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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: 1101750-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady Suspected Maltreatment Reported: It was reported that on November 12, 2022, a vulnerable adult (VA) was admitted to the hospital due to sepsis. At the hospital, there were concerns about the condition of pressure sores on the VA and whether their condition was related to the VA not being repositioned as often as required. Date of Incident(s): Ongoing, prior to November 12, 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 December 19, 2022, from documentation at the facility and medical records; and through interviews conducted with a facility staff person, two facility health care professionals, the VA, a family member of the VA, and health care professional from a wound clinic. On September 23, 2022, the Minnesota Department of Human Services (DHS) issued report number 202203705 where it was reported that the VA’s cares regarding pressures sores were being neglected and the finding was inconclusive. The VA’s Master Care Plan stated: · The VA moved to the facility on July 14, 2020. The VA’s diagnoses included multiple sclerosis. At that time, the VA had a pressure sore of the sacral region. · The VA needed assistance with his/her activities of daily living. · The VA needed to be transferred by two staff persons. The VA was non ambulatory and used an electric wheelchair for mobility. · The VA was “prone to pressure ulcers” located near buttocks and heels. · The VA had a urostomy and a catheter and catheter bag for urine output. · The VA enjoyed hunting, fishing, and watching television. The VA had an alternating pressure air mattress on his/her bed. The air mattress sat on top of the regular mattress. The mattress was able to be set to different settings. On the day of this investigator’s site visit, the air mattress was on the bed, turned on, and working. The VA’s hospital records stated: · On November 12, 2022, the VA was seen and admitted to the hospital. The VA’s suprapubic catheter was exchanged on November 8, 2022, and it was noticed that the VA had bloody urine in the catheter since it was last changed. The VA was septic with a fever of 103 degrees Fahrenheit (F). The VA was started on intravenous fluids and antibiotics. · On November 28, 2022, the VA was discharged with an order to change the bandage two times a week on his/her right foot/leg, right lateral calf, dorsal aspect of foot, and posterior ankle. Staff persons were also to clean with a wound cleanser and cover with Mepilex foam, a wound covering. · For the VA’s sore on his/her sacrum, staff persons were to change the bandage two times a week using Mepilex foam. The VA’s family member/guardian (FM) stated that when the VA was admitted to the hospital there were concerns with the VA being repositioned every two hours and the VA’s air mattress was on incorrect settings or on one occasion a couple weeks prior to his/her hospitalization it was shut off. The VA stated that the tube that was used to flush his/her kidney was clogged so the VA was taken into the hospital. The VA believed that they had to flush the tube every other day. The VA believed that staff persons took the VA into the hospital in a timely manner. The VA stated that s/he was repositioned every two hours. Staff persons used pillows to position the VA. The VA was not sure what the air mattress did for the VA. Medical records from the wound care clinic dated October 11 through November 9, 2022, included the following: · The VA was being seen for an ongoing pressure sore on the sacrum. On October 13, October 26, and November 9, 2022, documentation was the same and stated that the VA’s stage 4 pressure sore on the sacrum reopened. Staff persons were to cleanse the site daily and apply Santly (prescription ointment) to the wound. The VA was to be turned and repositioned. The wound recurred from the VA lying on his/her back. · On October 13, 2022, it was documented that the VA’s air mattress was to be “remapped” as soon as possible. Staff persons needed to contact the company who supplied the air mattress and have them complete the mapping. On October 26, and November 9, 2022, it was documented that staff persons were to “make sure” that the VA’s mattress was either on “alternating pressure” or “rotating” setting and document that in the VA’s daily documentation. · October 11 through November 9, 2022, the VA also had smaller pressures sores on his/her buttocks that were being monitored. · The VA also had pressure sores on his/her feet, ankle, and calf. On October 13, 2022, the VA had stage 4 pressure sore on his/her right heel. Staff persons were to keep pressure off of the VA’s heal at all times. The VA was to be repositioned every two hours. The VA was to wear a Prafo boot (orthotic boot) at all times. Staff persons were to check the boot straps every four hours and make sure no new areas of injury were occurring under the straps. Checks were to be documented. · On November 9, 2022, the stage 4 pressure sore on the VA’s right heel needed the dressing changed daily and the VA was to avoid pressure to his/her right heel, ankle, and foot. There were stage 2 pressure sores on the VA’s right dorsal foot. Staff persons were to cleanse the sore, apply an ointment, and change the dressing once a day. Staff persons were to avoid pressure to the site and ensure that the boot straps across the foot were not too tight. There was also a stage 2 pressure sore on the VA’s right calf. Staff persons were to cleanse the sore, apply an ointment, and change the dressing once a day. Staff persons were to avoid pressure to the site. A nurse (N) from the wound care clinic provided the following information: · The N stated that there were concerns with the facility not taking preventative measures necessary to prevent the VA’s wounds from occurring. The N was concerned about repositioning and using the VA’s Prafo boot. · There were concerns that the facility was not using the VA’s air mattress correctly and one time they sent a person out from the company who supplied the air mattress and they said the mattress was on the wrong setting but staff persons told the company that it was a “fluke” that it was on that setting. The VA’s progress notes stated: · Between November 1 and November 7, 2022, it was regularly documented that the VA was repositioned and the VA’s Prafo boot straps were checked and documented as loose on the VA’s foot. · On November 8, 2022, around noon, the VA was transported to the emergency room because his/her urinary catheter was clogged. The catheter was replaced at the emergency room and the VA returned around 7 p.m. When the VA arrived home, his/her catheter bag was bloody and per physician order, the VA’s drainage should clear up within three days. The VA’s Prafo boot straps were assessed and were “lightly loose” around his/her foot. · On November 9, 2022, in the morning, the VA’s blood sugar was high and it could have been related to the procedure to replace the catheter. The VA sat up in his/her chair and watched television. In the morning the VA had an appointment at the wound care clinic. There was a minimal amount of drainage in the VA’s catheter bag and it was “bloody.” When the VA returned home from the appointment, s/he sounded congested with a cough. The VA’s temperature was 99.2 degrees Fahrenheit (F). · On November 9, 2022, in the evening the VA did not have a cough and his/her temperature was 98.7 degrees F. The VA was repositioned every two hours and the Prafo boot straps were “lightly loose” around foot. The VA’s urine output was clear bloody. · November 10, 2022, in the morning the VA’s urine output was “dark blood urine” from the catheter change at the hospital. The VA’s catheter was flushed and after the urine color was “light bloody.” The VA’s buttock sore was cleansed and dressing applied per wound care clinic order. The VA’s right foot sore treatment was not completed because the orders stated keep dressing on wound until new wound care supplies arrived. · On November 10, 2022, in the evening the VA’s urine was “clear bloody.” The VA was repositioned every two hours and his/her Prafo boot straps were checked and “lightly loose” around the foot. · On November 11, 2022, in the morning, the sore on the VA’s buttocks was cleansed and dressing applied per orders. The VA’s right foot sore treatment was not changed because the required supplies had not been delivered to the facility. The VA’s urine had blood in it. The VA’s temperature was 97.4 degrees F. · On November 11, 2022, in the evening the VA was repositioned per orders and Prafo boot straps were lightly loose around the foot. Urine was “clear bloody.” During the overnight, the VA was repositioned as ordered and the VA was given extra water to due urine still being bloody. · On November 12, 2022, in the morning the VA, the VA’s urine was “very dark red,” the VA was sneezing and complaining of stomach pain. The VA’s temperature was 101.2 degrees F, pulse was 126, and the VA was not comfortable so 9-1-1 was called and the VA was transported to the hospital. Documentation between October 1 and November 12, 2022, regarding the VA’s being repositioned showed the following: · The VA was regularly repositioned approximately every two hours. On a few occasions, staff persons documented that the VA did not want to be repositioned. · On October 6, 13, 19, and November 8, 2022, the VA was not repositioned every two hours due to the VA being at medical appointments. A supervisory staff person (P) provided the following information in the internal review report and in an interview with this investigator: · Due to the VA’s skin condition the VA always had pressure sores. Staff persons repositioned the VA every two hours per orders. Staff person used pillows to help position the VA. At one point a new bed was ordered for the VA. There were some issues getting the funding to pay for it and then issues having a company come out to set it up. There were also issues with the type of bed and at one point they switched mattresses between the beds, but they were not the same size. The VA’s air mattress was moved to the new bed. The VA went a couple days without the air mattress when they were waiting for the medical supply company to come out and switch the bed. The medical supply company never came so HCP1 switched the bed. Otherwise, the VA’s air mattress was consistently used. · The VA had a urostomy and a catheter that needed to be flushed daily. On November 12, 2022, the water for the flush was not going in and when that happened the VA was to be taken to the emergency room. · The P stated that s/he received training specific to the VA. HCP1 provided the following information in the internal review report and in an interview with this investigator: · HCP1 stated that the VA was repositioned every two hours as required. Sometimes the VA refused to be repositioned, but staff persons always attempted to reposition him/her. Staff person used pillows to help position the VA. · The VA’s air mattress had specific settings and was checked every shift. HCP1 was not aware of any issues with the mattress. At one point the VA did get a new bed and initially there were issues with getting it set up and which a regular mattress worked best with it, but the air mattress could be used on both mattresses. The new bed did not help with the VA’s bed sores. · HCP1 stated that s/he received training specific to the VA. HCP2 provided the following information in the internal review report and in an interview with this investigator: · HCP2 stated that the VA was repositioned every two hours as required. Staff persons used pillows to position the VA. · The VA’s air mattress was consistently used. The setting on the air mattress was always on alternating. The FM reported that the mattress was not on the correct setting, but it was on the correct setting. · HCP2 stated that s/he received training specific to the VA.
Facility documentation showed that the P and HCP2 each received training on the VA’s Master Plan and that the P, HCP1 and HCP2 each received training on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: On November 12, 2022, the VA was admitted to the hospital with sepsis. Documentation showed that prior to his/her hospitalization staff persons were regularly monitoring the VA’s health. On November 8, 2022, the VA needed a new catheter placed and at that time, staff persons were told that the VA would likely have blood in his/her urine for several days. There was no information that staff persons did not provide the VA with timely medical care prior to his/her hospitalization. At the time of the VA’s hospitalization, the VA’s wound care clinic and the FM had concerns about ongoing pressures sores with the VA and whether the staff persons were repositioning the VA as required, checking his/her Prafo boot as required, and utilizing his/his air mattress as required. Information showed that the VA had a history of developing pressure sores that required ongoing treatment. Documentation and information from staff persons showed that the VA was regularly repositioned and that staff persons were regularly checking on the VA’s Prafo boot to see if the straps were too tight. Although there was information provided that the VA’s air mattress was not always on the correct setting and on at least one occasion was turned off, staff persons stated that the VA’s air mattress was working properly and turned on. In addition, when this investigator was at the facility the air mattress was on the VA’s bed, was turned on, and was working. Although it was possible that on occasions the VA was not repositioned every two hours, the VA’s Prafo boot straps were not checked, and/or the VA’s air mattress was not utilized or the on the correct setting every day, given the VA’s history of pressures sores and that information showed that staff persons regularly implemented the preventative measures for the VA, there was not a preponderance of the evidence whether there was a failure to provide the VA with care which was reasonable and necessary to maintain or obtain his/her physical or mental 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 of the incident and determined that their polices were adequate. There was a delay in submitting the internal review due to a supervisory staff person change. The VA no longer lived at the facility. Action Taken by Department of Human Services, Office of Inspector General: On July 7, 2023, the facility was issued a Correction Order for failure to maintain documentation that a staff person received training on the VA’s support plan or support plan addendum.
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