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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: 1097945-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that a staff person (SP) did not change the VA’s absorbent adult undergarment (brief) during the overnight resulting in open wounds on his/her buttock. Date of Incident(s): July 13, 2022 and prior 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 July 21, 2022; from documentation at the facility; and through eight interviews conducted with the VA, facility staff persons (P2-P4), a facility health care professional (HCP1), the VA’s guardian (G), and a hospice health care professional (HCP2). Attempts were made by this investigator to contact a staff person (P1) via telephone and email; however, no response was received. The VA enjoyed shopping at various community stores, dining out, using his/her wheelchair to go for walks, and visiting his/her family member (FM) via Zoom meeting or the telephone. The VA enjoyed listening to music, especially Johnny Cash. The VA was described as very social and enjoyed joking with people. The VA’s diagnoses included moderate intellectual disability, seizure disorder, cerebral palsy, depression, and arthritis. The VA moved into the facility in February 2022. The VA’s Community Support Plan (CSP) stated that “getting a good night’s sleep is crucial to assist with better managing psychosocial symptoms.” The VA required total assistance with dressing and wore incontinence briefs at all times. The VA was able to verbalize when s/he needed to use the toilet or when s/he needed his/her brief changed. The VA required staff persons to assist him/her with repositioning while in bed or in his/her wheelchair “every two to four hours.” (A review of the plan showed there was no information regarding the number of times or frequency in which to change his/her incontinence brief.) The VA’s Coordinated Services and Support Plan (CSSP) stated that the VA received hospice services since August 2021 so in the event of a medical situation, hospice staff persons were consulted and attempts were made to treat the VA at the facility. The facility was located in a residential area and was a single level with wheelchair accessibility. There was a patio off of the back door and an attached sidewalk went around the side of the garage leading to the driveway. During overnight hours the facility was staffed with one awake staff person. An Incident Report dated July 13, 2022, stated that at 7:30 a.m., a staff person (identified as P1) observed that the VA’s brief was wet, his/her shirt was “soaked up the back” and his/her sheets were “soiled.” P1 changed the VA’s wet clothing and applied a mepilex bandage (a foam shield to protect wounds from infection) to a sore on the VA’s “bottom.” The SP worked the overnight shift, just prior to P1’s observation. (Information showed that the SP worked rotating overnight shifts, one week on, and then one week off.) P1 provided the following information via documentation: · P1 first documented a wound/pressure sore on the VA’s “bottom” on June 26, 2022. (This would have been after the SP’s first night of his/her seven days on.) · The VA generally needed to go to the bathroom during the night; however the SP “never” changed the VA resulting in a “really bad bed sore.” · On July 7, 2022, at 9 p.m., P1 drew a star on the VA’s brief. The next morning, July 8, 2022, the VA was wearing the same brief with the star indicating the SP did not change the VA’s brief during the overnight. · On the morning of July 13, 2022, the VA’s bedding and shirt were wet due to the VA urinating during the overnight. (A review of P1’s documentation for July 13, 2022, showed no mention of a sore on the VA’s “bottom” as referenced on the Incident Report.) When interviewed by this investigation, P2, a supervisory person, provided the following information: · The VA did not have a pressure sore on his/her buttock prior to the end of April 2022. · When asked how often the SP failed to change the VA’s brief, P2 said, “a lot” and as a result, the VA’s pressure sores on his/her buttocks did not clear up. P2 believed that the SP failed to change the VA’s brief during the overnight hours for “about a week” but did not provide specific dates. · The VA was aware when s/he needed his/her brief changed and “will scream” to let staff persons know. When P2 was asked by this investigator if the VA ever said the SP refused to change him/her, P2 said, “No.” · On some mornings, after the SP worked, the VA wanted staff persons to “hurry” and get him/her out of bed; however, when other night staff persons worked the overnight and changed the VA during that shift, the VA wanted to remain sleeping in the morning. · The SP told P2 that when the VA was sleeping, the SP did not want to “bother” the VA by waking him/her up to change his/her brief. The VA was interviewed by this investigator and said that s/he liked living at the facility although “I don’t sleep that good at night.” When asked if staff persons changed his/her brief during the night, s/he said, “Now and then they do.” The VA said there were staff persons who did not change his/her brief at night; however, the VA was not able to identify those persons by name or gender. The VA did not know about any sores on his/her body. P3 told this investigator that s/he did the majority of the SP’s initial training; however, it was “mainly on day shift.” P3 said that the SP “did not have a lot of training on NOC (overnight) shift” but initially worked with another unidentified staff person on the overnight shift. P4 said that the VA’s brief had a line that changed color and indicated when the brief was wet. The VA was repositioned every two hours and his/her brief was also supposed to be changed every two hours, even when the VA was sleeping. P4 believed that the VA developed a pressure sore on his/her coccyx (tailbone) because the SP “was not changing” the VA’s brief at night. P4 believed this to be true because staff persons were “finding [the VA] wet in the morning.” HCP1 said that the VA’s wound was likely caused by “not being repositioned, wetness, irritation, or friction on the bed.” The VA was supposed to be repositioned every two hours during the day and night. HCP1 said that HCP2 was concerned about the VA’s briefs not being changed during the overnights when the SP worked. HCP1 was aware that the VA had a “slight wound” on his/her buttock when the VA initially moved to the facility (February 2022, prior to the SP’s employment). HCP1 said that it was not possible to identify one specific person whose actions or inactions caused the VA’s wounds or caused the wounds to not heal. For example, the VA’s brief could be changed and could be wet again immediately after. Repositioning was supposed to be documented; however, HCP1 acknowledged that it was possible for staff persons to document repositioning without having done so. HCP1 did not monitor the VA’s wound because HCP2 came once per week and a hospice aide (HA) came twice a week to monitor the VA’s wound. HCP2 provided the following information: · HCP2 saw the VA two times per week and said that s/he was “thriving” since s/he moved to the facility. HCP2 did not always observe the wound on the VA’s buttock because if the VA was in his/her wheelchair when HCP2 arrived, the VA did not want to go back to his/her bed where HCP2 would be able to view the wound. · On June 29, 2022, HCP2 said that the wound on the VA’s tailbone “was not looking good.” HCP2 asked unidentified persons at the facility how often the VA’s brief was changed and s/he was told there were “problems” with the SP not changing the VA’s brief. HCP2 “added to the (VA’s) plan” that his/her brief was supposed to be changed “every two hours if wet, even if sleeping” and P3 initiated a “toileting and repositioning schedule” for “every two hours.” · HCP2 said that due to the VA’s cerebral palsy, his/her body was shaped in such a way that pressure sores were “unavoidable” and a “pressure relieving mattress,” repositioning, and brief changes each attempted to reduce the likelihood of pressure sores. Although “incontinence” was “maybe” part of the issue related to the VA’s wound, HCP2 was not able to “medically say that one thing or another” caused the pressure sore. HCP2 heard about occasions when the VA brief was saturated in the morning; however, s/he did not know if it was “a fluke, or if something happened in the night, or if [the VA] declined” to have his/her brief changed. The SP said that the VA was able to tell staff persons “what [s/he] wants.” During the overnight hours the SP was responsible for “checking” on the VA every two hours and repositioning him/her. In addition, the VA required staff persons to change his/her brief “once a night or as needed.” The VA usually did not “soak” his/her brief during the night; however, it “depends on when the last shift changed [the VA].” The SP said that s/he often changed the VA “twice” during the night but occasionally when the VA had difficulty sleeping, the SP did not change the VA’s brief when the VA finally went to sleep because the SP did not want to “bother” the VA by waking him/her up. The SP was aware of a sore above the VA’s tailbone that started on an unknown date after the SP began working overnights. The SP said there was interpersonal conflict and “bickering” between unidentified staff persons and the SP. A Record of Discussion showed that on July 7, 2022, there was a meeting with the SP and two supervisory staff persons (P2 and P3). The meeting addressed several issues including “changing a resident on night shift every two to three hours/repositioning.” The VA’s Mayo Clinic health note dated June 29, 2022, stated that “skin and/or wound care” was started on May 17, 2022, for a wound on the VA’s “coccyx-midline crease and left buttocks.” The wound was identified as “pressure stage 1” and was to be cleaned daily with a “baby wipe then pat dry and apply 4x4 Mepilex (an antimicrobial foam dressing). Apply thin layer of barrier cream to left buttock area.” Staff persons were to reposition the VA every two hours for comfort. An Overnight Cleaning List showed that nightly, staff persons were to provide two hour checks on residents, reposition residents every two hours, and “change if needed and when needed.” A NOC Shift report showed that staff persons were to document when the VA was checked for incontinence, visually checked for safety, toileted, brief changed, repositioned, or document if the VA declined. On July 7, 2022, the SP documented that s/he did a visual check for safety every two hours between midnight and 5:30 a.m. and repositioned the VA seven times. The SP worked the overnights on July 11 and 12, 2022; however, there was no documentation regarding the VA’s care between 10:30 p.m. and 5:30 a.m. on either of those nights. The facility’s Internal Review provided the following information: · The SP said that P3 provided his/her initial training during a day/evening shift; however, the SP did not believe s/he received “a good initial training” regarding the overnight shift. The SP talked to P2 who was supposed to come in during the middle of the SP’s overnight shift to provide training; however, P2 “never came.” · HCP2 said s/he nor the HA typically documented on the status of the VA’s wound. HCP2 said that on June 29, 2022, the HA told HCP2 that it “looked worse.” The G stated that at the VA’s prior residence “s/he never got bed sores,” however, since moving to the facility (February 2022), HCP2 told the G that the VA had bed sores on “several occasions.” In May 2022 the VA had an “open wound that was substantial from bed sores.” The G said it was “pecuiliar that the arrival of the bed sores coincides with [the VA’s] transfer to the new residence and new caregivers.” This investigator reviewed the facility communication log that only showed documentation for a few days between June and July 21, 2022. One of those notations, dated June 29, 2022, stated that the VA “now has repositioning sheets that need to be filled out each shift.” There was no further documentation regarding the VA or any other clients between June 29 and July 21, 2022. A review for prior documentation or information in the communication log showed no notes between October 2021 and June 2022, indicating that the communication log was not regularly used/reviewed by staff persons. Facility documentation showed that all staff persons were trained regarding the VA’s program plans. In addition, documentation showed the SP was trained regarding the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information showed that the VA required repositioning every two hours and brief changes to prevent pressure sores on the VA’s “bottom.” Despite that plan of care, wound care began for a sore on the VA’s bottom on May 17, 2022. On June 29, 2022, HCP2 said the VA’s bottom was “not looking good” and a plan was implemented to change the VA’s brief every two hours, even if s/he was sleeping. The plan did not indicate if the brief was dry, whether staff persons had to still change the brief. P1, P2, and P4 believed that the SP’s care or lack of care resulted in the VA’s wound. However, the SP said there was interpersonal conflict at the facility, that s/he repositioned the VA every two hours and changed his/her brief once or twice each night or as needed with the exception of some nights when the VA had difficulty sleeping and after finally falling asleep, the SP did not want to “bother” the VA by waking him/her up to change his/her brief. Information also showed that the SP did not always document the VA’s cares. According to the VA, “now and then” staff persons did not change his/her brief during the overnight; however, the VA was not able to identify which staff persons s/he was referring to. Because of the VA’s diagnoses and history of having a pressure sore prior to his/her admission to the facility, that the VA’s brief could be changed and wet/soiled immediately after, and because HCP1 and/or HCP2 provided information that it was not possible to identify one specific person or cause of the pressure sore, there was not a preponderance of the evidence whether the VA developed a pressure sore as a direct result of the SP’s failure to reposition or change the VA’s brief as required. 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. Plans were made to the VA’s Individual Social Service Assessment to include repositioning and changing needs. All staff persons at the facility were retrained regarding the VA’s needs and related protocols. 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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