19, 2025, but did not recall what was discussed with P1 or P2. The VA stated that s/he “could not recall much.” The VA was not always able to recall details because of the medications’ side effects. The VA later stated that when P1 came over on April 19, 2025, P1 told the VA, “You’re not looking good,” and that P1 wanted to bring the VA to the hospital. P2 visited the VA and said that s/he could tell that “something was up” but the VA refused help. · Staff persons did not have “any idea” about the “stashed” medications and “did everything in their power” to ask and attempt to take the VA to the hospital on April 19, 2025, but the VA “refused” to go to the hospital, which was the VA’s decision. On Monday, April 21, 2025, the VA woke up and called P1 to tell P1 what happened. P1 went to the VA’s apartment right away. After the VA told P1 about the incident, P1 did “everything correct[ly]” and contacted CM1 And CM2. The VA “felt totally safe.” · P2 was scheduled to provide services to the VA on Thursdays through Mondays, arriving at around 9 a.m. and staying until 3 or 4 p.m., with every Tuesday and Wednesday off. The VA sometimes called P2 to tell him/her that s/he “could just be on call” if the VA woke up not feeling well or when the VA’s “other alter [ego]” took over. The VA’s “other alter [ego]” was “not [a] nice [person].” The VA self-described him/herself as having a “very short fuse” with staff persons when s/he was in that mood and could “snap on someone.” The VA was not “physical” with others during these moods, but s/he wanted to prevent him/herself from getting upset at others, so the VA had P2 be “on call.” The VA did not know where P2 was while s/he was “on call” and was unsure if P2 was in the facility office. The office space was obtained for staff persons about a month prior. The VA said that s/he suggested that P1 get the office space and hire an overnight staff person to be available but the VA was unsure if anyone was scheduled to work in the office during overnights currently. The VA called P1 or other supervisory staff persons if s/he needed something after P2 went home. · When the VA was in the “depressive” aspect of bipolar disorder, s/he needed a staff person that would try to “cheer” him/her up and get him/her out of “that headspace.” The VA wanted to have staff persons that were “bubbly.” The VA “loved [P2] like a little [sibling],” and P2 was “supportive,” but P2 was “timid,” “quiet,” and would “watch” the VA when s/he was in “those moods.” The VA needed someone who was more “talkative.” The VA stated that there were some “big signs” that indicated when s/he was starting to “get depressed.” The VA would begin to withdraw and become “really quiet,” or turn away staff persons from coming to provide services. · The VA’s medication was distributed through a medication dispenser. The dispenser had a screen which allowed the VA to get medications “as needed” or scheduled. The VA could get an early dose or get a missed dose. The VA could also get refills approved through the dispenser and the machine set various reminders to take medications. The VA had not had the machine very long and the initial medications were set up by someone who did not work for the facility. P1 and P2 were not “medication certified” and so the VA was to fill the dispenser while staff persons watched the VA. P2 provided the following information: · P2 worked with the VA on April 17 and 18, 2025. On April 17, they watched TV, went for a walk, and went for a ride. P2 worked from 10 a.m. to 3 p.m., like s/he did on “most days,” and the VA’s mood was “fine.” On April 18, 2025, they went for a ride and the VA wanted to go to the pawn shop to trade in his/her TV, but they did not accept the TV. P2 offered the VA to go for a car ride to calm the VA and they went for a ride. · On April 19, 2025, at about 9:40 a.m., P2 missed a phone call from the VA but “immediately” called back. The VA told P2 that s/he was about to send P2 a text message stating something along the lines of, “I was just about to send you a message to let you know not to come back to work, assuming you hadn’t call[ed] me back this quickly.” The VA then asked if they could drive to the cities when P2 arrived to see a friend of the VA’s but P2 began to tell the VA that it was “sudden notice” and “long distance,” and suggested waiting until Monday, April 21, 2025. The VA “refused” the suggestion and was “very upset.” The VA stated that if P2 could not take him/her to the cities, P2 should “never [come] back to work again,” then “hung up” on P2 while s/he was talking. · P2 then called the VA back, but s/he did not answer. P2 then went to the VA’s apartment and knocked. When the VA opened the door, the VA told P2 to leave and was “very stressed.” Several attempts were made by P2 to reach the VA by phone again, but the VA was unreachable. P2 then called P1 and told P1 and “that was it.” The VA was not slurring words and was not standing unevenly. P2 said when the VA asked P2 to leave, that s/he would notify P1 and P1 would usually “follow up” with the VA by calling or visiting. · The VA no longer wanted P2 to work with him/her and P2 had not worked since April 19, 2025. P2 did not know who was providing service hours to the VA and said that it was maybe P1. P2 did not know who else worked with the VA. P2 stopped by to see the VA one day recently and the VA said s/he was “fine.” · P2 heard that the VA ingested “old” medications recently but did not know more about the incident. P2 did not know that the VA had “old” medications, and the VA never “threatened” to take a lot of medications before. P2 had never witnessed the VA hurting him/herself in the past. The VA would sometimes tell P2 after the fact. · P2 was not trained to help with the VA’s medications and the VA did not take medications when P2 was there. P2 thought that there was a staff person assigned to the building but did not know if other clients receiving services lived at the building. · P2 stated that s/he was scheduled to work with the VA every day except Tuesdays and Wednesdays. The VA would tell P2 if s/he wanted P2 to be with the VA or would tell P2 to “stay at home.” The VA would call P2 when s/he “needed to” or would ask P2 to come in at a certain time. P2 provided in-person services to the VA, typically for five hours, unless the VA “preferred” P2 to “work from home.” P2 typically took the VA for rides, cleaned, ran errands, watched TV, and listened to music with the VA, but did not “control” medications. The VA called P2 sometimes to help with errands on Tuesdays and Wednesdays, which were P2’s days off. P2 did not know what “remote hours” meant and described them as working with the VA, when the VA “needed” a person to be there for him/her. P2 did not know what hours s/he was getting paid for when s/he did not work on site and did not know if s/he got paid when s/he was called by P2 on his/her days off. P2 did not know how many hours of services the VA’s plans stated that s/he received. · The progress notes that P2 provided this investigator for April 17 and 18, 2025, were typed on April 18, 2025. The April 19, 2025, notes were completed later that evening. P2 documented shift and progress notes on a phone application. The progress notes typed by P2 differed than the progress notes sent to this investigator by P1, which had more information than what P2 documented. P2 did not notice the VA acting “differently” on April 18 or 19, 2025. P2 stated that the VA had “mood swings.” P2 denied typing progress notes that were sent to this investigator by P1 for the dates in which P2 worked in the middle and end of April 2025 and stated that s/he believed P1 maybe typed those notes. P2 stated that the notes s/he typed were not always typed on the day that s/he provided services. P3 provided the following information: · On Sunday, April 20, 2025, P3 was working with another client at the same building where the VA resided and received a phone call from the VA at 3:55 p.m. The VA was “anxious,” and was trying to get some money, so s/he asked P3 if they could go sell his/her TV at a pawn shop and then go to a smoke shop. P3 tried to calm the VA and said that s/he would be available soon but that they could not go pawn the TV because the VA did not have a state identification card. P3 refused to pawn the TV for the VA. P3 then called P1 at 4 p.m. to let him/her know that s/he would be helping the VA run errands. · When P3 finished with the client, s/he went to the VA’s apartment unit about 10-20 minutes later and the VA was outside waiting. The VA was “talking slurrish” and was acting “really anxious and down.” The VA stated that s/he had not had a “smoke” for “a couple of days.” P3 was wondered what was going on because the VA seemed “desperate” for money. The VA told P3 that s/he was “very depressed” because s/he did not have any “weed.” The VA did not “want to keep paying smoke shop prices” for marijuana. The VA told P3 that s/he had taken pills, which “worried” P3. P3 asked the VA if s/he was okay, and the VA said that s/he was, so P3 thought the VA was “fine” other than “talking slurrish.” P3 asked again if the VA was “good” and the VA said, “Yeah.” · When they arrived at the smoke shop, the VA did not want to go into the smoke shop because the VA did not feel like talking to anyone. P3 thought that it was because the VA was “slurrish,” so the VA gave P3 $20 and P3 got the VA “some [marijuana] joints.” They drove back to the VA’s apartment building and the VA thanked P3, before exiting P3’s car and began to smoke. · P3 attempted to contact P1 after dropping off the VA. At 5:50 p.m., P1 called P3 and P3 let P1 know that the VA told P3 that s/he ingested pills because P3 really did not know what pills or “about” the pills the VA ingested and that the VA’s “speech [was] slurred.” Based on screenshots viewed by this investigator, P1 called P3 back at 5:50 p.m. on Sunday, April 20, 2025, and they had a conversation about the VA ingesting pills. P3 had not seen the VA since that day. · P3 was not “formally trained” to work with the VA, but was “filling in.” P1 and P2 were the two staff persons who worked with the VA. The VA had P3’s phone number because P3 helped the VA move into the apartment. · P3 did not know if s/he was “working” when s/he helped the VA. P3 “clocked out” with the other client. P3 was not trained to work with the VA so P3 was unable to “clock in” to work with the VA because the VA was not on the list of P3’s clients in the phone application staff persons used to clock in and clock out on. P3 was also unable to compose progress notes about the VA into the VA’s file because s/he did not have access to it. P3 took notes on the Notes application on his/her cell phone regarding the incident. The notes stated that P3 went to the VA’s apartment as a “backup staff [person]” and the notes were consistent with what P3 told this investigator. P1 provided the following information: · On April 19, 2025, P2 called the VA as s/he did every morning. P1 said that P2 and the VA “talked” and then s/he went to see the VA at around 9 a.m. When P2 arrived, the VA told P2 that s/he did not “need company, but to stick around,” and then told P2 to “leave” because the VA “would rather be alone.” P2 then notified P1 that this had happened, what the VA said. P1 told P2 that “we” would keep an eye on the VA who sometimes had “mood swings.” · P1 said that s/he stopped by to see the VA on April 19, 2025, at around 4 or 5 p.m. and the VA “seemed sleepy” and had awoken from a nap. The VA was talking and speaking “normal.” There was “nothing wrong.” P1 asked the VA if everything was okay and the VA responded that s/he did not sleep the night before, that s/he was “fine” and that s/he “just wanted to sleep.” This conversation was five to ten minutes long. P1 did not see anything with the VA’s behavior that was “severe” or that “needed medical attention.” P1 stated that s/he came back at 7:30 p.m., and that the VA did not answer when P1 knocked on the door. · Progress notes written and provided by P1 stated that on April 19, 2025, P1 called the VA several times and the VA was “unreachable.” Upon knocking at the VA’s door, there was no answer. P1 returned to his/her office which was not located on site to “document the situation” before returning to the building where the VA’s apartment was located. P1’s additional attempts to contact the VA, including phone calls were “unsuccessful.” Additional bullet points in the notes stated that the VA did not respond to phone calls or door knocks, was “unresponsive,” and that there were “no face-to-face interaction[s]” that occurred. P1 stated that s/he meant that the VA was “unreachable” when s/he documented that the VA was “unresponsive.” · On April 20, 2025, P1 stated that s/he did not get a hold of the VA by phone, so P1 went to the VA’s apartment twice, once in the morning and once in the evening. The VA did not open the door when P1 knocked at around 11 a.m., but opened the door at about 7 p.m. P1 said that the VA was “fine” and that s/he had taken a ride with a P3, who “worked in the building” but could help the VA by providing transportation. P1 asked P3 to see if the VA “needed help.” P1 stated that P3 did not work directly with the VA but “knows” and was aware of the VA’s plans. · The progress notes written and provided by P1 for April 20, 2025, stated that “due to previous concerns regarding [the VA’s] agitation and unresponsiveness” P1 checked on the VA. Initial attempts to reach the VA were “unsuccessful” but the VA “eventually” opened the door. The VA appeared “sleepy” and told P1 that s/he had been sleeping. P1 offered to enter the VA’s apartment, and the VA “declined” stating s/he preferred to “be alone.” The progress notes stated that the VA appeared “fatigued,” and that P1 would be “around the building.” P1 noted that there were “no signs of immediate crisis observed.” Progress notes did not include a reference to the VA going to the smoke shop with P3 or P3’s conversation with P1 that referenced a conversation about the VA ingesting pills. · On April 21, 2025, the VA told P1 that s/he took pills two days prior. Progress notes written and provided by P1 for April 21, 2025, stated that P1 arrived at the VA’s apartment for a scheduled check and cleaning session. P1 observed that the VA was “speaking sluggishly and was unsteady while walking.” P1 asked the VA what was wrong. The VA stated that s/he was in a “bad mood” and had “thought about ending [his/her] life.” The VA “downplayed the severity” and stated that s/he had “done it before,” and would be okay if s/he drank enough fluids. P1 “urged” the VA to accompany P1 to the hospital for evaluation and vitals monitoring but the VA “declined medical assistance.” The VA “kept improving [his/her] speech as the day went on,” eventually looking “normal.” P1 stated that s/he was with the VA from about 11:30 a.m. or 12 p.m. until about 2 p.m. · P1’s progress notes stated that P1 notified CM1 and CM2 on April 21, 2025, about the incident. · P1 also stated that the VA said that s/he was “hiding pills” which the VA had prior to arriving at the facility. P1 stated that the pills were not labeled. The VA initially would not tell P1 what the pills were, but later told P1 that it was Klonopin and another medication and the amounts the VA stated s/he took varied from “a bunch” to “a bottle.” P1 got the rest of the pills from the VA and had them in his/her possession. · P1 denied knowledge of anything “major” going on with the VA that day or the day before s/he took the medications. · P1 stated that s/he and P2 were the only two staff persons who worked with the VA, and initially stated that both P1 and P2 worked five hours per day with the VA when they were assigned to work with the VA. P1 later stated that s/he “does not work directly with” the VA and that P1 “only did check-ins” or “helped” when the VA was “in need” and when P2 was unavailable. P1 stated that s/he “covered” for P2 when P2 was sick or had days off. P1 then stated that s/he “covered” P2’s days off, Tuesdays and Wednesdays, each week. Upon further questioning, P1 stated that s/he did not always stay with the VA for the five hours and that it “varied.” P1 stated that staff persons’ “target” start time was 11 a.m., and would continue if the VA needed to run errands, but that the VA did not always ask staff persons to stay, and instead, that staff persons were “available to” the VA. · P1 later explained that staff persons would either sit in the VA’s apartment or at the office in the building where the VA’s apartment was located, or would be “in the area,” and would be “available” to the VA. Progress notes for the VA were not always completed on the date in which they occurred. · P1 provided his/her schedule for the month of April 2025, which showed that s/he worked with the VA from 11 a.m. to 3:30 p.m. from April 19 through May 3, 2025. · P1 was unable to provide documentation from the VA’s plans that showed that the VA only needed “some” of the five hours daily. P1 stated that the VA sometimes did not want services and that sometimes the VA declined services on the days that P2 had scheduled days off. · P3 did not work with the VA “at all besides the couple times” that P3 gave the VA a ride. P1 later stated that P3 was not “working” on April 20, 2025, as s/he was not scheduled but was willing to give the VA a ride. · P1 did not report that the VA ingested pills because it “slipped off” his/her mind, because s/he was “overwhelmed,” and it “didn’t come to [P1’s] attention.” · There were “no specific trainings” for P1 or P2 for the VA’s plans. P1 stated that s/he made a “mistake” by not assigning trainings sooner to staff persons. · When asked, P1 stated that they were still implementing but at the time of the incident, there was not 24-hour staff on site. The VA had P1’s phone number in case of an emergency. P1 stated that the “plan” was to “eventually” have someone working on site overnight. P1 stated that most staff persons in the building were done daily, between 3 and 5 p.m. P1 stated that the facility was only paid for 7 hours daily for services provided to the VA. CM1 provided the following information: · On April 22, 2025, CM1 learned that on April 19, 2025, the VA was having a hard time with his/her mental health, was out of marijuana, “expressed suicidal ideations,” and took an unknown amount of an unknown medication. From April 20 to 21, 2025, the VA had “side effects” such as “slurring” words and had trouble talking and walking. The VA “refused” to be transported to a crisis center or hospital, but no staff persons called 9-1-1 to have the VA examined at the VA’s apartment, which, according to CM1, was “a huge disservice” to the VA in the “long term.” · CM1 was notified of this event on April 22, 2025, when CM1 was unable to reach the VA. CM1 contacted P1 and learned that the VA got a new phone number. The VA and CM1 met that day, and by then, the VA was “fully coherent” and had “fully recovered” from taking the medications. CM1 stated that the VA and P1 provided “consistent information” to CM1 as to what happened from April 19 until April 22, 2025. The VA was not examined by a health care professional after the incident. · There “weren’t really any decisions” made by staff persons regarding getting the VA to the crisis center or hospital or examined by a medical professional after the VA “refused” treatment. · According to the VA, the VA used marijuana to “manage” his/her mental health symptoms. The VA had “limited income” and could only buy “so much” marijuana. When the VA ran out of marijuana or ran out of money to get marijuana, which was usually near the last third of each month, the VA had “behaviors.” The VA’s behaviors were that s/he would “act” on his/her “suicidal ideations” or self-injure. This process repeated itself and had been going on for several months since the VA started receiving services from the facility. The VA’s support staff persons and team had been trying to find ways to help the VA manage his/her funds and get access to a medical marijuana card. The VA was not interested in having a representative-payee. · The VA “did pretty well” when communicating with CM1 but had some “delusional thinking” and was “set in stone” with some of his/her thoughts. · CM1 and P1 had had “a lot” of interactions and when things came up with the VA, P1 notified CM1. P1 was “helpful” and “very proactive,” but was not aware of “crisis resources” available to the VA until CM1 told P1, after the incident. As of recently, the VA only wanted to work with P1 and no other staff persons. · The VA had a “MedaCube” medication dispenser at the facility monitored by staff persons. · Staff persons were at the building where the VA resided 24/7. · After this incident, the VA’s care team had a meeting and CM1 told P1 to call 9-1-1 “immediately” if the VA “refused” to go to the emergency room or a crisis center in the future, when experiencing a mental health crisis. After the incident, the VA only wanted to work with P1. CM2 provided the following information: · CM2 was notified of the incident on April 28 or 29, 2025, and spoke to the VA about two weeks after the incident. CM2 did not know what pills the VA took, if the pills were something that the VA had access to in the medication dispenser, something given to the VA by a friend, or something the VA bought. When CM2 and the VA spoke several weeks after the incident, the VA told CM2 the following information: o On April 18, 2025, the VA was having a bad night and found old bottles of medication. The VA ingested “three whole random bottles” and the VA was unsure how many pills there were. o P1 stopped by the facility to check on the VA over the weekend but the VA did not specify which date. P1 asked the VA if s/he wanted to go to the hospital, but the VA declined and asked P1 not to call 9-1-1. o The VA did not tell P1 about the medications until April 21, 2025. P1 now had the rest of the VA’s old medications. · Staff persons were to be on site 24 hours a day in case of an emergency. · The VA had “sporadic moods” when s/he was struggling financially which often led the VA to go to the emergency room or to a crisis center. · The VA was “strong willed” and “vocal” in terms of informing staff persons and the care team of what the VA needed for his/her own benefit, health, and safety. The VA was typically “vocal” when s/he was having a problem or “mental stress” issue and was “honest” and “accurate.”
· In-person supports included budgeting, helping with medications, going shopping, driving to and attending appointments, and anything else that helped support the VA’s needs. · Currently, staff persons at the facility were attempting to help the VA get a medical marijuana card through the State of Minnesota, but the VA needed a Minnesota identification card before being approved for that. · CM2 stated that it was expected that staff persons spent five hours per day with the VA, breaking up the hours into smaller groupings of hours throughout the day, when needed. Staff persons at the facility were being paid to provide services for seven hours a day (five in person and two remote) and it was the expectation that they were spending that time with the VA. It would be “very concerning” if staff persons did not stay with the VA to monitor the VA if the VA was “disoriented” during those few days. P1 and P2 were trained on the Reporting of Maltreatment of Vulnerable Adults training. P3 was not trained on the VA’s plans and was not trained on the Reporting of Maltreatment of Vulnerable Adults until May 7, 2025. Conclusion: The VA stated that on April 18, 2025, at around 10:30 or 11 p.m., the VA ingested Klonopin and trazodone pills which staff persons were unaware the VA had in his/her possession. The VA stated the amount s/he took was a “handful” and also stated it was a “whole bottle.” On April 19, 2025, the VA thought that P1 and P2 each checked on the VA, but “could not recall much” other than the VA declined P1’s offer to bring the VA to the hospital. P1 and P2 each stated that they checked on the VA in person. P2 stated that the VA was upset and asked him/her to leave. P2 stated that the VA was standing fine and was not slurring his/her words. Facility documentation, written by P1 showed that P1 did not have any “face to face interactions” with the VA that day as the VA was “unreachable” and attempts to contact the VA were “unsuccessful.” However, P1 told this investigator that s/he saw the VA on April 19, 2025, at around 4 or 5 p.m. and that the VA “seemed sleepy” but was talking “normal.” On April 20, 2025, P1 stated s/he could not reach the VA by phone, so s/he went to the VA’s apartment in the morning and evening. The VA did not open the door in the morning. The VA called P3 and was “anxious,” and wanted to go to a smoke shop. The VA was “talking slurrish” and was acting “really anxious and down.” P3 tried to calm the VA and although s/he was not working with the VA, nor was “formally trained” to work with the VA, drove the VA to the smoke shop. The VA told P3 that s/he was “very depressed” and that s/he had taken pills, which “worried” P3. P3 asked the VA if s/he was okay, and the VA said that s/he was, so P3 thought the VA was “fine” other than “talking slurrish.” P3 asked again if the VA was “good” and the VA said, “Yeah.” P3 stated that after dropping off the VA, s/he let P1 know that the VA said s/he ingested pills. P3 did not know more, other than the VA’s “speech [was] slurred.” P3 did not know which medications the VA took. Based on screenshots viewed by this investigator, P1 and P3 spoke on the phone at 5:50 p.m. on April 20, 2025. Facility documentation provided by P1 did not include a reference to the VA going to the smoke shop with P3 or P3’s conversation with P1 that referenced a conversation about the VA ingesting pills. P1 stated that s/he went back to the VA’s apartment around 7 p.m. and the VA was “fine.” The VA appeared “sleepy” and told P1 that s/he had been sleeping. P1 offered to enter the VA’s apartment, and the VA “declined” stating s/he preferred to “be alone.” The progress notes stated that the VA appeared “fatigued,” and that P1 would be “around the building.” P1 noted that there were “no signs of immediate crisis observed.” On Monday, April 21, 2025, the VA stated s/he was still “a little bit wobbly” on his/her feet from taking the medications but was “feeling good.” According to P1’s progress notes, on April 21, 2025, P1 arrived at the VA’s apartment for a scheduled check and cleaning session. The VA said s/he took pills two days prior. P1 said s/he observed the VA “speaking sluggishly and was unsteady while walking.” P1 asked the VA what was wrong. The VA stated that s/he was in a “bad mood” and had “thought about ending [his/her] life.” P1 “urged” the VA to accompany P1 to the hospital for but the VA “declined medical assistance.” The VA “kept improving [his/her] speech as the day went on,” eventually looking “normal.” P1 stated that s/he was with the VA from about 11:30 a.m. or 12 p.m. until about 2 p.m. According to CM1, the VA took an unknown amount of an unknown medication on April 19, 2025. From April 20 to 21, 2025, the VA had “side effects” such as “slurring” words and had trouble talking and walking. The VA “refused” to be transported to a crisis center or hospital, but no staff persons called 9-1-1. According to CM2, s/he was notified of the incident and did not know what pills the VA took but had learned from the VA that on April 18, 2025, the VA took “three whole random bottles” of pills. P1 told CM2 that s/he stopped by to see the VA over the weekend but did not specify which date. The VA “refused” to have 9-1-1 called or go to a hospital or crisis center. The VA’s plans stated that the VA “required a 24-hour on-site staff person.” The facility’s PAPP stated there was 24/7 staffing with awake overnight coverage to ensure individuals are never left unsupervised in the facility. P1 stated that there were not 24/7 staff persons at the facility. P1 did not report that the VA ingested pills because it “slipped off” his/her mind, because s/he was “overwhelmed. Although the VA ingested an unknown amount of pills and did not receive medical care, given that the VA had the pills prior to moving into the facility and staff persons did not know s/he had them, that staff persons checked on the VA and the VA either did not display symptoms or declined medical care including requesting that 9-1-1 not be called, that the VA’s symptoms were slurred speech and possible unsteady gait but there was no information that the VA was harmed or did not later return to his previous condition, there was not a preponderance of the evidence whether there was a failure to provide 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). Action Taken by Facility: The facility’s Internal Review stated that their policies and procedures were adequate and followed. There was a need for additional staff training and corrective action was needed. Staff persons were retrained, and VA plans were updated. Action Taken by Department of Human Services, Office of Inspector General: On January 22, 2026, the facility was issued a Correction Order for not training staff persons as required and not having staff persons on site 24 hours as outlined in client plans and the Program Abuse Prevention Plan.
|
