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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: 1068272-CRS (Community Residential Setting) 1068269-HCBS (Home and Community-Based Services) Investigator(s): Deb Neubauer-Hoffman/Christine Henne Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was unable to bear weight and follow up medical appointments were not completed; the VA was hospitalized and diagnosed with a fractured left hip. Date of Incident(s): Between September 5 and October 14, 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 on November 7, 2022; documentation from the facility and the VA’s medical records; and through six interviews conducted with two facility staff persons (P1 and P2), two supervisory staff persons (P3 and P4), one health care professional (HCP2), and the VA’s guardian (G). This investigator met the VA, but the VA was not able to provide information for this investigation due to his/her diagnoses. The facility’s records for the VA documented that the VA enjoyed being read to, doing crafts, going for walks, taking a whirlpool bath with the jets on, and eating meals out on the deck. The VA was diagnosed with intellectual disabilities, mild cerebral palsy, asthma, seizure disorder, and mild spastic quadriparesis. The VA was also non-verbal. According to the VA’s Intensive Support Self-Management Assessment (ISSA), the VA had a risk of falls and getting injured from them. The VA was less able to ambulate independently due to weak ankles, feet, and legs that turned inward. The VA also had a history of an unsteady gait when ill with infections. The ISSA documented that the VA had a wheelchair to use when going longer distances or displaying episodes of an unsteady gait. The ISSA also stated that when the VA fell, staff were to clearly document how the VA fell and hit the ground, and identify what parts of his/her body may develop bruising or other injury. P1-P4, HCP2, the G, documentation from the facility, and the VA’s medical records provided the following information and timeline: · According to the internal review (IR) and the facility health progress notes (HPNs) dated September 5, 2022, P1 contacted one of the facility’s health care professionals (HCP1) at 11:05 a.m. because the VA was unable to bear weight. The VA also had a runny nose the night prior and was given one tab of Sudafed PE 10mg. HCP1 said to monitor the VA for “varying” symptoms and to contact him/her if the · The HPNs showed that on September 6, 2022, the VA had “red raised skin” and a “yellow/purple” bruise on his/her left thigh that measured eight by four inches and another “black/purple” circular bruise behind the left knee that measured one by one-and-a-half inches. The IR stated that on September 7, 2022, the bruising on left thigh “expanded significantly” and the HPNs showed that the bruising spread to the VA’s entire left groin from the knee to the scrotum. · The IR stated the following information occurred on September 7, 2022, however, according to the HPNs the date was September 8, 2022. On the date, another facility health care professional (HCP2) messaged the VA’s primary health care provider (PCP) about the large bruise; HCP2 sent a photo, noting that the VA’s left leg was also swollen. HCP2 messaged that the VA’s typical signs of a UTI were difficulty standing/weight bearing; HCP2 collected a urine sample and had it tested. Later that day, a physician’s assistant (PA1) messaged the facility back that the VA did not have a UTI, and recommended a protocol of “simple icing” and gentle heat therapy until the bruise resolved. PA1 faxed the facility instructing staff persons to apply ice to the bruised area twenty minutes at a time, four times daily for the next three days. After the three days, staff persons were instructed to alternate between ice applications for ten minutes, remove ice for ten minutes, and then apply heat for ten minutes (contrast therapies) and to continue twice daily until bruise fully resolved. PA1 also said that s/he would discuss further labs or imaging at the VA’s next visit and if the swelling in the leg increased, the VA may need to be evaluated at a local emergency room (ER) to rule out a blood clot. (The HPNs showed that the bruise on the VA’s left thigh resolved on September 13, 2022, and the bruise behind the left knee resolved on September 22.) Later in the day on September 8, 2022, the HPNs showed that the VA had a new quarter sized “blue/purple” bruise on the right kneecap “possibly from bumping something.” The next day, that bruise resolved. · The HPNs showed that on September 13, 2022, a new four by three inch “purple blue” bruise appeared on the VA’s left calf, but was “consistent with same injury as [left] thigh.” (This bruise resolved on September 20, 2022.) · The HPNs showed that on September 16, 2022, a new “quarter size” bruise appeared on the VA’s left glute as well as a “dime size” bruise on the VA’s right glute. Both of these bruises were “consistent with sitting down hard.” The VA’s Support Self-Management Assessment (SSMA) stated, “[The VA] tends to sit down hard on chairs.” (These bruises resolved on September 30, 2022, and all bruises associated with the VA’s lower extremities were resolved as of September 30, 2022.) · P2 told this investigator that the VA had a history of frequent falls due to the VA’s feet pointing inwards and the VA throwing his/her head backwards; however, the VA was able to walk short distances with staff assistance. P2 was unsure what happened to the VA, but “all of a sudden” at some point in late September or early October, the VA was not “bearing weight well.” P2 said the VA was not interested in walking and refused to take more than two or three steps and would proceed to sit on the floor. · P2 provided consistent information in his/her interview with what s/he wrote in the HPNs. On September 30, 2022, P2 documented in the HPNs that the VA was “very weak,” and unable to support his/her own weight. When P2 assisted the VA to stand for a brief change, the VA “needed to sit on the ground.” After resting for several minutes, the VA was able to “gradually” stand and get into his/her chair, though it was “very difficult” for him/her to do so. P2 notified P4 and HCP2 about the VA’s condition. HCP2 told P2 to take the VA’s full vital signs (temperature, blood pressure, pulse, oxygen, and respiration rate) and that s/he would contact the PCP. According to the IR and the VA’s medical records, the PCP was contacted by one of the facility’s on-call health care professionals (HCP3). HCP3 told the PCP the VA was having an “exceptionally” hard time bearing weight and that in the past this had been a sign of infection such as pneumonia. HCP3 shared the VA’s vitals with the PCP and noted the VA’s blood pressure was elevated and to 152/78, but there were no other signs of illness. Another physician’s assistant (PA2) messaged the facility to monitor the VA, but to let him/her know if the weakness continued or new symptoms developed. · The HPNs showed that on October 1, 2022, the VA’s had a new “softball-sized purple” bruise on the VA’s right inner thigh that was “most likely from [bumping] something while walking.” The IR stated that on October 2, 2022, HCP2 told the PCP that the VA had a new bruise on the right inner thigh, that it was not known how the VA sustained the bruise, and sent a photo of it. (This bruise resolved on October 6, 2022.) HCP2 documented that s/he was concerned that the VA might be injured and that was the cause for the VA having difficulty with transferring. PA2 ordered an X-ray of the VA’s right thigh and said that the VA could transfer via a Hoyer lift if s/he was weak. The X-ray was completed at the facility that same day. · HCP2 told this investigator that s/he messaged staff persons on October 2, 2022, and said due to the VA’s difficulty transferring, the PCP approved Hoyer transfers until the VA was able to bear weight again. The message also said that the PCP ordered an x-ray to rule out a fracture on the VA’s right thigh. · The X-ray report on October 3, 2022, stated there was no fracture, dislocation, nor other “intrinsic abnormality,” and the bony pelvis was intact. An additional view of the right hip also was “normal”. However, the X-ray showed that the VA had “symmetrical moderately advanced” hip degenerative joint disease (DJD). · The HPNs showed that on October 4, 2022, P2 told HCP2 that the VA was still “very weak” and asked if another “test” could be ordered. HCP2 notified the PCP, but “no further instructions” were given at that time. P2 told this investigator that the “test” s/he requested in the HPNs “probably” referred to a UTI test because the VA had a history of them that sometimes resulted in weakness. On this same date, the HPNs showed a three by three inch red area on the VA’s left thigh, “consistent with bumping into something while ambulating.” (The red area resolved on October 11, 2022). · There was no information in the HPNs on October 5 or 6, 2022, regarding the VA’s weakness or inability to bear weight. · The G told this investigator that at the VA’s annual meeting on October 7, 2022, s/he requested follow up appointments be made regarding the VA’s inability to stand as well as some other health concerns such as the VA’s arm twitching. The G requested gerontology and neurology appointments. P3 told this investigator that s/he attended the meeting and the VA saw his/her neurologist yearly (last appointment was December 2021). There was no HPN documentation regarding the VA’s inability to bear weight on October 7 or 8, 2022. · P1 told this investigator that s/he was aware that the VA was not able to bear weight “that well,” but was not instructed to change any transfer protocols. According to the IR, on October 9, 2022, the VA lost his/her balance and fell when P1 tried to transfer the VA from his/her wheelchair to a futon. P1 provided consistent information to this investigator with what was written in the IR. P1 said that VA’s legs were “a little bit wobbly” and the VA “slowly” fell and hit his/her “bottom” on the floor (not carpeted). The IR stated the fall was “graceful” and “not hard,” and P1 held the VA by the hand which “lessen[d] the fall.” The IR also clarified that the VA fell on the left side of his/her “bottom.” P1 said that the VA’s face “might have scrunched up in pain a little bit,” but the VA “seemed pretty normal” and P1 did not see any further signs of pain or discomfort. P1 asked P4 to help assist the VA back into his/her wheelchair. P4 was unable to recall the specific fall on October 9, 2022, but the IR stated that P4 did not observe any signs of pain and the HPNs showed no new marks or bruises. · P1 told this investigator that if the VA fell, s/he was trained to look for any signs of pain or discomfort and contact a supervisor or nurse if the VA was in pain as well as document it. P1 did not document the fall in the HPNs because “that day was a little bit busy;” however, P4 (supervisor) was aware of the fall because s/he helped assist the VA back into his/her wheelchair. P1 was not fully able to recall, but thought that the VA “wasn’t really bearing weight” the day following the fall; however, there was no documentation. P1 thought s/he “might” have tried to get the VA out of his/her wheelchair on that shift, but was unsuccessful. · P4 told this investigator that s/he recalled several instances during the time the VA was unable to bear weight where staff persons would ask him/her to help transfer the VA up off the floor after the VA would sit down during brief changes. P4 said that s/he would not have considered these instances a “fall” and if the VA did not hit his/her head, it would be more of a “behavior” documentation rather than a documented fall/injury. · There was no documentation in the HPNs from October 9, 2022, to October 13, regarding whether the VA was able to bear weight. P2 said that the VA’s ability to bear weight was “on and off” depending on the day and that the VA “wasn’t back to normal,” but “some days did a little better than others.” · P3 said that the VA walked following the October 9, 2022, fall; however, this investigator did not find any documentation to support this. P3 said the VA went to his/her day program on the October 10, 2022, through October 13, but did not know if the VA walked those days. · According to the IR, on October 13, 2022, P2 notified HCP2 that the VA’s shins and feet were “very swollen.” HCP2 instructed to raise the VA’s feet in his/her bed as s/he allowed. P2, the G, hospital medical records, the IR, and a Serious Injury Report provided the following consistent information: · The IR said that on October 14, 2022, at 9 p.m., P2 notified HCP1 and HCP2 that the VA was “not feeling well” and “not acting like his/her normal self.” P2 said that “every time” the VA was transferred back into his/her chair, the VA “slumped forward” and was “in a dazed state.” P2 also noted that the VA did not move around in his/her chair at all, “like [s/he] normally [did]” and was “very weak” for the last two weeks. The VA was only able to stand for a few seconds at a time and unable to walk at all (normally the VA was able to walk short distances with no trouble). The VA’s shins and feet were “very swollen” and the VA had been wheezy whenever s/he was lying flat or standing up for any length of time. · The IR stated that at 9:20 p.m. on October 14, 2022, HCP1 told P2 the VA needed to go to the ER. At 10:30 p.m., the VA was transported by a facility supervisory staff person (P6) to a local ER. P6 provided information to the ER that the VA had not been able to bear his/her weight or walk for about two weeks and had increased lethargy. P6 also told the ER of the VA’s recent X-ray and urinalysis. The VA was admitted and had testing completed. · Hospital medical records showed on October 15, 2022, a CT scan revealed a left lateral femur fracture. · A Serious Injury Report written by a supervisory staff person (P5), on October 16, 2022, showed that P1 provided information to P5 that was consistent with the information P1 provided above regarding the fall on October 9, 2022. · Hospital medical records showed that on October 18, 2022, the VA was discharged with a left lateral femur fracture and cellulitis of his/her left leg. The VA was ordered to take Tylenol for pain, cephalexin for a skin infection, and apply lidocaine patches on skin. · Medical records from the PCP showed that on October 28, 2022, the VA was evaluated via telehealth by PA1 for follow up. PA1 ordered to elevate the VA’s legs with one to two pillows behind the calves when in bed to help prevent “dependent” edema in the feet/lower legs. PA1 also said to avoid “pivoting” or “abducting” the left leg with standing/transfer maneuvers and continue to use a Hoyer lift as needed. It was also noted that in-home physical therapy was started, but the VA was unable to actively participate. PA1 instructed staff persons to ask the physical therapist to “guide” them on home exercises to help the VA with “simple passive” range of motion exercises to help the VA “maximize” recovery. · P2 said that s/he was unsure what caused the facture in the VA’s left femur. The VA was occasionally unstable and even though the VA only walked with staff assistance, there were still circumstances when the VA fell. P2 said that the VA did not fall on his/her left side within the last two or three months when she was on shift. · The G told this investigator that s/he called the VA’s home at some point after the VA was discharged from the hospital and asked P2 if the appointments s/he requested at the annual meeting were ever made and P2 stated that they were not. (Note: Although the G expressed concern to this investigator that the requested appointments with gerontology and neurology were not scheduled as of November 2, 2022, it was likely that neither appointment would have diagnosed the VA’s fractured hip.) Facility documentation showed that all staff persons interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans. Conclusion: On September 5, 2022, the HPNs showed that the VA was unable to bear his/her own weight. There was no information regarding this concern until September 30, 2022, when the VA stopped bearing weight again and was “very weak.” On October 1, 2022, an X-ray was completed and showed no fracture, dislocation, or “intrinsic abnormality.” On October 4, 2022, it was documented that the VA was “very weak” and according to the IR, HCP2 notified the PCP, but no further instructions were given at that time. On October 9, 2022, the VA fell, but P1 and P4 did not observe any signs of pain and there were no documented new marks or bruises in the HPNs after the fall. P1 thought the VA was still unable to bear weight the day following the fall, but there was no documentation of that in the HPNs. There was also no documentation in the HPNs from October 9, 2022, to October 13 regarding whether the VA was able to bear weight. P2 said that the VA’s ability to bear weight was “on and off” depending on the day and that the VA “wasn’t back to normal,” but “some days did a little better than others.” P3 said that the VA walked following the October 9, 2022, fall. P3 said the VA went to his/her day program on the October 10, 2022, through October 13, but did not know if the VA walked those days.
On October 14, 2022, the VA went to ER because P2 had multiple concerns regarding the VA’s inability to bear weight and increased lethargy. On October 15, 2022, a CT revealed a fracture in the VA’s left femur. The VA was discharged from the hospital on October 18, 2022, with a left lateral femur fracture and cellulitis of his/her left leg. P2 said that the VA was able to stand next to his/her bed and in the bathroom for brief changes on that day. Given that P2 contacted HCP2 when the VA was “not acting like his/her normal self;” that multiple messages/calls were made between staff persons, including the facility’s HCP’s, and the PCP to discuss concerns regarding the VA’s health; that an X-ray was taken when the bruising occurred on the VA’s right thigh; and that staff persons continued to monitor the VA and document bruising, there was not a preponderance of the evidence whether there was a failure to supply the VA with reasonable and necessary care. 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’s internal investigation stated that their policies and procedures were adequate and followed except for P1’s failure to document the fall the happened on October 9, 2022. PCP2 had been notified about concerns of episodes of weakness/difficulty standing and bruising, and was in communication with the PCP from September 7, 2022, to October 4, 2022, to determine the cause. On November 10, 2022, the VA’s fall protocol was updated to specify that staff persons would document all falls; all staff persons were retrained on this updated fall protocol at a meeting on November 20, 2022. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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