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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: 1072941-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s):
Scott Broady & Marie Tierney Suspected Maltreatment Reported: On August 31, 2022, a vulnerable adult (VA) fell around 8 p.m. The VA was left on the facility’s living room floor all night and was not given his/her 8 p.m. medications. On the morning of September 1, 2022, the VA was found on his/her bedroom floor with multiple bruises, scratches, rug burns, and facial swelling.
On September 2, 2022, the VA fell while transferring from a wheelchair to a toilet. Emergency medical services (EMS) was called to help the VA get up. Staff persons told EMS that the VA was fine and just needed help getting up. EMS took the VA to an emergency room where the VA was diagnosed with five broken ribs and was hospitalized. Date of Incident(s): August 31 through September 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 September 15, 2022; from documentation at the facility and medical records; and through six interviews conducted with the VA, a facility health care professional (HCP), and four facility staff persons (P1 – P4), including supervisory staff persons. The facility was a two level home. The VA’s bedroom was on the facility’s main level, and led directly off the facility’s living room. The living room connected to the facility’s kitchen. The bathroom led off the kitchen. The facility's record for the VA included the following information:
· The VA's conditions included autism, schizoaffective disorder, arthritis, and high cholesterol. The VA's mental health conditions caused isolation, "dwelling," ignoring prompts, antagonizing others, crying, and persecutory delusions. When the VA displayed these "behaviors," staff persons were to verbally redirect the VA. · The VA used a wheeled walker at times, but sometimes chose to walk without it. The VA was at risk of falls and needed reminders to wear his/her glasses and to avoid shuffling to prevent tripping. · The VA engaged in self-injurious behaviors however the specific behaviors were not described. · The VA had a recent history of falls with injury. On June 20, 2022, the VA was seen in an emergency department due to bruises and complaints of pain in many areas of the VA's body, which were attributed to bumping into things and falls. No fractures were detected, and there was concern for possible concussion. In July,2022, it was noted that the VA had experienced "many falls" in the last month, with noticeable injury during at least one. · The VA’s mental health had recently deteriorated. In July, 2022 it was noted that the VA spent the majority of his/her days in bed and had lost interest in artistic and recreational activities s/he once enjoyed. "Staff [persons] and management have observed [the VA] not seeming like [him/herself] for many, many months.” The VA saw a psychiatrist regularly to manage his/her psychiatric conditions. The VA provided the following information during his/her interview: · On an unspecified date, the VA fell in the facility’s living room after dinner. The VA tried to get up but was unable to do so. P2 tried to help the VA get up but s/he was still unable to get up. The VA slept on the floor in the living room all night and P2 gave him/her a pillow and a blanket. In the morning an ambulance came and EMS helped the VA get up. The VA said s/he was not injured during this incident. The VA had no concerns about the care provided to him/her during this incident. · On an unspecified date, P2 helped the VA use the bathroom. When the VA tried to sit down on the toilet, s/he fell on the floor. The VA could not get up so P2 called an ambulance and EMS helped the VA get up. The VA thought s/he broke his/her ribs on the floor during this incident. The VA had no concerns about the care s/he received from P2 during this incident and said P2 did what s/he was supposed to do to assist the VA. The following is a summary of information about the incident obtained from the facility’s records for the VA, interviews, and the VA’s medical records: · On August 31, 2022, at 9:15 a.m., the VA attended an in-person appointment with his/her primary care physician. No physical exam was completed. It was noted that the VA was not consistently using speech to communicate his/her pain levels, and therefore staff persons would need to rely on "non-verbals/inaudibles or body language to help gauge [the VA's] pain." The physician made behavioral health referrals. A staff person documented about the visit: "Much of the visit circled around whether [the VA's] listlessness is psychiatric/behavioral or medical. [The VA's doctor] thoroughly and thoughtfully covered a list of possibilities, ending on [his/her] opinion that this is a behavioral health issue but that any health improvement that can be made is worth pursuing." · On August 31, 2022, in the evening while the VA was emptying the dishwasher, the VA went to the kitchen floor. P1 did not know whether the VA fell or intentionally placed him/herself on the floor. P1 contacted P2 and the HCP for guidance, then (following the HCP’s guidance) encouraged [the VA] to pull [him/herself] up on [his/her] walker. After about an hour, the VA got up and sat near a table, then the VA stood up near his/her walker, “all crunched over.” A housemate told the VA s/he should sit down so [s/he] did not fall again. “Right afterwards,” the VA's legs “gave out" and the VA went back to the floor. P1 said it appeared the VA did this intentionally. The VA told P1 s/he was not in pain but s/he could not get up. P1 encouraged the VA to get up several times but the VA did not appear to attempt to get up. · On August 31, 2022, at 11 p.m., P4 arrived at the facility and the VA was still laying on the kitchen floor. P4 documented the following about the 11 p.m. to 7 a.m. shift: [P1] talked with [the HCP] and was told to just leave [the VA] on the floor and to finish the work that needed to be done. [P1] said that [the VA] did not have p.m. meds or a snack yet. Staff [persons] tried to encourage [the VA] to get up to have [his/her] p.m. meds and a snack. Staff [persons] gave [the VA] prompts to get up, but [s/he] did not try very hard, just kind of squiggled on the floor. Staff [persons] got a gait belt and gave [the VA] prompts and got [him/her] up just a little and then [s/he] laid back down. Staff [persons] got a blanket and put it under [the VA] and [P1 and P4] pulled [the VA] into the living room so [s/he] would not be in the way of other residents. Staff [persons] gave [the VA] a pillow and a blanket. [The VA] would just squiggle on the floor, but not get up. Staff [persons] got up at 3:00 a.m. and [the VA] was still in the living room. When staff [persons] got up at 6:00 a.m. [the VA] was not in the living room. [The VA] was in [his/her] bedroom on the floor. So [the VA] managed to get up by [him/herself] and walk into [his/her] bedroom without [his/her] walker, and yet not get into bed. · According to P2, if the VA was on the floor in his/her bedroom, staff [persons] were supposed to make sure the VA was comfortable and leave the door open. The VA had a call button s/he could use to request assistance as needed. · During their interviews, P1 and P4 each said they did not think the VA sustained any injuries while they moved the VA to the living room on August 31, 2022, because his/her skin did not make contact with anything that would cause injury, and the VA did not bump into anything. · The VA did not receive his/her nighttime medications on August 31, 2022. P1 said this was because the VA refused to sit up to take his/her medications. P1 told the HCP about this during their phone conversations that evening. · On September 1, 2022, around 7 a.m., P2 returned to the facility. P2 and P4 provided consistent information that they helped the VA get off the floor. However, P4 documented that the VA did this “with ease” and P2 documented that the VA did so “with a lot of assistance given.” P2 and P4 each documented that the VA’s pants were wet with urine. · P4 denied that the VA had any injuries on the morning of September 1, 2022, but P2 provided consistent information in his/her interview and on an injury diagram in the VA’s file that the VA had scrapes on his/her nose and right cheek, his/her left eye and the left side of his/her face was “puffy,” there was “slight” bruising on the VA’s left cheek, two small bruises on the VA’s right wrist, a scratch on the left side of the VA’s stomach, a bruise on the VA’s left knee, a scratch and a bruise on the VA’s right ankle, and a red mark on the VA’s left tricep area. The facility supplied photos taken September 1 and 2, 2022, that confirmed the presence of most, but not all, of these injuries. · On September 1, 2022, P2 documented the following additional information about the 7 a.m. to 3 p.m. shift: [The VA] was administered [his/her] a.m. meds and breakfast by [P4]. Writer checked [the VA] for stroke like symptoms, [the VA] was able to grip writer’s hands the right grip was slightly weaker than the left, [the VA] was able to answer questions such as [his/her] name, parents’ names, birthdate, the year . . . no drooping of facial features noted. Writer took a blood pressure result was 92/77. [Management] notified and images of [the VA’s] bruising both cheeks, nose, forearms have bruising noted until a full body check was completed during [his/her] shower. . . While in the shower [the VA] was leaning so far forward that [his/her] stomach was resting on [his/her] thighs. [The VA] was not sitting up, writer stood in front of [the VA] and no fall occurred. . . [The VA] did not brush [his/her] teeth as [s/he] was not standing, nor was [s/he] sitting safely on the toilet while on the toilet. . . With much assistance verbal cueing and gait belt assist, [the VA] was transferred to the loveseat where [the VA] rested. . . [the HCP] was at the home and assessed [the VA] and found no deficits. [The VA] was able to follow commands, use both hands equally and bear weight. . . [The VA] is walking with verbal cueing and gait belt 100% of the shift. No verbal outburst falls or putting [him/herself] on the floor have occurred this shift. · P1 worked with the VA on the evening of September 1, 2022. P1 said s/he placed a gait belt on the VA to assist with walking and transfers due to the VA’s recent falls and behavior. · On September 1, 2022, at 10:30 p.m., P1 helped the VA get out of bed and walk to the bathroom, holding onto the VA’s gait belt. In the bathroom, the VA turned to sit on the toilet and fell onto the floor. The VA said s/he was not hurt but that s/he could not get up. P4 was called to come in early to help get the VA up off the floor. With assistance the VA got up, walked to his/her bedroom and went to bed. · On the morning of September 2, 2022, at an unspecified time prior to 7 a.m., P4 found the VA on his/her bedroom floor with his/her blanket underneath him/her, calling for P4 to help him/her back into bed. P4 asked the VA how s/he got to the floor and the VA said, “I crawled there.” P4 told the VA s/he could help him/her after s/he gave breakfast and medications to the other residents. Around 7 a.m., when another staff person arrived, P4 and P3 helped the VA get into a wheelchair. The VA ate breakfast and brushed his/her teeth in the wheelchair, then wheeled him/herself to his/her bedroom and transferred to his/her bed independently. · On September 2, 2022, the VA went to urgent care for evaluation for any possible injuries after being on the floor several times in recent days. The VA was examined including lab work, urine analysis, chest x-ray, electrocardiogram, chest CT, bladder ultrasound, and head CT; no bruises or other injuries were found; and the VA denied pain. · On September 2, 2022, at approximately 6:30 p.m., the VA returned to the facility from urgent care in a wheelchair. The VA transferred into his/her bed independently. A “short time later,” the VA walked out of his/her bedroom to the bathroom without hunching or wobbling. The VA then ate dinner and went to bed, declining a shower. · On September 2, 2022, at approximately 11 p.m., the VA was laying on his/her bed with half his/her body on the bed and his/her legs “dangling” on the floor. The VA said, “Help me get up.” P1 told P4 that s/he knew the VA could get up and walk independently because s/he walked to the bathroom independently earlier in the evening, and that P1 was not going to assist the VA. After P1 left, P4 helped the VA walk to the bathroom. · When s/he was finished in the bathroom, the VA began to walk with his/her walker, with P4 following behind the VA and holding the VA’s gait belt. P4 said the VA “just kind of fell over to [his/her] right on the floor.” The VA said s/he was “okay” but could not get up. P4 called the HCP for guidance, and at the HCP’s instruction waited 15 minutes and encouraged the VA to get up again however the VA was still unable to get up. P4 called for non-emergency assistance. EMS arrived and determined that the VA had high heart rate, low blood pressure, and low oxygen. The VA asked P4 if s/he should go to the hospital and P4 initially said s/he did not think the VA needed to. However, EMS personnel said the VA should go to a hospital and then P4 encouraged the VA to go. P4 supplied the VA’s pertinent medical information to EMS personnel, and the VA was transported to a hospital by ambulance. At the hospital multiple new rib fractures were found on the VA’s left side. · All staff persons interviewed said sometimes the VA cooperated with staff persons’ assistance, and sometimes s/he did not. · Information was consistent that the VA often went to the floor said s/he could not get up. P1, P3, P4 and the HCP each said that on many occasions, the VA got up independently soon after saying s/he was unable to do so. The HCP said if the VA did not choose to help get off the floor, it was safest for the VA to remain on the floor. If the VA was on the floor, staff persons tried to make him/her comfortable. · P2 said the VA often chose to sleep on the floor of his/her bedroom, but it was unusual for the VA to sleep on the floor in other areas of the facility. When the VA chose to sleep on his/her bedroom floor, staff persons were to make sure the VA was comfortable with a pillow and blanket, ensure the VA had his/her call button, and keep the VA’s bedroom door open. · The HCP said the VA was able to walk without a mobility aid, and did not use the walker “properly.” The HCP explained that the VA typically either had his/her arms fully extended with just his/her fingertips touching the walker, or stood so close to the walker that s/he was bent far over the walker. In addition, the VA moved “very fast” with the walker and seemed to use it more as a “weapon” than an assistive device, often running over other persons’ feet with it. P2, the HCP, and P3 each said the VA had a history of “lunging,” “diving,” or “throwing” him/herself toward where s/he wanted to go, and the VA had sustained bruises from doing this in the past. P3 said sometimes the VA bumped into things or fell and did not notify staff persons. · P1, P2, and P4 each said they did not know how the VA fractured his/her ribs, and denied doing anything that would cause the VA’s fractured ribs. The HCP and P3 each said falling could have injured the VA’s ribs, but the HCP added that s/he was surprised to learn the VA had fractured ribs because s/he had no information that the VA ever complained of rib pain. In addition, P4 told the HCP that the VA fell to his/her right on September 2, 2022, and the VA’s rib fractures were on his/her left side. The facility’s personnel files and training records documented that P1, P2, P3, P4, and the HCP were each trained on the VA’s individualized plans prior to the incidents; and P1, P2 and P4 were each trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incidents. Conclusion: Regarding leaving the VA on the floor and the VA not receiving medications on the night of August 31, 2022:
It was possible that the VA was physically unable to get off the floor, which may have warranted medical attention. However, given that the VA had a history of choosing not to get up from the floor, that staff persons consulted with the HCP and followed the HCP’s instructions during the incident, and that there was no inherent risk in laying on the living room floor, there was not a preponderance of the evidence as to whether there was a failure to supply the VA with reasonable and necessary care or services. Regarding the VA’s injuries on September 1, 2022: Although P4 denied that the VA had injuries on the morning of September 1, 2022, information from P2 (as provided in his/her interview and in P2’s documentation from September 1, 2022) and photographs was consistent that the VA had multiple scrapes, scratches, bruises and red marks on various parts of his/her body on the morning of September 1, 2022. However, neither the VA, P2, P4 nor any other source provided information as to how the injuries occurred. In addition, the VA had a history of bumping into things, falling, “lunging,” “diving,” or “throwing” him/herself toward where s/he wanted to go, which had caused injury in the past. Therefore, there was not a preponderance of the evidence as to how the VA sustained the injuries or whether the injuries were a result of a failure to provide the VA with reasonable care and services. Regarding the VA’s fractured ribs: The VA was seen in urgent care on September 2, 2022, for evaluation for possible injuries, including a chest x-ray that was negative for new fractures. On September 3, 2022, the VA was taken to a hospital where s/he was diagnosed with multiple new left rib fractures. The only documented incident that occurred between the two x-rays that might explain the VA’s new fractures was when the VA “just kind of fell over” to his/her right side while P4 helped the VA walk using the VA’s walker and a gait belt. However, it was also possible that the VA sustained the injury during an unwitnessed fall or similar incident. Further, there was no information that the VA complained of rib pain to any staff person, and the VA received prompt medical attention. Therefore there was not a preponderance of the evidence as to whether staff persons failed to supply reasonable and necessary care to the VA. 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 internal reviews and determined that policies and procedures were adequate but were not followed because facility management was not notified of the August 31, 2022, incident until the following morning; there was no need for additional staff person training, and the incidents were not similar to past events with the persons or services involved. The facility placed an alarm on the VA’s bed to help alert staff persons if the VA tried to get up without assistance. The VA continued to decline to wait for staff persons to assist him/her when s/he wanted to move about. Staff persons continued to provide “stand by assist” to the VA to the extent possible. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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