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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: 1090681-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 a staff person (SP1) did not puree a vulnerable adult’s (VA’s) food properly and a second staff person (SP2) fed the food to the VA knowing it was not pureed properly. The VA was later taken to the hospital and diagnosed with aspiration pneumonia. Date of Incident(s): September 21, 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 October 2, 2025; from documentation at the facility and medical records; and through five interviews conducted with a facility supervisory staff person (P1), SP1, SP2, the VA’s case manager (CM), and the VA’s guardian (G). The VA was not able to participate in an interview because of his/her abilities. The VA enjoyed listening to music and watching television. The VA’s diagnoses included profound developmental disability, seizure disorder, cerebral palsy with spastic quadriplegia, shunted hydrocephalus, and gastroesophageal reflux disease (GERD). The VA used a wheelchair for mobility. The VA’s Self-Management Assessment stated that when the VA felt unwell, s/he might express it by grimacing, groaning, yelling, and moaning. The VA had episodes of choking on his/her food and medications. The VA did not feed him/herself and was dependent on the staff persons to cook, blend, and feed food to the VA. The staff persons were trained to puree the VA’s food according to his/her doctor’s orders, which were to puree the food to a pudding consistency. The staff persons were to ensure that the food was blended and smooth, with no chunks. When assisting the VA with eating, the staff persons were to ensure that the VA was awake enough to eat and sitting upright. The VA did not use words to communicate and was unable to ask for help. The VA’s Annual Physical Exam form stated that the VA was to receive a 1,200 calorie diet with food “pureed with pudding consistency thickened liquids.” The VA’s posted doctor’s orders required that the VA’s food be “Pureed: smooth, blended from applesauce to mashed potato consistency. Desserts and bread soaked in milk or sauce to pureed consistency.” The facility’s menu for lunch on September 21, 2025, included roast beef with gravy, mashed potatoes, and baby carrots. SP1 provided the following information: · SP1 stated that on September 25, 2025, s/he prepped the VA’s food and chopped the food before s/he pureed the VA’s food. SP1 had to use a food processing machine more than once to get the correct consistency. SP1 did not put a lot of carrots in the VA’s food because the VA did not like vegetables. SP1 then “sifted through” the food with a spatula to look for chunks. SP1 brought the food to the table and SP2 “insisted” on assisting the VA with eating while SP1 returned to the kitchen to clean and tell the other clients that lunch was ready. · Everyone sat at the table and ate and the VA then started to “cough up” food and turned blue. SP2 told SP1 that the VA coughed up a “chunk” of carrot and showed it to SP1. SP1 stated that the piece of carrot was “maybe a centimeter in length, about the tip of my finger.” SP1 believed s/he would have noticed the chunk of carrot when s/he looked through the VA’s food prior to bringing it to the table. · SP1 and SP2 moved the VA away from the table and after the VA finished “aspirating for a couple of minutes,” they tried to give him/her some lemonade, but the VA spit it out. Approximately 15 minutes later, the VA began making “happy noises,” which SP1 thought meant that the VA felt better. SP1 was going to check the VA’s adult absorbent undergarment, but SP2 wanted to keep the VA sitting upright in his/her chair for a while. SP2 provided the following information: · At lunchtime on the day of the incident, SP2 offered to assist the VA with eating so that SP1 could eat his/her lunch. SP2 asked SP1 if s/he cooked the carrots “really good” because carrots were a choking hazard and SP2 told SP1 that s/he had ground the carrots up twice. SP2 looked at the carrots and s/he “smashed it up” a little more. SP2 slowly fed the VA his/her fruit and main meal and then gave the VA a “tiny bit” of the carrots and the VA immediately started coughing. SP2 checked the VA’s mouth and saw a “thin little piece of carrot,” which the VA spit out. The VA then stopped coughing. After waiting ten minutes, SP2 gave the VA two spoons of his/her lemonade, which the VA swallowed with “no problem.” SP2 did not believe that the VA had “any issues” from the carrot after s/he spit the piece of carrot out, but the VA seemed to “have some kind of breathing thing with phlegm.” · The VA drooled “a lot” that day and 20 minutes after giving the VA his/her lemonade, the VA coughed up a lot of phlegm. At 2:30 p.m., a staff person (P2) arrived at the facility for his/her work shift and talked with SP1 and SP2 about whether someone should take the VA to be seen by a physician because the VA “seemed different.” The VA’s temperature and blood pressure were normal so they waited to see if the VA would take his/her 4 p.m. medications. The VA spit out his/her medications, so SP2 talked to the on-call facility nurse, who told SP2 to take the VA to urgent care, which SP2 did. · At urgent care, the VA “seemed fine” and had stopped coughing. The VA’s airway was free and there was nothing in his/her throat, but the urgent care physician could not take a chest x-ray because they were not equipped for x-rays. SP2 and the VA returned to the facility and at approximately 8 p.m., P2 took the VA to the emergency room (ER) because the VA coughed up a lot of phlegm. P1 stated that all of the staff persons, including SP1 and SP2, received training on preparing the VA’s food. After the VA and P2 returned to the facility from urgent care, the staff persons attempted to give the VA some crystal light, but the VA spit it out and coughed up a lot of phlegm. At that point, P2 took the VA to the ER. The VA was admitted to the hospital. The G and the CM each stated that they had no concerns about the care the VA received at the facility. In the past year, the VA had aspiration pneumonia three or four times. After the latest incident, the VA was put on a g-tube diet. A review of the Individual Progress Notes for September 21 - 29, 2025, provided the following information: · On September 21, 2025, at 2:04 p.m., SP1 wrote, “[The VA] experienced a seizure while eating breakfast. [The VA] seemed to be okay afterwards. . . [The VA] ate all of [his/her] lunch before coming to the living room to watch TV with the rest of staff.” · At 8:51 p.m., SP2 wrote, “At lunch [the VA] started to cough and a piece of carrot came out. After, [the VA] started coughing with a lot of phlegm. At first [s/he] coughed after 20 minutes. Each time it got longer between coughs. Staff took [the VA] to urgent care. [The VA] saw a nurse practitioner which [s/he] could hear airflow through out with a lot of fluids. [S/he] said [the VA] would be constantly coughing if [s/he] had something in [his/her] throat. Orders to continue to monitor for cough or fever if any changes take [him/her] to the ER. At dinner [s/he] would not eat anything and was still coughing a lot of phlegm. Staff brought [the VA] to the ER. Waiting for a report from staff at ER.” · On September 22, 2025, at 6:47 p.m., P2 wrote, “This writer took [the VA] to the [ER]. Earlier in the day, [the VA] choked on some carrots during lunch. [S/he] was initially taken to urgent care and they didn’t do much for [him/her] there. [The VA] still seemed to be in some distress, so this writer took [him/her] in. [The VA] ended up being admitted. While there with [the VA], [s/he] got an x-ray done, was given a medication called Nitro. It was given to help [his/her] esophagus relax. [The VA] was also placed on oxygen.” · On September 29, 2025, at 3:52 p.m., SP1 wrote, “[The VA] appeared to have swallowed a piece of carrot during feeding Sunday afternoon at lunch time. Writer had used both blenders to break down and puree [the VA’s] food and blended the food not once but twice before placing it at the table. Writer had already sat down to feed [the VA] when [SP2] had asked to feed [the VA]. . . [SP2] insisted on feeding [the VA] so writer allowed it and decided to finish cleaning up in the kitchen. [The VA] was nearly done with [his/her] food when [s/he] began coughing. Writer went to observe [him/her] and [the VA] appeared to have something lodged in [his/her] throat. [The VA] eventually coughed up a small piece of carrot. About 10 minutes coughing some more and drooling all over [his/her] chest. About 20 minutes later [the VA] began calming down in regards to [his/her] coughing. [S/he] began smiling and yelling like how [s/he] usually does when [s/he] enjoys [his/her] food. Writer insisted on laying [the VA] down for repositioning and changing after [s/he] finished with [his/her] symptoms but staff agreed to keep [the VA] sitting up in [his/her] chair in case there was anything else still left for [him/her] to cough up. [The VA] was not coughing when writer left from work around 3:20 p.m.” The hospital’s Discharge Summary Notes stated that on September 21, 2025, the VA was admitted to the hospital, where s/he was diagnosed with aspiration pneumonitis, acute hypoxemic respiratory failure, and dysphagia. The VA’s initial x-ray was “unremarkable.” On September 24, 2025, while in the hospital, the VA had an “aspiration incident” overnight, which caused his/her oxygen level to drop to the 70s (percent blood oxygen saturation). The VA was given a percutaneous endoscopic gastrostomy (PEG) feeding tube. On October 8, 2025, the VA was discharged back to the facility.
Facility documentation showed that SP1, SP2, 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 September 25, 2025, SP1 chopped the VA’s food and then pureed the food twice to ensure that it was the necessary consistency. SP2, who assisted the VA with eating, looked at the carrots and “smashed it up” a little more before assisting the VA with his/her fruit and main meal and a “tiny bit” of the carrots. The VA immediately started coughing. SP2 checked the VA’s mouth and saw a “thin little piece of carrot,” which the VA spit out. The VA then stopped coughing. After waiting ten minutes, SP2 gave the VA two spoons of his/her lemonade, which the VA swallowed with “no problem.” That afternoon, the VA drooled more than usual and “seemed different,” so SP2 consulted with the facility’s nurse and then took the VA to urgent care. No treatment was given by the urgent care physician and SP2 took the VA back to the facility. When the VA continued to cough up phlegm, the VA was taken to the ER and admitted 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 fed food that was not properly pureed, given that SP1 pureed the food twice, that SP1 and SP2 each examined the food prior to feeding the VA, and that SP1 and SP2 continued to monitor the VA after s/he initially coughed up a piece of carrot, SP1’s and SP2’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 coughed up phlegm and a piece of carrot, staff persons provided care to the VA by first taking the VA to urgent care and then when the VA continued to cough up phlegm, 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 eating the carrots; (iii) The SPs 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 SP1’s and SP2’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 staff persons. After the incident, all of the staff persons were retrained on the VA’s dietary requirements. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were not substantiated as perpetrators of maltreatment of the VA because the Department of Human Services found that the incident for which SP1 and SP2 were responsible met the criteria to be determined an error. SP1 and SP2 were notified by the Office of Inspector General that any future incident of possible neglect of a vulnerable adult for which SP1 or SP2 is responsible might not be considered an error.
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