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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: 1068512-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) sustained second-degree burns on his/her hand, arm, chest, abdomen, and groin. Date of Incident(s): December 5 to 6, 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 December 12, 2022; from documentation at the facility; from the VA’s medical records; and through seven interviews conducted with the VA’s guardian (G), a facility health care professional (HCP), and five facility staff persons (P1-P4, and the SP). The VA was non-verbal and because of his/her diagnoses could not provide information related to the investigation. The facility had a handicapped accessible walk-in shower. The VA used a shower chair equipped with a safety belt. The shower had a handle to change the water temperature and there was a sprayer, where water came out of, attached to a wall in the shower. The VA’s Individual Abuse Prevention Plan showed that the VA “needs assistance” with bathing/showering and that “staff [persons] will touch the water to check for appropriate temperature before [the VA] touches the water.” When the VA used the bathroom, staff persons were to “wait outside the door for 5 min. or check on [the VA] every 5 min.” There was no specific information provided in terms of the level of supervision that was to be provided while the VA showered. The VA’s Activities of Daily Living Training Form showed that the VA took a shower in the evening and staff persons should “allow [him/her] some time to play in the bath/shower as [s/he] really enjoys playing in/with the water.” The level of supervision was not identified. The facility’s Program Abuse Prevention Plan stated, “Individuals are supervised during bathing at all times unless otherwise stated” in the client’s specific plans. The VA’s diagnoses included an intellectual disability and epilepsy. The VA enjoyed listening to music and accessing the community. Interviews with P1-P4, the SP, the HCP and the facility’s Notification of an Internal Review provided the following information: · At about 8:30 p.m. on December 5, 2022, the SP assisted the VA with a shower. The SP stated that the VA did not have the ability to adjust the temperature and that before the SP began to shower the VA, the SP touched the water and it was “comfortable.” After the SP assisted the VA with washing his/her body, the SP “gave [the VA] time to play in the water.” The SP checked the water temperature again and it was fine. The SP turned the direction of the sprayer so that it was not directly spraying into the VA’s face and was spraying “off to the side.” The VA was sitting in the shower chair with a safety belt fastened. The SP then left the bathroom to assist another client with personal cares. When the SP returned about three minutes later, the SP noticed that the sprayer was pointing toward the VA’s knees and the VA had “some redness” on his/her skin, but nothing out of the ordinary and the SP retested the water temperature and did not have concerns. The SP noted that the VA’s skin was a “rosy, red color,” but the VA did “not appear distressed.” When the shower was over, the SP performed evening cares for the VA, put his/her pajamas on and the VA went to bed. The SP described the VA as “behaving normally.” The SP noticed “some noise” from the VA at 9 p.m., but that was “not unusual as [the VA] is settling down for the night.” The SP left the facility at 10 p.m. · P1 came to work at 10 p.m. that night and checked on the VA at midnight, 2 a.m., and 4 a.m. and the VA was sleeping each time. During those checks, P1 did not notice anything unusual with the VA and the VA did not show signs of pain. · At about 6:45 a.m. on December 6, 2022, P1 went to wake up the VA and noted that the VA’s shirt was “stuck to [his/her] stomach” and his/her chest was “bright red” and there were some “blisters” on the VA’s skin. P1 went to get P2 (who arrived for the morning shift shortly prior), and call the HCP. · P2 stated that shortly after P1 went to get the VA up for the day, P1 began “hollering for me.” When P2 got to the VA’s bedroom, P1 told P2 that the VA had a “rash.” P2 stated that s/he was “astounded” that the VA’s skin was “red and peeling.” · The HCP stated that s/he was notified by P1 at 6:57 a.m. on December 6, 2022, that the VA’s shirt was “stuck to [his/her] chest.” When the HCP got to the facility that morning, s/he saw the VA and what s/he thought was a rash so initially thought that the VA might have had an allergic reaction to “strawberry yogurt.” After further assessment, the HCP determined that the VA was in pain and needed medical care. The HCP also stated that s/he thought that the VA had a “rash” because it was red. The HCP took the VA to the emergency room. · P1-P4, the HCP, and the SP stated that they were trained to touch the water before any water was put on a client. They each also stated that the VA did not have the ability to change the water temperature in the shower. P2 did not have concerns related to the temperature of the water heater, but stated that s/he did not turn the hot water “on all the way,” when showering the VA.
· On the morning of December 6, 2022, a maintenance person from the facility went to the facility and saw that the water heater was set to 140 degrees (⁰) Fahrenheit (F) and should have been set to 120⁰ F. The maintenance person checked the temperature of the water coming out of a kitchen facet and the temperature was 135.9⁰ F. The water heater was reset to 116⁰ F. The facility’s internal review indicated that no one said they changed the setting on the water heater. · The facility’s internal review included interviews with five staff persons about their knowledge of showering the VA. The “majority stated that they would not leave any of the individuals unattended in the shower and that they test the water with their own hands prior to using the shower sprayer on an individual.” There were some “discrepancies” in staff person training regarding the supervision of the VA in the shower while the VA was allowed time to “play” in the water. The VA’s medical records from a hospital in Rochester, Minnesota stated that the VA was seen in the emergency room (ER) on December 6, 2022, for “lesions on [his/her] right hand and forearm,” as well as a “very well demarcated area anterior chest right upper shoulder down into [his/her] inguinal area thighs with areas of blistering and weeping all consistent with second degree burn.” In addition, the records said that eight to ten percent of the VA’s “body surface area” had second degree burns. The VA was given two milligrams (mg) of morphine for pain and later transferred to another hospital in St. Paul, Minnesota. The records from that hospital showed that while hospitalized, the VA was given additional pain medications. When the VA was discharged from that hospital on December 9, 2022, staff persons were given instructions to care for the VA’s wounds, which included dressing changes. The facility had a document which showed that on February 17, 2022, the water temperature was checked and it was 119⁰ F. On May 23, 2022, the water temperature was again checked and it was 117.9⁰ F. After the incident on December 6, 2022, the water temperature was checked and was 135.9⁰ F. The facility’s training records showed that P1, P2, the HCP, and the SP were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s specific care plans prior to December 5, 2022. Conclusion: On December 5, 2022, around 8:30 p.m., the SP assisted the VA with showering. According to the SP, prior to the beginning of the shower, and at least two times throughout, the SP tested the water temperature and did not have concerns and the water temperature was “comfortable.” When the SP finished showering the VA, the SP left the water running moving the sprayer to the side so the VA could “play” in the water. Then, the SP left the bathroom for three minutes to assist another client. When the SP returned, s/he noticed some redness on the VA, but nothing out of the ordinary. The SP felt the water temperature and did not have concerns. The SP then assisted the VA out of the shower and with personal cares and then the VA went to bed. The VA was “behaving normally” and did not express pain. P1 worked the overnight shift and stated that s/he checked on the VA at midnight, 2 a.m., and 4 a.m., and did not notice anything unusual and the VA did not express pain. The following morning, P1 was waking up the VA and noticed that the VA’s chest was “bright red” and P1 had difficulty removing the VA’s shirt because it was “stuck” to the VA’s skin. P1 contacted the HCP and after the HCP’s assessment that morning, the VA was taken to an ER in Rochester, transferred to another hospital and admitted, given pain medications for second degree burns on eight to ten percent of the VA’s body, and discharged on December 9, 2022. After the incident, the water heater temperature setting was checked and noted that it was set at 140⁰ degrees F and the water temperature from the kitchen facet was tested reading 135.9⁰ F. No one stated that they adjusted the water heater temperature setting so it was not determined when or how this occurred. The water temperature was checked on two occasions prior to the incident and both were documented to be below 120⁰ F. The facility’s Program Abuse Prevention Plan stated that, “Individuals are supervised during bathing at all times unless otherwise stated” in the client’s specific plans. The VA’s plans did not specify the VA’s supervision requirements while the VA was showering and said that the VA “needs assistance” with bathing/showering and that “staff [persons] will touch the water to check for appropriate temperature before [the VA] touches the water.” When the VA used the bathroom, staff persons were to “wait outside the door for 5 min. or check on [the VA] every 5 min.” Although the VA sustained burns and it was not determined why or when the water heater was set at 140⁰ F, given that the facility provided immediate medical care to the VA when the injury was discovered; that the SP and P1 each stated that the VA did not express pain or act unusual; that it was reasonable for the SP to leave the VA to assist another client; and that the SP checked the water temperature multiple times including before and during the VA’s shower, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care to maintain his/her physical 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were not followed because the water heater was supposed to be set lower than 120⁰ F. In addition, the facility determined that its policies and procedures were not adequate. The VA’s Individual Abuse Prevention Plan was being updated to reflect the incident. In addition, because the facility found that there appeared to be some discrepancy in staff person training as to the supervision of the VA while the VA was given time to “play” in the water, the facility provided additional training to all staff persons and “have procedures in place to ensure regular monitoring of these temperatures throughout the agency beyond what was already being done.” Action Taken by Department of Human Services, Office of Inspector General: No action taken.
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