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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: 1068359-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Alice Percy 651-431-6569 Suspected Maltreatment Reported: It was reported that a heating pad was left on a vulnerable adult’s (VA’s) stomach for several hours instead of the prescribed 20 minutes. The VA sustained burns with blisters and was taken to the emergency room. Date of Incident(s): March 15, 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 29, 2024; from documentation at the facility and medical records; and through seven interviews conducted with two facility staff persons (P1 and P2), an administrative staff person (P3), the facility’s health care professional (HCP), the SP, the VA, and the VA’s guardian (G). The VA’s diagnoses included mild intellectual disability, partial complex seizures, hyperlipidemia, major depressive disorder, and hypertension. According to the VA’s Intensive Support Self-Management Assessment, the VA was able to report when s/he was feeling unwell. The staff persons were to administer the VA’s medications and complete all treatments as ordered by the VA's physician. The VA stated that s/he went to the hospital for surgery and then returned to the facility. The VA did not recall if either a heating or cooling pack was placed on his/her stomach while s/he was at the hospital. Later that day, the SP heated a cooling pack in the microwave for 35 seconds and then placed it on the VA’s stomach. The VA told another staff person that the pack was too hot on his/her stomach. The pack caused a burn on the VA’s stomach. P1, P2, P3, the HCP, the SP, and the facility’s documentation provided the following information: · On the morning of March 15, 2023, the VA went to the hospital for out-patient surgery and then returned to the facility at approximately 2:45 p.m. P3 stated that s/he accompanied the VA to the hospital and then back to the facility. After they returned to the facility, the VA lifted his/her shirt to show P3 his/her incision. P3 stated that there was no redness on the VA’s stomach at that time. Consistent information was provided that when the VA returned to the facility, s/he had a “pack” placed on his/her stomach and held in place by the waistband of his/her pants. P3 stated that s/he saw a warm pack tucked into the VA’s waistband and it was room temperature. The other staff persons provided inconsistent information as to whether it was a cold pack or a warm pack. It was later determined that the pack provided by the hospital was a cold pack. · At approximately 1:45 p.m., P1 left the facility to go grocery shopping for the residents’ groceries. P2 and the SP remained at the facility with the residents. At 2:40 p.m., P1 returned to the facility and then took another resident to an appointment. · At 4:15 p.m., P3 left the facility. Prior to leaving, P3 checked the VA’s stomach again and stated that there was no redness at that time. P3 was certain that none of the staff persons reheated the pack while s/he was at the facility because s/he sat next to the microwave oven while s/he was completing paperwork. At approximately 4:30 p.m., P1 returned to the facility after taking the resident to his/her appointment. P1 asked the VA how s/he was doing and the VA told P1 that s/he was “good.” · The SP stated that at some point that afternoon, the VA asked the SP to heat the pack, so the SP took the pack the VA received from the hospital, placed it in the microwave for 30 seconds and then gave it back to the VA, who placed it on his/her stomach. The SP asked the VA if it was too hot and the VA told the SP that s/he would prefer it to be hotter but the SP did not heat the pack more. The SP did not wrap the pack in anything prior to giving it to the VA. The SP did not recall seeing any instructions on the pack. The SP told the VA to take the pack off after 20 minutes. The SP did not follow up with the VA at any point regarding the heat pack and see who took the pack off the VA’s stomach. P2 stated that s/he did not know who placed the pack on the VA’s stomach. · At approximately 5:30 p.m., the HCP arrived at the facility and asked the VA how s/he was doing. At this time, P1 and P2 were at the facility and the SP was at the pharmacy picking up a resident’s prescription. The VA told the HCP that s/he had a warm pack over his/her incision area. The HCP reminded the VA and the staff persons to only use the warm pack for 20 minutes at a time. The HCP did not check the VA’s stomach. P1 stated that s/he later in the afternoon s/he saw the pack on the chair next to the VA and put it away. · At approximately 7:30 p.m., P1 assisted the VA to the bathroom and left the VA in the bathroom while P1 waited outside the door. When the VA called P1 back into the bathroom, P1 saw the VA’s stomach. P1 stated that it was “red red” and P1 did not believe the redness was caused by the VA’s surgery because of how the area appeared when the VA had returned from the hospital. P1 telephoned P3 and the HCP. The HCP told the staff persons to keep the area cool by covering it was a cool damp cloth and then to apply Bacitracin to the red area. The HCP also told P2 to take the VA to the hospital and then telephone the G. The VA was taken to the hospital so that the burn on his/her stomach could be evaluated. P2 stated that the burn on the VA’s stomach was “bigger than the palm of a hand” and had small blisters. The physician told P2 to place a cold wet towel on the VA’s stomach to cool the area. After P2 brought the VA back to the facility from the hospital, P2 assisted the VA to bed. The G stated that the VA sustained two burns with blisters on his/her stomach from the heating pack placed on his/her stomach. The VA was seen by his/her physician, but no treatment was prescribed for the burn other than to monitor the area for infection. Two photographs of the cold pack given to the VA by the hospital, heated by the SP, and placed on the VA’s stomach showed that it was labelled as an “Instant Cold Compress.” The instructions printed on the front of the cold pack stated that it was “ready to use” and was activated by folding it in half, shaking it, and applying directly to the skin. It was not necessary to use a towel to cover it. The back of the cold pack included information that it was for single use only and was to be discarded after using. It was necessary to monitor skin frequently to check for frostbite and application was not to exceed 20 minutes. According to the physician’s After Visit Summary, on March 15, 2023, the VA was diagnosed with a first degree burn on his/her abdomen. The physician recommended that the VA use an over-the-counter pain medication as needed for discomfort as well as placing a cool, damp cloth on the area of the burn as needed. According to the facility’s Protocol for a Warm Pack, the staff persons were to heat the warm pack in the microwave for 30 seconds, wrap the warm pack in a towel, test the warm pack on their skin to assure it was not too hot, and place the wrapped warm pack on the area to be warmed. The staff persons were trained to ask the resident if it was too hot and then check with the resident again at three minute, five minute, and ten minute intervals. If the resident told the staff person that the warm pack was too hot, the staff person was to remove the warm pack and contact the facility’s HCP. The warm pack was to be left on the area for no more than 20 minutes. Facility documentation showed that P1, P2, P3, the HCP, and the SP each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Conclusion: A. Maltreatment: On March 15, 2023, the VA went to the hospital for out-patient surgery and returned to the facility that afternoon. A cold pack was placed over the VA’s incision at the hospital. At some point, the VA asked the SP to heat the pack and the SP heated the pack in the microwave for 30 seconds and returned it to the VA, who placed it on his/her stomach. The SP stated that s/he did not read the instructions on the pack and believed that it was a warm pack, not a cold pack. Later that day, P1 observed a red area on the VA’s stomach and telephoned the HCP, who told P2 to take the VA to the hospital, where s/he was diagnosed with a first-degree burn. The SP’s actions of heating a single use cold pack and placing it on the VA’s stomach were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, was not therapeutic conduct or accidental, and caused first-degree burns to the VA’s stomach. Given that the cold pack was clearly marked that it was to be used as a cold pack and included instructions on its use, there was a preponderance of the evidence that there was a failure to provide care or services which was reasonable and necessary to obtain or maintain the VA’s physical health and safety. 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. Facility documentation showed that the SP received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to 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 or serious because it was a single incident and although the VA was seen at the emergency room, the VA was instructed to take over the counter pain reliever. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate, but were not followed by the staff persons. After the incident, the staff persons were retrained on the protocol for using a warm compress. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.
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