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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: 1057445-AFC (Adult Foster Care) 1071191-HCBS (Home and Community-Based Services) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) sustained injuries to his/her neck when s/he became wedged between a mattress and a bedrail in the bed where s/he slept at the facility. Date of Incident(s): December 29, 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 January 9, 2023; from documentation at the facility and the VA’s medical records from two hospitals (hospital A and hospital B); and through interviews conducted with facility staff persons (SP1 and SP2), a resident at the facility (R), and one of the VA’s guardians (G1). On January 9, 2023, during the site visit to the facility, this investigator saw and photographed the bed with adjustable length rails in which the VA slept when the incident occurred. During the site visit, the bed was being used by an individual who was receiving respite care from the facility and a canopy that belonged to the individual had been temporarily added to the bed. The rails that were on the bed when the incident occurred were made of smooth metal. There were screws on the outside of the rails pointed away from the mattress, and the rails could be adjusted for length, raised, or lowered using spring tension. Facility documentation showed that the VA was diagnosed with a developmental disability, cerebral palsy spastic quadriplegia, and contractures. The VA used a wheelchair for mobility and vocalized to communicate. A mechanical lift was used to move the VA between his/her bed, wheelchair, and the shower chair in which s/he sat when others assisted him/her to take a shower. The VA’s plans of care did not describe the type of bed the VA should sleep in, how s/he should be supervised when s/he was lying in a bed, or how often s/he should be checked on. G1, and the VA’s other guardian (G2) were the VA’s primary caregivers and took him/her on daily community outings and played games with him/her, which the VA enjoyed very much. The VA’s family members and the Gs were loving and extremely involved in his/her care. The facility was a licensed adult foster care provider and provided a few hours of respite care a month to the VA as requested by the Gs. The facility provided respite care to the VA two times prior to the incident. According to the MnCHOICES Support Plan for the VA, the facility was to assist the VA with his/her medical, mobility, fine motor skills, expressive and receptive communication, self-preservation, daily living/home management, community living, leisure, and recreation needs. A facility tour on January 9, 2023, showed that when the VA received respite care services at the facility, the VA shared a bedroom on the main level of the facility with a facility resident (R). The bed in which the VA slept had rails on the sides, and it was positioned against a wall in the bedroom. The SPs resided at the facility and slept on the upper level. There were two dogs who lived at the facility; one dog was about five years old and weighed less than 10 pounds and the second dog was a “senior” dog that had stiff legs and difficulty walking, which weighed about 35 pounds. Facility documentation, the VA’s medical records, records from the law enforcement agency, information provided by SP1, SP2, the R, G1, and the Internal Review provided the following: According to SP1, at about 7:30 a.m., on December 29, 2022, s/he checked on the VA and the R, who were in the shared bedroom. SP1 heard the VA laughing as s/he approached the bedroom and when s/he opened the bedroom door, SP1 saw that the VA was “stuck” between the bed’s mattress and the raised exterior bed rail. SP1 “panicked and yelled” for SP2. The VA’s head/left side of his/her upper body was wedged between the mattress and the bedrail with the VA’s face looking up toward the ceiling, so s/he removed the mattress from the bed which freed the VA. SP2 then entered the bedroom, assisted SP1 to place the VA on a comforter and pillow on the floor, and assess the VA for injuries. The VA’s neck was red and there were “pinch marks” on the neck, but the VA was not bleeding. A 9-1-1 was made and law enforcement officers (LEOs) and emergency medical technicians (EMTs) arrived in a few minutes. The dogs were not in the bedroom when SP1 entered. SP2 stated that on the date of the incident, s/he heard SP1 call out and immediately went to the VA’s bedroom. In the bedroom, the VA was lying on the floor and the mattress from the VA’s bed was in the hall near the bedroom door. SP1 was on the floor holding the VA’s head and there were marks/bruises on the left side of the VA’s neck that were red, but not bleeding. SP2 called 9-1-1; LEOs arrived within a few minutes, and EMTs arrived within 10 or 15 minutes. The VA did seem to be “in pain.” SP2 thought that prior to SP1 finding the VA that morning, SP2 last checked on the VA between 3 and 5 a.m. The VA was “good” at that time, breathing regularly, and snoring. SP2 said that s/he checked on the VA and the R about every three hours when they were in their beds but there was no set time that s/he checked on them and nothing in the VA’s plans showing that s/he required additional supervision when s/he was lying in bed. SP2 thought that s/he would hear the SP or R if they needed assistance during the overnight hours since the R could call out loudly when needed. The SPs provided consistent information that after the EMTs arrived, they checked the VA’s vital signs, put a dressing on the marks on the VA’s neck which had begun to bleed “a few drops,” and placed a “neck brace” on the VA to prevent him/her from moving his/her head, then transported him/her to the emergency department of hospital A via ambulance a short time later. The VA’s medical records from hospital A showed that at 8:34 a.m. on December 29, 2022, the VA was evaluated at the emergency department for an injury to the left side of his/her neck. The VA had a “perforation” of the skin on the left side of the neck above the collarbone, with surrounding abrasions to the neck, left shoulder, and the front of his/her chest. The VA was awake and following instructions and no other injuries or concerns were noted. A computerized tomography (CT) scan of the VA’s head, neck, and cervical spine showed that there was no evidence for acute intracranial injuries, intracranial masses, hemorrhages, or fractures. The VA had a “small puncture wound” to the left side of his/her neck and a small bruise on the left hyoid bone (a small U-shaped bone in the neck), appeared to be neurologically at baseline, and had no airway compromise. The VA was given antibiotics intravenously and transferred to hospital B for additional care. Records from hospital B were requested, but not received. G1 said that s/he thought the injuries sustained by the VA were not consistent with SP1’s explanation of how s/he found the VA and was concerned that the injuries were caused when a dog at the facility bit the VA. Information was consistent from the SPs that the dogs were not confined to certain parts of the facility. However, the dogs did not have a history of biting, the smaller dog usually slept upstairs, and the larger senior dog had difficulty walking on floors that were not carpeted, including the bedroom in which the VA slept. On uncarpeted floors, the senior dog usually slid into a “spread eagle” position according to SP1, and then required assistance to stand. The R said that the VA got stuck in the bed for “four minutes” and the SPs helped the VA, but s/he was unable to provide any additional details about the incident. The R said that the dogs at the facility did not bite anyone. Records from a law enforcement agency showed that the agency assisted EMTs and the SPs when 9-1-1 was called but did not investigate the allegations in this report. The facility’s personnel and training records showed that staff persons interviewed for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: Information was consistent that on December 29, 2022, the VA was at the facility for respite care services that s/he occasionally received at the facility. SP1 checked on the VA at about 7:30 a.m. and discovered that the VA’s head and upper left side of his/her body were stuck between the mattress and bed rail. SP1 called for SP2 and quickly removed the mattress, which freed the VA. SP2 heard SP1 call for him/her, went to the VA’s bedroom, assisted SP1, and called 9-1-1. LEOs and EMTs responded to the call, and the VA was transported to hospital A, then transferred to hospital B for additional care. The VA sustained an injury to the left side of his/her neck when s/he became stuck between the mattress and a bed rail of the bed in which s/he slept. The VA’s medical records from hospital A showed that the VA had a perforation/puncture of the skin on the left side of his/her neck, abrasions to the neck, left shoulder, and the front of his/her chest. The VA had no acute intracranial injuries, intracranial masses, hemorrhages, or fractures, and seemed to be neurologically at baseline. The records for hospital B were requested, but not received. G1 thought that the VA’s injuries were not consistent with SP1’s explanation of how the injuries were sustained and was concerned that the VA was bitten by a dog at the facility. However, no information showed how the VA should be supervised at the facility or how often s/he should be checked on. SP2 said that the VA was not injured when s/he saw him/her between 3 and 5 a.m. Given this, and that SP1 said that the dogs were not in the VA’s bedroom at 7:30 a.m. when SP1 opened the door and entered, that the R said that a dog did not bite anyone, and that the SPs immediately sought medical care for the VA when they became aware of his/her injury, there was not a preponderance of the evidence whether there was a failure to provide the VA with care and supervision which was reasonable and necessary to obtain or maintain the VA’s 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 which determined that its policies and procedures were adequate and were followed. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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