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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: 1109538-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden Suspected Maltreatment Reported: Allegation One: It was reported that staff persons put a vulnerable adult (VA) into a bathtub containing “hot” water causing burns to his/her feet, ankles, perineal area, and buttocks. Allegation Two: It was reported that following the aforementioned burn incident, staff persons failed to administer pain medications to the VA. Date of Incident(s): Allegation One: October 15, 2022 Allegation Two: October 25 through 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 1, 2022; from documentation at the facility and medical records; and through interviews conducted with the VA’s guardian (G), facility staff persons (P1, P2, and P3), and a supervisory staff person (P4). (Note: At the time of the site visit, this investigator met the VA, who was sitting in his/her wheelchair in the living room. This investigator spoke to the VA; however, s/he did not respond or acknowledge the interaction. The VA was not interviewed due to his/her limited communication skills.) The VA’s support plan and support plan addendum provided the following information: · In April 2022, the VA moved into the facility seeking support and services relating to his/her diagnoses, which included developmental and intellectual disabilities, and triplegia (paralysis of three limbs). · The VA used an electric wheelchair to move around. · “[The VA] needs full staff assistance for transferring to and from [his/her] wheelchair, bed, bath/shower, and living room furniture.” A mechanical lift was used for this purpose by staff persons. · “[The VA] is unable to speak using words. Staff will watch for changes in behavior which might indicate pain or illness. Signs and symptoms include: crying, lack of appetite, lethargy, congestion, increased skin temperature or sweating. Staff will follow instructions given by nurse.” · “Emergency medical needs are assessed by staff nurse or in-charge staff and [the VA] receives treatment as needed with staff assistance. If necessary, [9-1-1] will be called. Staff will consult with the nurse when illnesses or injuries occur and will follow instructions given.” The G said that s/he did not have concerns with the facility’s overall care and supervision of the VA. Facility documentation stated that P1-P4 received training on the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. P1 and P4 received training on the VA’s support plan and support plan addendum; P3 was not required to receive this training because s/he did not work direct care with the VA. P2 was required to receive training on the VA’s support plan and support plan addendum, but was not trained prior to providing direct care services. (Note: The failure to provide this training was in violation of Minnesota Statutes section 245D.09, subdivision 4a, paragraph (c), which states the license holder must ensure that staff providing direct support review and receive instruction on the person's support plan or support plan addendum as it relates to the responsibilities assigned to the license holder, and when applicable, the person's individual abuse prevention plan, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans.) Allegation One: It was reported that staff persons put the VA into a bathtub containing “hot” water causing burns to his/her feet, ankles, perineal area, and buttocks. The VA’s support plan addendum stated, “[The VA] cannot turn on the water faucet or adjust the water temperature. Staff will turn on water and adjust water to a safe temperature. Hot water which [the VA] has access to will be maintained at 110 degrees (°) or cooler.” P1-P4 provided the following information: · P1 and P2 were each scheduled to work until 9 a.m., on October 15, 2022. P1 was familiar with the facility and had worked with the VA prior. P2 had been called-in at the last minute to assist P1 between 6 and 9 a.m., on this day. P2 had never worked direct care at the facility and/or with the VA. · Around 7:30 a.m., P1 began preparing the VA’s bath. (Note: At the time of the site visit, this investigator saw the bathtub, which was larger than a standard size tub with tall walls and a deep basin.) Consistent information was provided that “every morning,” including the day prior, the VA took a 45 minute bath. P4 said that the VA’s baths were not only for hygiene, but also to relax the VA’s muscles and contractures. The facility treated the VA’s bath time like “a spa.” P1 started battery operated candles in the bathroom and turned on “calming” music. · P1 said that s/he was familiar with assisting the VA in the bathtub, and had done so about ten times prior to October 15, 2022 (the date of the incident). The facility did not have specific training or written protocols for baths. Instead, P1 had been trained on baths by another staff person who had about 25 years’ experience working in the direct care field. P1 said that on the day of the incident, s/he followed the same procedure as s/he had done before and consistent with how s/he had been trained. · P1 started the bathwater and adjusted the temperature by feeling the water as it came out of the spigot. The facility did not have a thermometer in the bathtub or any way to determine the exact temperature of the water. · P1 explained that s/he prepared the VA for his/her bath by removing the VA’s clothes and bringing the VA into the bathroom using a mechanical lift. P1 placed his/her hand under the water spigot and, believing that the water temperature was appropriate, lowered the VA into the bathwater and removed the mechanical lift. The VA was placed so that his/her head was towards the back of the tub and his/her feet were towards the front of the tub where the water spigot was located. The bathwater continued to run during this time and the VA’s feet were directly under the spigot. · P1 asked P2 to sit in the bathroom while the VA bathed to ensure the VA remained safe. P2 sat in a nearby chair and watched P1 wash the VA’s hair and body using the bathwater. P1 and P2 each said that P1’s hands were in the bathwater for about ten minutes assisting the VA. P1 later said that the water felt “a little warmer than usual, but it didn’t feel hot.” P1 was able to keep his/her hands in the water and did not sustain any burns to him/herself. · P1 put conditioner in the VA’s hair and planned to rinse it out at the end of his/her bath. Before P1 left the room, s/he instructed P2 to turn off the water spigot when the water level reached the VA’s shoulders. P1 then dimmed the bathroom lights creating a spa-like ambiance, and left the room. P1 planned to prepare the VA’s medications and breakfast while the VA bathed. · About five minutes had passed with the water continuing to run and the VA lying in the bathtub. P2 was sitting a distance from the bathtub to allow the VA the maximum amount of privacy. P2 could not see the VA’s feet from where s/he was sitting. P2 did not see any steam from the bathwater, and the VA did not make any vocalizations or sudden movements. P2 had been told that the VA would scream or yell if s/he were in pain or discomfort. P2 walked over to the tub to check the water level. In doing so, P2 could see the VA’s feet under the water. The VA had a lighter skin tone, and at this point, his/her feet appeared “super red.” P2 put his/her hand in the bathwater where the VA’s feet were and immediately pulled it out due to the water being “hot.” P2 turned off the water spigot and yelled for P1. · P1 arrived and also noticed that the VA’s feet “were getting red.” P1 turned the water back on and turned it to a cold temperature. P1 also used the mechanical lift and lifted the VA out of the water. P1 next sprayed the VA’s feet with cold water from the showerhead; this made the redness go away. P1 checked the bathwater, which had cooled down, and then lowered the VA back into the water. The VA then completed his/her bath with P1 rinsing the conditioner out of his/her hair. · Around 8 a.m., P1 removed the VA from the bathwater and assisted him/her in getting dressed. P1 stated that at this point, the VA’s feet appeared “red.” P2 described the VA’s feet as “a soft pink” and similar to how a light skin tone might look after sitting in a whirlpool or hot tub. P1 and P2 each said that the VA’s feet did not look burned or in need of medical attention. In addition, the VA continued to not show any signs of pain. Previously, P1 had witnessed the VA cry out when s/he was in pain; and so P1 believed that if the VA was in pain, s/he would have made some type of noise. However, according to P1 and P2, the VA did not make any noises during, and/or following, the bath. · Shortly thereafter, P1 called P3 and P4. (Note: P3’s job responsibilities included consulting on medical-related needs; and P4 said that staff persons were trained to call P3 if they had questions about these needs.) · P3 recalled receiving the phone call from P1. P1 said that the redness on the VA’s feet had lessened since being removed from the bathwater. P1 and P2 did not believe the VA was in pain. P1 also texted a photograph of the VA’s feet to P3. P3 described the VA’s feet, according to the photo, as not matching that of a burn. The VA’s skin appeared “splotchy,” and “lightish, pinkish, red.” P3 advised that staff monitor the VA’s feet and contact him/her if anything changed. (Note: This photograph was not available for this investigation.) · P4 also recalled receiving the phone call from P1 and understood that the VA’s skin tone appeared “normal” (not red) after being removed from the bathtub. P1 sent a photograph to P4. P4 did not see anything in the photo or discern anything from P1’s description that “set off alarms … It didn’t raise any alarms for me.” P4 did not believe the VA required medical attention at that time. (Note: P4 believed this photograph had been sent to him/her as an attachment to a progress note; however, this photo was not found during the review for this investigation.) · P1 and P2 each said that when they left at the end of their shifts at 9 a.m., the VA’s feet were “still pink,” but not blistering or showing any sign of burn. The VA’s socks had been removed so staff could continue to monitor more easily. · P3 said that around 10:45 a.m., s/he received a call from staff that the skin on the VA’s feet had started to peel. P3 advised that the VA be taken to the emergency room. The VA’s medical records, dated October 15 to 25, 2022, provided the following information: · On October 15, 2022, at 12:13 p.m., the VA arrived at an emergency room accompanied by a facility staff person. Information was provided that the VA had been placed into a bathtub containing water of unknown temperature. Emergency room healthcare professionals diagnosed the VA with “burns to bilateral feet … The rest of [the VA’s] body looks okay, but [his/her] feet have significant appearance of burns on the plantar feet that will require debridement and intervention by the burn team.” The VA was transferred to a hospital that specialized in treating burns. · At 5:41 p.m., that same day, the VA was admitted to the hospital burn unit. The VA was diagnosed with partial thickness burns on 2.8% of his/her body surface area, including both of his/her feet and ankles, and buttocks and perineum area. During the course of the VA’s stay in the burn unit, healthcare professionals monitored the VA for infection, and applied barrier creams and dressings. · On October 25, 2022, the VA’s burn injuries were improved and s/he was discharged back to the facility. P4 and facility documentation stated that the facility’s hot water heater had been installed in October 2021. The water heater had a six-year parts and tank warranty; and had been inspected for functionality on October 13, 2022 (two days prior to the incident). At that time, the water heater had an internal temperature of 108°, which was consistent with standards. The facility had never had an issue with the bathtub or water heater prior to October 15, 2022. The facility also had never had an issue with water being too hot, and so at the time of the incident, there was not a thermometer used in the bathwater. Rather, staff typically checked the water temperature by placing their own hands in the water. However, after the incident, later that same day, a maintenance person determined that the water heater thermometer had failed and had most likely failed while the VA’s bathtub was filling. The G described the VA as being “nonverbal,” and because of this, the VA would not have been able to verbally alert staff if the bathwater was too hot. However, the VA had a history of making “loud noises when [s/he] is displeased with something.” The G was surprised that, in this incident, the VA did not make any noises to alert staff that s/he was being burned by hot water. Conclusion for Allegation One: On October 15, 2022, the VA presented to the emergency room, and was later admitted to a hospital burn unit, with partial thickness burns on 2.8% of his/her body surface area, including both of his/her feet and ankles, and buttocks and perineum area. Information was provided that the VA sustained these burns when s/he was submerged in “hot” bathwater; and it was later determined that the facility’s water heater thermometer had failed. Consistent information was provided that there had been no warning or information prior of a malfunction with the water heater. The water heater was approximately one year old, and had been inspected for functionality two days prior to the incident with no issues. The VA had also taken a bath the day prior with no issues. Therefore, there was not a preponderance of the evidence whether the facility should have known or taken prior action to prevent the water heater malfunction. In addition, when P1 completed the VA’s bath on the day of the incident, s/he did so in the same manner as s/he had done so in the past and as s/he had been trained. P1’s own hands were in the bathwater for about ten minutes during this time without sustaining any burns or noticing the water being too “hot.” P2 did not see any steam from the bathwater, and the VA did not make any vocalizations, which, at that time, staff persons believed was how the VA would indicate pain. Once P2 saw redness on the VA’s feet and felt that the water was hot, s/he immediately alerted P1, and the VA was removed from the bathwater and cooled down. At that time, P1 and P2 did not believe the VA’s skin looked burned and, again, the VA did not indicate pain by making any vocalizations to suggest that was the case. P3 and P4 were contacted and each did not believe based on the information provided that the VA was burned or required medical attention. When the VA’s skin started to peel, staff persons took immediate action by transporting the VA to the emergency room. Given that the staff persons’ responses at various points in time appeared consistent and reasonable given the information available and the VA’s own response to the situation, but that once the VA’s condition changed, there was an immediate response in seeking additional care, there was not a preponderance of the evidence whether any staff failed to supply healthcare in a manner necessary to maintain the VA’s physical or mental health or safety. 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). Allegation Two: It was reported that following the aforementioned burn incident, staff persons failed to administer pain medications to the VA. The VA’s support plan and support plan addendum provided the following information: · “[The VA] is unable to set up and take [his/her] medications independently … [The VA] does not know the importance of [his/her] medications [and] is unable to comply with doctor's medication orders without assistance … Staff is trained in medication administration and give medications as instructed.” · “[The VA] is unable to make [his/her] own appointments. [S/he] does not seek treatment for medical needs. Living Well Disability Services staff will assist [the VA] to seek treatment for medical needs … Living Well Disability Services staff will follow through on doctor's orders.” The VA’s medical records and facility documentation, and the G and P1-P4 provided the following information: · The G, P1, P2, and P4 each said that the VA had a history of being vocal when in discomfort. The VA would typically cry or yell out. P1 had witnessed the VA become vocal in the past when s/he was in pain. P4 said that if the VA had a headache, s/he would typically hold his/her head or say something like, “Ah.” However, following the incident on October 15, 2022, when the VA was burned due to “hot” bathwater, awareness was made that the VA might not always vocalize if s/he were in pain as was the case with this incident. · As a result of this burn incident, the VA was hospitalized until October 25, 2022; and during that time, P4 updated the VA’s support plans to include information that the VA might “not consistently respond to pain” or “possibly [have] no response at all.” P4 said that all staff persons were trained on these updated plans. · The VA’s medical records stated that on October 25, 2022, the VA was discharged from the burn unit and returned to the facility. At that time, the VA was prescribed oxycodone (narcotic pain reliever) to be taken as 2.5 milligrams (mg) by mouth two times daily as needed (PRN) for pain. · The facility also received a facsimile from the hospital, dated October 25, 2022, containing a prescription for the VA’s oxycodone to be taken as 2.5 mg by mouth two times daily as needed (PRN) for pain. · P3 had contacted the hospital and “confirmed” that the hospital had already sent the VA’s prescription for oxycodone to the pharmacy upon the VA’s discharge. P3 told staff about the pending prescription and asked to be called when the prescription arrived and also to be called if it did not arrive. On October 26, 2022, P3 called the facility to follow-up on the VA’s condition. Staff told P3 that the VA appeared to be “happy” and did not show any signs of pain, and that as a result, no pain medications were administered. P3 forgot to ask if the oxycodone prescription had arrived; however, based on the staffs’ communication, P3 assumed it had but was not needed yet due to the VA’s lack of pain. · The facility’s Internal Review interviewed five staff persons who worked with the VA between October 25 and 31, 2022. Each staff persons said that after the VA arrived home from the hospital, s/he showed no indication of pain. Instead, staff described the VA as “in great spirits … laughing, singing, waving [his/her] arms to the music, smiling.” As a result of the VA not showing any obvious signs that s/he was in pain, the staff persons did not administer over-the-counter pain medications or follow up on the VA’s oxycodone prescription. · On October 31, 2022, a staff person noticed that the VA was “grunting and biting the inside of [his/her] hand.” The staff person believed the VA was communicating that s/he was in pain. When this staff person went to administer the VA’s pain medication, s/he called P3 to inquire why there was no specific prescription for pain medication. P3 instructed the staff person to use the standing facility orders for acetaminophen and ibuprofen (over-the-counter pain medication) while P3 followed up with the physician. · At this point it was discovered the VA’s oxycodone prescription had not been sent by the hospital to the pharmacy and that no one followed up or noticed because the VA did not show signs that s/he needed pain medication. Upon consulting with the physician, the physician discontinued the oxycodone prescription and advised that the VA’s continued pain management could be handled with over-the-counter medications. · P4 said that in hindsight, given that they discovered the VA might not indicate pain in an obvious manner, they should have requested the oxycodone be a scheduled medication and not a PRN. Although staff persons did not notice the VA indicating pain, it was reasonable to expect that after having sustained a burn injury, the VA was most likely experiencing some level of pain, but not showing it outwardly. However, P4 added that during that time, staff persons were instructed to provide “bed baths” to the VA instead of a regular bath in a bathtub, and because of this, the VA was not moved around much and therefore, most likely had lessened pain for that reason. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.05, subdivision 1, clause (b), items (1) and (2), states if responsibility for meeting the person's health service needs has been assigned to the license holder in the support plan or the support plan addendum, the license holder must maintain documentation on how the person's health needs will be met, including a description of the procedures the license holder will follow in order to provide medication administration; and to monitor health conditions according to written instructions from a licensed health professional. Conclusion for Allegation Two: The VA’s prescription for oxycodone was not received from the pharmacy or administered at any point following his/her hospitalization for burns. The oxycodone was prescribed to be administered as needed (PRN) for pain; however, previous to this, the facility had been made aware that the VA might not always show signs of pain and so it would be difficult for staff to determine when the PRN was needed. The conduct of not administering the medication or ensuring proper administration was in violation of Minnesota Statutes section 245D.05, subdivision 1, clause (b), items (1) and (2). However, given multiple staff persons stated that during the timeframe in question that VA appeared “happy” and “smiling,” and showed no indication of pain; that when the VA did appear to be in pain they administered over-the-counter pain medication; and that when this omission was noticed, the oxycodone was immediately discontinued by the physician without incident, there was not a preponderance of the evidence whether the lack of pain medications included a failure to supply the VA with care which was reasonable and necessary to maintain the VA's physical or mental health or safety, and which was not the result of an accident or therapeutic conduct. 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: Allegation One: The facility completed an internal review, and determined that policies and procedures were adequate and followed. Maintenance determined the incident occurred as a result of a faulty water heater thermometer, which was repaired. The facility also created a procedure specific to the bathtub and trained all staff persons. The facility purchased floating thermometers to be used in each bathtub. The facility also updated the VA’s support plan and support plan addendum to include that s/he might not always vocalize when in pain. Allegation Two: The facility completed an internal review, and determined that policies and procedures were not adequate and were not followed. “[The VA] is unable to communicate when [s/he] is experiencing pain. In cases where a person may not show outward pain or verbally express pain, and it is reasonable to believe the average person would have pain, [supervisory or nursing staff persons] will advocate to have [the person’s doctor] schedule pain medication instead of PRN (as needed) administration. If the pain medication is unable to be scheduled, [supervisory or nursing staff persons] will develop a plan to address reasonably expected pain and train staff accordingly. The facility provided additional training to all staff persons regarding communication on pharmacy deliveries and PRN medications. Action Taken by Department of Human Services, Office of Inspector General: On December 9, 2022, the facility was issued a Correction Order for the violations outlined in this report.
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