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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: 1109496-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady/Kyle Youker Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) suffered a fractured jaw while a staff person (SP) was working. Date of Incident(s): September 1 or 2, 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 October 4, 2022; from documentation at the facility and medical records; and through three interviews conducted with the VA and two staff persons (P1 and P2). Attempts were made via telephone, e-mail, and certified mail to contact and interview the SP, but the attempts were unsuccessful. The SP provided information to the facility for the internal review and that information is included below. The facility was a single level residential home. There was living room and kitchen directly off the front door. Off the kitchen was a hallway with the two bedrooms, one of which was the VA’s. The VA was the only person who lived at the facility. The VA’s medical records and support plans stated: · The VA’s diagnoses included an intellectual disability and cerebral palsy. The VA spoke in short phrases or one-word answers. · The VA ambulated with the use of a wheelchair and relied on staff persons to maneuver him/her through day-to-day life. Staff persons were required to utilize a Hoyer (mechanical) lift to transfer the VA. · The VA enjoyed going to work, watching Golden Girls, going to the American Legion for Bingo, and people watching in the community. A Hoyer lift was a mechanical lift used to transfer the VA between his/her wheelchair, bed, chairs, etc. The lift had an arm that staff persons used a lever to manually raise or lower the VA. When transferring the VA, the VA was placed on a sling, which was then attached to the arm of the lift, which had a four point attachment. The sling had four straps, two straps attached behind the VA and two straps were crisscrossed between the VA’s legs and then attached to the lift. There was more than one sling that was available to use with the VA and the slings were different sizes. One of the slings was designed to be used in the shower. Information from a facility internal review report and medical records showed the following: · P2 stated that s/he worked the overnight shift August 31 to September 1, 2022. That morning, P2 woke the VA for the day. The VA “was in a good mood” after his/her morning routine. When P2 dropped off the VA’s at the VA’s day program, the VA hugged P2. That morning, P2 did not see any bruises on the VA’s face. · P2 then worked the overnight shift September 1 to 2, 2022. Upon waking the VA up for the day on September 2, 2022, P2 noticed bruising and swelling on the VA’s face. · The VA was transported to the hospital via ambulance where the VA received computerized tomography (CT) scan and was admitted for a facial infection. The CT scan also stated, “bony detail is suboptimal.” There was no information that the VA had a fracture at this time. · On September 7, 2022, while still in the hospital the VA received another CT scan and the results of the CT scan showed the VA had a fractured jaw that required surgery. Interviews with P1 and P2 and information from the facility internal review report provided the following: · On September 1, 2022, at 11 a.m., the SP picked up the VA from the day program. According to the SP, the VA became upset after leaving and as the VA sat in the vehicle, the VA began “smacking herself/himself in the head and chest” which made it difficult for the SP to buckle the VA into the vehicle. · The SP said that when the SP and the VA returned to the facility, the VA was ate lunch and then transferred into a recliner in the living room. The SP did not recall the VA striking his/her face on anything during the transfer to the recliner. · At 2:30 p.m., P1 arrived at the facility. Upon P1’s arrival, the VA “pointed to his/her mouth.” P1 examined the VA’s mouth and did not notice any swelling or visible bruises. P1 did not notice food particles in the VA’s teeth, but asked the VA if s/he had something stuck in his/her teeth and the VA said, “Yeah.” P1 then flossed the VA’s teeth. Shortly after, P1 left. · The SP stated that after P1 left, the VA was in a “better mood.” At the VA’s request, the SP read the VA a book and the VA went to bed at 8 p.m. The SP did not recall the VA hitting his/her head on anything during the SP’s shift. · P2 stated that upon arriving to the overnight shift to relieve the SP, the SP left the facility without speaking to the P2. The SP did not make any mention of the VA indicating pain in his/her jaw. · On September 22, 2022, P1 interviewed the VA for the internal review while the VA was in the hospital. P1 asked the VA a series of yes/no questions. Based on these yes/no questions, P1 determined that the VA remembered P1 being at the facility and flossing his/her teeth on September 1, 2022, and the VA was not hurt before that time. The VA said that something happened after P1 left. When asked if the VA got hit or the VA fell, the VA responded that s/he fell at the facility. The VA s did not fall in the living or bedroom, but fell in the bedroom and that s/he was in the Hoyer lift when s/he fell. When asked if P2 was working when s/he fell, the VA said, “No.” When asked if the SP was working when the VA fell, the VA said, “Yeah.” · P1 asked P2 and the SP whether either recalled the VA “bumping his/her face on the Hoyer lift,” both P2 and the SP did not recall the VA “bumping his/her face or complaining of pain. P1 and P2 each told this investigator that they did not cause the injury to the VA. The VA was interviewed by this investigator and a law enforcement officer. The VA initially stated that s/he fell out of his/her wheelchair but did not provide information in what room the incident occurred. The VA told P1 that s/he fell out of his Hoyer lift in his/her bedroom when the SP was working. The VA then said that a staff person was not with the VA when s/he fell, but then said P1, P2, and maybe another staff person were at the facility when s/he fell. The VA said that the SP was not at the facility when the VA fell. Law enforcement investigated the allegation, but did not take any additional action. Facility documentation shows that P1, P2, and the SP were each trained on the Reporting of Maltreatment of Vulnerable Adults Act and P2 and the SP on the VA’s plans. Conclusion: On September 2, 2022, after P2 noticed bruising on the VA’s face, the VA was transported to the hospital via ambulance. The initial diagnosis after a CT scan on September 2, 2022, was a facial infection. On September 7, 2022, an additional CT scan was conducted and at that time, the VA was diagnosed with a fractured jaw. In the 24 hours prior to P2 noticing the injury, P1, P2, and the SP each worked with the VA. The VA provided different information regarding how s/he sustained the injury and who was present when s/he sustained it. The VA told P1 that s/he fell out of his Hoyer lift in his/her bedroom when the SP was working. The VA told this investigator and law enforcement that s/he fell out of his/her wheelchair, but said that the SP was not at the facility. The SP did not provide information for this report, but told P1 that s/he was not aware of the VA bumping his/her head or complaining of pain. P1 and P2 each told this investigator that they did not cause the injury to the VA. Prior to P2 noticing injuries to the VA’s face, P1, P2, and the SP each denied knowing how the VA might have received the injury to his/her face. Given the different accounts provided by the VA and that the VA was diagnosed with the jaw fracture five days after being admitted to the hospital, it was not determined how the VA broke his/her jaw. Without knowing how the VA broke his/her jaw, there was not a preponderance of the evidence whether the VA sustained the injury by any means other than accidental or whether there was a failure by a staff person to provide the VA with care or services which were reasonable and necessary. 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 report and determined that their policies and procedures were adequate and followed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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