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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: 1071717-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Elisa Montgomery elisa.montgomery@state.mn.us 651-431-6474 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) did not receive medications for an unknown period, as a part of a protocol resulting in a bowel impaction requiring hospitalization. Date of Incident(s): September 9, 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 September 30, 2025; from documentation at the facility, and medical records; and through five interviews conducted with facility staff persons (P3 and P4), facility supervisory staff persons (P1 and P2), and the VA’s Guardian (G). The VA declined to provide information related to the incident during the site visit. The VA enjoyed spending time with family members, going shopping, and watching television. The VA attended a day program virtually on weekdays and attended in-person for one hour one day per week. The VA’s diagnoses included depression, anxiety, and Down syndrome. The VA had a history of complaining of stomach pain. The VA’s Intensive Support Self-Management Assessment provided the following information: The VA was aware of his/her irregular bowel patterns and was aware when s/he was constipated. The VA could become fixated on his/her bowel habits which had increased his/her risk for rectal digging. The VA had a history of bowel obstructions. The VA had a history of refusing bowel movement medications related to fears of diarrhea. Staff persons would crush the VA’s medications and administered them with applesauce, pudding, or yogurt. Staff persons were to report any concerns with the VA’s medications to his/her providers and facility supervisors. Information regarding the VA’s bowel protocol was unclear from May 2025 through August 2025 as a bowel protocol was not put in place by the facility until September 17, 2025, following the VA’s hospitalization from September 9, 2025, through September 15, 2025. The VA was prescribed PRN medications to address constipation and staff persons at the facility were documenting the VA’s bowel movements (BM) to determine if PRN medications were to be administered. Prescriptions included PRN Senna as needed for no bowel movement in two days and an additional tablet as needed but no specification as to when to give an additional tablet; PRN glycerin suppository once daily as needed but no specification as to when it would be needed; and PRN Miralax powder once daily listed in the PRN medications section and “as needed” indicated as time to be administered with no specification as to when it was needed. The VA’s BM Chart (used May to August 2025), Bowel Movement Tracking (used September 2025), and the VA’s Medication Administration Records (MAR) provided the following information: · In May 2025, the VA had a bowel movement on May 1, 6, 8, 9, 10, 14, 19, 22, and 30, 2025. MAR records show that VA was administered PRN Senna on May 5, 2025, and was administered Senna as a scheduled medication on May 1, 2025, but the medication was discontinued as a scheduled medication after May 1, 2025. · In June 2025, the VA had a bowel movement on June 4, 5, 8, 24, 25, and 27, 2025. MAR records show the VA was not administered PRN Senna in June 2025. The VA had two PRN Senna prescriptions noting, “take 1 tablet by mouth at bedtime as needed for no BM in two days,” and “take one additional tablet by mouth at bedtime as needed”. · In July 2025, the VA had a bowel movement on July 2, 5, 9, 12, 13, 19, 30, and 31, 2025. MAR records show the VA was not administered PRN Senna in July 2025. The VA had two PRN Senna prescriptions noting, “take 1 tablet by mouth at bedtime as needed for no BM in two days,” and “take one additional tablet by mouth at bedtime as needed.” · In August 2025, the VA had a bowel movement on August 3, 6, 11, 16, 20, 22, 23, 24, 28, and 30, 2025. The VA’s MAR showed that the VA was not administered any PRN medications for constipation in August 2025. The VA had two PRN Senna prescriptions noting, “take 1 tablet by mouth at bedtime as needed for no BM in two days,” and “take one additional tablet by mouth at bedtime as needed.” · In September 2025, unknown staff persons documented the VA had bowel movements on September 3 and 4, 2025. The VA’s MAR showed that the VA received PRN Senna on September 3, 7, and 8, 2025. · A note on the BM chart listing dates from May 1 to August 30, 2025, stated that dates listed on the BM chart were indicated in shift notes but other dates not listed on the BM chart, notes indicated that the VA “went to the bathroom” but there was no information whether the VA had a bowel movement or not. Most dates documented that the VA had a bowel movement on the BM chart there were no staff initials. · The VA’s Bowel Movement Tracking dated September 2025 stated that if the VA did not have a bowel movement after 24 hours, administer 1 Senokot tablet, after 48 hours, administer an extra dose of MiraLAX and give 2 tablets of Senokot daily, after 72 hours administer a suppository in addition, and after 96 hours contact the G and the VA should be evaluated that same day. · MAR records indicated that weekly MAR reviews occurred. It was unknown if the MAR reviews included weekly reviews of the VA’s BM Chart. The facility’s Internal Investigation provided the following information: · The VA was scheduled for appointments with his/her physician on September 9 – 11, 2025. Prior to the appointment, the facility had not received procedure preparations from the physician for the appointments but received a message from the G stating, “Stop taking sleeping medication, stomach medications, and pain medication 48 hours before appointment on September 10, 2025.” · On September 8, 2025, P1 contacted the physician regarding procedure preparations but the physician was not able to give clear instructions regarding which medications to withhold as the VA had not previously received care from the physician and the appointment was an initial appointment. P1 contacted the VA’s primary care provider but did not receive a response. P1 contacted the VA’s pharmacy and was instructed to give medications as prescribed. · On September 8, 2025, the G called the facility and instructed staff to withhold the VA’s Senna medication so the VA “did not have an accident in the car on the way to the appointment.” P1 explained to the G that the VA had not had a bowel movement (BM) since September 4, 2025. The G told P1 that s/he would come to the facility or FaceTime the VA and tell the VA to “refuse” the medication. · Staff persons reviewed the VA’s BM chart and determined that the VA had not had a BM since September 4, 2025, and administered the VA’s PRN Senna on September 7 and 8, 2025. · On September 9, 2025, the G texted P1 and informed P1 that the VA was being admitted to the hospital but did not receive further information from the G regarding the VA’s hospitalization. · On September 10, 2025, P1 and P2 had not heard back from the G. P2 contacted the G and was told that the VA was “extremely constipated,” and the VA was being prepped to assist with moving his/her bowels and that the VA would not be discharged. · On September 11, 2025, P1 and P2 attempted to contact the G but were unsuccessful. The G contacted P2 and informed them that the VA received suppositories and an enema with no success and that the VA would be discharged when s/he was not “as backed up.” · P1 contacted the hospital to get more information and was told by the physician that the VA had a small bowel impaction, and the VA would be discharged once s/he passed some of his/her bowel movement. · Due to staff persons missing documentation and charting regarding the VA’s bowel movements, all staff at the facility received retraining regarding the VA’s Bowel Protocol from the facilities nurse on September 23, 2025. · P2 stated that a staff person administered Senna to the VA on an unknown date in August 2025 but then the G called staff persons and said s/he did not want the VA to have Senna because it caused diarrhea. · From February to May 2025, the VA would have a bowel movement while rectal digging which often occurred daily, but staff persons did not document those bowel movements. Also, staff persons were not always in the bathroom with the VA so did not know if the VA had a bowel movement sometimes if they did not see it. P1 provided the following information: · P1 reviewed the VA’s BM Chart when the VA was admitted to the hospital and believed that documentation beginning on May 1 through September 9 or 10, 2025, was not completed as required leading to inaccuracies and missed doses of PRN bowel regimen medication. · The BM Chart outlined that staff persons were to document date, time, size, and consistency of the VA’s bowel movement to determine if PRN bowel regimen medications were to be administered. · On September 7 or 8, 2025, the G contacted the facility and expressed concerns that s/he did not want the VA to have “an accident” in the car on the way to his/her scheduled medical appointment on September 9, 2025, and instructed staff persons to withhold PRN bowel regimen medications. · On September 9 or 10, 2025, P1 was checking the VA’s BM Chart and observed that there were discrepancies, and the VA had not received bowel regimen PRN medications on some occasions. · On September 9, 2025, the G had taken the VA to a routine doctor’s appointment, and the VA was admitted to the hospital for possible bowel impaction. · P1 had concerns that discrepancies in the VA’s BM Chart could have been attributed to staff confusion as the G would call staff persons at the facility and instruct staff persons to withhold bowel regimen medications when it was contradictory to the BM Protocol. · When the VA returned from the hospital on September 15, 2025, P1 began reviewing the VA’s BM Charts on a weekly basis. P2 provided the following information: · Prior to the VA’s hospitalization September 9 to 15, 2025, there was not a formal bowel protocol in place, but staff were to document the VA’s bowel movements. The VA was prescribed Senna to be taken daily and at some point, it was changed to a PRN medication to be given after two days of no bowel movement. · The VA had a history of refusing to take the PRN medication and was able to identify the medication due to the medication being orange in color. · The VA had “anxiety” related to using the bathroom and was “afraid” of having diarrhea. The VA also had a history of rectal digging. · P2 was concerned that the VA’s refusal of the PRN bowel regimen medication was related to the G telling the VA to refuse the medication. P2 was concerned that staff persons were afraid to administer the medication per physician’s orders and BM Protocol instructions due to the G calling the facility and instructing staff persons to withhold the medication. P3 provided the following information: · Prior to the VA’s hospitalization, staff were monitoring the VA’s bowel movements due to the VA’s history of constipation. Staff would document this on paper forms at the facility but there was not a formal protocol regarding bowel movement monitoring. · P3 was concerned that the VA was refusing his/her PRN bowel movement medication when needed. On some occasions, when the VA was on the phone with the G, P3 heard the G instructing the VA to not take the PRN Senna medication. · When the VA returned from the hospital, P3 and other staff persons working at the facility were trained by the facility nurse on the BM Protocol that was created by the hospital. The training included how to measure and identify types of bowel movements and how to document using the facility’s electronic platform.
P4 provided the following information: · The VA received PRN Senna medication when s/he did not have a bowel movement after a “certain number of days.” The VA would refuse medication and had a history of complaining of stomach pain, yelling, and declining to go out into the community prior to the VA’s hospitalization. · When the VA returned from the hospital, P4 observed that the VA had less complaints of stomach pain and was “getting out more.” A bowel protocol was put in place by the VA’s physician. · P4 had not been instructed by the G to withhold the VA’s PRN Senna medication but noted that there were times when P4 would observe that the VA’s PRN medication was “discontinued” per verbal instruction from the G in the VA’s MAR. The G provided the following information: The G took the VA to his/her medical appointments. On September 9, 2025, the G took the VA to a routine medical appointment. It was found that the VA had a slight bowel impaction. The VA has a history of stomach pain and constipation. The G was concerned that the VA’s bowel protocol was not being followed. The hospital had provided the facility with a bowel protocol when the VA was discharged from the hospital. Medical records provided the following information: · On September 9, 2025, the VA was admitted to the hospital for evaluation and management of worsening abdominal pain and fecal impaction. The VA had a history of alternating constipation and diarrhea. · Physicians attempted to perform a colonoscopy and endoscopy, but the VA was unable to complete oral bowel preparation. The VA received CT scans and ultrasounds, and it was determined that the VA’s bowel impaction was resolved through suppositories and oral supplements to treat moderate colonic stool burden. · The VA was discharged on September 15, 2025, and a copy of the recommended bowel protocol was sent to the facility. · On September 29, 2025, the VA attended a virtual follow-up appointment. It was noted that the VA had a history of increased self-injurious behavior related to constipation. The VA was experiencing diarrhea when taking MiraLAX and Linzess. MiraLAX was discontinued and the VA’s diarrhea was resolved. As a result, the VA’s mood had improved. The VA’s BM Protocol which was effective on September 17, 2025, provided the following information: The VA was prescribed Linzess once daily and if no bowel movement occurred, MiraLAX was to be administered once daily. If no bowel movement occurred after two to three days, MiraLAX was to be increased by one capful every two to three days. If diarrhea occurred, MiraLAX was to be discontinued, if diarrhea persisted for seven days or longer, an additional half dose of Linzess could be administered. If constipation persisted, the VA could be administered a suppository every 48-72 hours. All staff person’s interviewed were trained on the VA’s plan of care and the Reporting of Maltreatment of Vulnerable Adults. Relevant Minnesota Rules and or Statutes Minnesota Statues, section 245D.05 subdivision 1, paragraphs (a) and (b) stated that the license holder is responsible for meeting health service needs assigned in the support plan or support plan addendum, consistent with the person’s health needs and must maintain documentation on how the person’s health needs will be met, including a description of the procedures the license holder will follow. Conclusion: Information showed that P1 reviewed the VA’s BM Chart and believed that documentation of the VA’s bowel movements beginning on May 1, 2025, through September 9 or 10, 2025 was not completed consistently leading to inaccuracies and missed doses of PRN bowel regimen medication. P1 had concerns that discrepancies in the VA’s BM Chart could have been attributed to staff confusion as the G would call staff persons at the facility and instruct staff persons to withhold bowel regimen medications when it was contradictory to the BM Protocol. P2-P4 provided information that prior to the VA’s hospitalization from September 9 to 15, 2025, there was not a formal protocol in place. The VA was prescribed Senna to be taken daily and at some point, it was changed to a PRN medication to be given after two days of no bowel movement. Medical records identified that the VA had a history of constipation, and the VA was admitted to the hospital on September 9, 2025, for further evaluation and management of abdominal pain and fecal impaction. The VA received CT scans and ultrasounds, and it was determined that the VA’s bowel impaction was resolved through suppositories and oral supplements to treat moderate colonic stool burden. The VA was discharged from the hospital on September 15, 2025, and a protocol was sent to the facility to maintain the VA’s bowel regimen. The facilities Internal Investigation identified that due to inaccurate charting regarding the VA’s bowel movements, all staff at the facility received retraining regarding the VA’s Bowel Protocol from the facilities nurse on September 23, 2025. Although information was consistent regarding the lack of a formal bowel protocol prior to the VA’s hospitalization even though the VA had a history of constipation, and possible inaccuracies with the documentation of the VA’s bowel movements which were violations of Minnesota Statues, section 245D.05 subdivision 1, paragraphs (a) and (b), given that it was unknown if the VA should have received or missed needed PRN bowel medications or if the VA had bowel movements that were not documented correctly because staff were not always in the bathroom with the VA and the VA had a history of rectal digging; that in September 2025, when it was identified that the VA needed medical evaluation for constipation it was sought; and that from May to August 2025, there was no information that the VA needed medical attention or had health issues related to constipation or not receiving PRN bowel medications if needed, there was not a preponderance of the evidence whether there was a failure 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.) Action Taken by Facility:
The facility completed an internal review and determined that policies and procedures were adequate and were followed but the VA’s plan of care was not followed. All staff persons received retraining on the VA’s BM Protocol on September 23, 2025. Action Taken by Department of Human Services, Office of Inspector General: On June 17, 2026, the facility was issued a Correction Order for the violations outlined in this report.
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