|
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: 1070367-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Anna Parkin Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) experienced symptoms including abdominal bloating, fatigue, and decreased appetite. A supervisory staff person (P1) was notified about the VA’s condition worsening but the VA did not received medical treatment. The VA was later diagnosed with a twisted bowel that required surgery. Date of Incident(s): ongoing since October 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 8, 2026; from documentation at the facility and medical records; and through nine interviews conducted with a supervisory staff person (P1), four facility staff persons (P2-P5), two facility nurses (RN1 and RN2), and the VA’s guardians (G1 and G2). The VA was diagnosed with a mild developmental disability and used a wheelchair to ambulate. Consistent information was provided that the VA was diagnosed with progressive spinal cerebellar degeneration which resulted in the VA eating and drinking slowly but s/he still ate the majority of his/her food. According to the VA’s Self-Management Assessment, staff persons scheduled the VA’s medical appointments, provided transportation, and followed medical instructions. According to the VA’s Support Plan Addendum, the facility provided the VA with all daily needs including medication management and administration, monitoring the VA’s health conditions according to written instructions from a doctor, and coordinating and assisting with medical appointments. The facility was responsible for health services and G1, G2, and the CM were “promptly” notified of changes in the VA’s physical or mental health needs. There was an additional concern that after the VA left the hospital, the VA’s prescribed suppository was supposed to have been administered with the VA lying in bed and remaining there for 20 to 30 minutes. Information in the VA’s medical records and the instructions on the suppository bottle did not require the VA to lay down so it was not included in this report. P2 provided the following information: · Beginning the middle of October 2025, the VA’s health started declining with increased fatigue, decreased appetite, bowel changes, stomach bloating, and discomfort. On an unknown date, P2 told P1 about the bloating and having to administer as needed medication. P1 responded that P2 was “overreacting” and that other staff persons had not brought up the concerns. · During the next week the VA’s conditions worsened, his/her bowel movements were “watery” and “not soft with grit as usual.” The VA had a decrease in bowel movements, his/her stomach was bloated, and s/he “frequently” said s/he did not feel well or s/he was not hungry. The VA also had an increase in thick mucus coming from his/her mouth. P2 continued to tell P1 that the VA needed to see a doctor while other staff persons documented the concerns in the VA’s progress notes. · On October 23, 2025, during a staff meeting, all staff persons discussed the VA falling asleep throughout the day. P2 said that the VA’s bowel movements were “not normal” and s/he had “more discomfort.” RN1 told P1 that the VA needed medical treatment including an abdominal scan “as soon as possible.” P1 documented the information but did not schedule an appointment or bring the VA for medical treatment. · All staff persons continued to document in the VA’s progress notes the changes in the VA’s symptoms. The VA was “constantly” falling asleep and going to bed for the night at 7 p.m. and slept for 10 to 12 hours. The VA also had an increase in “thick and sticky” mucus draining from his/her mouth. · On November 12, 2025, when P1 brought the VA to see a doctor, P1 only told the doctor some of the concerns and there was no mention of bloating or stomach discomfort. After the VA returned to the facility, s/he “almost immediately” started declining including no bowel movements for multiple days until s/he was then hospitalized for a twisted bowel. P2 documented the above concerns in the VA’s progress notes but on an unknown date, s/he went back to read the notes and they were no longer there. [Note: there were no notes in the VA’s progress notes about these concerns from P2, see below.] The VA’s medical records provided the following information: · On November 12, 2025, the VA was seen at his/her primary doctor because for approximately one week and a half, s/he had an increase in fatigue and decrease in eating. The doctor completed a physical exam and noted that the VA’s abdomen was “soft” with no distention or tenderness. Tests were completed and showed high sodium levels, elevated kidney levels, low potassium, elevated inflammation levels, and mild leukocytosis (infection). The VA was diagnosed with a urinary tract infection and prescribed an antibiotic. The VA remained hospitalized until November 15, 2025. · On November 19, 2025, the VA was seen at the emergency room for abdominal pain and distention. Imagining showed the VA had a large bowel obstruction. On November 25, 2025, the VA had surgery for a twisted bowel and had a rectal tube placed. · On December 16, 2025, the VA was discharged with prescribed antibiotics and the following bowel movement protocol: o The VA was prescribed one milligram Motegrity (anti-constipation), one senna tablet, and ten milligrams of bisacodyl (laxative) once daily. The VA was prescribed two grams of glycerin suppositories twice daily. o If the VA did not have a bowel movement for over 48 hours, staff persons administered one packet of MiraLAX twice daily, a Dulcolax suppository once daily, and an additional senna tablet once per day. o If the VA did not have a bowel movement within 72 hours, staff persons administered a mineral oil enema and then contacted the VA’s primary doctor for additional steps. The VA’s progress notes and bowel movement tracking form provided the following information: · On October 7, 2025, P3 wrote that the VA was “really tired” and had a lot of discharge from his/her nose. The VA said s/he felt “fine, just tired.” · On October 8, 2025, the VA “barely” ate dinner and P4 saw the VA’s head “looked very heavy leaning” and his/her face was “slightly flushed red.” The VA ate dinner later that night. · In the evening of October 10, 2025, the VA was given a fiber bar and an as needed dose of laxative because the VA had not had a bowel movement in two days. · On October 11, 2025, at approximately 12 noon, the VA was administered a suppository because s/he had not had a bowel movement in three days but there was “still no results” so RN1 and RN2 were notified. Later that day the VA had a bowel movement. · On October 21, 2025, the VA fell asleep a few times during the day so P3 asked the VA if s/he was feeling “okay” and the VA did not respond and was “red in the face.” The VA communicated on his/her letter board that s/he was “not feeling the best” and was “tired.” At approximately 3 p.m., P4 asked the VA if s/he was feeling “okay” and the VA “smile[d]” and nodded “yes.” · On October 22, 2025, the VA ate a “few” bites of dinner and said s/he was not hungry. Later that evening, the VA kept falling asleep while watching TV. On October 28, 2025, P3 assisted the VA with toileting and the VA had a “large loose” bowel movement. · In the morning of October 30, 2025, when P5 assisted the VA out of bed and into the shower, the VA kept falling asleep. While showering, the VA refused to hold him/herself up in the shower. · Later on October 30, 2025, the VA told P1 that the left side of his/her stomach “hurt.” When P1 “gentle [sic]” pushed on the left side, the VA said it hurt. The VA denied constipation, did not have a fever, and refused pain medication. On October 31, 2025, the VA told a staff person (P6) that his/her side did not hurt anymore. · On November 3, 2025, the VA fell asleep twice during the day. · On November 4, 2025, during the morning, the VA had “a large loose” bowel movement. The VA fell asleep throughout the day, including while trying to drink water and during his/her bedtime cares and slept from 8:30 p.m. until the next morning. · On November 5, 2025, the VA had an extra-large, loose bowel movement before breakfast. The VA fell asleep later that morning. · On November 6, 2025, there were two occasions when the VA fell asleep while eating food. P6 reminded the VA not to sleep with food inside his/her mouth because it was a choking hazard. The VA fell asleep more than a “dozen times” between 9:30 a.m. to 1:30 p.m. RN1 and RN2 were notified. · On November 7, 2025, the VA came home from his/her day program, took his/her afternoon medications, and then fell asleep. The VA kept falling asleep throughout dinner so P1 asked the VA if s/he was too tired to eat and the VA responded, “Yes.” The VA did not finish dinner and slept most of the evening in his/her wheelchair until s/he got ready and went to bed. · On November 8, 2025, the VA fell asleep with food in his/her mouth and P5 reminded the VA multiple times that s/he cannot fall asleep with food inside his/her mouth as it was a choking hazard. The VA also fell asleep multiple times while in his/her wheelchair and on the toilet. The VA had “not really” ate or drank throughout the day. · Later on November 8, 2025, the VA had “more mucus” in his/her mouth and throat than typical. The mucus did not go away and built up around the corners of his/her mouth. P2 asked the VA if it seemed like more mucus than usual and the VA responded, “No.” P2 gave the VA lemon in his/her water to thin the mucus. The VA was less talkative than usual and did not laugh or smile as s/he typically did. P2 asked the VA if s/he felt okay because s/he read in the VA’s notes that s/he had been tired and not eating lately. The VA “nodded [his/her] head yes.” The VA said s/he was “really tired” but otherwise feels “fine.” · Throughout the day on November 9, 2025, the VA refused to drink water and P4 continually reminded the VA to drink liquids. The VA ate a small amount of his/her snack during the day. P4 made the VA dinner and assisted the VA with eating. P4 did not document how much the VA ate. · Later that night, a staff person (P7) asked the VA if s/he did not feel good and the VA nodded his/her head “yes.” P7 asked if it was something similar to a cold and the VA nodded his/her head “yes.” · On November 10, 2025, P7 noticed the VA’s phlegm was “foamy, clear, and thick” when the VA drooled but the VA did not have nasal drainage. The previous two nights the VA’s lower legs were “swollen fluid filled like.” The VA did not show pain when staff persons touched his/her legs. · On November 11, 2025, the VA had an extra-large bowel movement that was “watery.” The VA’s face, eyelids, and ankles were “puffy.” During lunch, the VA ate “very slow” and told P3 that s/he was tired. The VA did not finish eating lunch. Later that day, the VA said his/her ankles “hurt” so P3 elevated the VA’s legs under a pillow. P3 took the VA’s temperature and there was no fever. · On November 12, 2025, the VA was brought to the doctor because s/he had been tired, retaining fluid, and not eating meals because s/he fell asleep. The VA’s lab results showed high sodium of 150, creatine of 1.43, potassium of 3.3, elevation in CPR, and mild leukocytosis. The doctor referred the VA to the emergency room where urine tests showed that the VA had a urinary tract infection. The VA was given fluids and potassium and admitted to the hospital. P1 notified RN1, RN2, G1, G2, and the CM. · On November 15, 2025, the VA returned to the facility from the hospital. Staff persons monitored the VA for fatigue and loss of appetite and if s/he had signs of either then the VA was brought to a doctor for blood tests to monitor the VA’s potassium and sodium. That evening, the VA appeared “tired” but ate all his/her dinner. · On November 16, 2025, the VA ate breakfast slowly and P3 pushed the VA with drinking liquids. The VA did not have a bowel movement but had an increase in urine because of the amount of liquids s/he drank. The VA had difficulties eating lunch and ate dinner “a little better” and continued drinking liquids. The VA slept “on and off most of the evening.” · The tracking form for the VA’s bowel movements showed that the VA had a bowel movement every day (with the exception of when s/he was in the hospital) up until November 16, 2025. · On November 17, 2025, the VA was administered a laxative because s/he had not had a bowel movement in two days. There were no concerns with the VA eating or drinking throughout the day except the VA did not eat a full dinner or have a bowel movement. · In the morning of November 18, 2025, the VA was tired and wanted to sleep late. Once the VA woke up, P3 assisted the VA off the toilet and saw “clear mucus” coming out of the VA’s rectum but no bowel movement. The VA’s upper stomach was bloated and “hard.” The VA drank water but did not eat “much” for breakfast. After breakfast, P3 assisted the VA to the toilet and s/he did not have a bowel movement so P3 administered a suppository. The VA did not eat “much” lunch and said his/her stomach hurt. The VA declined a snack when offered and appeared tired throughout the day. Staff persons continued to have the VA drink water and use the bathroom. At dinner, the VA ate for one hour and 30 minutes but did not finish dinner. At 6:26 p.m., the VA tried to have a bowel movement but had mucus in the toilet. · In the morning of November 19, 2025, the VA’s stomach looked “visibly bloated,” hard to the touch, and the VA indicated his/her stomach hurt. There was mucus inside the VA’s adult undergarment and when P4 assisted the VA on the toilet, there was “mucus looking bits” in the toilet. P4 contacted RN1 and RN2 and per their instructions, P4 administered a fleet oil enema. P4 also massaged the VA’s legs and stomach but the VA did not have a bowel movement. · On November 19, 2025, (no time provided) P1 brought the VA to the emergency room. Xray and other tests were done which showed a twisted bowel, gallstones, and kidney stones. The VA’s potassium was still low but his/her sodium was “okay.” RN1, RN2, G1, G2, and the CM were notified. · On December 16, 2025, the VA was discharged from the hospital with three new medications, including amoxicillin, a suppository if the VA did not have a bowel movement for 48 hours, bisacodyl (laxative), and desmopressin (regulated fluid balance). P1 provided the following information: · Between November 18 and 19, 2025, the VA was tired, did not want to eat, and his/her stomach was bloated and “hard.” RN1 and RN2 received notifications from staff persons when they were flagged in the VA’s progress notes. Prior to this, P1 was not aware that the VA’s stomach was bloated, and the VA had regular bowel movements. · Staff persons followed the VA’s bowel movement protocol and on November 19, 2025, the VA went 72 hours without a bowel movement so P1 brought the VA to the hospital. The VA had a history of being tired for years prior to this. P3, P4, P5, RN1, and RN2 each stated the VA was tired and slowed down eating so on November 12, 2025, the VA was brought to the doctor. There was no concern with the VA’s bowel movements, bloating, or being uncomfortable. P4 did not notice a change in the VA’s bowel movements at that time. On November 19, 2025, P3 called RN2 and P1 about the VA being bloated. RN2 advised P3 to administer an enema and P3 did. P3 called RN2 and P1 who told P3 that the VA needed to be brought into a doctor. RN1 and RN2 each stated that they did not attend the October 2025 staff meeting and denied providing instructions to any staff persons during that time. G1 and G2 stated that they were notified by the facility that the VA was tired but G1 and G2 were not concerned because the VA recently started attending a day program once per week so they associated the tiredness with the change in the VA’s schedule. G1 and G2 saw the VA on November 10, 2026, and did not notice that the VA was bloated and did not have concerns. G1 and G2 did not have concerns with the facility. According to the facility’s Health Service Coordination and Care Policy, if a vulnerable adult had a change in his/her physical and/or mental health needs assigned to the facility in the client plans, the facility notified the guardian(s) and case manager. The facility documented all health changes including the notifications of the guardian(s) and case manager. Facility documentation showed that all staff persons interviewed for this investigation were trained on the VA’s plans, the facility’s Health Service Coordination and Care Policy, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: P2 stated that since the middle of October 2025, the VA had increased fatigue, decreased appetite, bowel changes, stomach bloating, and discomfort. P2 told RN1 and P1 about the concerns but P1 did not bring the VA to the doctor. The VA’s progress notes and all staff persons interviewed except P2 stated that there were concerns for about a week and a half prior to November 12, 2025, that included tired and loss of appetite. Staff persons monitored the VA’s symptoms during that time and there was no concern about bloating or bowel movements. On November 12, 2025, the VA was seen by a doctor and diagnosed with a urinary tract infection and hospitalized. The doctor noted that the VA’s abdomen was “soft” with no distention or tenderness. On November 15, 2025, the VA returned to the facility and staff persons continued monitoring the VA, including following the VA’s bowel movement protocol. Once the VA went 72 hours without a bowel movement staff persons contacted RN2 who then instructed staff persons to bring the VA to the doctor. Given this information, there was not a preponderance of the evidence that there was a failure 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed. There was no additional training to staff persons. Action Taken by Department of Human Services, Office of Inspector General: No further action taken at this time.
|
