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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: 1069027-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) sustained first and second degree burns on both of his/her feet during a bath. Date of Incident(s): October 31, 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 a site visit conducted on November 4, 2022, from documentation at the facility, from the VA’s medical records, and through seven interviews conducted with the VA’s guardian (G), the facility’s health care professional (HCP), two facility maintenance persons (FMP1 and FMP2), the SP, a management staff person (P1), and a facility staff person (P2). Although this investigator met the VA, the VA was unable to provide information in an interview due to his/her disability. The facility had a handicapped accessible bathroom equipped with a changing table, Hoyer lift, a shower chair for the VA, a container to hold water, and a temperature gauge. The bathtub had one control to turn the water on and as the control was moved upwards, the water temperature increased. There was a connected sprayer with an on/off switch. When in the on position, the water came out of the sprayer and when in the off position, the water came out of the bathtub faucet. On the wall by the bathtub was a sign that said “STOP” and “water temperature must be tested with a thermometer prior to a bath or a shower with all individuals. Water temperature cannot exceed 104 degrees!!!” The VA’s individual Abuse Prevention Plan showed that s/he enjoyed accessing the community with staff and spending time with his/her family. In addition, the plan showed that s/he had a “severe” developmental disability. The VA’s Support Plan showed that s/he was diagnosed with Cerebral palsy and that “staff will keep water temperature for [the VA’s] daily bath between 100-104 degrees. Staff will test the water temperature with a thermometer before each bath.” The SP provided the following information: · On the day of the incident, the SP got to work at about 2:45 p.m. Shortly thereafter, the SP began to get the VA ready for a bath. When the SP got the VA to the bathroom, the SP began his/her “normal process,” which was to undress the VA on the changing table, transfer him/her with the Hoyer lift to the shower chair, and “test the water” temperature two times, once with his/her hand and then using the thermometer in a container of water. · The water temperature was “comfortable” for the SP when s/he put his/her hand under the water and although the SP used the thermometer, s/he did not remember what the temperature was, but stated that “nothing was unusual.” · The SP brushed the VA’s teeth while the VA was in the bathtub and then used the sprayer to wet the VA’s hair. While the SP used his/her hands to rub shampoo into the VA’s hair, the SP again noted that nothing was unusual. When the SP was done washing the VA’s hair, s/he turned off the sprayer and the water began to run through the bathtub faucet. The VA’s feet were directly underneath the faucet. · At some point, the VA cried, which was not unusual because the VA did not like bathing. When the SP was done washing the VA’s hair, the SP tried to readjust the VA in the shower chair to see if that might help, but the crying was “different” and the VA cried more than normal. The SP asked the VA what was wrong and then noticed that both of the VA’s feet looked “really red.” The SP turned off the water and called P1 for help. When P1 got to the bathroom, P1 and the SP used the Hoyer lift to get the VA out of the bathtub. The SP then called the HCP and explained what happened. The SP also notified the G and shared that medical attention would be sought. · The SP, who had worked for the facility for over 17 years, was not aware of a previous time that the water temperature was that hot and did not know if any other staff had assisted other clients with bathing that day. On October 31, 2022, the SP wrote a note in the VA’s file that stated, “Staff check the water and it read 101 temp.” P1 said that s/he was working on the lower level of the facility when s/he heard the SP “yell” for help. When P1 got to the bathroom, P1 noted that the VA’s feet were “very red.” P1 said that when s/he called the HCP, the HCP told P1 to take the VA to an emergency room for medical care, but that the HCP called back later and stated that an ambulance should be called. P1 said that s/he was not aware of a time that the water heater malfunctioned and produced very hot water and that s/he had used the hot water that day without incident. Photographs, taken by the HCP on October 31, 2022, showed that both of the VA’s feet were red and some areas appeared to have blistering. The VA’s medical records showed that the VA was admitted to the hospital on October 31, 2022, for “observation,” diagnosed with second degree burns on both feet, and discharged on November 2, 2022. In addition, the records showed that the VA was given a prescription for pain medications (Ibuprofen, Tylenol and Oxycodone) to be used at the facility. The HCP stated that staff were required to check the water temperature before it was used on a client and that when the SP called the HCP, who was not aware of previous issues with the water heater, to inform him/her of the incident, the SP told the HCP that s/he had checked the water and that it was “fine.” P2 said that it was typical for the VA to cry when taking a bath because the VA did not like bathing. P2 also stated that s/he had used the water earlier that day without incident and that s/he was not aware of a time that the water heater produced very hot water. FMP1 said that s/he got a call from the SP on the day of the incident. After the SP told FMP1 what happened, s/he told the SP to ensure that the water was not used until FMP1 got to the facility and evaluated the water situation. When FMP1 got to the facility about a half hour later, FMP1 checked the “tempering valve,” which was a valve near the water heater that “blends the hot and cold water before it goes upstairs.” FMP1 said that the tempering valve was on the “high end” so FMP1 readjusted the valve and within minutes, the temperature was 102 Fahrenheit. When FMP1 was asked what might cause the tempering valve to read high, s/he stated that a “particle” could get into the water heater or get “plugged up” which would stop the “blending process from happening properly.” FMP1 was not aware of previous concerns with the water heater or tempering valve. FMP2 stated that s/he looked at the water heater the day after the incident and did not notice any abnormalities, but stated that mechanical devices were “subject to failure.” FMP2 also stated that the water heater and tempering valve were checked “pretty much quarterly” and that the water heater/tempering valve were last serviced on September 12, 2022, and that no abnormalities were found. The G did not have concerns related to the SP. The facility’s Death or Serious Injury Report stated that the “staff checked” the water temperature and that it was “o.k.” The report also stated that the VA had “redness and blisters” on both feet, that the SP turned the water off when s/he noted that the VA “began to show pain,” and that maintenance determined a “possible malfunction.” The facility’s Incident Report and Internal Review stated that “water temperature safety procedure notes that water temperature is checked with a thermometer before assisting the individual into the shower or tub. Testing the water for a shower should be done by filling a container with water and placing the thermometer before helping the individual into the shower. The staff member reported that they used the showerhead to rinse the resident’s hair, at that point, the water was significantly hotter than water from the tub faucet. However, the staff member did not check the showerhead temperature according to the procedure.” The review also included a written statement from the SP that said that when s/he rinsed the VA’s hair, the SP noticed that the VA’s “foot was red.” As a result of that, the SP turned off the water. 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 VA’s specific care plans. Conclusion: On October 31, 2022, the SP assisted the VA with a bath. Once the VA got into the shower chair, the SP checked the water temperature two times, once with his/her hand and the other time by using the thermometer, and documented it was 101 Fahrenheit. After the SP used the sprayer to wash/rinse the VA’s hair, the SP turned the sprayer off and the water began to flow from the bathtub faucet, which was directly above the VA’s feet. Because the VA was crying, which was somewhat typical behavior from the VA because s/he did not like bathing, the SP tried to readjust the VA in the shower chair. When the VA’s crying intensified, the SP noticed that both of the VA’s feet were red. The SP immediately turned off the water and called P1 for help. The VA was taken to the hospital, diagnosed with second degree burns, and given pain medications to take home when discharged on November 2, 2022. Although it was not fully established what caused the water to be hot enough to cause burns, FMP2 stated that the water heater/tempering valve was typically checked quarterly and there was no information obtained during the investigation to show that there were previous concerns with the temperature of the water. In addition, information showed that the SP followed the facility’s written instructions in the bathroom related to checking the water temperature and the VA’s Support Plan. Given that conflicting information was provided in terms of when the SP turned off the water, there was not a preponderance of the evidence whether neglect occurred. It was not determined whether neglect (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) did not occur. Action Taken by Facility: The facility’s Incident Report and Internal Review stated that although policies and procedure were adequate, they were not followed by the SP. The review also showed that additional training was provided to “the staff members who provide direct care services” related to “bathing/water temperature monitoring procedures on November 1 and 2, 2022.” Action Taken by Department of Human Services, Office of Inspector General: No action taken.
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