|
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: 1100712-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lisa Shock 651-431-6142 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had a lapse in dental appointments between November 20, 2024, and May 27, 2026. On May 3 and November 20, 2024, the VA was referred for two teeth extractions. The VA was not seen again by a dentist until May 27, 2026, when it was then recommended that the VA have all his/her teeth extracted. It was alleged that a supervisory/administrative staff person (SP) was responsible for ensuring the VA’s dental needs were met/completed. Date of Incident(s): Between May 3, 2024, and May 27, 2026 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 June 16, 2026; from documentation at the facility and dental records; and through six interviews conducted with the SP; three additional supervisory and/or administrative staff persons (P1, P2, and P3), the VA’s guardian (G), and the VA’s case manager (CM). This investigator met the VA but s/he was unable to provide information due to his/her diagnoses. The VA enjoyed going out into the community including bowling and movies, attending his/her day program, and having a Diet Pepsi. The VA was diagnosed with severe intellectual disabilities and generalized anxiety disorder. The VA’s Support Plan Addendums dated October 1, 2024 and October 1, 2025, stated that the facility coordinated the VA’s medical needs including accompanying the VA to appointments and conveying needed information to providers and team members. The VA needed assistance with preventative screenings appointments and setting up appointments so staff persons made appointments for the VA, transported the VA to and from appointments, and ensured information was exchanged with the provider and the VA’s team. The SP’s job description, signed with the SP’s name and dated March 5, 2021, stated that s/he was responsible for identifying and meeting the assigned health needs of the individuals supported. The VA’s dental records provided the following information: · On May 3, 2024, the VA attended a dental appointment and it was recommended that the VA have two teeth extracted “due to severe attrition/necrotic pulp” (excessive tooth wear from grinding or clenching and death of the tooths inner pulp tissue) and a referral was made for IV sedation extraction. · On November 11, 2024, the VA attended a dental appointment. The VA had stage 2 periodontal disease and it was noted that the VA had not had the teeth extracted from the prior appointment. Another copy of the previous referral from May 2024, was given for the two teeth that needed to be extracted. · On May 27, 2026, the VA’s attended a dental appointment and it was noted that the VA had not had the two teeth extracted. Another referral was made for IV sedation and extraction of the two teeth “versus full mouth extraction.” P1 and P2 and facility case notes provided the following information: · At the end of April 2026, P1 and P2took over supervisory/administrative duties for the facility because the two supervisory/administrative persons, including the SP, were out on leave. · When a client had a medical or dental appointment, the after-visit documentation was to be put into the clients computer chart and the paper copy put into the clients medical administration record book. A person in the SP’s, position were to then make any necessary follow-up appointments. · On an unknown date, P2 reviewed and audited records for the VA and discovered that the VA had not been to the dentist for two years and had not had two teeth extracted as referred. P2 called the dentist’s office and was told that the VA had not been seen since November 20, 2024. P2 then scheduled an appointment for the VA for May 27, 2026. At that appointment, the VA was given another referral for teeth extractions and that appointment was scheduled for August 3, 2026. · P1 and P2 each stated that the SP was to complete weekly checks for the VA which the SP should have seen that the VA had missed appointments. The supervisory/administrative staff person who previously had P1’s position was also to review the records monthly and quarterly and should have noticed/discovered the missed appointments. In addition, facility nursing staff persons were to conduct quarterly reviews. P1 and P2 each stated that neither saw any documentation in the facility computer system that any of these reviews were completed. The G and the CM provided the following information: · The facility managed the VA’s medical and dental appointments and provided updates to each after the visits. Neither the G nor the CM were told about the recommended teeth extractions after either the May 3 and/or November 11, 2024, appointments. · On an unknown date in May 2026, after the VA’s dentist appointment (May 27, 2026), the dentist called the G with concerns that despite two referrals for tooth extractions (May 3 and November 11, 2024), the facility had not scheduled the extractions and the VA had not been seen by the dentist since November 11, 2024. · The G stated that the dentist said the VA had five teeth remaining, two of the teeth are “damaged” (the teeth previously referred for extraction) and the other three were “non-functional” so the dentist had concerns that the VA would choke while eating. They discussed the next steps for the VA and they decided that the VA would have all of his/her five remaining teeth pulled which was scheduled for August 3, 2026. P3 provided the following information: · P3 was an administrative/supervisory staff person for the facility from 2022 through November 2024 and had several facilities that s/he provided oversight for. During that time, it was the SP’s responsibility to make medical and dental appointments and to document any follow up appointments. · P3 stated that the protocol for a referral was to enter the results into the computer system, notify the facility nurse and clients team, and then set up the appointment. · P3 did not recall seeing any information that the VA had a referral for teeth extractions in the facility computer system but a/he received an email on November, 22, 2024, regarding the referral as s/he was transitioning out of his/her role. P3 was not sure what was done at that time to ensure the appointment was completed. · P3 stated a person in P3’s role would have been the person to verify and ensure that the SP had scheduled and/or followed up on client appointments. The SP provided the following information: · The SP was responsible for coordinating medical and dental appointments and follow up referrals for clients including the VA. · The SP denied that two years passed since the VA had seen the dentist and did not recall any referrals for the VA to have teeth extracted. · When the VA returned from an appointment it was the SP’s responsibility to make the next appointment, scan any related documents into the computer system, and notify the facility nurse, who followed- up if an appointment was not scheduled as directed. Facility documentation showed that the SP was trained on the VA’s plans, facility policies, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (a) states that the license holder is responsible for meeting the health service needs assigned in the coordinated service and support plan or the coordinated service and support plan addendum, consistent with the person’s health needs. Conclusion: A. Maltreatment: The VA’s support plans stated that the facility was responsible for coordinating, scheduling, and attending the VA’s medical/dental appointments. After the VA’s dental appointment on November 14, 2024, the VA did not receive dental care until May 27, 2026, 18 months later. In addition, despite two referrals for two teeth extractions (May 3 and November 14, 2024, respectively) the VA did not have his/her teeth yet extracted and was scheduled for the extraction to occur on August 3, 2026. These were a violation of Minnesota Statutes, section 245D.05, subdivision 1, paragraph (a). Given that the facility was responsible for coordinating, scheduling, and attending the VA’s medical/dental appointments; that on May 3, 2024, when the VA saw the dentist s/he required and was referred for two teeth to be extracted yet that this did not occur by the time the VA next saw the dentist on November, 20, 2024, or as of May 27, 2026, when the VA next saw the dentist; and that it was 18 months between the VA’s dental appointments and the dentist had concerns regarding the VA’s ability to chew his/her food appropriately which was likely resulting in all of the VA’s teeth needing to be extracted, there was a preponderance of the evidence that there was a failure to supply the VA with care or services which were reasonable and necessary to maintain the VA’s physical health. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. Facility documentation showed that the SP was trained on the VA’s plans, facility policies, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Although the SP was responsible for ensuring the VA saw the dentist regularly and for scheduling the VA’s referral appointment for extractions, additional facility supervisory/administrative staff persons and facility nurses were also responsible for ensuring the SP completed those tasks by conducting monthly and/or quarterly reviews of the VA’s records and appointments to ensure the VA’s appointments were scheduled and completed as ordered. P1 and P2 each stated that neither saw any documentation in the facility computer system that any of these reviews were completed. Given that over the course of approximately two years, multiple staff persons failed to ensure the VA received dental care and failed to ensure his/her teeth were extracted as ordered, individual responsibly was mitigated and the facility was responsible for maltreatment of the VA. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated maltreatment for which the facility was responsible was serious. Although the VA initially required two teeth to be extracted, when that did not occur, two years later the VA required all of his/her teeth extracted. Action Taken by Facility: The facility completed an Internal Review and determined that policies and procedures were not adequate and not followed. Policies and procedures were not followed surrounding compliance with individual health needs as determined in the VA’s support plan. On June 23, 2026, the facility changed to a new electronic health record which features the ability to establish reminders for ensuring compliance with preventative medical appointments. Action Taken by Department of Human Services, Office of Inspector General: On July 27, 2026, the license holder was ordered to forfeit a fine of $5000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the order to forfeit a fine are each subject to appeal.
|
