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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: 1072847-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Sarah Schumacher Suspected Maltreatment Reported: It was alleged that a staff person (SP) did not promptly seek medical care or consult with a supervisor after a vulnerable adult (VA) fell out of bed resulting in multiple abrasions on the VA’s face. Date of Incident(s): January 26, 2020 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 25, 2020; from documentation at the facility and law enforcement records; and through seven interviews conducted with two facility staff persons (P1 and P2), three facility supervisors (P3, P4, and P5), the VA’s guardian (G), and the SP. The VA was non-verbal and not able to respond to interview questions so this investigator met the VA but did not interview him/her. Facility documentation showed that the VA’s diagnoses included a profound intellectual disability, epileptic seizures, and hypotonia. The VA used an iPad to help him/her communicate. The VA was unable to report any injury. The VA had an unsteady gate and was “prone to falls.” Staff persons offered the VA their arm to hold onto on uneven and slippery surfaces and on curbs and hills. When going up the stairs, a staff person was to walk behind the VA and when going down the stairs, a staff person was to walk in front of the VA. If the VA were to fall, staff persons would assess the VA for injuries and seek medical care for “any injuries outside the scope of their training.” The VA enjoyed listening to music and visiting with family. The VA’s Intensive Support Services plan dated April 18, 2019, stated that the VA used a “monitor” in his/her bedroom to let staff persons know if s/he was awake. The VA had an alarm in his/her bedroom to help monitor the VA for health and safety reasons that sounded so staff persons were aware that s/he was moving around in his/her room. The VA had different types of seizures. The most common seizures were “staring episodes” which occurred up to 20 times daily. The VA would lower his/her head and stare ahead with no response to visual or physical stimuli. Occasionally, the VA had “drop attack” seizures where s/he would “suddenly” fall to the floor without warning with or without continued seizure activity once s/he fell. The facility had three levels. The door to enter the facility opened into the main level. Near the door were stairs that went to the upper level. Around the corner from the stairs to the right was a dining room and then a kitchen. To the right of the kitchen, behind the stairs, was a resident’s bedroom. The upper level had a small, carpeted landing with three bedrooms next to each other including the VA’s bedroom. The VA’s bedroom was at the top of the stair landing and mostly directly above the resident’s bedroom on the main floor. At the time of the incident, there were two alarms in the VA’s bedroom. One alarm was a motioned censored camera that sounded an alarm when the VA moved from his/her bed. The other alarm was on the bedroom door and sounded when the door was opened. Both alarms sounded in the kitchen. The VA’s door also had a code keypad on the outside that needed a code to be entered to open and enter the VA’s bedroom. The key code did not keep a person confined to the bedroom and a person could exit the bedroom at any time. Interviews with P1, P2, P3, P4, P5, and the SP, a law enforcement report, and facility documentation provided the following information: · The SP provided the following consistent information to this investigator, a law enforcement officer (LEO), and a facility administrator for the facility’s Internal Review, and when documenting the incident in the facility’s General Events Record (GER): o On January 26, 2020, the SP arrived at the facility at 9 p.m. for his/her shift. Shortly after, the SP checked to see that the VA and the other resident were in their bedrooms. The VA was asleep near the edge of the bed facing out towards the room with his/her knees folded into his/her chest and a blanket wrapped around him/herself. o At 1 a.m. the SP was in the other resident’s bedroom on the main floor assisting that resident. Around 1:15 p.m., the SP heard a “loud thump” from the VA’s bedroom. The SP “ran” upstairs and opened the VA’s bedroom door by entering the code. The SP went into the bedroom and saw the VA face down on the floor next to his/her bed with his/her blanket partially wrapped around him/her. The SP checked the VA’s pulse and the VA was breathing. The SP assisted the VA off of the floor and saw that the VA had some blood on his/her forehead and had abrasions on his/her face. The SP dampened a towel with cold water and pressed it on the VA’s forehead to stop the bleeding. The VA “seemed to be doing better” and was “responsive and showing expression.” The SP switched out the towel for an ice pack and the VA sat on the side of his/her bed and drank a glass of water. At 1:45 a.m., the SP gave the VA ibuprofen for pain and continued to have the VA use the ice pack for “discomfort.” The VA started to push the SP’s hand away and lay down in his/her bed. The VA went back to sleep at 2:40 a.m. and slept through the night with “no concern.” The SP checked on the VA every 30 minutes and “continued to ice [the VA’s] head while [s/he] was asleep.”
o The SP showed the LEO a photo from his/her cell phone that s/he took of the VA at 2:12 a.m. The photo showed a large red abrasion, similar to rug burn, covering almost the entire left side of the VA’s forehead. There was a smaller abrasion on the right side of the VA’s forehead and some redness on the VA’s nose. o At 6 a.m., the SP text messaged P3, “At 1:15 a.m., [the VA] had a pretty bad fall,” and sent the photo of the VA from 2:12 a.m. At 7:20 a.m., P3 replied, “Did you tell the on call? [The VA] is going to need to go in for that.” The SP replied, “Yes, I did call [P5].” o At 6:05 a.m., the SP text messaged P4, “[The VA] had a pretty bad fall last night in [his/her] room. I did a high T-log and a GER,” and sent the photo of the VA the SP took at 2:12 a.m. P4 replied at 9:25 a.m., “Holy shit! I was just gonna tell you that’s the perfect log I’m not gonna send it to [P3] I just wanted to have it. What a fucking weekend I’ll see you Monday.” o At 7 a.m., P1 and P2 arrived. The SP told P1 and P2 that the VA fell and P2 asked the SP if s/he had contacted the on-call supervisor. The SP said s/he had not and “didn’t realize” s/he was supposed to. The SP then called P5 who told the SP that the VA should go to the emergency room (ER) to be evaluated. The SP told P1 who was going to take the VA to the ER. · P2 stated that s/he arrived at 7 a.m. and needed to take the other resident to an appointment. As P2 was leaving, the SP told P2 that the VA fell and that s/he had not had an incident like this happen before. P2 asked the SP if s/he called the on-call supervisor and the SP said s/he did not. P2 told the SP that s/he needed to call and then P2 left the facility. · P5 stated that the SP called him/her just after 7 a.m. and told him/her that the VA fell out of bed at 1:15 a.m. The SP said s/he heard a “big thump” and went upstairs and found the VA on the floor in his/her bedroom. The SP told P5 that the VA had a bump on his/her chin and that s/he administered ice and ibuprofen but that the bump was “bigger this morning.” P5 asked the SP why s/he did not notify P5 until 7 a.m. rather than when the VA fell and the SP “did not have a reason why.” P5 told the SP, “Isn’t it the protocol to take [the VA] in if [s/he] hits [his/her] head.” The SP responded, “I think so. This never happened to me before.” P5 told the SP that the VA needed to go to the ER to be evaluated to “make sure everything is okay.” The SP said his/her shift was almost over so P1 would bring the VA to the ER. After the call, P5 sent out an email notification to the VA’s team stating what the SP told him/her. P5 stated that later that morning s/he saw a photo of the VA’s forehead and “found out” the injury was not on the VA’s chin. P5 stated that from his/her conversation with the SP, s/he did not realize how “significant” the injuries were and that was why s/he did not have the SP call 9-1-1 rather than taking the VA to the ER. · P3 stated that around 7:20 a.m., P3 saw the text message with the photo of the VA that the SP sent. P3 “immediately” texted the SP back and said that the VA needed to be seen at the ER. Then P3 called P1 because P3 knew P1 was at the facility for his/her shift. P1 told P3 that s/he was in the process of getting the VA ready to go to the ER. · P1 stated that while the SP was talking to P5, P1 was preparing the VA’s medications and other things for the day. Prior to calling P5, the SP told P1 that the VA fell out of bed during the night but it “didn’t sound like the fall was too big of an issue.” After talking to P5, the SP told P1 that the VA needed to be taken to the ER. P1 stated that P3 called P1 and P1 told P3 that s/he was planning to take the VA to the ER. Around 7:40 a.m., P1 went upstairs to the VA’s bedroom. When P1 opened the door, the VA woke up and “hopped” out of bed. At 7:54 a.m., P1 took a photo of the VA. (Note: This investigator saw that this photo showed similar injuries to the photo the SP took but this photo showed a bump on the VA’s left forehead that was swollen to the VA’s eyelid.) P1 sent the photo to the G via cell phone. P1 and the G arranged for the G to meet the VA and P1 at the ER around 9:30 a.m. P1 gave the VA ibuprofen and applied ice to the VA’s injuries. At 9:15 a.m., P1 left the facility to take the VA to the ER. · P1 communicated with P5 to keep him/her informed of what was happening with the VA. P1 stated that the VA had scans at the ER and they were there “a couple of hours.” While at the ER, P1 called P3 and told P3 that the VA’s “wounds didn’t add up with a fall out of bed.” The VA was not admitted to the hospital and went home with the G. P1 documented that the VA had CT scans of his facial bones, head, and neck and “no issues [were] reported.” · The VA’s After Visit Summary stated that the VA was diagnosed with “abrasion of face” and “contusion of face.” The VA’s instructions were to use Tylenol three times daily for pain, ice three times per day, use bacitracin once daily to the abrasions and cover the “small” areas with bandages if able, and keep the “large” areas moist with bacitracin two times daily. A follow-up was recommended with the VA’s primary physician in five to six days. · P4 stated that s/he saw the SP’s text message and the photo of the VA when s/he woke up that morning but did not recall what time. P4 described the photo as the VA’s face with a “scrape on it.” P4 asked the SP if s/he called the on-call supervisor and the SP said s/he did. P4 did not have further conversation with the SP. While the VA was at the ER, P1 sent P4 a photo of the VA and the VA looked “a lot worse” than the earlier photo. P4 stated the VA was “more scratched up” and it looked like some skin was “rubbed off” and the VA’s face “started swelling up.” The places that looked like a scrape in the photo form the SP looked “ten times worse” in the photo from P1. P4 stated that the injuries looked worse because “sometimes it takes a while for things to show up.” P4 asked P1 to ask a doctor at the ER if the VA’s injuries were “rug burn.” P1 asked and told P4 that the doctor “couldn’t tell” but that it looked like the VA’s face “slid” on something. · The facility’s GER documented the following regarding the VA’s injuries: o On January 26, 2020, the VA had: § A “baseball sized” abrasion on the left side of the VA’s forehead from his/her hairline to the top of his/her eyebrow; § A “half dollar” sized abrasion on the front right side of the VA’s forehead; § A “nickel” sized abrasion on the VA’s right upper cheek; § “Pea” sized abrasions on the bridge of the VA’s nose, on the middle of the VA’s nose, under the VA’s right nostril, and on the right corner of the VA’s lips; § A two-and-a-half-inch long abrasion on the left side of the VA’s throat; § An abrasion on the left side of the VA’s abdomen approximately three inches by one inch; § A cut above the VA’s right eye that ran about two inches vertically; and § A “black left eye” and a “half black” right eye. o On January 27, 2020, the VA’s face was swollen and his/her eyes were swollen shut.
o On January 29, 2020: § The swelling in the VA’s cheeks had increased; and § The swelling on the VA’s eyes started to subside, however, his/her vision was still “significantly impacted.” o On January 30, 2020, the VA had a routine dental exam that was rescheduled sooner as a result of the incident. Radiographs were not possible because of the VA’s “cooperation level.” The dentist noted “enamel fractures” on two teeth and a possible “minor enamel edge fracture” on one tooth and “no pulp exposure, and no alveolar bone segment mobile or shifted.” The VA was to follow up on April 2, 2020, or sooner if concerns arose. o On January 31, 2020, the VA had: § A three-inch vertical bruise appeared on the VA’s right shoulder blade; § A two-inch round bruise appeared on the VA’s left shoulder;
§ A four by two-inch bruise appeared on the VA’s left outer thigh; and
§ A two-inch abrasion on the VA’s left elbow. · The SP stated that the alarm on the VA’s bedroom door did not go off because the VA did not open his/her door. The motion sensor alarm had not been working for “three to four months” so that did not sound when the VA fell out of bed. The SP would have called the on-call supervisor and 9-1-1 if the VA did not respond or was reluctant to get off of the floor or looked dizzy. The SP stated that the VA did not have any of those symptoms. The SP checked the back and front of the VA’s head and it looked “normal.” The VA did not have swelling so the SP did not suspect the VA had a head injury.
· P1 stated that s/he was trained that when the VA hit his/her head, the VA was to be taken “immediately” to the ER. If P1 was not sure if the VA hit his/her head, P1 stated s/he would call a supervisor or the facility nurse for guidance. P2, P3, and P4 each stated that any time a resident fell, even if they did not have an injury, a supervisor or the on-call supervisor needed to be notified. P5 stated that staff persons were to contact the on-call supervisor when incidents, including falls, occurred. If a client hit their head, they should be seen at the ER. · P1 stated that “as far as I know” both alarms were working and if the alarms were not working, P1 was not aware of it. When the alarms went off, staff persons were to go to the VA’s bedroom to assist the VA. P2 knew the alarm on the VA’s bedroom door was working but s/he was not sure if they were using the motion sensor alarm or not. P3 stated that s/he knew the alarm on the VA’s bedroom door was working but was not “100% sure” that the motion sensor alarm was working. P3 stated that when the alarms in the VA’s room sounded, staff persons were supposed to go upstairs and check on the VA. The VA was not supposed to walk down the stairs by him/herself. P4 stated that at the time of the incident, the motion sensor alarm was not working and had not been working for “a while.” After the incident, the motion sensor alarm was “immediately fixed.” P4 stated that the VA’s door alarm was working and that was the “important” alarm so the VA did not walk out of his/her bedroom without supervision and fall down. P5 did not regularly work at the facility location where the incident occurred so did not know if the alarms in the VA’s bedroom were working or not. · The day after the incident, the facility administrator went to the facility and tested both the motion sensor alarm and the door alarm and determined they were both working. The facility administrator talked to the other resident about the night before. The resident said the SP was in his/her bedroom and heard a “bump” and then the SP left the bedroom. When asked what happened, the resident said the VA fell but s/he did not remember seeing the VA. The resident was not able to provide further details. · P1, P3, and P4 each stated that the VA’s injuries “seemed” like a lot more than falling out of bed. · The next day, a facility administrator asked the SP about the incident and told the SP that the VA’s injuries did not appear consistent with a fall out of bed. The SP provided the same account of the incident as s/he had the day before. The LEO asked the SP if the VA “actually fell down the stairs” rather than out of bed and the SP told the LEO that the VA did not fall down the stairs and maintained that the VA fell out of bed. · The law enforcement report stated that given the nature of the VA’s injuries, including several “rug burns,” the severity and location of the injuries, the injuries being “inconsistent with a fall from bed,” and that the only carpeted area in the facility was the small hallway outside of the VA’s bedroom and the stairs, it was “apparent” that the VA sustained his/her injuries by either falling partially or all the way down the stairs. The SP “failed” to respond to the VA’s door chime and would have “reason to know” that failure to respond would likely result in the VA falling. The G provided the following information to the LEO and to this investigator: · On January 26, 2020, around 7:30 a.m., P5 notified the G via email that the VA fell out of bed and had a “minor cut on [his/her] chin.” Shortly after, the G called P1 and P1 told the G that the VA had “more than just a minor cut on [his/her] chin.” The G asked P1 to send a photo of the VA and P1 did so. The G saw the photo and was “horrified.” The G saw several large abrasions on the VA’s head and face. The G requested P1 take the VA to the hospital “immediately” which P1 did. · P1 brought the VA to the ER. There were “no apparent serious injuries” but they could not “rule out concussion or other type of head trauma.” A doctor indicated that many of the abrasions were consistent with “rug burn.” The VA was released after tests and went home with the G. The VA was ordered a follow-up with his/her primary physician. · The G did not think that the VA’s injuries were a result of the VA falling out of bed because the VA did not have carpet in his/her bedroom. The only carpet was immediately outside the VA’s bedroom and the stairs leading downstairs to the main level causing the G to believe that the VA fell down the stairs. The G was concerned that the VA’s fall occurred around 1 a.m. but that the VA did not receive medical care until 9:30 or 10 a.m. because the SP did not notify anyone about the fall. The VA had “no way to communicate” and was “completely non-verbal.” · On February 11, 2020, P4 and the G were talking about the VA and P4 told the G that the motion sensor in the VA’s bedroom had not been working for a while and was “just fixed.” Law enforcement investigated this report and the SP was charged with criminal neglect. On February 27, 2023, the SP pled guilty to gross misdemeanor criminal neglect. The facility’s Policy and Procedure on Responding to and Reporting Incidents stated that staff persons were to “immediately” notify the facility supervisor that an incident or emergency had occurred and follow direction issued to them. P1, P2, P3, P4, P5, and the SP were each trained on the VA’s plans, on the Reporting of Maltreatment of Vulnerable Adults Act, and on the facility’s Policy and Procedure on Responding to and Reporting Incidents. Additionally, the SP was trained in First Aid. Relevant Rules/Statutes: Minnesota Statutes, section 245A.04, subdivision 14, stated that the license holder shall monitor implementation of policies and procedures by program staff. Conclusion: A. Maltreatment: Information showed that on January 26, 2020, at 1:15 a.m., the VA sustained multiple facial abrasions and over the course of the next few days the VA was observed with other injuries on his/her body. The SP provided consistent information to this investigator, the LEO, and a facility administrator for the facility’s Internal Review, and when documenting the incident in the facility’s GER that s/he was on the main level in a resident’s bedroom and heard a “thump” from upstairs. This was consistent with the information provided by the resident. The SP then went upstairs, opened the VA’s bedroom door, and found the VA lying face down on the floor next to his/her bed. The SP assisted the VA to stand and sit on the bed and provided the VA with first aid including stopping the bleeding, applying an ice pack, and administering ibuprofen. The SP stated that the VA responded to the SP, was able to get off the floor, and did not show symptoms of head injury. Then the VA went back to bed and the SP checked on the VA every 30 minutes. At about 6 a.m., the SP text messaged P3 and P4, who were facility supervisors and around 7 a.m., when P1 and P2 each arrived at the facility, the SP told them that the VA fell. P2 told the SP that s/he should have called a supervisor. Then, the SP called P5. P5 stated that the SP told P5 that the VA had a bump on his/her chin and that s/he administered ice and ibuprofen but that the bump was “bigger this morning.” P5 asked the SP why s/he did not notify P5 until 7 a.m. rather than when the VA fell and the SP “did not have a reason why.” P5 told the SP, “Isn’t it the protocol to take [the VA] in if [s/he] hits [his/her] head.” The SP responded, “I think so. This never happened to me before.” P5 told the SP that the VA needed to go to the ER to be evaluated to “make sure everything is okay.” At approximately 9 a.m. the VA was taken to the ER. There were “no apparent serious injuries” but they could not “rule out concussion or other type of head trauma.” A doctor indicated that many of the abrasions were consistent with “rug burn.” The VA was released after tests and went home with the G. The VA was ordered a follow-up with his/her primary physician. The VA had a motion sensor in his/her room that was supposed to sound an alarm when the VA got out of bed. The SP stated that s/he did not hear an alarm and information from all sources was inconsistent regarding whether the alarm was working at the time of the incident. However, after the incident facility administrative staff persons tested the alarm and found it to be working. The G, P1, P3, and P4 each thought the VA’s injuries were not consistent with a fall out of bed and rather that the injuries appeared like the VA fell down the stairs. The SP told the LEO, the facility administrator, and this investigator that the VA did not fall down the stairs and his/her information regarding the incident remained consistent. The law enforcement report stated that given the nature of the VA’s injuries, including several “rug burns,” the severity and location of the injuries, the injuries being “inconsistent with a fall from bed,” and that the only carpeted area in the facility was the small hallway outside of the VA’s bedroom and the stairs, it was “apparent” that the VA sustained his/her injuries by either falling partially or all the way down the stairs. The SP “failed” to respond to the VA’s door chime and would have “reason to know” that failure to respond would likely result in the VA falling. It was concerning that the VA sustained multiple severe injuries and that the SP did not immediately notify the on-call supervisor which resulted in the VA being evaluated medically approximately eight hours after the incident. The SP’s actions were in violation of the facility’s Policy and Procedure on Responding to and Reporting Incidents and Minnesota Statutes, section 245A.04, subdivision 14. Although the VA did not require a staff person to remain in his/her bedroom while s/he was asleep, the SP and the resident each stated that the SP immediately went to the VA when s/he heard a noise, and the SP stated that s/he administered first aid to the VA and checked on the VA every 30 minutes throughout the night, given that several people provided consistent information that they thought the VA’s injuries were the result of falling down the stairs, and that regardless of how the VA fell, information was consistent that the VA likely hit his/her head and should have received medical attention sooner. In addition, on February 27, 2023, the SP pled guilty to gross misdemeanor criminal neglect, therefore there was a preponderance of the evidence that the SP failed to provide the VA with reasonable and necessary care and services. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on the Maltreatment of Vulnerable Adults Act and on the facility’s Policy and Procedure on Responding to and Reporting Incidents. In addition, the SP was responsible for the VA’s care and supervision at the time of the incident. The SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the SP was responsible did not meet statutory criteria to be determined as recurring maltreatment because it was a single incident or serious maltreatment because even though the VA sustained multiple injuries, the treatment the VA received did not meet the definition of “requires the care of a physician.” However, information obtained by the Department of Human Services resulted in the SP being disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The SP did not follow the facility’s Policy and Procedure on Responding To and Reporting Incidents. The VA’s plans were updated to include additional details to his/her care. Staff persons were trained on the VA’s updated plans. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. The facility was not issued a correction order for the violation outlined in this report because they took immediate corrective action.
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