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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: 1115479-H_ICS (Integrated Community Supports) Investigator(s): Scott Broady 651-431-6557 Suspected Maltreatment Reported: It was reported that when a vulnerable adult (VA) moved out of the facility, the VA had a pressure wound that contained live maggots. Date of Incident(s): Ongoing, prior to June 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 for this investigation was obtained remotely, including documentation from the facility and medical records; and through interviews conducted with the VA, the VA’s case manager, and three facility staff persons. The VA’s support plans stated: · The VA had a history of having strokes which affected his/her mobility. · Staff persons were to assist the VA with dressing, grooming, bathing, meal preparation, shopping, light housekeeping, laundry, scheduling appointments, and getting out into the community. · The VA enjoyed listening to music and watching the news and sports on television, and when s/he was feeling well, going out in the community. · The VA was not subject to guardianship. The VA’s case manager (CM) stated that prior to June 15, 2023, the VA lived in an apartment by him/herself and received 1:1 staff person supervision for 10 hours each day. On June 15, 2023, the VA was scheduled to move to a new facility which provided a higher level of care 24 hours a day and at the intake assessment, the staff persons at the new facility noticed a wound on the VA’s leg and took the VA to the emergency room. The wound had maggots living in it. Medical records stated that on June 15, 2023, the VA arrived at the emergency room and stated that s/he had a wound on his/her right lower extremity that was painful. The VA denied any drainage or fever. The VA stated that s/he had the wound for a while. The VA was observed to have a few small open round wounds over his/her right anterior (front) shin with a larger area over his/her distal (lower) shin. Per nursing, the evaluated wounds did have some maggots which were cleaned out and no longer present. The wound looked “relatively well” at this time with no signs of infection. There were additional wounds on the left lower extremity (leg) that did not contain maggots. The VA was prescribed an antibiotic and continued wound care and discharged back to his/her new home. The VA stated that s/he fell before moving to the facility and injured his/her lower right leg. The VA had a “scab thing” that s/he did not wash and kept covered with his/her sock. The VA did not say anything to staff persons about the wound because it did not seem serious to the VA. Staff persons did not assist the VA in the shower, but did assist him/her with getting dressed. The VA stated that the wound had nothing to do with the facility and that s/he did not have concerns about the care that s/he received at the facility. The CM stated that the VA told him/her that s/he would not allow staff persons to come in the bathroom with him/her and that s/he hid the wound on his/her leg from staff persons. Three staff persons (P1, P2, and P3), who regularly worked with the VA, provided the following information: · Staff persons made sure the VA put on clean clothes, ate meals, and took his/her medications. Staff persons did not administer the VA his/her medications. Staff persons also took the VA out in the community. The VA needed assistance with making medical appointments, but the VA did not like medical appointments and often rescheduled them. · P1, P2, and P3 each stated that they never saw the VA’s leg and that the VA never complained or told staff persons that s/he had a sore on his/her leg. The VA did not want assistance in the shower or with dressing. The VA always wore long pants and socks, so his/her legs were always covered. P1, P2, and P3 each provided the VA with the required care, but at times the VA would refuse care.
Facility documentation showed that staff persons received training on the Reporting of Maltreatment of Vulnerable Adults Act and on the VA’s plans. Conclusion: On June 15, 2023, as the VA was moving out of the facility to a new 24 care facility, it was noticed that the VA had a sore on his/her leg with maggots living in it. Medical records stated that the hospital cleaned the wound and noted that it looked “relatively well” with no signs of infection. There were additional wounds on the left lower extremity that did not contain maggots. The VA was prescribed an antibiotic and continued wound care and discharged back to his/her new home. The VA said that s/he kept the wound covered by clothing and did not say anything to staff persons about the wound because it did not seem serious to the VA. The CM stated that the VA told him/her that hid the wound on his/her leg from staff persons. P1, P2, and P3 each stated that they never saw the VA’s leg and that the VA never complained or told staff persons that s/he had a sore on his/her leg. The VA did not want assistance in the shower or with dressing and the VA always wore clothing that covered his/her legs. It would be reasonable to expect that staff persons who worked with the VA for 10 hours each day might notice a pressure sore that got to the point of having maggots living in it. However, the VA and staff persons each stated that in the course of working with the VA, staff persons would not see the sore area of the VA’s leg because the VA kept the area covered by clothing. In addition, the VA did not indicate to staff persons that anything was wrong with his/her leg. Therefore, 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 obtain or maintain 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 and determined that their policies and procedures were adequate and followed. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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