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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: 1072685-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) sustained a pressure sore “roughly the size of a tennis ball” that was “severely infected to the point [the VA] now has a bone infection.” Date of Incident(s): Ongoing prior to December 13, 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 February 15, 2023; from documentation at the facility and medical records; and through interviews conducted with the VA’s supported employment specialist (SES) and a facility supervisory staff person (P). At the time of the investigation, the VA no longer lived at the facility. Attempts were made via telephone and mail to contact and interview the VA, but the VA did not respond to the requests. The VA’s case manager (CM) was also contacted but did not provide additional information. The VA’s support plan and support plan addendum provided the following information: · In 2009, the VA moved into the facility seeking supports and services relating to his/her diagnoses, which included spina bifida. · The VA was not able to walk, but used an electric wheelchair, independently. Staff assisted with all transfers into or out of the VA’s wheelchair using a transfer board. · The VA communicated his/her wants and needs, independently. However, “[the VA], at times, will ‘shut down’ in situations that [s/he] feels uncomfortable in (talking about neglecting cares, health concerns, etc.) … At times staff will need to use a direct approach when [the VA] is neglecting [his/her] personal cares.” · The VA completed his/her own hygiene- and dressing-tasks for his/her upper body. Staff assisted with the VA’s lower body cares; and assisted with or offered a shower to the VA every other night. “On occasion, [the VA] does require verbal reminders to complete certain tasks. [The VA] has a history of noncompliance … will refuse showers and isolate in [her/her] room. Staff will provide verbal reminders to [the VA] as needed. Staff will provide physical assistance as requested. Staff additionally will document all [the VA’s] refusals … and report these concerns to [the VA’s] team should they arise.” · According to the VA’s Individual Services & Supports Plan, dated March 2022, the VA did not have chronic medical conditions that required assessment or support from staff. The VA’s “ongoing health and medical needs” were marked N/A (not applicable) without a need for assessment or support from staff. “[The VA] is independent with scheduling all appointments and transportation.” The VA accessed the community unsupervised “with no concerns.” Staff assisted “as needed or requested by” the VA. · The VA was not subject to guardianship. The facility was a single-family home where the VA lived with three housemates. The facility provided at least one staff person 24 hours a day for care and supervision. The facility’s policies and procedures stated, “It is the policy of the Company to meet the health service needs of each person being served as defined and assigned in each person’s Support Plan or Support Plan addendum(s).” At the outset of this investigation, the SES provided information that the VA had a “pressure sore roughly the size of a tennis ball” on the VA’s buttocks. “The pressure sore was severely infected to the point [the VA] now has a bone infection.” The VA’s medical records and facility documentation provided the following timeline: · M Health Fairview After Visit Summary, dated October 20, 2022, stated that the VA attended an appointment for “pressure injury of skin of right buttock.” A wheelchair cushion was ordered to alleviate pressure when the VA was sitting in his/her wheelchair. The VA was prescribed a barrier cream to be applied to the wound. A “wound care referral” was made for in-home nursing care. A follow-up appointment was scheduled for October 26, 2022. [Note: It was not stated in the medical record(s) if the VA attended this appointment, or any of the forthcoming appointments, independently or with a staff person.] · M Health Fairview After Visit Summary, dated October 26, 2022, stated that the VA attended an appointment for “pressure injury of skin of right buttock.” The VA received wound care instructions, which included daily cleansing and dressing changes. “Seek medical care if you have an increase in swelling, pain, or redness around the wound … increase in the amount of pus … a bad smell coming from the wound … appears to be worsening or enlarging … you have a fever.” A follow-up appointment was scheduled for November 1, 2022. · M Health Fairview Office Visit Summary, dated November 1, 2022, stated that the VA attended an appointment for a wound check. A medical doctor noted, “The [right buttock] wound appears healthy with no sign of infection … [The VA] has not had any symptoms of infection relating to the wound recently and is not currently on antibiotics.” The doctor instructed the VA to minimize his/her time spent in a sitting position, and to return for a follow-up appointment in one week. · Facility documentation, dated November 7, 2022, stated that staff brought the VA to an emergency room for a worsening cough. The VA was diagnosed with pneumonia and admitted to a hospital for observation. The VA also had an “approximately 5 x 5 cm [centimeter] wound involving the skin and subcutaneous tissues” on his/her left buttock. [Note: Within this same medical record dated November 7, 2022, it stated that the VA’s left buttock wound measured “4 x 4 cm,” and then at a later point stated that it measured “5 cm x 5cm x 4 cm.”] On November 10, 2022, the VA’s left buttock wound was debrided (damaged tissue was removed). “It was discussed with the hospital social worker about getting home health set up before discharge for wound care since we had been awaiting the setup for these services from [the VA’s] visit on 10/26/2022.” · Allina Health records stated that on November 15, 2022, a consult occurred, which affirmed/determined the VA’s need for in-home skilled nursing. “[The VA] currently requires assistance to mobilize wheelchair due to positioning to keep pressure off pressure ulcer. [S/he] fatigues easily, after transfers to wheelchair and being up for an hour or more. [S/he] also is limited to prolonged sitting secondary to stage 3 pressure ulcer [left ischial decubitus] and needs to limit [his/her] sitting time to [less than] 1 hour.” · Allina Health Discharge Instructions, dated November 16, 2022, stated that the VA was being discharged from the hospital after having underwent treatment for pneumonia, asthma exacerbation, and decubitus ulcer. The VA received additional wound care instructions, which included cleansing and changing dressings. The VA was able to verbalize and “teach back” his/her wound care instructions to the doctor. · Allina Health records, dated November 17, 2022, stated that in-home wound care was completed by skilled nursing. The VA’s left buttock wound measured 5 x 5 x 4 cm. · Allina Health records, dated November 19, 2022, stated that in-home wound care was completed by skilled nursing. The VA’s “wound is malodorous.” The nurse instructed the VA on eating a high protein diet and offloading pressure (minimizing the amount of time sitting on the wound) from his/her wound. · Allina Health records, dated November 21, 2022, stated that in-home wound care was completed by skilled nursing. The P was present during this time and told the nurse, “[The facility has] been packing [the VA’s left buttock wound] with alginate dressing and covering with ABO pad. New wound care orders from [in-home skilled nursing] is for silver alginate, so wound packed with alginate dressing. No foam dressing in home, covered with folded ABO pad and secured with tape.” The nurse encouraged the VA to increase his/her fluid intake and to consume a high protein diet. “Key to wound healing will depend on effective offloading. Instruct [the VA] and caregivers on importance of repositioning frequently to redistribute pressure points. Demonstrate techniques to offload pressure. Make sure skin is kept dry and check frequently for early [signs and symptoms] of skin breakdown or reddened areas.” · Allina Health records, dated November 22, 2022, stated the VA attended an “assessment,” which resulted in a referral for the VA to obtain a mechanical lift and a hospital bed for at-home use. · Allina Health records, dated November 25, 2022, stated that in-home wound care was completed by skilled nursing. The previously mentioned wound on the VA’s right buttock had completely resolved and was removed from the VA’s care plan. “Issue no longer present.” The nurse educated staff on wound healing relating to the VA’s left buttock wound. “No signs and symptoms of infection.” · Allina Health records, dated November 28, 2022, stated that in-home wound care was completed by skilled nursing on the VA’s left buttock wound, which was 6 cm with a depth of 5 cm. “Case manager contacted wound team stating wound care supplies have not arrived yet. [Voicemail] was left with [medical supply company] on 11/21. Called [medical supply company] to get a status update. They state they did not have an active order but acknowledged they are upgrading their phone system and may have lost the order. Order placed again today. It will be released today on verbal order.” · Allina Health After Visit Summary, dated December 1, 2022, stated that the VA attended an appointment for “buttock wound, left.” “Left buttock – 5 x 5 x 4 cm down to presacral fascia … further debridement deferred, no purulence (pus) encountered, no surrounding cellulitis.” A doctor noted, “It appears [the VA’s] local wound care is inadequate, as [the VA] has insensate in the area.” The doctor adjusted the type of wound dressing, and encouraged the VA to “off-load the area, padded cushion, frequent position changes, etc.” The VA received additional wound care instructions, which included increasing dressing changes to three times a day. “Off load the area with a padded cushion and move positions frequently. Schedule a debridement in the [operating room] in 1-2 weeks. Call or return to clinic as needed if these symptoms worsen or fail to improve as anticipated.” · Allina Health records and facility documentation, dated December 2, 2022, stated that in-home wound care was completed by skilled nursing. The CM was contacted to order a hospital bed and mechanical lift for the VA’s at-home use. · Facility documentation, dated December 5, 2022, stated that staff brought the VA to an emergency room “due to [the VA’s] pressure sore having a dark color.” The VA was admitted to a hospital at that time. · Allina Health records, dated December 5, 2022, stated, “Wound present on left buttock measures: 5 cm x 5 cm x 4 cm ... foul-smelling … blackish discoloration.” [Note: Within this same medical record dated December 5, 2022, it stated that the VA’s wound “measured 8 cm x 6 cm x 5 cm.”] The VA told a healthcare professional that s/he ran out of his/her at-home wound care products and was having issues with his/her insurance company to resupply. · Facility documentation, dated December 6, 2022, stated that the P contacted a hospital social worker to order a hospital bed and mechanical lift for the VA. The facility hoped to obtain these items prior to the VA’s discharge from the hospital. “Staff were still attempting board transfers, and this was not an adequate transfer method for [the VA] with the pressure sore location. The social worker ordered these devices, and they were to be delivered on 12/8/2022.” · Facility documentation, dated December 8, 2022, stated, “[The VA] was currently needing a 2 person assist with a [mechanical] lift for all transfers and an air mattress on the hospital bed. [The VA] had a new wound on [his/her] right ankle and was needing to wear ankle boots while lying in bed. [The VA’s] wound on the buttocks was still to the bone and the size was still the size of a tennis ball. It was recommended that [the VA] needed a lot of medical care and that the best placement for [him/her] at this time, was to continue [his/her] care at the [trauma intensive care unit].” The orders for an in-home hospital bed and mechanical lift were placed on hold until the VA’s future living arrangements were determined. · Allina Health Discharge Instructions, dated December 13, 2022, stated that the VA was discharged to a skilled nursing facility. [Note: At the time of this investigation, the VA remained at the skilled nursing facility, and it was stated that most likely the VA would not be returning to the facility.] The P provided the following information: · The VA was “sweet,” but did not always like to follow others’ instructions. The VA liked to “take charge” and “be independent.” · Around November or December 2022, the P saw a wound on the VA’s buttock about the size of a skin mole. At that time, the doctor ordered a cushion for the VA’s wheelchair. However, the cushion was delayed or backordered, and the P repeatedly called to check the status. The doctor also instructed that the VA offload from his/her wound to let it heal. · Staff completed the VA’s wound cares, including cleansings and dressing changes, and encouraged the VA to offload from his/her wound (reposition), but the VA repeatedly declined. The VA “refused to stay off of it,” and, “We can’t force [him/her].” The VA got “upset” and told staff, “Don’t tell me what to do. I don’t care.” The P added, “It was hard. Very hard. We had to wait on the cushion to come in … [S/he] wouldn’t offload off of it. [S/he] was independent.” · In addition to this, the VA declined to use his/her catheter correctly, and so at times the VA’s urine contacted his/her wound, which further compromised the healing process. The doctor recommended the VA “wear pads” to prevent urine from contacting the wound, but the VA declined to wear the pads. [Note: The VA “cathed independently.” The VA managed his/her catheters without staff assistance.] · Also, around November or December 2022, the VA began receiving in-home skilled nursing visits to supplement the staff wound care efforts. However, as soon as the nurse left, the VA was back to sitting directly on his/her wound. “It was a fight. [The VA] was [his/her] own [person]. That was tough. [S/he] didn’t know how important it was. [S/he] wasn’t having it.” · At least two different times, the VA’s wound looked “dark,” which prompted staff to bring the VA to an emergency room. Each time, the doctor instructed the VA to offload from his/her wound, and yet as soon as the VA arrived home, s/he “refused” to do so. · The P said that the VA did not miss any in-clinic appointments with a doctor or any in-home skilled nursing visits. However, as soon as the appointment ended, the VA would start “refusing” to do what had been recommended by a doctor or nurse. The facility kept progress notes, which were supposed to be completed daily by staff to record the VA’s activities. However, when the facility reviewed the notes for this investigation, there were days without any progress notes, and/or notes with little detail or no cares mentioned. Of the progress notes that contained information about the VA’s cares, it was noted, more days than not, the VA “refused” staff assistance. The failure to document all the VA’s “refusals” was inconsistent with the VA’s support plan and support plan addendum, and there was no documentation that the VA’s “refusals” were reported to the VA’s team, which was also inconsistent with these plans. This was in violation of Minnesota Statutes section 245D.07, subdivision 1, which states that the license holder must provide services as assigned in the support plan. Facility documentation stated that the P received training on the VA’s support plan and support plan addendum; the facility’s policies and procedures; and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: The VA developed a pressure injury (wound) that ultimately led to him/her moving into a skilled nursing facility for a higher level of care. Concern was raised regarding the wound care and services provided by the facility. The VA was not subject to guardianship. The VA’s support plan and support plan addendum stated that the VA did not have chronic medical conditions or ongoing health and medical needs that required staff assessment or support. The VA was independent with scheduling all his/her appointments and transportation. Staff assisted “as needed or requested by” the VA. The P and the VA’s medical records each stated that the VA attended all his/her wound care appointments, including in-clinic with a medical doctor and skilled in-home nursing. The P added that as soon as the appointment ended, the VA “refused” to follow the doctor’s or nurse’s recommendations, including to offload from his/her wound. Staff encouraged the VA to offload from his/her wound, but the VA repeatedly declined. The VA got “upset” and told staff, “Don’t tell me what to do. I don’t care.” The P added, “It was hard. Very hard … [S/he] wouldn’t offload off of it. [S/he] was independent.” Although all the VA’s “refusals” to offload and/or receive cares were not completely documented and/or reported to the VA’s team, it was not determined if this would have changed the outcome. The VA was seen by a medical doctor or nurse almost every other day; however, the VA’s wound persisted even with this additional level of care. Given this, that the VA was not subject to guardianship and could freely make decisions regarding his/her health and care, and that the VA did not respond to the investigator or provide a statement regarding his/her observations of the facility’s cares, there was not a preponderance of the evidence whether there was a failure to supply care or services, which were reasonable and necessary to maintain the VA's physical health, considering the mental capacity of 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 an internal review; and determined that policies and procedures were adequate and followed. The facility did not determine a need for additional staff training or corrective action. At the completion of this investigation, the VA had not yet returned to the facility, and it was unknown if s/he would be. Action Taken by Department of Human Services, Office of Inspector General: On April 12, 2023, the facility was issued a Correction Order for the violation outlined in this report.
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