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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: 1070425-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux/Gessner Rivas Minnesota Department of Human Services Suspected Maltreatment Reported: Allegation One: It was reported that a vulnerable adult’s (VA1’s) bedroom had a foul smell from VA1’s open wound and there were flies on VA1’s bedding. VA1’s bedroom had soiled adult undergarments on the floor and in garbage bags and a soiled towel on the floor. VA1’s bed had a dirty mattress protector with no sheets on the bed. Allegation Two: It was reported that there was a “strong odor of urine” in a vulnerable adult’s (VA2’s) bedroom. There were also concerns that staff persons had been putting VA2 to bed at night with no pajamas but covered with two blankets. Date of Incident(s): Unknown prior to and ongoing from September 23, 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 14, 2022; from documentation at the facility; through four interviews conducted with VA1, VA2, and two facility staff persons (P1 and P2); information from a law enforcement agency, and information provided by a supervisory staff person (P3) in the facility’s Internal Review. The facility was a single-family home with four bedrooms, housing four clients, including VA1 and VA2. The facility had two bathrooms, but one was designated for staff person use only. On September 23, 2022, a Stearns County Licensor (CL) visited the facility and observed that there was dried feces on the clients’ toilet, on the wall opposite the toilet, and the floor. There was also dried blood on the bathroom wall and floor. Within VA1’s bedroom, there were soiled absorbent pads on the floor and bed, bagged garbage with flies, and a dirty mattress cover. The CL also noticed flies in the facility and along with a foul smell. The CL issued the facility a correction order regarding the unsanitary conditions on September 23, 2022. At the time of the site visit, investigators observed no dried feces or blood in the bathroom used by residents. VA1 was away at a medical appointment receiving wound care. Investigators observed that VA1’s bedroom had an unpleasant odor, there were soiled absorbent pads on the floor and bed, fly strips hung by the bedroom closet, and there was a garbage bag on the floor containing soiled absorbent pads and other garbage. There was a blue pillow on VA1’s bed that appeared to be soiled and there were no sheets on the bed. After VA1 returned from his/her appointment, VA1’s bedroom was cleaned with the assistance of staff persons. VA2 was at work but also arrived later during the site visit. VA2’s bed did not have sheets, but the bedroom was clean and did not smell of urine. Allegation One: It was reported that VA1’s bedroom had a foul smell from VA1’s open wound and there were flies on VA1’s bedding. VA1’s bedroom had soiled adult undergarments on the floor and in garbage bags and a soiled towel on the floor. VA1’s bed had a dirty mattress protector with no sheets on the bed. VA1’s diagnoses included but were not limited to mild developmental disability, lymphedema (a condition that resulted in swelling of a person’s arms or legs), morbid obesity, adjustment disorder with mixed anxiety, and depressed mood. VA1 also had a history of methicillin resistant staphylococcus aureus infection. VA1 was not subject to guardianship. VA1 enjoyed doing arts and crafts and had numerous goals including increasing his/her independence skills so that s/he may one day move to his/her own home. VA1 aspired to become an American Sign Language interpreter working with children. VA1’s Coordinated Services and Support Plan said that VA1 relied on staff persons to provide assistance with personal care tasks, wound care, and lymphedema wraps. VA1 had a goal that stated that VA1 would keep his/her room clean by making his/her bed and picking up items off the bedroom floor (Note: VA1’s file contained numerous monthly tracking sheets for this goal and all sheets that were obtained by the investigators were blank). VA1 provided the following information: · VA1 stated that s/he was “trying to get some organizational skills so that that stuff is not on the floor.” VA1 said that staff persons were wanting him/her to “move a lot faster than [s/he could] and [that VA1] can’t with [his/her] mobility.” VA1 said that it was going to take him/her a “lot longer” because s/he could not always ask the staff persons for help because sometimes there was “one staff [person]” with the other clients. · VA1 tried to take out the garbage in his/her bedroom when s/he could. However, sometimes VA1 could not because a more pressing matter arose such as the need to use the restroom. · VA1 stated that some time ago, s/he had been told by a supervisor that staff persons would clean his/her room while s/he was at an appointment. However, the next time VA1 went to an appointment, his/her room had not been cleaned and the bed had not been made. VA1 did not mind if staff persons cleaned his/her bedroom while VA1 was at an appointment. · VA1 had concerns when persons entered his/her bedroom without introducing themselves or knocking first and said that a supervisor had done that a couple of times. · VA1 stated that sometimes staff persons would prop open an exterior door and flies would get into the house. P1 and P2 provided the following information: · P1 stated that VA1 was “pretty independent” but needed help with his/her wound care. · VA1 had a wound care nurse that visited three times a week to perform wound care. VA1 had an appointment every Friday for wound care at a local medical clinic. · Staff persons placed a pillow under VA1’s legs at night. Staff persons were to put on a pillowcase to absorbed leakage from VA1’s wound. · Staff persons placed absorbent pads under VA1’s sheets at night and under his/her legs because the wound from his/her legs leaked but noted that the smell from the wound leaking spread throughout the house. · When VA1 declined to get out of bed, staff persons reminded VA1 that it would be better for his/her wound if s/he moved around. · Staff persons were to encourage VA1 to clean his/her bedroom on days of his/her appointments. · VA1 liked his/her privacy but would only allow staff persons into his/her bedroom when s/he was present. · The facility was located next to a farm and sometimes staff persons would prop open exterior doors like the patio door and flies got into the facility. Flies were attracted to the smell from VA1’s wound leakage. P3 provided the following information: · Information provided by P3 in the facility’s Internal Review noted that it was difficult for VA1 to get in and out of bed as s/he had limited mobility. Staff persons were to change VA1’s bedding when s/he was on community outings or in another part of the facility.
· VA1 was evaluated once a week by a physician specialized in wound care. On September 23, 2022, while VA1 prepared for his/her appointment with the physician, fluid from VA1’s wound leaked onto the hallway, bathroom floor and toilet. Staff persons did not have time to clean up the fluid before taking VA1 to his/her appointment. Shortly thereafter the CL arrived at the facility. · Staff persons cleaned the fluid leakage after the CL left. P3 noted that staff persons did not find any dried feces or blood in the bathroom. · Flies from the neighboring farmland were drawn to the leakage from VA1’s wound and it was not possible to eliminate all smells from the wound. VA1 hung fly strips in his/her bedroom and staff persons were instructed to catch flies in the facility and keep the exterior doors closed to prevent flies from entering the facility. Facility documentation P1 and P2 received training on the plans for VA1 and VA2 and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion for Allegation One: VA1 had an open leg wound which at times leaked and smelled attracting flies. There were soiled absorbent pads in VA1’s bedroom and VA1’s bedroom was generally unsanitary at the time of the site visit by both the CL and these investigators. VA1, P1, and P2, acknowledged that VA1 liked his/her privacy. VA1 stated that s/he did not mind if staff persons cleaned his/her room while s/he was out of the house but both P1 and P2 stated that VA1 did not like people entering his/her room when s/he was not there. As part of VA1’s goal to become more independent, staff persons would encourage VA1 to get out of bed and clean his/her room. VA1 stated that it took him/her longer to do so because of his/her mobility. Although at times VA1’s room became unsanitary, information was consistent that VA1 often declined to allow staff persons into his/her bedroom to clean or assist in cleaning. In addition, there were no concerns regarding the care that VA1 received for his/her wound. Therefore, there was not a preponderance of the preponderance of the evidence whether there was a failure to provide VA1 with reasonable and necessary care and services. 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). Allegation Two: It was reported that there was a “strong odor of urine” in VA2’s bedroom. There were also concerns that staff persons had been putting VA2 to bed at night with no pajamas but covered with two blankets. VA2 was diagnosed with a traumatic brain injury, was paralyzed below the waist, and had limited use of his/her right arm. VA2 needed a Hoyer lift or stander for transferring from bed to a motorized wheelchair. VA2 enjoyed working at his/her day program. VA2 was subject to guardianship. During an unannounced site visit, VA2 was away at work. Investigators found VA2’s bed did not have sheets, the room was clean, and there was no scent of urine in the room.
VA2’s Coordinated Services and Support Plan provided the following information: · VA2 was able to move independently when s/he used his/her motorized wheelchair. · VA2 needed assistance with self-care needs. · VA2 was prone to urinary tract infections and had been experiencing incontinence at night. Staff persons would encourage VA2 to relieve him/herself during the day or evening to help avoid incontinence at night. · VA2 was able to verbally communicate but persons not familiar with his/her speech pattern may have trouble understanding him/her. VA2 provided the following information: · VA2 stated that s/he had not noticed the facility being dirty. · VA2 slept with sheets and blankets all the time and staff persons did his/her laundry. · VA2 stated that s/he did not typically need help but said that s/he got help when s/he needed help. P1 and P2 provided the following information: · When VA2 was incontinent at night, the following morning, his/her bed sheets were put in a laundry basket that was kept in the bedroom. Overnight staff persons would take care of VA2’s laundry but sometimes it was done during the day. Staff persons would sanitize VA2’s bed and wheelchair daily. · VA2 had a urinal by his/her bed but did not use it. · Staff persons would put VA2 to bed without pajamas because his/her pajamas started to deteriorate due to being soiled. VA2 was dressed in a t-shirt and underwear and covered with blankets when s/he went to bed. P3 provided the following information: · Information provided by P3 in the facility’s Internal Review noted that the absorbent pads on VA2’s bed had been placed with the absorbent side facing the mattress which prevented the fluids from being absorbed by the pad. · VA2’s bed had a plastic lining which was washed with soap and water and disinfectant. Conclusion for Allegation Two: VA2 was incontinent at night and slept with no pajamas but wore a t-shirt and underwear and was covered with blankets. When investigators arrived at the facility, there were no sheets on VA2’s bed, his/her bedroom was clean, and there was no noticeable odor of urine as was reported. Although VA2 soaked through absorbent pads at night, staff persons would launder his/her bedding the following day and sanitize his/her mattress regularly. Therefore, there was a preponderance of the evidence that there was not a failure to provide VA2 with reasonable and necessary care and services. It was determined that neglect did not occur (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 not followed. With respect to VA1, staff persons were retrained to pay close attention to when VA1 was out of the room and change the bedding daily and clean the bedroom when the environment became unsanitary and was a health and safety hazard. With respect to the fly strips, staff persons were retrained to immediately catch any flies and not leave outside doors propped open. With respect to VA2, staff persons were retrained to properly place absorbent pads on VA2’s bed to absorb overnight urine leaks and to properly clean the mattress. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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