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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: 1101750-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt/Danielle Morrison Suspected Maltreatment Reported: It was reported that a vulnerable adult’s (VA’s) cares were being neglected. Date of Incident(s): prior to May 15, 2022 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 site visits conducted on June 2, 2022, and August 5, 2022; from documentation at the facility, medical records; and through seven interviews conducted with the VA, a facility management staff person (P), two facility health care professionals (HCP1 and HCP2), the VA’s case manager (CM), the VA’s medical doctor (MD1), and the VA’s guardian (G). The VA’s Master Care Plan showed that s/he enjoyed hunting, fishing, and watching television. Some of the VA’s diagnoses included multiple sclerosis, “atypical facial pain,” ”chronic pain syndrome,” diabetes and major depressive disorder. The plan further showed that the VA “needs two people to transfer” and was “unable to walk.” The VA used an electric wheelchair for mobility and was “prone to pressure ulcers.” The VA returned to the facility on January 21, 2022, after an unrelated hospitalization. Progress notes on that date from the facility indicated s/he had a “little toe scab” on his/her right foot 2 cm x 1.5 cm in size. MD1 and his/her written orders stated that when MD1 saw the VA on February 10, 2022, the VA had a “deep tissue injury” on his/her ”right 5th metatarsal (small toe).” The injury was “dark purple” and “not open.” MD1 instructed staff to use Betadine daily, reposition the VA every two hours, have the mapping done on the VA’s bed, and to have the VA see MD1 if the wound did not improve. After that appointment, MD1 did not hear anything from the facility regarding the VA or the wound. In May 2022, the VA showed signs of having a “cold” or “Covid.” Staff continued to monitor him/her and when his/her condition did not improve for two days, the VA was taken to the hospital and records showed s/he was admitted to the hospital on May 10, 2022, had surgery to remove the small right toe, but the surgery date was not specified. The VA was released on May 14, 2022. The VA’s discharge orders from the hospital, dated May 14, 2022, indicated that the VA had “osteomyelitis” (an infection of the bone), that the VA’s toe was amputated, and that “surgery was thought to have removed full infection.” A culture from the area removed was positive for “staphyloccus lugdunensis.” On May 19, 2022, the VA started receiving wound care. Wound Care Notes (WCN) provided by Allina Home Health from May 19-June 29, 2022, provided the following information: · The VA was discharged on May 14, 2022, and needed wound care for a surgical wound to the amputated fifth metatarsal of the right foot, for a pressure injury to the fifth metatarsal of the left foot, and a pressure injury to the coccyx. Discharge from home health care was to occur when the patient/caregiver was able to demonstrate knowledge of proper wound care. · On May 19, 2022, WCN noted the surgical incision was intact, there were no signs of surgical site (s/s) infection, no notation in regards to left foot was made, and the coccyx area had full thickness, but no exposed tendon or bone. · On May 26, 2022, WCN noted that wound care to surgical wounds was to be performed by a surgical nurse, MD2 was to be notified if a decline in status or failure to progress after three weeks. No infection was noted, the coccyx area was cleansed with soap and water, patted dry, and covered with dressing, and no notation of injury to left foot was made. · On May 31, 2022, WCN noted that wounds appeared stable at that time, the coccyx care remained the same as previous visit, and no notation of injury to left foot was made. · On June 3, 2022, WCN noted that no s/s infection appeared, the wound appeared to be healing as evidenced by decreased draining and improved color, the coccyx care remained the same as previous visit, and no notation of injury to left foot was made. · On June 7, 2022, WCN noted that the wound progressed well, the coccyx care remained the same as previous visit, and no notation of injury to left foot was made. · On June 9, 2022, WCN noted a new wound on left foot that appeared to be a suspected deep tissue injury, was deep purple in color; however skin was intact, and there was no drainage. The coccyx care remained the same as previous visit, but it was noted that it was “nearly closed.” The incision remained intact on right foot and it had not changed since last visit. · On June 13, 2022, WCN noted no change in status. · On June 21, 2022, WCN noted no s/s infection appeared, the incision was healing. Minimal change to left foot, and the coccyx area care remained the same. · On June 23, 2022, WCN noted no s/s infection appeared, the left foot was stable but had not shown improvement, and the coccyx wound was closed but redness was still noted. · On June 29, 2022, WCN noted sutures from right foot removed per orders from MD2, the left foot was unchanged, and the coccyx area was healed. The VA was discharged from home health care on this date due to goal being met (patient/caregiver was able to demonstrate knowledge of proper wound care). Per the facility’s Progress Notes it was noted that the VA’s wound on his/her coccyx area opened up again on July 2, 2022. The Progress Notes documented this wound area was cleaned and redressed on July 4 and July 7, 2022. Per the Monthly Report provided from the facility, the VA’s leg was reassessed on July 20, 2022, the left fifth metatarsal was warm to the touch, some necrosis, and maceration was noted as well as a foul smell. The surrounding skin had redness. A facility nurse also noted another wound on the back of the VA’s right lower leg. Staff called for an ambulance to take the VA to the hospital at 5:15 p.m. on July 20, 2022. Hospital records showed the VA was admitted again on July 20, 2022, due to a left foot infection. The VA had osteomyelitis of the fifth toe of his/her left foot and his/her small left toe was amputated on an unspecified date. The VA was released on July 27, 2022, with a wound on the right heel/Achilles tendon area noted. The VA started home health wound care again on July 29, 2022. WCN stated wound care to left amputated site to be performed by surgical nurse, sutures were intact, and no s/s infection noted. On August 1, 2022, there was a full thickness ulceration with exposed tendon noted on the right heel. There was no surrounding erythema (superficial reddening of the skin), streaking, purulence (discharge of pus), malodor (an offensive odor), or soft tissue crepitance (crackling or popping sounds experienced under skin) reported. Home health visits were to continue for the next four weeks. This investigator only received reports through August 1, 2022. Per the G, on August 8, 2022, the VA was admitted again to the hospital per the urging of the home health wound nurse. The VA’s right heel tendon was exposed and infected. The G provided the following information: · The G stated that in early February 2022, s/he found out from a former facility staff person that the VA had an abrasion on his/her small toe on the right foot. When the G did not hear anything further, s/he believed that the abrasion had healed. However, when the VA was hospitalized in May 2022, the G learned that the toe needed to be amputated. The G believed the injury to be a result of the VA’s diagnosis of multiple sclerosis. The VA did not have feeling in his/her legs and would “push” against the foot board of his/her bed. The G informed facility staff persons to place pillows at the foot board to address this. · Prior to the VA’s July 2022 hospitalization, the G was not informed of any changes to the VA’s wound. It was also found that the VA had exposed tendons near his/her right ankle from an unknown wound the VA did not have before. · The G asked the P about the wounds and the P “blamed” this on the VA’s bed saying the bed is “too small” for the VA. The G stated that it is the facility’s responsibility to provide an adequate bed for the VA. · The G found out from the hospital social worker that MD2 was reluctant to see the VA after his/her August 2022 hospitalization because the facility failed to bring the VA to three prior appointments, nor did they cancel the appointments. Per the Monthly Reports provided to the G from the facility, the VA missed two follow up appointments with the podiatrist (MD2), June 17 and June 30, 2022, due to the VA’s wheelchair not working. The VA was supposed to have another follow up appointment on July 22, 2022, but was in the hospital at that time. The P provided the following information: · When the P began employment at the facility in February 2022, the VA’s small right toe was “dry” and “dark” from the medicine (Betadine) that was used on it daily. When the P was asked how the toe changed over time, s/he stated that it “never changed” and that staff followed the doctor’s orders. The P also stated that when s/he read the orders, it was mentioned that the VA needed to have his/her bed mapped (MD1 stated that mapping was a process done on the bed to reduce injury when patients, who had no “sensation,” were in bed). The P called the company three times to do the mapping, but the mapping was not done. · Because the VA spent a considerable amount of time in his/her bed, staff repositioned him/her every two hours, as well as moving pillows to “protect” his/her feet. · In May 2022, the VA showed signs of illness. As a result, the VA was hospitalized after a couple days and his/her toe was amputated a couple days later. When the VA returned home from the hospital, the facility obtained a “boot” that the VA could wear in an effort to minimize contact with the VA’s toes and the end of the bed. Orders from a follow up appointment on May 24, 2022, stated the VA “should order a longer bed to ensure no pressure to feet.” · The P called a medical supply company in May 2022 to discuss a new bed. On July 21, 2022, the P emailed for follow up as s/he had not heard back. On July 26, 2022, the P received a response stating that insurance would not cover the new bed, but the VA could get a new longer mattress for the cost of $1828.96 out of pocket. The G handled the VA’s finances and the facility was not involved. · The P stated that the facility did not cancel or reschedule the VA’s follow up appointments. When the VA was not able to make the appointment due to his/her wheelchair not working, the P tried to get MD2 to come remove the VA’s stitches at the facility. MD2 was not able to do this, so the P asked if the wound nurse could remove the VA’s stitches from his/her right toe on the next visit. MD2’s office faxed over approval for that. HCP1 provided the following information: · The VA was hospitalized for an unrelated reason and released in January 2022. At that time, facility staff persons observed an “open” and “reddened” area on his/her small right toe. The facility contacted MD1, who was a wound specialist. MD1 saw the VA on February 10, 2022, and ordered Betadine (over the counter medication used to treat various skin conditions) to be applied daily. When HCP1 was asked if that worked, s/he stated, “Yes” and that the open area remained, but that staff “inspected” the toe daily and that there was no “redness,” “changes” or “signs of infection.” Staff repositioned the VA every two hours. · When Betadine was used, the area appeared to be “stained.” HCP1 demonstrated to this investigator that when it was used on a tissue, the tissue turned dark red. · In May 2022, the VA showed signs of having a “cold” or “Covid.” Staff continued to monitor him/her and when his/her condition did not improve for two days, the VA was taken to the hospital and admitted. Two days after the VA was admitted to the hospital, the G called the facility to inform staff that the VA’s toe was infected and was amputated. · When HCP1 was asked to provide information in terms of the time frame that a wound could become infected, s/he stated that it could happen “very rapidly.” HCP2 provided information to this investigator that was similar to the information provided by the P and HCP1. The G and the facility provided pictures of the VA’s toe. Although the dates of when the pictures were taken was unclear, at least one of the pictures was taken when the VA was hospitalized (May 10-14, 2022). The pictures showed darkened areas on the small right toe. Other pictures, taken by the facility on unknown dates, showed that the toe was dry and did not appear to be open. The VA provided limited information, but stated that his/her bed was “too small” and that for a “few weeks” before the amputation of his/her right toe, staff “squirted” something on the toe, but the VA did not know what it was. The VA stated that his/her left toe was amputated in July, but could not remember when his/her right toe was. Job descriptions for the P, HCP1, and HCP2 stated that they were to “assist with implementation of physician orders or new services.” The website, www.betadine.com stated that it was “naturally a golden-brown color. It will not permanently stain your skin, although you can see where it has been applied.” The facility’s training records showed that all staff interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VAs specific care plans prior to March 1, 2022. Conclusion: When the VA returned from a hospitalization in January 2022, facility staff persons observed a wound on his/her small right toe. MD1 saw the VA on February 10, 2022, for wound care. MD1 ordered repositioning every two hours, use of Betadine daily, and to have mapping done on the VA’s bed. Although the mapping was not done, attempts were made by the P to do this as well as attempting to order a longer bed for the VA, and information from the investigation showed that repositioning and use of Betadine occurred, per MD1 orders, and that staff did not see signs of infection or changes in the toe’s condition. In May 2022, the VA showed signs of being ill so s/he was hospitalized on May 10, 2022. Although medical records do not indicate the date, the VA’s small right toe was amputated a couple days later. Although the VA’s toe became infected, which resulted in amputation, given that facility staff persons stated they followed MD1’s orders and there was not information that staff persons observed signs of infection before the VA was hospitalized and once the VA exhibited signs of illness, medical care was sought. When the VA was discharged from the hospital on May 14, 2022, s/he was provided with home health care to provide care to the VA’s wounds and educate the patient/caregiver of proper wound care. Per the orders, discharge was to occur when the patient/caregiver was able to demonstrate knowledge of proper wound care. The VA was discharged from home health care on June 29, 2022. While it was noted that the VA did not attend three follow up appointments, two of those appointments occurred while the VA was still receiving care from the home health service. The third was missed because the VA was back in the hospital. There was no indication that missing those appointments affected the outcome of the VA’s condition. After the VA was discharged on July 27, 2022, s/he was provided home health care again and there were documented WCN from the home health service until August 1, 2022. The VA was admitted to the hospital again on August 8, 2022. Although unfortunate the VA’s wounds progressed and an infection developed in the VA’s bones that resulted in amputation, given the aforementioned factors, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary healthcare to maintain his/her physical condition given the VA’s physical capacity and underlying conditions. 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’s Vulnerable Adult (VA) Internal Reporting Form stated that policies and procedures were adequate, followed, and that no additional training was needed. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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