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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: 1070425-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman Suspected Maltreatment Reported: Allegation One: It was reported that there were multiple concerns regarding a facility staff person’s (SP’s) care and services provided to four vulnerable adults (VA1-VA4.) The concerns included that: · The SP pulled VA1’s arm aggressively to move VA1. On one occasion the SP did not get VA1 out of bed to eat dinner so VA1 missed dinner and his/her evening medications. · The SP left VA2 sitting in a chair for three hours in pain and refused to assist VA2 until another staff person arrived. · The SP aggressively pushed a vulnerable adult (VA3) into a wall while VA3 was in a mechanical lift. · The SP “stomped” on a vulnerable adult’s (VA4’s) foot and pulled his/her arm. Allegation Two: During the course of the investigation, it was reported that VA2 had a wound that did not heal and staff persons were not providing care as prescribed. Date of Incident(s): Prior to June 8, 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 2, paragraph (b), clause (1); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on June 23, 2022; from documentation at the facility; and through 11 interviews conducted with four VA’s (VA1-VA4), VA4’s guardian (G), and facility staff persons (the SP and P1-P5). Attempts to contact VA1’s and VA3’s case manager (CM1) as well as VA4’s case manager (CM2) were not successful. VA1 enjoyed reading and listening to the radio, particularly “All Things Considered” on Minnesota Public Radio. VA1’s diagnoses included traumatic brain injury (TBI), seizure disorder, and left side hemiparesis. VA1 used a wheelchair for mobility and used his/her feet to propel him/herself. VA1’s Intensive Support Self-Management Assessment stated that s/he no longer used an EZ Stander due to decreased stamina and difficulty with balance. VA1 had difficulty holding his/her head upright as a result of his/her hemiparesis and his/her head and neck tilted to the extreme right with his/her chin close to his/her chest, impacting his/her peripheral vision. VA1’s hemiparesis limited his/her ability to complete self-care. VA1 needed at “two person team to lift [him/her] in [his/her] Hoyer lift (a mechanical lift used to transfer). VA1’s TBI affected his/her memory and s/he had “instances of periodic confusion” that impacted his/her ability to remain alone in community settings. VA1’s Coordinated Service and Support Plan Addendum (CSSPA) stated that s/he had “two overnight staff [persons] on site and during the day for transferring and changing [him/her] as needed.” VA1 was not subject to guardianship. VA2 enjoyed arts and crafts and listening to audio books. VA2’s diagnoses included mild intellectual disability, borderline personality disorder, morbid obesity, granulomatous disorder of the skin and subcutaneous tissue, edema, anxiety disorder, major depressive disorder, lymphedema, venous insufficiency (leg veins did not allow blood to flow back to the heart), pain in left knee, ankle and foot, and muscle weakness. VA2’s Intensive Support Self-Management Assessment stated that s/he was able to ask staff persons for assistance. Due to VA2 weighing over 550 pounds, s/he needed staff person assistance for putting on clothing such as socks and shoes, peri care, and repositioning while in bed. VA2 used a cane or walker with a seat to assist with mobility. Staff persons were responsible to care for VA2’s wounds/skin folds in his/her legs. VA2’S CSSPA stated that “health services responsibilities” were assigned to the facility and medical documentation was to be maintained in VA2’s record. The facility was also responsible for the administration of VA2’s medications. VA2 was not subject to guardianship. VA3 enjoyed being outside, going to parks, socializing with others, and spending time with his/her family. VA3 was described as a very social and caring person. VA3’s diagnoses included paraplegia, chronic respiratory failure, type 2 diabetes, and chronic pain. VA3 had a tracheostomy making it difficult to talk so the VA3 relied on electronic communication devices, such as typing a message on his/her cell phone or IPad. VA3 was aware of his/her chronic medical conditions and was able to inform others how to aid him/her. VA3 was dependent on the use of an electric wheelchair for mobility and the use of a Hoyer/mechanical lift for all transfers. VA3 was not subject to guardianship. VA4 enjoyed telling jokes, going to McDonald’s and Dairy Queen, and working in the community at a thrift store and humane society. VA4 enjoyed watching MASH and Andy Griffith on TV and drinking an occasional beer. VA4’s diagnoses include traumatic brain injury, paralysis below the waist, and limited use of his/her right arm. VA4 had a trapeze bar attached to the head of his/her bed for repositioning him/herself while in bed, and used a Hoyer lift or stander (an alternative positioning device used for passive standing) for transfers. VA4 was independently mobile when s/he was in his/her wheelchair. Allegation One: It was reported that there were multiple concerns regarding the SP’s care and services provided to VA1, VA2, VA3, and VA4. Regarding the SP pulling VA1’s arm aggressively to move VA1, and on one occasion not getting VA1 out of bed for dinner resulting in VA1 not eating dinner or receiving his/her evening medications: An Incident Report Form written by P1 around June 9, 2022, stated that “sometime last year” P1 witnessed the SP “pull on [VA1’s] arm (the one that doesn’t move) to change [him/her] while telling [VA1] to help [the SP].” P1 provided the following information to this investigator: · P1 initially said that s/he observed the SP “pull” on the VA1’s left arm “every time” the SP assisted VA1 with changing VA1’s incontinence brief after lunch. P1 later said s/he saw the SP pull on VA1’s arm roughly “two to three times” and that it occurred “last year” and s/he told a supervisory staff person (P4) who said s/he would talk to P6 (a management person) but “nothing would happen.” When asked how VA1 responded when the SP pulled his/her arm, P1 said s/he did not respond verbally; however, VA1 looked like s/he was “in pain.” · The SP was also “rough” with VA1’s “private parts when changing [him/her].” P1 observed that the SP wiped VA1’s private parts “too hard” and his/her privates looked “red” and VA1’s face looked like s/he was in pain. P1 did not know how long VA1’s privates stayed red because s/he did not see VA1 until the next day and by that time VA1’s privates were no longer red. P1 said those incidents occurred “last year” and s/he told P4 about those incidents as well. · P1 said that s/he addressed the SP pulling VA1’s arm and being rough with VA1’s privates “multiple times” and the SP replied that s/he was “stressed out” or offered other excuses. P3 told P1 that s/he observed similar interactions between the SP and VA1. · When asked if any injuries resulted as a result of the SP’s interactions with VA1, P1 said, “None that I saw.” · VA3 told P1 that on one occasion (determined to be around June 8, 2022) after VA1 returned from an appointment, VA1 wanted to nap so the SP never gave VA1 dinner nor his/her evening medications. When P1 looked at the Medication Administration Record (MAR), VA1’s evening medications were not initialed. P1 said that indicated the medications were not administered. · P1 said there was interpersonal conflict between him/herself and the SP and also between P3 and the SP. VA1 said that as a result of his/her hemiparesis, s/he “lost all the muscles” on his/her left side and did not regain full use of his/her left arm. When asked if a staff person at the facility ever physically hurt VA1, s/he replied, “I can’t think of any.” VA1 did not know about missing any meals or medications. VA4 described the SP as “rough” and said the SP “slammed” VA1’s wheelchair into the table. However, VA1 did not react/respond to the incident and VA4 did not believe VA1 was injured. P2 described the SP and “rough” and said that s/he observed the SP “tug” on VA1’s arm. When P2 told the SP not to do that, the SP had “nothing to say.” P2 did not observe any injuries to VA1 as a result of the SP’s interactions. P2 said s/he talked to P4, a supervisory person, about the SP being on his/her phone “all the time.” P2 believed P4 talked to the SP about the phone; however, it seemed like the SP “got worse and did not really care.” On an unidentified day (determined to be early June 2022), P3 returned to the facility with VA1 after an appointment. P3 brought VA1 into his/her room and prior to leaving the facility, P1 told the SP that VA1 was tired and ready to lay down. P3 heard from an unidentified person that the SP “put [VA1] to bed and never got [him/her] up for supper.” P4, a former supervisory person, stated that s/he did not recall anyone telling him/her about concerns related to anyone pulling VA1’s arm. If anyone told P4 about such incidents, s/he would have documented the concerns. P5 did not identify concerns related to the SP’s interactions with VA1 other than to say s/he observed that the SP liked to “rush” VA1 when VA1 was eating. Documentation from P6, a supervisory person, showed that s/he talked with the SP on June 8, 2022, regarding VA1 not receiving his/her medications. The SP stated that s/he “forgot” to initial the medication administration record, but did administer VA1’s medications. The SP denied pulling VA1’s arm. When interviewed by this investigator, the SP denied aggressively pulling VA1’s arm and said when s/he moved VA1’s arm s/he asked VA1 if s/he was doing his/her cares correctly. Regarding VA1 missing dinner after a medical appointment, the SP said VA1 slept for an hour and a half and then the SP fed VA1 dinner. The SP said there was animosity between him/herself and P1 and P3. Regarding the SP leaving VA2 sitting in a chair for three hours in pain and refusing to assist VA2 until another staff person arrived: An Incident Report Form written by P1 stated that on June 6, 2022, the SP told P1 about an unidentified date that the SP did not complete VA2’s wound care and the SP had VA2 sit in a chair for an hour while s/he was in pain until the next staff person arrived. Facility information showed that VA2 had an open wound on the back of his/her lower left leg. VA2 saw a wound care specialist and staff persons were supposed to administer care to VA2’s wound as prescribed. Brief liners were used to absorb the fluid that came out of the wound. VA2 said that due to the location of the wound, s/he needed to be standing when his/her wound care was completed. On one occasion when the SP was working, the “extra padding” on VA2’s wound was wet and “added weight” to his/her legs. As a result, VA2 was not able to get up from where s/he was seated in the kitchen area and s/he had to wait “quite some time” until P2 arrived to assist him/her. P2 was able to “yank” VA2 off the chair so that s/he was able to stand. VA2 said, “I felt so weak that I actually had to have [P2] follow me.” P1 said that on one occasion VA2 was “in severe pain” and the SP told P1 that the SP “could not get [VA2] up” and VA2 had to wait until P2 arrived to assist him/her. P1 said there was interpersonal conflict between him/herself and the SP and also between P3 and the SP. P2 said on one occasion when s/he arrived at the facility at 11 p.m., VA2 was sitting at the table “crying.” VA2 had “heavy padding” on his/her left leg that was “soaked” all the way “up to [his/her] butt” and P2 helped VA2 stand and removed and changed VA2’s wound dressing. P3 said that s/he “heard” about a time when VA2 was sitting at the dining room table and the SP was not able to lift VA2. VA2 told P3 that s/he had to sit at the table for “seven hours” until P2 arrived to assist with lifting VA2. Documentation from P6 showed that when s/he talked to the SP about VA2, the SP denied refusing to assist VA2 with his/her wound care. The SP said there was a day when VA2 was sitting on a kitchen chair and was not able to get him/herself up. The SP “tried” to assist VA2 “over 10 times” but was not able to assist VA2 by him/herself due to VA2’s size. The SP attempted to get another staff person to come to the facility to assist and eventually P2 came to the facility late that evening. The SP denied that VA2 sat “for hours” while waiting for assistance. The SP said there was animosity between him/herself and P1 and P3.
Regarding the SP aggressively pushing VA3 into a wall while VA3 was in a mechanical lift: VA3 said that on one occasion in early June 2022, the SP was assisting VA3 in his/her room. The SP used the mechanical lift to get VA3 out of his/her wheelchair and into his/her bed. During the transfer, the SP “slammed” VA3 legs into a wall resulting in a “red mark” below VA3’s right knee that lasted a “couple of days” but did not turn into a bruise. P3 said that VA3 told him/her that the SP “knocked” VA3’s leg against a wall when VA3 was in a Hoyer lift. P3 asked VA3 if there was any injury as a result and VA3 stated s/he was not injured. P2 did not witness the incident nor the SP being aggressive with VA3. However, after the incident VA2 told P2 that s/he “did not trust” the SP to lift VA2 into bed. P1 had no information regarding the incident. P5 said that VA3 told him/her about the SP bumping VA3’s leg into a wall. P5 observed VA3’s leg and did not see any injury “other than wounds [VA3] had before” the incident occurred. The SP said that on one occasion when s/he was working by him/herself, s/he used the Hoyer to move VA3. The SP “did not mean to” but in the process of moving VA3, VA3’s arm hit a wall. The SP asked VA3 if s/he was injured and VA3 said no. The SP described animosity between him/herself and P1 and P3. Regarding the SP stomping on VA4’s foot and pulling on VA4’s arm: P1 provided the following information: · VA4 had sensitive feet due to nerve damage. When the SP assisted VA4 onto a “lift” VA4 would push his/her feet out and the SP got “mad” and stepped on VA4’s feet with “force.” P1 heard VA4 say, “Ow!” P1 said this occurred “every morning” when the SP worked and P1 would step in and take over working with VA4. · P1 said that on unknown days s/he also saw the SP be “rough” with VA4’s arm and “pull” it “to straighten it out.” VA4 would “snap” and “go off on [the SP].” · P1 said there was interpersonal conflict between him/herself and the SP and also between P3 and the SP. P2 said that s/he did not witness the SP stepping on VA4’s foot; however, s/he said that P1 said that s/he saw that occur. P3 describe the SP as “rough” and said that on two occasions s/he observed the SP pulling VA4‘s arms to get VA4 into the stander. The SP also “stomps” on VA4’s feet to hold them tight when assisting VA4 into the stander. P3 said that s/he observed this “a couple of times” but also heard about it from P1, P2, and P5. The SP also “yells” at VA4 “when [s/he] does not cooperate.” P3 did not say anything to the SP about his/her observations and was not aware of any injuries as a result of the SP’s actions. P4 said that s/he did not remember anyone telling him/her about the SP stomping on VA4’s foot; however, P4 believed that a supervisory person talked to the SP about being “mean” to VA4. P5 said that the SP “hurries” and was not careful with VA4; however, P5 did not see any injuries as a result. P6 documented that on June 8, 2022, s/he talked to the SP about stepping on VA4’s feet and the SP denied that occurred. VA4 was not able to identify any staff persons by name. VA4 was aware that s/he used a stander and said that s/he did not remember a time when any staff person stepped on his/her feet, was rough with him/her, or yelled at him/her. The G said that when VA4 got a new stander, “they did not put [VA4] in it because they don’t have enough staffing.” The facility was “not staffed correctly since the pandemic (COVID-19).” Frequently only one staff person worked with four clients and three clients used wheelchairs and all four needed physical assistance. VA4 used to have one-to-one staffing during the day; however, the facility “can’t get people to work there.” The G said that s/he asked VA4 about a staff person stepping on his/her feet; however, VA4 did not remember due to his/her diagnoses. The G had concerns regarding staffing and other issues that were county jurisdiction were shared with the county licensor. The SP stated that s/he did “not stomp on [VA4].” When VA4 used his/her stander, his/her feet moved if they were not held. The stander “was breaking down for over a year” and the SP had to “squat, hold [VA4’s] feet” and “try to push the button when the battery does not stay charged.” The SP said there was animosity between him/herself and P1 and P3. Facility information showed that staff persons were trained regarding Hoyer transfers, medication administration, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion for Allegation One: Regarding pulling VA1’s arm and on one occasion, VA1 missing dinner and medications: Information from P1, P2, and VA4 was consistent that the SP was “rough” when assisting VA1; however, no one interviewed stated VA1 had any injuries as a result of the SP’s actions. Although P1 said that it looked like VA1 was in pain when the SP pulled on his/her arm, P1 provided inconsistent information and admitted there was animosity between him/herself and the SP. VA1 did not remember anyone pulling his/her arm, not eating dinner, or missing his/her medications; however, VA1’s memory was likely affected by his/her TBI diagnoses. The SP denied pulling VA1’s arm aggressively and stated VA1 did not miss dinner nor his/her medications; however, the SP admitted forgetting to document the medication administration. Although the SP’s actions of being “rough” were non-therapeutic and were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, given there was no injury to VA1, and no information to support or refute whether VA1 ate dinner and received his/her medications, and given the interpersonal conflict between the SP and other staff persons, there was not a preponderance of the evidence whether the SP pulled VA1’s arm aggressively or failed to provide him/her with dinner and medications. Regarding VA2 being left in a chair: VA2 said that on an unidentified date around June 2022, s/he sat in a chair for “quite some time” because the wound dressing on his/her leg “added weight” and s/he was not able to get him/herself off the chair. VA2 said that s/he needed to be standing when the wound dressing was changed. P1 said that the SP told him/her that VA2 sat there for an hour and P3 said VA2 told him/her it was seven hours. Although the exact amount of time was not determined, the SP said that s/he “tried” to assist VA2 but was not able to due to VA2’s size. The SP attempted to get another staff person to come to the facility and at 11 p.m. P2 arrived and was able to physically assist VA2. P2 said when s/he arrived VA2 was sitting at the table crying and his/her wound dressing was “soaked” all the way “up to [his/her] butt.” Given there was no information that the SP refused to assist VA2, that VA2 needed to be standing to have the dressing changed, and that the SP said s/he attempted and was unable to lift VA2 to a standing position, there was not a preponderance of the evidence whether the SP failed to provide reasonable and necessary care to VA2. Regarding the SP aggressively pushing VA3 into a wall while VA3 was in a mechanical lift: VA3 said that when the SP was transferring him/her from his/her wheelchair to the bed, the SP “slammed” his/her legs into the wall resulting in a “red mark” that lasted a couple of days but did not bruise. No other staff persons were present; however P2, P3, and P5 each heard about the incident from VA3. P2 said that after the incident VA3 said s/he “did not trust” the SP lifting VA3 into bed. P3 said VA3 told him/her there was no injury and P5 did not observe any injury as a result of the incident. The SP admitted there was one occasion when s/he believed VA3’s arm hit the wall when the SP was assisting him/her with the Hoyer lift. Given that VA3 provided inconsistent information regarding any injury and no staff persons observed an injury, and that there was no information that the SP intended to cause harm to VA3 during the process of transferring him/her, there was not a preponderance of the evidence as to whether all of the SP’s actions were therapeutic conduct or whether VA3 sustained a red mark by any means other than accidental. Regarding the SP stomping on VA4’s foot and pulling his/her arm: P1 and P3 each stated they observed the SP stomping on VA4’s feet and pulling his/her arm. Despite P1 saying the SP stomped on VA4’s feet “every morning” with “force,” P3 and P5 said that no injuries were observed. P1 also said that s/he told P4 about it; however, P4 did not remember anyone telling him/her about these concerns. VA4 had no recollection of the incidents. Although the SP admitted holding VA4’s feet so that they did not slip when assisting him/her into the stander, given that s/he denied stomping on VA4’s feet, that there were no injuries observed, and that the only two staff persons (P1 and P3) who said they observed this had interpersonal conflicts with the SP, there was not a preponderance of the evidence whether the SP stomped on VA4’s feet or pulled his/her arm in an aggressive manner. It was not determined whether abuse or neglect occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult and 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: During the course of the investigation, it was reported that VA2 had a wound that did not heal because staff persons were not providing care as prescribed. A review of VA2’s medical appointments, Medical Notes, Annual Health Review, Appointment Forms, After Visit Summaries, and Medication Administration Records (MARs) showed: · VA2 moved into the facility on June 10, 2021. · VA2’s January 2022 MAR showed that s/he had a skin wound (unidentified location) that was supposed to be cleaned “daily” at “8 p.m.” and an ABD pad (a non-woven, thick, absorbent dressing used for heavily draining wounds) was to be applied and secured with tape. · On January 20, 2022, VA2’s Medical Notes written by the facility health care professional (HCP) stated VA2 had a wound on his/her “LLE” (left lower extremity). · On January 28, 2022, the VA saw a physician for “lymphedema and cellulitis of LLE.” A referral was made to a wound care clinic. · The January 2022 MARs showed four days (three consecutive days and a single day later in the month) that were not initialed by any staff persons regarding VA2’s wound care. · On February 1, 2022, VA2 was seen at the wound care clinic. The Appointment Form orders stated that “Therahoney” was supposed to be applied to the wound bed and then covered with gauze and an ABD pad and secured with tape. The order stated it was “okay to leave honey in place for up to 1 week;” however, the gauze and ABD pad was to be changed daily or twice a day as needed. In addition, it was okay for VA2 to shower with the wound uncovered and then cleaned with one tablespoon of vinegar and one cup of distilled water, let soak for five minutes and pat dry. (The February 2022 MAR was not updated to include this information.) · On February 15, 2022, VA2 was seen at the wound care clinic for two areas of skin break down on his/her lower left leg. Clinic orders included each wound having calazime applied around the wound. In addition, the larger wound was supposed to have Iodosorb gel. Both wounds were supposed to be covered with Tagaderm Ag mesh, an ABD pad, and secured with tape. Progress Notes identified the changes in care as stated on the clinic appointment record. Documentation showed that staff persons initialed cleaning VA2’s wound all days except one in February 2022; however, the MAR was not updated and it was not known if topical medications were applied as ordered. · On March 1, 2022, VA2 was seen at the wound care clinic. The after visit orders stated “same plan but change outer dressing TID (three times a day) for drainage.” The “inner honey/legederm ag mesh may stay in place for up to 7 days.” Cleansing the wound in between inner dressing changes was supposed to include one tablespoon of vinegar in one cup of distilled water, VA2’s legs were to be elevated above his/her heart, and s/he was to be encouraged to use “lymph pumps 2-3 times per day.” (No updates were made to the March 2022 MAR about the orders.) · On March 16, 2022, VA2 was seen at the wound care clinic and notes as well as the MAR showed that VA2 was prescribed an antibiotic for seven days. “Tagaderm Ag Mesh” was continued and “every other day” it was supposed to be cut to fit the wound, covered by an ABD pad, and secured with tape. · On March 17, 2022, VA2 was seen in the emergency room for “possible infection” of his/her “leg ulcer.” VA2 was to continue the antibiotic previously prescribed. · The March 2022, MARs showed two days without staff persons’ initials so it was not known if VA2 received wound care on those days. · VA2’s After Visit Summary for March 22, 2022, stated that s/he had a follow up appointment scheduled for April 5, 2022. (The facility did not provide information regarding that appointment.) · VA2’s April 2022 MAR stated that the lower leg dressing change for the “AM” included the vinegar and water for cleaning. (That order was initially prescribed February 1, 2022.) This order was only documented as completed one time during April 2022. The order stated that VA2 could shower without the wound being covered and then “may clean with one tablespoon white vinegar and one cup distilled water, let soak for five minutes and pat dry,” but did not specify how often. · On April 19, 2022, VA2 was seen at the wound care clinic and orders stated his/her dressing was supposed to be changed daily and as needed if saturated. Tagaderm Ag mesh could remain in place for up to three days. (No changes were made to the April MAR regarding these orders.) · The April 2022 MARs showed seven days (two single and then five consecutive days) without staff persons’ initials so it was not known if VA2 received wound care on those days. · On May 3, 2022, VA2 was seen at the wound care clinic and his/her dressing was supposed to be changed “twice daily and as needed for saturated dressing.” Tagaderm Ag mesh and Iodosorb was supposed to be applied every two to three days. · On May 5, 2022, a facility health care professional (HCP) documented that s/he observed VA2’s leg wound and described it as a “large wound, black/red in color, draining clear fluid” with a “foul odor.”
· On May 31, 2022, VA2 was seen at the wound care clinic. · The May 2022 MAR showed four days (three consecutive days and one single day) without staff persons’ initials so it was not known if VA2 received wound care on those days. · The HCP completed Quarterly Reviews and Reporting of Medication and Treatment Issues for December 2021 through February 2022, and March through May 2022. Each quarter the HCP documented that s/he reviewed the MARS and no medication errors were discovered. · On June 14, 2022, VA2 was seen at the wound care clinic and a wound VAC (used to remove excess fluid) was discussed.
· On June 24, 2022, VA2 reported to the HCP that an unidentified staff person applied his/her wound dressing “too thick” and “necrosis in wound worsened.” · VA2’s June 2022 MAR documented VA2’s wounds were to be cleaned “daily.” Between June 1 and 22, 2022, there were 20 days without staff persons’ initials so it was not known if VA2 received wound care on those days. VA2 provided the following information: · VA2 was not able to see the back of his/her leg but knew s/he had a wound on his/her left leg below the knee. Because of this, staff persons were responsible to “keep an eye on” the wound. At the time of the interview (June 2022), VA2 said that “at least twice a day” staff persons were supposed to remove the “previous dressing” and clean the wound. VA2 needed to stand while this care was provided and VA2’s “tolerance” for walking/standing varied. · There were no specific times identified but VA2 liked to have the dressing changed “when I get up” for the day and “definitely before I go to bed.” In addition, dressing changes/wound care was provided “throughout the day” if the dressing was “really soaked.” · Staff persons used an “anti-smell cream” in the wound bed as well as gauze soaked with iodine. A barrier cream was placed “around the wound” and because the wound “weeps so much,” a “brief liner” was used outside the wound to absorb fluid. Compression socks were placed over VA2’s legs holding the dressings in place. When the “brief liners” got soaked, the heaviness made VA2’s legs weaker “which made it harder for me to walk.” · VA2 said that s/he “can’t feel anything” where the wound was located, although s/he was able to feel “nerve pain” inside the wound. VA2 saw a wound specialist “every two weeks.” · On unknown dates, the SP attempted to change VA2’s wound dressing; however, did not complete the care properly because the SP said s/he was not able to get the “old” dressing out of the wound because the SP felt like “[s/he] is going to hurt me.” VA2 was not able to “continuously stand there” and this resulted in the SP placing new dressing over the “old” dressing. VA2 said the SP never “refused” the wound dressing but sometimes asked VA2 to “wait” until the next staff person arrived. P1 said that on unidentified occasions, the SP “refused” to assist with wound care on the back of VA2’s leg. P1 provided inconsistent information regarding what treatment was needed and/or the frequency of the wound treatment. P1 described some interpersonal conflict between him/herself and the SP and also between P3 and the SP. P2 said that VA2’s wound dressing was changed “every day.” On an unidentified night that VA2 was unable to stand up from his/her walker and P2 assisted when s/he arrived at 11 p.m., P2 observed that the SP had “so much padding” on VA2’s leg and the dressing was “soaked” all the way up to VA2’s buttocks. That was the first time P2 observed the VA2’s dressing soaked like that and s/he did not know if the SP changed the dressing on VA2’s wound that day. On another occasion P2 observed that VA2’s dressing was not properly changed and it took P2 approximately 10 minutes to remove the dressing that was packed inside the wound. VA2 told P2 that the SP was responsible for the dressing that was packed inside the wound that day. P3 said that VA2 had a “big wound” on his/her leg and the SP “does not want to do [VA2’s] wound care” that was needed “two to three times a day or more.” P3 said documentation of the wound care was not needed. P4 said that VA2 did not have the wound described in this report when P4 worked at the facility. P5 said that on one occasion the SP did not care for VA2’s wound and added “gauze on top of gauze” instead of removing the bottom layer of gauze inside the wound bed. The SP provided this investigator with verbal step by step instructions regarding how VA2’s wound was supposed to be cleaned. The SP’s description was nearly identical to the description given by the VA2. The SP said that “everyone” changed VA2’s dressing “once a day” and if the fluids leaked through the dressing, staff persons tried to do it “twice” but there were times VA2 only wanted it done once. When asked about a time when the SP left the gauze in VA2’s wound, the SP said, “I tried everything. It was stuck and [VA2] was in a lot of pain.” The SP told P2 about the gauze. The SP said there was no documentation required regarding VA2’s wound care. A list of duties for a “Residential Supervisor Deadlines” showed that daily that person in that role was supposed to check the MARs for documentation. Information showed persons in that position changed over the course of the investigation. In addition, the facility had difficulty scheduling two staff persons throughout the day/evening. The HCP’s job description stated that s/he was responsible for “administration and monitoring medications and medical treatments as ordered by a physician or health care professional” and provide in-service training including medication administration. Relevant Rules and/or Statutes Minnesota Statutes, section 245D.095, subdivisions 2 and 4 states that the license holder must implement medication administration procedures to ensure a person receives medications and treatments as prescribed and that medication administration records are reviewed as required. Conclusion for Allegation Two: Information was consistent that beginning in January 2022, VA2 had a wound on the back of his/her lower left leg that required dressing changes and frequent appointments at a wound care clinic. Over the course of six months, the orders for the care of the wound changed including the number of times per day the dressing was supposed to be changed as well as the topical medications that were to be used. Despite multiple changes in the orders, the January through June 2022, MARs were not updated to indicate those changes and documentation showed that during that six month period of time, staff persons failed to document even one dressing change on 38 of those days when in fact the orders stated dressing changes were supposed to occur between one and three times per day, which was a violation of Minnesota Statutes, section 245D.095, subdivisions 2 and 4. Given VA2’s diagnoses, that s/he was seen at a wound care clinic approximately twice per month for six months, and that it was not known whether staff persons provided the care as ordered because documentation was inconsistent, there was not a preponderance of the evidence as to whether there was a failure to provide care which was reasonable and necessary to maintain VA2’s health and 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but were not followed regarding reporting procedures and lift safety resulting in retraining of P1 and the SP. Action Taken by Department of Human Services, Office of Inspector General:
On December 21, 2022, the facility was issued a Correction Order for the violations outlined in this report and for not following VA1’s CSSP as required.
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