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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: 1069982-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman/Alice Percy Minnesota Department of Human Services 651-431-6567 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was lethargic during the day and was later found unresponsive in his/her bed, but the staff person (SP) did not start CPR and the VA subsequently passed away. Date of Incident(s): March 18, 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 6, 2025; from documentation at the facility and law enforcement records; and through eleven interviews conducted with two facility administrative staff persons (P1 and P2), six staff persons (P3 – P8), the SP, the VA’s case manager (CM), and the VA’s guardian (G). The VA enjoyed going to the park, listening to music, watching television, going to the movies, going out to eat, and conversing with the staff persons. The VA’s diagnoses included severe intellectual disabilities, epilepsy, cerebral palsy, quadriplegia, lymphedema, and hyperlipidemia. The VA used a wheelchair for mobility. The VA went to a day program two days each week. The VA’s Intensive Support Self-Management Assessment stated that the staff persons were trained to administer the VA’s medications. The VA was unable to ambulate or transfer independently. The VA’s Support Plan Addendum stated that the VA did not require a staff person who was trained on cardiopulmonary resuscitation (CPR) to be available or at the site to provide direct service when the VA was at the site. [Note: There was no information in the VA’s plans that the VA had a do not intubate/do not resuscitate order (DNI/DNR).] The staff persons were responsible for setting up and administering the VA’s medications. The VA’s Medication Administration Record (MAR) dated March 2025 showed that the VA was not prescribed suppositories or enemas. There was no documentation on the MAR that the VA was administered either an enema or suppository on any date in March 2025. The MAR provided the following information about the VA’s prescribed medications: · Metamucil powder: One tablespoon with water two times each day at 8 a.m. and 4 p.m. o The VA received the 8 a.m. dose on March 1 – 13, 2025. o The VA received the 4 p.m. dose on March 3, 4, 5, 7, 8, 9, 11, 12, 13, 16, 17, and 18, 2025. o The VA did not receive any of the medication on March 14 and 15, 2025. · Polyethylene glycol: Take 34g twice a day for three days, then 34g by mouth once a day. May take additional 17g daily as needed. o The VA received the medication at 8 p.m. on March 3, 4, 5, 7, 8, 9, 11, 12, 13, 16, 17, and 18, 2025. o The VA did not receive any of the medication on March 1, 2, 6, 10, 14, and 15, 2025. o The VA did not receive the initial two doses for three days. · Senna laxative: Take one time a day at 8 a.m. o The VA received the medication on March 1 – 13, 2025. o The VA did not receive any on March 14 – 18, 2025. The VA’s Standing Order Medication List provided the following information: · If the VA had “hard stools” s/he could take docusate sodium/Colace 100 milligram (mg) capsules once a day. · If the VA had “constipation” s/he could take: o Milk of Magnesia one ounce (30 cc) as needed; or o Psyllium Fiber/Metamucil one rounded teaspoon in six to eight ounces of juice or water up to three times a day as needed; or o Metamucil wafers two wafers up to three times a day. o Milk of Magnesia produces faster results. Metamucil will need to be given for two to three days to produce desired effect. · For both “hard stools” and “constipation,” if the VA had “no results” within two days, a health care professional was to be notified. P1, P2, P3, P4, P5, P6, P7, P8, and the SP provided the following information: · P1 stated that for approximately two months prior to the VA’s death, the VA wanted to remain in bed and did not want to get up or do anything. The VA’s appetite was poor and staff persons encouraged the VA to drink liquids. P2 believed that one of the VA’s medications affected the VA and they planned to discuss the issues at the next scheduled appointment with the VA’s mental health physician. [Note: There was no information regarding when the VA’s next scheduled appointment was and the VA’s yearly physical was September 24, 2024, approximately six months prior.] · On March 18, 2025, P3 and P4 worked the morning shift at the facility. P3 was worried because the VA seemed “a little different” and his/her stomach was “really hard.” P3 called P2, who told P3 to administer a suppository to the VA. The suppository did not result in a bowel movement. P3 stated that s/he administered an enema two days earlier, but the VA was still having difficulty having a bowel movement. [Note: The suppositories and enemas were over-the-counter medications but neither were prescribed by the VA’s doctor, on the VA’s standing orders, or on the VA’s MAR as medications to be administered or documented as having been administered.] P4 stated that the VA was not hungry during lunch, but P4 keep offering juice to the VA. The VA was sleepy, which was not unusual for the VA, depending on how well s/he slept the previous night. The VA was warm so P4 took the VA’s temperature, which was 100 degrees Fahrenheit (F). The VA also had a slight temperature the previous day. P4 told P1 or P2 about the VA’s temperature. · P5 worked at the facility from 2 to 9 p.m. P4 said that at the end of his/her work shift, P4 told P5 that the VA had a slight fever, did not eat lunch, and was administered a suppository. P5 stated that in recent months, the VA’s medications were changed and s/he became more lethargic and wanted to sleep more. The VA appeared to be in pain because s/he was “moaning and groaning but was not talkative.” P3 told P5 that the VA had been constipated for a day or two so P3 administered a suppository earlier that day. At 7 p.m., P6 arrived for his/her work shift and had to “coax” the VA to take his/her medications. P5 stated that the VA’s stomach was swollen and hard. The VA ate some of his/her dinner. P6 told P5 that s/he would tell P2 about the VA’s constipation and at 8:30 p.m., P6 called P2 with updates on the VA and P2 told P6 to call P1. P5 stated that s/he did not remember whether s/he saw the VA prior to leaving at the end of his/her shift but if s/he had then s/he did so after 8:30 p.m. and there were no changes to the VA’s condition. · P6 stated that at 8:40 p.m., s/he checked on the VA and told the VA to have a good night and the VA told P6 s/he would see him/her in the morning. P6 called P1 and told him/her that the VA should be seen by his/her physician the following morning because s/he had not had a bowel movement in several days. When the SP arrived at the facility for his/her work shift at 9 p.m., P6 told the SP that the VA did not eat all of his/her dinner, that his/her stomach was warm and hard, that s/he was given a suppository earlier in the day, and that the SP should check on the VA. · At 9 p.m., the SP began his/her work shift. Soon after the SP arrived at the facility, P1 called the SP to update him/her on the VA. P1 told the SP that the VA had been constipated and s/he was going to take the VA to see his/her physician the following day. While speaking to P1, the SP entered the VA’s bedroom. The SP stated that the VA looked “off” and that his/her face was “washed out.” The VA did not respond when the SP called the VA’s name and did not move when the SP touched the VA. The SP checked the VA’s pulse at the VA’s neck and wrist and then told P1 that s/he believed the VA had passed away. P1 told the SP to call 9-1-1, which the SP did. While talking to the 9-1-1 dispatcher, the SP told the dispatcher that the VA had a DNR order. When the paramedics arrived approximately five minutes later, the SP told them that s/he was unable to find the VA’s DNR order. Shortly after the paramedics arrived at the facility, P1 and P2 arrived and told the paramedics that the VA did not have a DNR order. The SP stated that s/he “mistakenly” believed the VA had a DNR order and so did not perform CPR. The paramedics told the SP that “it did not matter because the VA was gone too long anyway.” · The SP usually worked the overnight work shift which was a sleep position unless a client required assistance. The SP typically checked on the clients at 10 p.m. The VA slept through the night “most nights,” but some nights s/he screamed so the SP then checked on him/her. P6 stated that during the day when the VA was in his/her bedroom, the staff persons checked on the VA every hour or if the VA called for assistance. · P2 stated that the staff persons were trained to administer CPR unless the client had a DNR order. P2 stated that the SP called him/her to ask if the VA had a DNR order and P2 told him/her that s/he did not, but by then the paramedics had arrived at the facility. P1 did not know if the VA had a DNR order but knew there was not one in the VA’s file. P4, P5, P7, and P8 did not know if the VA had a DNR order. P6 believed the VA “probably” did not have a DNR order. P1 stated that the clients’ guardians gave copies of any DNR orders to the facility so they could keep in the clients’ files. The G stated that prior to the incident, s/he had concerns about the VA missing medical appointments, but the facility followed through on ensuring that the VA was seen by his/her physician. On March 12, 2025, the G visited the VA at the facility and the staff persons told the G that the VA was often constipated and frequently only had a bowel movement once a week. The VA was on psychotropic medications and sometimes was sleepy and refused to get out of his/her bed. The G’s Notes for March 11, 2025, stated that P2 told the G that the VA was frequently constipated and had a bowel movement “about once a week, if that.” The CM stated that prior to the incident, s/he had no concerns about the care the VA received at the facility. On March 19, 2025, at 12 a.m., the SP completed a T-Log entry that stated, “At 9 p.m., [the SP] was on phone with [P1] being informed of [the VA’s] current medical state and was asked to check on [the VA]. When [the SP] checked [the VA] was not responding. [The SP] checked for a pulse and breathing and could not detect anything. [P1] told [the SP] to call 9-1-1. Ambulance arrived and reported that [the VA] had passed away.” A law enforcement officer’s (LEO’s) Supplemental Report, completed on March 18, 2025, at 9:11 p.m., the LEO was dispatched to the facility and arrived a few moments after the paramedics. The paramedics were evaluating the VA and told the LEO that the VA had no pulse and his/her fingers were “stiff.” The paramedics told the LEO that they saw some “livor mortis” (a reddish-purple discoloration of the skin that occurs after death within 20-30 minutes) and showed the LEO an area of the VA’s right arm. Life saving measures were not performed by either paramedics or the LEO. The VA did not have an autopsy and his/her cause of death was determined to be “complications of cerebral palsy.” Facility documentation showed that P1 – P8 and the SP each received training on the Reporting of Maltreatment of Vulnerable Adults act, on the facility’s policies, including the CPR policy, and on the VA’s plans prior to the incident. Relevant Rules and Statutes: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (b), clause (1), which states in part if responsibility for medication administration is assigned to the license holder, the license holder must implement medication administration procedures to ensure a person takes medications as prescribed. Minnesota Statutes, section 245D.06, subdivision 2, paragraph (a), clause (1), item (iv) states that the license holder must ensure that a staff person is available at the service site who is trained in basic first aid and, when required by the person’s support plan or support plan addendum, cardiopulmonary resuscitation (CPR) whenever persons are present and staff are required to be at the site to provide direct support services. The CPR training must include instruction, hands-on practice, and an observed skills assessment under the direct supervision of a CPR instructor. Conclusion: In the days leading up to the VA’s death, the VA experienced constipation and was administered an enema on March 16, 2025, and a suppository on March 18, 2025, the day the VA passed away. These were over-the-counter medications that were not included in the VA’s MAR or Standing Order Medication List and therefore administering them to the VA and not documenting having administered them were violations of Minnesota Statutes, section 245D.05, subdivision 2, paragraph (b), clause (1). The VA’s Standing Order Medication List also stated that if the VA did not have a bowel movement in two days, the staff persons were to notify a health care professional. The VA’s bowel movements were not documented, but the staff persons provided information that the VA did not have a bowel movement for between two days to several days and on the day of the incident, his/her stomach was “really hard,” and neither the suppository nor the enema produced a bowel movement. The G stated that staff persons told him/her that the VA was often constipated and frequently had bowel movements once a week. Information showed that the plan was to take the VA to see a doctor on March 19, 2025, which was the day after the VA passed away. P6 said that on March 18, 2025, at 8:40 p.m., P6 checked on the VA and told the VA to have a good night and the VA told P6 s/he would see him/her in the morning. At 9 p.m. the SP arrived and shortly after P1 called the SP to update him/her on the VA. While speaking to P1, the SP entered the VA’s bedroom. When the VA did not respond and did not move, the SP called 9-1-1. At 9:11 p.m., the paramedics arrived at the facility, moments later followed by the LEO. The paramedics told the LEO that the VA had no pulse, his/her fingers were “stiff,” and s/he had signs of having been deceased for 20-30 minutes as noted by the observation of the VA’s right arm so life saving measures were not performed by either paramedics or the LEO. The VA did not have an autopsy and his/her cause of death was determined to be “complications of cerebral palsy.” While the SP was talking to the 9-1-1 dispatcher, s/he told the dispatcher that the VA had a DNR order. Despite the SP “mistakenly” believing the VA had a DNR order and did not perform CPR, given that the VA’s Support Plan Addendum stated that the VA did not require a staff person who was trained on cardiopulmonary resuscitation (CPR) to be available or at the site to provide direct service when the VA was at the site, that the paramedics said the VA showed signs of having been decease for 20-30 minutes, and that neither the paramedics nor the LEO performed life saving measures, there was not a preponderance of the evidence whether the SP’s failure to perform CPR was a failure or omission to supply the VA with care or services which were reasonable and necessary. The staff persons provided information that prior to his/her death, the VA seemed “a little different,” his/her stomach was “really hard” and “swollen and hard,” and s/he was “moaning and groaning.” While not in accordance with the VA’s standing orders and a violation as previously outlined, attempts were made to assist the VA with having a bowel movement via enema and suppository which did not produce results. The enema was administered two days before the VA’s death and the suppository was administered the day of the VA’s death. The VA did not have a bowel protocol but his/her Standing Order Medication List for both “hard stools” and “constipation,” stated that if the VA had “no results” within two days after administration of his/her medications for each, a health care professional was to be notified. Information showed that the plan was to take the VA to the doctor the following morning. The VA’s MAR for March 2025, showed that the VA was not administered all his/her prescribed doses of Metamucil powder, polyethylene glycol, or senna laxative and on two dates (March 14 and 15, 2025), the VA did not receive any of the medication doses. However, on nine dates, the VA received all of the medication doses and on the remaining seven days, the VA received two of the medications although not the same two each day. Without additional information that the VA’s lack of a bowel movement was related to his/her death, there was a preponderance of the evidence whether there was a failure to supply the VA with reasonable and necessary care or services to obtain or maintain the vulnerable adult's physical or mental health or safety. It was not determined whether neglect occurred (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, the staff persons were retrained on the facility’s CPR procedures. Action Taken by Department of Human Services, Office of Inspector General: On March 3, 2026, the facility was issued a Correction Order for the violations outlined in this report.
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