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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: 1068932-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux/Gessner Rivas Suspected Maltreatment Reported: It was reported that a staff person (SP) applied a heat pad without a barrier to a vulnerable adult’s (VA) knee without a doctor’s order. The VA sustained a second degree burn and blistering on the knee. Date of Incident(s): November 15, 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 November 30, 2022; documentation from the facility, medical records; and through six interviews conducted with the VA, the VA’s guardian (G), a facility nurse (N), the SP, facility staff persons (P1-P2), and a supervisory staff person (P3). The VA’s Coordinated Services and Supports Plan (CSSP) noted that the VA was diagnosed with mild intellectual disabilities and diabetes. The VA enjoyed fishing, bowling, and painting. According to the VA’s Medication Administration Record (MAR), the VA was taking Tylenol for headaches, body aches, and fevers. Per the facility, clients could be given a cold pad for aches but not a heat pad unless the client had a doctor’s order. The VA provided the following information: · The VA recalled that s/he asked the SP for a heat pad, but that the SP put in the microwave for too long. The VA stated that November 15, 2022, was the second time that a heat pad was used on her/him. · The VA recalled that the SP did ask if the heat pad was too hot but stated that the SP was supposed to come back but never did. The VA said that s/he had long johns under his pajama pants. The VA noted that s/he took the heating pad off, but it was sometime the following day. · The VA stated that the burn was getting better but with diabetes, it would take longer to heal. The VA further stated that s/he was nice and did not like to give people trouble. The VA’s medical record stated that the VA had a superficial burn, blister above her/his right kneecap measuring 2.5 x 3 cm. A bacitracin antibiotic ointment was applied along with a bandage dressing, recommended care consisted of changing the dressing once a day and monitoring for infection. The SP provided the following information: · The SP noted that the VA had been having issues with her/his knee for two weeks prior to the incident and staff persons tried to find a solution. The SP noted that another staff person had brought a combination heating/ice pad to the facility. · The SP stated that on the night of the incident, prior to the end of her/his shift, s/he and the VA were talking and the SP asked the VA if s/he wanted an ice or heating pad for her/his knee; the VA asked for heat. The SP stated that s/he placed the pad in the microwave, pressed 35, and then pressed start. After getting the pad out of the microwave, the SP said it was warm in her/his hand and s/he punched it and tossed it in the air. The SP stated that the pad was not hot when it was taken out of the microwave, s/he was playing with it and did not place it on the VA right away. Five minutes later, the SP asked the VA if s/he wanted it on her/his knee and the VA said, “Yes.” The SP stated that s/he wrapped the pad in a towel from the kitchen and placed it on the VA’s knee who was wearing pajamas pants. The SP asked the VA how it felt and the VA said it felt “good.” The SP stated that approximately ten minutes had passed from the time s/he took the pad out of the microwave to the time s/he placed it on the VA’s knee. · The SP stated that s/he got the VA’s meds, sat with the VA, and they talked. The SP then proceeded to enter her/his notes in the T-logs. At some point, P2 arrived. The SP told P2 to check on the VA and take the heat pad off in five minutes. The SP then left the facility around 9:10 p.m. · The SP stated that the pad was on the VA’s knees for “maybe 20 minutes” when s/he left and told P2 to remove it and that s/he also told the VA that s/he could take the pad off anytime s/he wanted. · The SP stated that the pad had a pillow like case with beans or clay inside and there were instructions on the inside which s/he recalled saying “something like” heat for 45 seconds. · The SP stated that a couple of days later, at her/his next scheduled shift, s/he found out that the VA had been burned by the pad. · The SP noted that s/he did not know the VA was not allowed to have a heating pad since it was talked about in group discussions and another staff person had brought a pad to the facility. The SP stated that s/he would have never used a heating pad if s/he knew that the VA was not allowed to have one. The SP noted that the VA’s file was updated after the incident but at the that time, the file had no such information. · The SP stated that s/he followed polices. · Note: The facility’s T-log notes for November 15, 2022, time stamped 9:03 p.m. entered by the SP, note that the SP applied a heating pad which was heated a couple of times throughout the night. P1 provided the following information: · P1 stated that the day of the incident, s/he was charting in the living room before the end of her/his shift, P1 left the facility around 8:30 p.m. P1 stated that s/he believed that the SP heated the pad in the microwave more than once, the first time right before a staff person left around 7 p.m. P1 recalled the SP taking the heating pad out a second time and saying, “hot, hot, hot,” when the SP took it out of the microwave. P1 asked the SP if s/he was alright and the SP said the heating pad was hot, P1 told the SP to let it cool down but did not see if the SP let the pad cool down before applying it on the VA. · P1 stated that the following day s/he assisted the VA with bathing and noticed a blister on the VA’s right knee and asked what happened, the VA responded, “That damn heating pad.” P1 asked the VA if s/he told the SP that it was hot, the VA said, “No.” P1 noted that the VA avoided confrontation, did not like to speak up. P1 stated that the VA informed her/him that the SP had heated the pad two more times after P1 left the night prior. · P1 contacted P3 and the N to inform them of the injury to the VA’s knee. P2 looked at the notes from the previous night and found that a heating pad had been applied on the VA’s knee. P1 stated that the following day s/he took the pad apart and said that the “insides were blown up.”
· Note: A picture of the heating pad was provided by the facility. The pad consisted of a clay like substance contained withing a sealed plastic bag which had written instructions. The instructions provided two separate amounts of times to heat in a microwave. For a 1,200 watt microwave, the instructions specified 45 seconds and for a 800 watt microwave, the instructions specified 1 minute and 15 seconds. The plastic bag had a soft fabric removable cover. The picture provided showed that the left seam of the plastic bag had separated down most of the left side. · P1 stated that s/he did not know if anyone knew whether the VA could have heat therapy until the following day, but the VA’s plans did allow ice therapy. P2 stated that s/he arrived at the facility for the overnight shift around 9 p.m. P2 stated that s/he did not read anything in the T-logs and was not told anything by the SP about a heat pad being applied to the VA. The SP left the facility about ten minutes after P2 arrived. P2 stated that the VA slept through the night and did not tell P2 that s/he was in pain. P3 provided the following information: · P3 received a text message from P1 on November 16, 2022, that the VA had a blister on her/his knee. P3 noted that no other client at the facility used a heat pad and the heat pad had recently been brought to the facility by another staff person with the intention of using it as a cold pad. Cold pads could be used on residents without a doctor’s order. · P3 stated that when P3 talked to the SP, the SP changed her/his account of when the heat pad was applied stating at first around 8:00 p.m., then 15 minutes later, and then closer to the arrival of the overnight shift at 8:30 p.m. P3 stated that the SP said s/he did not read the instructions, s/he did not think the pad was hot, and s/he did not know s/he could not use a heating pad. P3 noted that the SP was present during a conversation on the use of heating pads with respect to another client and therefore should have known that the VA could not have a heating pad. · P3 also stated that the SP changed her/his account of how long the heating pad was on the VA’s knee and that the pad was heated more than once. · P3 stated that since the incident, client files specifically state whether or not heat therapy was allowed and that the use of heat pads required a doctor’s order. P3 stated that policy was not followed by the SP. · P3 spoke to P2, who did not recall anything being said to him/her by the SP about a heat pad applied to the VA. The N provided the following information: · The N looked at the VA’s knee and contacted the VA’s guardian. The VA’s guardian noted that the VA had a medical appointment later that day and the VA could be evaluated at that time for the burn to her/his knee. · The N stated that s/he spoke with the VA and asked it the pad was hot when it was placed on her/him, the VA said that it was. The N asked the VA if s/he called for assistance, but the VA said s/he did not. · The VA had been experiencing knee pain and was using Tylenol to address it, staff persons had been using cold pads which do not require a doctor’s order. · After the incident, all staff persons were informed that a head pad could not be used without a doctor’s order and a protocol was written for all staff persons to follow for clients that had a doctor’s order for heat therapy. Facility documentation showed that the SP and P1 – P3 were trained on the AV’s plan and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: On November 15, 2022, the SP applied a heating pad to the VA’s right knee where it remained for an unknown amount of time. The VA did not have a doctor’s order to use a head pad. The SP stated that s/he read the instructions for the use of the head pad, but provided inconsistent information regarding how long the pad was heated, how many times it was heated, and how long the pad was on the VA. The use of the heat pad resulted in a superficial burn above the VA’s right knee. Minnesota Statutes, section 626.5572, subdivision 17, paragraph (c), clause (5), stated a vulnerable adult is not neglected for the sole reason that an individual makes an error in the provision of therapeutic conduct to a vulnerable adult that results in injury or harm, which reasonably requires the care of a physician; and: (i) the necessary care is provided in a timely fashion as dictated by the condition of the vulnerable adult; (ii) after receiving care, the health status of the vulnerable adult can be reasonably expected, as determined by the attending physician, to be restored to the vulnerable adult's preexisting condition; (iii) the error is not part of a pattern of errors by the individual; (iv) if in a facility, the error is immediately reported as required under section 626.557, and recorded internally in the facility; (v) if in a facility, the facility identifies and takes corrective action and implements measures designed to reduce the risk of further occurrence of this error and similar errors; and (vi) if in a facility, the actions required under items (iv) and (v) are sufficiently documented for review and evaluation by the facility and any applicable licensing, certification, and ombudsman agency. Although the VA sustained a burned, the SP was attempting to provide relief for the VA’s knee pain. Therefore, for the following reasons, it was determined that the SP’s actions of using a heating pad on the VA’s knee constituted an error in the provision of therapeutic conduct: (i) The VA was brought in to see a doctor the same day that the burn was discovered and received over the counter remedies; (ii) The VA’s injury was healing and it was reasonably expected that the VA’s condition would be restored; (iii) The SP was not responsible for any previous errors; (iv) The facility reported and recorded the incident; (v) The facility identified what corrective actions were needed to be completed and provided retraining to staff persons; and (vi) The facility sufficiently documented their actions for review and evaluation. This error in the provision of therapeutic conduct to the VA by the SP was not maltreatment. 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 which stated that its policies and procedures were adequate but were not followed. The facility implemented new protocols for the use of head pads. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not substantiated as a perpetrator of maltreatment of the VA because the Department of Human Services found that the incident for which the SP was responsible met the criteria to be determined an error. The SP was notified by the Office of Inspector General that any future incident of possible neglect of a vulnerable adult for which the SP is responsible might not be considered an error.
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