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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: 1071579-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that when a vulnerable adult (VA) was taken to an emergency room (ER) for vomiting and difficulty breathing on March 11, 2023, the VA was diagnosed with aspiration pneumonia, respiratory failure, rib fractures, a fractured thoracic vertebrae, and an ulnar (wrist) fracture and staff persons were unaware of any recent falls or incidents. Date of Incident(s): Prior to March 11, 2023 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 March 21, 2023, from documentation at the facility, from the VA’s medical records and through seven interviews conducted with the VA’s guardian (G), a management staff person (P1), the VA’s medical doctor (MD) and four facility staff persons (P2-P5). The VA was non-verbal and unable to provide information in an interview. The VA’s ISSA Assessment Detail showed that s/he had “extremely brittle bones” and that the VA, who used a wheelchair, should be seen by his/her medical doctor for “any fall.” The plan further showed that although the VA was fed and received medications through a tube, the VA had the ability to eat and drink “orally” and the VA ate pureed foods. Also, the plan showed that the VA had a history of aspiration pneumonia. Because of that, staff persons were trained to “monitor” the VA. The VA had a seizure disorder and used, with assistance from staff persons, a surgically implanted “magnet” to stop the seizures. The VA used a hospital type bed at the facility. Information from the investigation and the VA’s medical record showed that in January 2023, the VA fell out of his/her wheelchair and was seen in the ER and discharged the same day. Information showed that the VA did not have any known injuries, that the VA’s bed was to be elevated to 30 degrees, and “no intervention regarding a small amount of pneumomediastinum (air present in the lungs) present.” The G provided the following information: · On March 11, 2023, the G received a phone call from a facility staff person because the VA had been vomiting for about 15 minutes and staff persons were preparing to take the VA to the ER. Later that day, the hospital called and told the G that the VA had some fractures. · On March 14, 2023, the G talked to a hospital nurse who told the G that the VA “flops” from one side to the other side in his/her wheelchair which might be the reason for the VA’s injuries. The G was not aware of any recent falls that might have caused the injuries. The only concern the G had with staff persons was that some of the staff persons were “just swabbing” the VA’s mouth instead of fully assisting the VA with brushing his/her teeth, but that had been resolved. The VA’s medical records showed that the VA was admitted to the hospital on March 11, 2023, for vomiting and aspiration. The records stated that the VA had “closed fracture of multiple ribs of left side with routine healing,” “other closed fracture of distal end of ulna, unspecified laterality, initial encounter,” and “closed fracture of eleventh thoracic vertebrae, unspecified fracture morphology, initial encounter.” The VA was treated in the hospital with various medications for aspiration and released on March 21, 2023. The MD stated that s/he reviewed the VA’s medical records and the VA had one new fracture (vertebrae) that would have most likely occurred between December 28, 2022, and March 11, 2023, and that the VA was “the most frail person” the MD had “ever seen.” The MD also stated that due to the VA’s “frail nature,” “any physical movement” could have caused the VA’s injuries. P1 stated that in the days leading up to March 11, 2023, the VA was in “good spirits.” In addition, P1 was not aware of any recent falls. P3 provided the following information: · In the days leading up to March 11, 2023, the VA was “fine” and not displaying signs of illness. · At about 7:30 a.m. on the day of the incident, P3 and P4 heard a “gurgling” sound coming from the VA’s bedroom. As a result, P3 went into the VA’s bedroom and the VA was “throwing up badly” for about 15 minutes. P3 described the VA as “thrusting [his/her] self forward” and vomiting excessively. P4 called 9-1-1 while P3 remained with the VA until paramedics took the VA to the ER. At the time, the VA’s bed was positioned at 30 degrees. P3 had never seen the VA vomit to that degree. · P3 was not aware of any falls, seizures or incidents that would have caused the VA’s injuries. When the VA appeared to be anxious or agitated, the VA “moves around” in his/her wheelchair. When that happened, staff persons provided pillows on the sides of his/her body in the wheelchair or repositioned the VA and “often times,” that helped the VA to calm down. P3 also stated that the VA’s foods were pureed and that s/he did well tolerating pureed foods. P2, P4 and P5 provided information that was mostly consistent with the information provided by P3. The facility had policies and procedures that stated, “Any time a person falls, twists their ankle, or is involved in some other form of accident where injury is possible, observe for pain, swelling, and/or discoloration, deformity, immobility, etc. Contact a health care professional to determine which treatments should be followed.” The VA’s case notes for March 10-11, 2023, stated that the VA “slept through the night. No seizures.” In addition, case notes between January 24, 2023 (the day the VA was seen in the ER) and March 11, 2023, were reviewed and there was no information documented that the VA had a fall or any incident that could have caused injuries. The facility’s training records for all staff persons interviewed for this investigation showed that they were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s specific care plans prior to March 21, 2023. Conclusion: Information showed that in January 2023, the VA was taken for medical evaluation when s/he fell from his/her wheelchair and that no known injuries existed at that time. On the morning of March 11, 2023, the VA vomited excessively and was taken to the ER and admitted to the hospital. While hospitalized, it was determined that the VA had some rib fractures with “routine healing,” a wrist fracture, and a vertebrae fracture. There was no information provided that the VA was ill or injured before the March 11, 2023, hospitalization. The VA was released from the hospital on March 21, 2023. Staff persons stated that when the VA appeared to be anxious or agitated, the VA “moves around” in his/her wheelchair. When that happened, staff persons provided pillows on the sides of his/her body in the wheelchair or repositioned the VA and “often times” that helped the VA to calm down. The hospital nurse told the G that movement could be the reason for the VA’s injuries. The MD stated that on March 11, 2023, the VA had one new fracture (vertebrae) that would have most likely occurred between December 28, 2022, and March 11, 2023, and that the VA was “the most frail person” the MD had “ever seen.” The MD also stated that due to the VA’s “frail nature,” “any physical movement” could have caused the VA’s injuries. Although the VA had a number of unexplained injuries, the origin of those injuries was not able to be determined because no one knew of any falls or incidents the VA had. In addition, the VA had “extremely brittle bones,” and if the VA’s injuries were from moving from side to side in his/her wheelchair, information showed that staff persons attempted to help the VA calm down so s/he would move about less and used pillows on the VA’s sides to attempt to prevent injury. Given this and that the VA did not have signs of illness or injury prior to March 11, 2023, and when the VA was vomiting, staff persons immediately sought medical care, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care to maintain his/her physical health. 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 Report Form for Internal Investigation showed that policies and procedures were adequate, followed, and that additional training was provided to all staff persons. Some of the additional training related to “limiting [the VA’s] time in [his/her] wheelchair.” In addition, the facility planned to obtain a new wheelchair, that was equipped with foot rests, for the VA. Action Taken by Department of Human Services, Office of Inspector General: No action taken.
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