Protecting, Maintaining and Improving the Health oj Minnesotans

Office of Health Facility Complaints Investigative Report PUBLIC Facility: Edgewood Vista Virginia 605 North 17th Street Virginia, MN 55792 Saint Louis County Date of Visit: 4/23/2009 & 4/24/2009 Time of Visit: 10:50 a.m.

Report #: HL21353017 Date: 8/31/2009

By:

Lori Wear, R.N. Special Investigator Deborah Neuberger, R.N. Special Investigator

Nature of Visit: An unannounced visit was made at Edgewood Vista Virginia, an assisted living facility, in order to investigate the following report of abuse in accordance with state licensing rules and the Vulnerable Adults Act (VAA), which occurred in the Edgewood Vista Virginia assisted living facility. The allegation is: It is alleged that two staffpersons, alleged perpetrators (AP#l and AP#2), emotionally and physically abused several clients. Client #1 was called names, such as "dick" and "retard" by AP#I. Client #2 was pinched (including her breast), slapped on her buttocks and had balls thrown at her by both AP#1 and AP#2. In addition, AP#1 poked her and teased her and hit her with a "noodle" and AP#2 told her that her husband was dead. Client #3 was yelled at by both AP#l and AP#2. Additional concerns include AP#l cutting the hair of client #5, giving another client (name unknown) a razor to shave his head and slapping the face of Client #4. The AP's are currently suspended. Investigative Findings: All employees and persons were interviewed in private as desired and given the Tennessen Statement. The investigation included a review of the following: Client #1, 2, 3 and 4's medical records; the facility's internal investigation; staffing schedules and assignments for 2116!2009-3/20/2009~ incident/accident reports for January, February and March 2009; personnel files for AP#I, AP#2 and AP#3 as well as 5 additional personnel files; facility training regarding abuse and dementia care and policies and procedures related to the Vulnerable Adults Act (V AA), dementia and behavior management. Observation of cares was completed and 6 clients were interviewed with no concerns identified.

Generallnfonnation: (651) 201·5000· rnrvrrv. (651) 201·5797· Minnesota Relay Service: (800) 627·3529· For directions to any of the MDH locations, call (651) 201·5000 • An Equal Opportunity Employer

www.health.state.mn.us

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Medical Record: A review of client #1's medical record revealed diagnoses of dementia and acute depression. An ADL Record/Plan of Care dated 1124/2009 documents that client # I requires assistance with activities of daily living (ADLs) and requires assistance of two staff members for transfers. Additionally, it documents that he yells out and his judgment and reasoning are impaired. A review of client #2's medical record revealed diagnoses of Alzheimer's disease and osteoarthritis. An ADL Record Plan of Care dated 1124/2009 documents that client #2 requires assistance with ADLs and walks independently with a walker. Additionally, it documents that she is resistive to cares at times and her judgment and reasoning are impaired. A review of client #3's medical record revealed diagnoses of Alzheimer's disease and anxiety. An ADL RecordIPlan of Care dated 1124/2009 documents that client #3 requires assistance with ADLs and needs assistance of one staff member to transfer. Additionally, it documents that at times she throws up when she becomes overly upset and her judgment and reasoning are impaired. A review of client #4's medical record revealed diagnoses of osteoarthritis and prostate cancer. An ADL RecordIPlan of Care dated] 124/2009 documents that client #4 requires assistance with ADLs and needs assistance of two staff members for transfers. Additionally, it documents that he is resistive to cares and his judgment and reasoning are impaired. Interviews: Employees (A) and (8)/administration were interviewed on 4124/2009 at 8:06 a.m., employee (8) was re-interviewed on 51712009 at 2:31 p.m. and stated the following: • During their investigation they suspended employee (M), AP# 1 and employee (N), AP#2. They gave coaching to employee (D), AP#3 and employee (K) and placed them on a 30 day performance plan. • Employee (8) stated that she rearranged staff at the end of November 2008 and beginning of December 2008 because people weren't working well together. She stated employees were being childish and were not productive. They were talking on cell phones, the noise level was too loud and they were talking to each other rather than residents. Employee (8) asked the LPNs to sit down in house C (where clients #1, 2, 3 and 4 reside and where AP#I, AP#2 and AP#3 worked) in November and December 2008. She stated when they were present interactions were appropriate. • They interviewed employee (F) on two occasions. During the second interview by the facility (date unknown) she retracted a lot of the concerns that had been noted in her initial letter reporting maltreatment. • AP#2 and AP#3 had coaching/corrective action in November 2008 for taking pictures of client #2 with a cell phone. • Employee (B) stated that, per facility protocol, an allegation does not have to be in writing for it to be acted on. She stated that she asked employees if they know they are mandated reporters. She stated that they "didn't want to tattle." • Employee (8) stated that the facility does not communicate back to a reporter regarding if a report is being forwarded to the Common Entry Point (CEP). • Employee (8) stated that the training provided after this investigation included: mandatory computerized modules on dementia, abuse, reporting and vulnerable adults; dementia training in the classroom and mandatory meeting regarding the Vulnerable Adults Act. Additionally employees signed the home care bi 11of rights.

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Employee (C)/nursing assistant (NA) was interviewed on 4/24/2009 at 9:25 a.m. and stated the following: • She heard an exchange between client #1 and AP#l and AP#2. Client #1 was yelling "help, help" and was getting louder and louder. AP#2 said "shut up" to him. AP# 1 told another client (name unknown) that she had to deal with the "ass." She heard AP#l ask AP#2 "where should I plop him." Employee (C) heard AP#2 state to put him in the chair and "don't forget the duct tape." Employee (C) stated she was not going to approach AP#l or AP#2 about it and that she reported it to her supervisor a day later. She gave no reason for not wanting to approach AP# 1 and AP#2. She stated she probably should have called the main building at the time it happened. She stated this event occurred approximately in late March 2009. • She had not witnessed any other interactions like this in the past. Employee (D)/alleged perpetrator (AP)#3/patient care attendant was interviewed on 4/24/2009 at 9:52 a.m. and stated the following: • She stated that approximately 2 is to 3 months ago AP# 1 was telling her a story at the dinner table and client # 1 said "shut up fat bitch" to AP# 1. She witnessed AP# 1 hit client # 1 in the chest with the back of her hand. AP#l 's hand was open and AP#3 described the slap as a 4 on a scale of 0 to 10 with zero being a tap and 10 being as hard as possible. She stated client # 1 looked shocked. She checked client #1 's chest later to see if there was a bruise and found none. She did not report this event. • She stated that approximately 1 is months ago she was assisting AP# 1 to provide cares to client #4. As AP#l was taking off client #4's shirt he stated "you're ripping my arms off' and tried to strike out at AP# 1. She stated client #4 often would lift his hand like he was going to strike out but due to his physical condition he was never able to hit staff. She witnessed AP# I slap client #4 in the mouth with an open hand. She described the slap as a 4 on a scale of 0 to 10. She checked back later to see if there was a mark or injury and found none. She did not report this event. • She witnessed AP# 1 give a client a hair cut because her hair gets matted. She stated that AP# 1 got partly finished and stated it looked like "crap" to AP #3. It is unclear if the client overheard this statement. AP#3 reported this event. • She stated that "everyone" knew that AP# 1 was like this but they were afraid to say anything. She stated she knew she was supposed to report these events. She stated she had coaching and is on a 30 day evaluation for using bad judgment in handling these events. • She stated that she had been written up because she did not fol1ow the facility policy related to client privacy when AP#2 had took pictures of client #2 and AP#3 together with a cell phone. AP#2 posted them on her internet social networking site. Employee (F), NA was interviewed on 4/24/2009 at 11: 10 a.m. and stated the following: • She saw a picture of client #1 in a clown outfit on AP#l 's digital camera in late October or November of2008. • She witnessed AP# 1 call client # I a "dick". • She witnessed AP# 1 put client # 1 in the sun room, telling him he would go to bed last because he'd been naughty. She stated there was nothing to do in the sun room and that he was in there for about an hour. She witnessed AP# I tum client # I 's chair to put him in a comer a couple of times for about Y2 hour at a time. She stated these events occurred in November or December of

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• •

2008. She stated that she asked AP#l "what are you doing" and told her she couldn't treat clients that way. She stated that AP#1 responded "he is my resident." She stated she talked to employee (E) and told her that AP# 1 needed to be watched. She witnessed AP#l, AP#2 and AP#3 antagonize client #2 by slapping her on the butt, pinching her breast on the side and bouncing a ball off her butt repeatedly. She stated that AP# I teased client #2 too much. She stated that client #2 got "meaner" and more depressed during this time and that she would not come out of her room. She witnessed AP#3 ask client #2 "silly" questions like "do you like vodka" and "do you want a drink?" She stated client #2 would become agitated. She stated that client #2 is now coming out of her room more. She stated she reported her concerns more than once and nothing happened, She stated that they do receive training on the computer but no one monitors completion. She stated that staff text message or sleep during training.

Employee 0), NA was interviewed on 5/4/2009 at 12:52 p.m, and re-interviewed on 5/6/2009 at 9:23 a.m. and stated the following: • She witnessed AP#l and AP#2 hit client #2 with water noodles (styrofoam pool toys). She stated that client #2 was laughing at first but became angry as the interaction continued. She stated that she told AP#l and AP#2 "you can't be hitting her" and that they responded "she likes it." She did not report this to her immediate supervisor, employee (Ij/Licensed Practical Nurse (LPN) because employee (I) was present when this happened. She witnessed AP#2 and AP#3 using the water noodles with client #2 another time. She did not witness AP#3 hit client #2 with the water noodle, however she was holding it and laughing as AP#2 was hitting client #2. This occurred approximately 1-2 months ago. • She witnessed AP#2 and AP#3 clock out for break and go into client #2's room. She heard them tell client #2 to give them $10,000. Client #2 became agitated after this exchange. She stated she reported this to employee (E), LPN. This occurred approximately 2-3 months ago. • She witnessed AP# 1 tell client #3 to "shut up" approximately 3 months ago. She witnessed AP#2 tell client #3 to "shut up" a few times approximately 4 months ago. She witnessed AP# 1, AP#2 and AP#I's boyfriend "badgering" client #3 by saying things like "shut up" and "you're crazy." Client #3 was agitated and yelled back "leave me alone" and "get out of here." Employee (H), NA was interviewed on 51112009 at 2:03 p.m. and stated the following: • He stated that he has witnessed staff hollering at residents and swearing near clients. He was unable to give examples of this. • He stated he witnessed a staff member (name unknown) take food away from clients. In addition the staff member wouldn't allow the clients to have dessert if they didn't consume their entree. He stated he talked to the staff member and she told him that the clients would not eat their entree's if they got dessert at the same time. He did not report this as he felt the explanation was reasonable. Employee (K), NA was interviewed on 5/4/2009 at 10:33 a.m. and stated the following: • He has witnessed AP# 1 and AP#2 come in from the cold and put their cold hands on the back of client #2's neck to startle her. He has witnessed AP#l and AP#2 "poke" a finger in the small of client #2's back. He stated this occurred sometime this winter but he cannot remember when. He witnessed AP#l and AP#2 throw a ball at client #2 and pat her on the butt. Client #2 would then pat them back on the butt.

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He witnessed AP#2 tell client #3 "he's dead" when she was looking for her husband causing her to become agitated. He stated this happened 3 months ago and he reported it to employees (A) and (8). He stated he heard from other employee's that AP#l called client #1 names but he never witnessed that. He stated AP# 1 told him about having a water noodle fight with client #2. He stated he "rolled his eyes" and walked away. He stated he had no authority to discipline staff and that it had already been reported.

Employee (E), LPN was interviewed on 4/24/2009 at 10:35 a.m. and re-interviewed on 517/2009 at 10: 17 a.m. and stated the following: • She had heard hearsay about how AP# I and AP#2 treated clients since July or August of 2008. She stated this hearsay prompted her to make unexpected visits to the work area and to spend more time there to see if she could observe any of the behavior. She did not witness any of this behavior. She stated the facility policy was that a verbal report would prompt monitoring and a written report would prompt the facility to act on it. • She stated she did not allow AP# 1 and AP#2 to work together on her shifts because there was always a lot of joking around. • She stated that client #2 became more aggressive and had more behaviors when AP # 1 and AP #2 were working with her. She statedthat client #2 was up all night and slept during the day. She stated that client #2's agitation has decreased and there are fewer reports of her hitting and client # I has not been throwing things since AP # 1 and AP #2 were suspended. • She stated that employee (B) was aware of the concerns in the memory care area. Four attempts to contact employee (I) for an interview were unsuccessful. Attempts to contact employee (M), AP# 1, by phone and subpoena for an interview were unsuccessful. Employee (N), AP#2 was interviewed on 5/22/2009 at 8:00 a.m. and stated the following: • Employee's (A) and (8) asked to talk to her; she didn't know what it was about. They asked her if she had done anything wrong, seen anything wrong or had any concerns. She stated she didn't know anything and hadn't witnessed anything. • She stated she had never slapped client #2 on the butt nor had she witnessed anyone do this to client #2. She stated client #2 would hit you with her purse as you walked by her. She never threw a ball at client #2 and never saw anyone else do this. • She saw AP# I get the water noodles out of the closet but did not see her hit client #2 with them. She stated she heard about it afterwards. She stated she was in the kitchen getting a meal ready during the time. • She stated she never went into client #2's room to tease her or ask for money. • She never placed her cold hands on client #2's neck or poked her in the back with her fingers. • She never stated nor heard anyone else state "he's dead" when client #3 was looking for her husband. • She stated that maybe she is being accused because of "guilt by association" with AP #1. • She stated she did take pictures of client #2 and AP#3 and place them on an internet social networking site. She stated that she did not realize that this wasn't allowed. After she was told that this wasn't allowed, she removed the pictures and did not take any more.

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During the course of the investigation, it was unable to be determined if the interactions between AP# 1, AP#2 and AP#3 and clients # 1, #2, #3 and #4 were reported, by the staff interviewed above, as they happened. Alleged Perpetrators: A review of AP #1, AP #2 and AP #3's personnel records revealed that each of them had received at least eight hours of orientation including abuse and dementia training. All three of them had cleared background studies indicating they could provide direct contact services. Policies & Procedures: A review of the facility's policies and procedures revealed a Reporting of Maltreatment of Vulnerable Adults, date unknown, documents that "any, all or suspected maltreatment" be reported. The facility's employee handbook dated 12/1/2007 documents that all residents have the right to be treated with courtesy and respect Additionally it documents that all residents shall be free from maltreatment or nontherapeutic infliction of physical pain or injury, or any persistent course of conduct intended to produce mental or emotional distress Conclusion: As defined by the current statutory definition specified within Minnesota Statutes §626.5572, there is a preponderance of evidence that verbal, physical and emotional abuse did occur when AP# I and AP#2 mentally and physically abused four clients. During the course of the investigation a third perpetrator, AP#3 was identified. Interviews and documentation review revealed the following: • Employee (C), NA witnessed AP#2 tell client #1 to shut up and heard AP#l call him an "ass." • AP#3 witnessed AP# 1 slap client # 1 in the chest with the back of an open hand and slap client #4 in the mouth with an open hand. • Employee (F) heard AP#1 call client #1 a "dick," witnessed AP#I place him into a comer in a sun room because he was "naughty." • Employee (F), NA witnessed client #2 being antagonized by AP# 1, AP#2 and AP#3 by slapping her on the butt, pinching her on the side of the breast and bouncing a ball off her butt repeatedly. She witnessed AP#3 antagonize client #2 by asking if she wanted vodka or a drink. • Employee (1), NA witnessed AP# I and AP#2 hit client #2 with water noodles until client #2 became angry. She witnessed AP#3 holding a water noodle and laughing. She heard AP#2 and AP#3 ask client #2 to give them $10,000 until she became agitated. She witnessed AP#l and AP#2 tell client #3 to "shut up," She also witnessed AP#I, AP#2 and AP#I's boyfriend tell client #3 "shut up" and "you're crazy" until client #3 became agitated and yelled "leave me alone" and "get out of here." • Employee (K), NA witnessed AP# 1 and AP#2 put their cold hands on client #2's neck to startle her and poke her in the small of the back. He saw AP# 1 and AP#2 throw a ball at client #2 and pat her on the butt. He heard AP#2 tell client #3 "he's dead" when she was looking for her husband. As a result of this investigation, the following state licensing orders are issued: Minnesota Statute 144A.44 Subdivision 1; Minnesota Statutes 2008 626.557 Subdivision 4 (a); and Minnesota Statutes 2008 626.557, Subdivision 4 (b). A revisit was conducted on 7/14/2009 and the state licensing orders were corrected.

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The "mitigating factors" in Minnesota Statutes §626.557, subdivision 9c (c) were considered and it was determined that AP# 1, AP#2 and AP#3 are responsible for the verbal, physical and emotional abuse. In addition the facility is responsible because of a lack of internal reporting of suspected maltreatment by multiple staff members. The facility and the employee's will be notified of the right to request reconsideration and/or appeal the maltreatment finding. Since the allegation of abuse by identified employees is substantiated, this report will be submitted to the nurse aide registry for possible inclusion of the finding on the abuse registry andlor to the Minnesota Department of Human Services for possible disqualification in accordance with the provisions of the background study requirements in State law. The employees will be notified of the right to request reconsideration and a hearing to challenge these findings. xc: Division of Compliance Monitoring - Licensing & Certification Minnesota Board of Examiners for Nursing Home Administrators Minnesota Board of Nursing Saint Louis County Medical Examiners Virginia City Police Department Saint Louis County Attorney Virginia City Attorney

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CERTIFIED MAIL #: 70071490 000108857092

FROM:

Minnesota Department of Health, Division of Compliance Monitoring 85 E eventh Place, Suite 300, P.O. Box 64970, St. Paul, Minnesota 55164-0970 e ~Heal Facility plaints

TO PROVIDER ADDRESS

Paul Clark. Administrator Edgewood Vista Virginia 605 North 17th Street, Virginia. MN 55792

DATE 6/12/2009 COUNTY

Saint Louis

On 6/1212009 an investigator with the Office of Health Facility Complaints completed a complaint investigation, which began on 412312009. The following correction orders are issued. When corrections are completed please sign and date, make a copy of the form for your records and return the original to the above address.

Signed:

_

Date:

_

In accordance with Minnesota Statute 144A.45, this correction order has been issued pursuant to an abbreviated standard survey including a complaint investigation. If, upon reinspection, it is found that the violation or violations cited herein are not corrected, a fine for each violation not corrected shall be assessed in accordance with a schedule of fines promulgated by rule of the Minnesota Department of Health. Determination of whether a violation has been corrected requires compliance with all requirements of the rule provided in the section entitled "TO COMPLY." Where a rule contains several items, failure to comply with any of the items will be considered lack of compliance. Lack of compliance on reinspection with any item of a multi-part rule will result in the assessment of a fine even if the item that was violated during the initial inspection has been corrected. You may request a hearing on any assessments that may result from non-compliance with these orders provided that a written request is made to the Department within 15 days of receipt of a notice of assessment for non-compliance.
L Minnesota Statute 144A_44 Subdivision 1. Statement

of rights,

A person who receives home care services has these rights: (14) the right to be treated with courtesy and respect, and to have the patient's property treated with respect; (15) the right to be free from physical and verbal abuse; Based on interviews and documentation review the facility failed to ensure that 4 of 6 clients were treated with courtesy and respect and that they were free from physical and verbal abuse. Findings include: Client's # 1,2,3 and 4 were physically, emotionally and verbally abused while at the facility by alleged perpetrators (AP) #1, #2 and #3. A review of client # 1's medical record revealed diagnoses of dementia and acute depression. An ADL Record/Plan of Care dated 112412009 documents that client #1 requires assistance with activities of daily living (ADL's) and requires assistance of two staff members for transfers. Additionally, it documents that he yells out and his judgment and reasoning are impaired. A review of client #2's medical record revealed diagnoses of Alzheimer's disease and osteoarthritis. AnADL Record/Plan of Care dated 1/2412009 documents that client #2 requires assistance with ADL's and walks independently with a walker. Additionally, it documents that she is resistive to cares at times and her judgment and reasoning are impaired. A review of client #3's medical record revealed diagnoses of Alzheimer's disease and anxiety state. An ADL Record/Plan of Care dated 1/2412009 documents that client #3 requires assistance with ADL's and needs assistance of one staff member to transfer. Additionally, it

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docwnents that at times she throws up when she becomes overly upset and her judgment and reasoning are impaired. A review of client #4's medical record revealed diagnoses of osteoarthritis and prostate cancer. An ADL Record/Plan of Care dated 1/2412009 documents that client #4 requires assistance with ADL's and needs assistance of two staffmembers for transfers. Additionally, it documents that he is resistive to cares and his judgment and reasoning are impaired. An interview with employee (C)/nursing assistant (NA) on 4/2412009 at 9:25 am. revealed that she witnessed client # 1yelling "help, help" to which AP #2 stated "shut up." She then heard AP # 1 tell another client she had to go take care of the "ass." She heard AP # 1 ask AP #2 "where should I plop him". Employee (C) heard AP #2 state to put him in the chair and "don't forget the duct tape." She stated she did not report this at the time because there was no nurse present then. She stated she reported it a day later but that she should ha ve called the main building to report it when it occurred. Resident # I and another unidentified client were present during this event. An interview with employee (F), NA on 412412009 at 11: 10 a.m. revealed that she heard AP #1 call client #1 a "dick". She also witnessed AP#l put client #1 in the sun room for up to an hour when she got mad at him and heard her tell him "you've been naughty, you'll go to bed last." Sbe has also witnessed AP#I turn client #1 's chair and put him in a corner for about 30 minutes. These incidents occurred in November or December of2008. Employee (F) witnessed client #2 having her "butt" slapped and her breast pinched on the side by AP # 1 and #2. She witnessed a ball being thrown at her buttocks. She states this "went on for months." Employee (F) stated that client #2 got meaner and more depressed and would just sit in her room and fall asleep. She witnessed APs #1, #2 and #3 bounce balls offofclient #2 as she was walking away from them. She witnessed AP#3 ask client #2 "silly" questions which would agitate her such as "do you like vodka" and "do you want a drink?" She stated she reported these events to employee (E)/nurse more than once and that they (the nurses) were trying to catch her at it.
An interview with employee (H), NA on 51112009 at 2:03 p.m. revealed that he witnessed an employee (name unknown) take away food from clients. He stated that this employee would not allow residents to have dessert or other food if they didn't finish their entree. He stated

he talked to the employee who did this and was told the clients would not eat their entree's otherwise. He stated he talked to this employee about the concern and didn't report it to anyone because he found her explanation reasonable. An interview with employee (K), NA on 5/4/2009 at 10:33 a.m. revealed that he witnessed AP #1 and #2 come inside during the winter and put their cold hands on the necks of client #2 to startle her. He also witnessed AP#l and #2 "poke" at client #2. He described the poke as "not hard" and as a finger in the small of the back. He witnessed AP #1 and #2 pat client #2 on the buttocks and then client #2 would pat them back on the buttocks. He stated that sometimes the AP's patted client #2 first and sometimes client #2 patted the AP's first. He witnessed AP # 1 and #2 aggravate client #2 until she was ready to throw water. He witnessed AP #2 ten a client who was asking for her husband "he's dead," and this would agitate her. He states that since AP #1 and #2 are no longer at the facility the clients are noticeably different and the atmosphere is calmer. He stated that approximately 3 months ago he told employee (A) and (B) about the things he had seen.

p.m, revealed that she witnessed on 3 separate occasions AP #1, #2 and #3 hit client #2 with foam water noodles. The first occasion she saw AP #1 and #2 hitting client #2 who was laughing but then became angry. She stated that her immediate supervisor employee (I)/nurse was present and did not say anything about the incident. The second time she saw this, AP #2 and #3 were present. She did not witness AP #3 hit client #2 but did see AP #3 laughing while AP #2 was hitting client #2. She witnessed AP #2 and #3 punch out for breaks and go into client #2's room and tease her by saying "give me $10,000." Client #2 would become agitated and say she didn't have money. She witnessed AP #] and #2 tell client #3 to "shut up" on more than one occasion. She thinks this was approximately 4 months ago. She witnessed AP #1 and #2 and AP#I 's boyfriend badgering client #3 by saying "shut up, you're crazy." Client #3 was agitated and yelling back at them "leave me alone, get out of here." She stated she told employee (E) and was told that she had to catch them doing these things.
An interview with employee (1), NA on 5/4/2009 at 12:52 An interview with employee (D)/patient care attendant (PCA), AP #3 on 4/24/2009 at 9:52 am. revealed that she witnessed AP #1 place client #1 in the sun room and close the door. She witnessed AP #1 hit client #1 in the chest open handed, with the back of her hand. She stated it was just enough to hear a hollow sound and described it as a 4 on a scale of zero to 10 with zero being a tap and 10 being as hard as

possible. She stated she looked at client # 1's chest later and did not see a bruise. She stated client # 1 looked shocked when AP # I slapped him. This occurred approximately 2 Y:z to 3 months ago. She did not report this incident to anyone. She witnessed AP # 1 slap client #4 in the mouth with an open hand. She stated that this too was a 4 on a scale of zero to 10. She went back afterwards to see if there were any marks on client #4 and did not see any. This occurred approximately I Y:z months ago. She did not report it to anyone. She witnessed AP # 1 cut a client's hair. She stated it looked bad and so AP #3 reported this incident. She stated she knew she was supposed to report abuse. AP #3

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CORRECTION ORDER REPORT # HL213530J7 Page 3 of5

stated she had been written up because she did not follow the facility policy related to client privacy when a picture of she and client #3, taken with a cell phone by AP #2, was posted on the internet. An interview with employee (Ej/nurse on 4/24/2009 at 10:35 a.m. revealed that had heard of concerns and she would go to observe the area but she could not see anything inappropriate happening. She stated there was a facility practice that a verbal report would prompt monitoring by the nurse but there would need to be a written report for them to act on it. She would not have AP #1 and #2 work together because they did a lot of joking around. She stated that now ifsomeone verbally reports to her she acts on it right away. Employee (E) noted that client#2's behaviors were increasing and she was more aggressive. She stated that client #2 was up all night and sleeping during the day. She stated that client #2's agitation has decreased since AP #1 and #2 are no longer working with her. She has fewer outbursts and there are fewer reports of her hitting out. She also stated that client # 1 has not been throwing things since AP # 1 and #2 are no longer working with him. Several attempts were made to contact employee (I), nurse with no response. The facility's employee handbook dated 12/1/2007 documents that all residents have the right to be treated with courtesy and respect. Additionally it documents that all residents shall be free from maltreatment or non-therapeutic infliction of physical pain or injury, or any persistent course of conduct intended to produce mental or emotional distress. TO COMPLY: A person who receives home care services has a right to be treated with courtesy and respect and to be free from physical and verbal abuse. TIME PERIOD FOR CORRECTION: Fourteen (14) days.

2. Minnesota Statutes 2008,626.557, Subd. 4 (a). Internal reporting of maltreatment.
(a) Each facility shall establish mandated responsible reporter and enforce an ongoing written procedure maltreatment requirements reporting are reported. requirements in compliance internally. with applicable However, licensing a rules to ensure that all cases of suspected may meet the reporting for complying If a facility has an internal reporting of this section. procedure,

of this section by reporting

the facility remains

with the immediate

Based on interviews and docurnentation review the facility failed enforce an ongoing written procedure in compliance with applicable licensing rules to ensure that all cases of suspected maltreatment are reported for 4 of 6 clients. An interview with employee (C)/nursing assistant (NA) on 412412009 at 9:25a.m. revealed that she witnessed client # 1yelling "help, help" to which AP #2 stated "shut up." She then heard AP #1 ten another client she had to go take care of the "ass." She heard AP #] ask AP #2 "where should I plop him". Employee (C) heard AP #2 state to put him in the chair and "don't forget the duct tape." She stated she did not report the incident immediately. She stated she reported it a day later but that she should have called the main building to report it when it occurred. Resident # 1 and another unidentified client were present during this event. An interview with employee (F), NA on 412412009 at 11: 10 a.rn. revealed that she heard AP #] call client #1 a "dick". She also witnessed AP#I put client #] in the sun room for up to an hour when she got mad at him and heard her tell him "you've been naughty, you'll go to bed last." She has also witnessed AP# 1 turn cl ient # 1's chair and put him in a comer for about 30 minutes. These incidents occurred in November or December of2008. Employee (F) witnessed client #2 having her "butt" slapped and her breast pinched on the side. She witnessed a ball being thrown at her buttocks. She states this "went on for months." Employee (F) stated that client #2 got meaner and more depressed and wouJdjust sit in her room and fall asleep. She witnessed AP's #1, #2 and #3 bounce balls offofcIient #2 as she was walking away from them. She witnessed AP#3 ask client #2 silly questions which would agitate her such as "do you like vodka" and "do you want a drink?" She stated she reported these events to employee (E)/nurse more than once and that they were trying to catch her at it. During the course of the investigation, it was unable to be determined if the interactions between APs # 1, #2 and #3 and clients # 1, #2, #3 and #4 were reported as they happened. An interview with employee (H), NA on 51112009 at 2:03 p.m. revealed that he witnessed an employee (name unknown) take away food from clients. He stated that this employee would not allow residents to have dessert or other food if they didn't finish their entree. He stated he talked to the employee who did this and was told the clients would not eat their entree's otherwise. He did not report this as he found the

HE-01239·03

Rev. 4/93

Minnesota Department Health, Health Policy, Information and Compliance Monitoring 8S East Seventh Place, Suite 220, P.O. Box 64970, St. Paul, Minnesota 55164-0970 Orders to Edgewood Vista Virginia

or

Division

CORRECTION ORDER REPORT # HL213530J 7 Page 4 of5

response reasonable. He stated he talked to this employee about the concern and didn't report it to anyone because he found her explanation reasonable.
An interview with employee (K), NA on 5/4/2009 at 10:33 a.m, revealed that he witnessed AP #1 and #2 come inside during the winter and put their cold bands on the necks of client #2 to startle her. He also witnessed AP# I and #2 "poke" at client #2. He described the poke as ''not hard" and as a finger in the small of the back. He witnessed AP #1 and #2 pat client #2 on the buttocks and then client #2 would pat them back on the buttocks. He stated that sometimes the AP's patted client #2 first and sometimes client #2 patted the AP's first. He witnessed AP # 1 and #2 aggravate client #2 until she was ready to throw water. He witnessed AP #2 tell a client who was asking for her husband "he's dead." He states that since AP #1 and #2 are no longer at the facility the clients are noticeably different and the atmosphere is calmer. He states he did report these concerns to a nurse. He stated that approximately 3 months ago he told employee (A) and (B) about the things he had seen. During the course of the investigation, it was unable to be determined if the interactions between APs # I, #2 and #3 and clients #], #2, #3 and #4 were reported as they happened. An interview with employee (1), NA on 5/4/2009 at 12:52 p.m. revealed that she witnessed on 3 separate occasions AP #1, #2 and #3 hit client #2 with foam water noodles. The first occasion she saw AP # 1 and #2 hitting client #2 who was laughing but then became angry. She stated that her immediate supervisor employee (D/nurse was present and did not say anything about the incident. The second time she saw this, AP #2 and #3 were present. She did not witness AP #3 hit client #2 but did see AP #3 laughing while AP #2 was hitting client #2. She witnessed AP #2 and #3 punch out for breaks and go into client #2's room and tease her by saying "give me $10,000." Client #2 would become agitated and say she didn't have money. She stated it crossed ber mind to report this incident but she did not report it because she did not have time. She witnessed AP #1 and #2 tell client #3 to "shut up" on more than one occasion. She thinks this was approximately 4 months ago. She witnessed AP #1 and #2 and AP#I 's boyfriend badgering client #3 by saying "shut up, you're crazy." Client #3 was agitated and yelling back at them "leave me alone, get out of here. " She stated she to1d empJoyee (E) and was told that she had to catch them doing these things. During the course of the investigation, it was unable to be determined if the interactions between APs # 1, #2 and #3 and clients #1, #2, #3 and #4 were reported as they happened.

An interview with employee (D)!patient care attendant (PeA), AP #3 on 412412009 at 9:52 a.m. revealed that she witnessed AP # 1 place client # 1 in the sun room and close the door. She witnessed AP # 1 hit client # 1 in the chest open handed, with the back of her hand, She stated it was just enough to hear a hollow sound and described it as a 4 on a scale of zero to 10 with zero being a tap and 10 being as hard as possible. She stated she looked at client #I's chest later and did not see a bruise. She stated client #1 looked shocked when AP # 1 slapped him. This occurred approximately 2 Y:i to 3 months ago. She did not report this incident to anyone. She witnessed AP # I slap client #4 in the mouth with an open hand. She stated that this too was a 4 on a scale of zero to 10. She went back afterwards to see if there were any marks on client #4 and did not see any. This occurred approximately 1 Y2 months ago. She did not report it to anyone. She witnessed AP # 1 cut a client's hair. She stated it looked bad and so AP #3 reported this incident. She stated she knew she was supposed to report abuse. She witnessed employee (G), N A tell a client who was repetitively asking if she needed money to pay for her room ''no, I'm not going to tell you again." AP #3 stated she had been written up because a picture of she and client #3, taken with a cell phone by AP #2, had been posted on the internet.
An interview with employee (E)/nurse on 4124/2009 at ] 0:35 a.m. revealed that had heard of concerns and she would go to observe the area but she could not see anything inappropriate happening. She stated there was a facility policy that a verbal report would prompt monitoring by the nurse but there would need to be a written report for them to act on it. She would not have AP # 1 and #2 work together because they did a lot of joking around. Sbe stated that now if someone verbally reports to her she acts on it right away. Employee (E) noted that client#2's behaviors were increasing and she was more aggressive. She stated that client #2 was up all night and sleeping during the day. She stated that client #2's agitation has decreased since AP #1 and #2 are no longer working with her. She has fewer outbursts and there are fewer reports of her hitting out. She also stated that client # 1 has not been throwing things since AP # I and #2 are no longer working with him.

Several attempts were made to contact employee 0), nurse with no response. A review of the facility's policies and procedures revealed a Reporting of Maltreatment ofVulnerabJe Adults, date unknown, documents that "any, all or suspected maltreatment" be reported. TO COMPLY: Each facility shall establish and enforce an ongoing written procedure in compliance with applicable licensing rules to ensure that all cases of suspected maltreatment are reported. Ifa facility has an internal reporting procedure, a mandated reporter may meet the reporting requirements of this section by reporting internally. However, the facility remains responsible

HE-01239-03 Rev. 4/93 Minnesota Department of Health, Health Policy, Information and Compliance Monitoring 85 EAst Seventh Place, Suite 220, P.O. Box 64970, St. Paul, Minnesota 55164-0970 Orders to Edgewood Vista Virginia Division

CORRECTION ORDER REPORT # HL213S3017
Page 5 of5

for complying

with the immediate

reporting

requirements

of this section.

TIME PERIOD FOR CORRECTION: Fourteen (14) days. 3. Minnesota Statutes 2008,626.557, Subd. 4 (b). Internal reporting of maltreatment.
(b) A facility with an internal reporting the mandated reporter written notice must be provided procedure that receives an internal report by a mandated the confidentiality reporter shall give a written notice stating whether the facility has reported the incident to the common entry point. The of the reporter.

within two working days and in a manner that protects

Employee (1), NA was interviewed on 5/4/2009 at 12:52 p.m. and stated that she does not get feedback about whether a report is made to the Common Entry Point (CEP) after making an internal report to the facility regarding suspected abuse or maltreatment. She stated "there should be follow up" if something is reported. She stated "there should be some kind offeedback." She stated that she can report a concern to the nurse but, "I don't know anything farther than that, whether it was taken care of or not." Employee (8) was re-interviewed on 517/2009 at 2:31 p.m. and stated that reporters of suspected abuse or maltreatment do not receive communication stating whether the facility has reported the incident to the Common Entry Point (CEP). A facility with an internal reporting procedure that receives an internal report by a mandated reporter shall give the mandated reporter a written notice stating whether the facility has reported the incident to the common entry point. The written notice must be provided within two working days and in a manner that protects the confidentiality of the reporter.

TO COMPLY:

TIME PERIOD FOR CORRECTION: Fourteen (14) days.

xc:

Division of Compliance Monitoring. Licensing & Certification State and County Departments of Welfare, Attn: Medical Assistance Program

Protecting, Maintaining and Improving the Health of Minnesotans

Post Correction Order Follow-Up PUBLIC DATA Facility: Edgewood Vista Virginia 605 North 1ih Street Virginia, MN 55792 S1. Louis County Date of Visit: July 14, 2009 Time of Visit: 7:40a.m.

Report #: HL21353017 Date: July 16, 2009

By:

Lori Wear, R.N. Special Investigator

Nature of Visit An unannounced visit was made in order to follow-up three State licensing order(s) which was issued on June 12,2009, as the result of an investigation which had been completed on April 23, 2009 . The status of each order is as follows: 1. MN Statute 144A.44 Subd. 1. - Corrected 2. MN Statute 2008,626.557, Subd. 4 (a) - Corrected 3. MN Statute 2008, 626.557, Subd. 4 (b) - Corrected xc: Minnesota Department of Health - Licensing and Certification

General Information : (651) 201-5000 TDDfITY: (651) 201-5797 Minnesota Relay Service: (800) 627-3529 www.health.state.mn.us For directions to any of the MDH locations, call (651) 201-5000 An Equal Opportunity Employer

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