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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: 1068719-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady 651-431-6557 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) fell getting out of bed during the overnight and cut his/her head and a staff person (SP) did not seek medical care for the VA. Several hours later the VA was taken in for medical care where the VA required five staples to close the cut. Date of Incident(s): June 3, 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 July 13, 2023; from documentation at the facility and medical records; and through interviews conducted with four facility staff persons and a family member/guardian of the VA. This investigator met the VA, but the VA was not able to provide information pertinent to the investigation. The facility was a single level. At one end there was a living room, dining room, and a kitchen. Down a hallway there were four bedrooms and an office. The VA’s bedroom was at the end of the hallway. (At the time of the incident there was a dresser in the VA’s bedroom, but after the incident it was removed.) The VA’s diagnoses included a profound intellectual disability. The VA did not communicate verbally, but had some limited expressive communication skills. The had a history of falls with injuries. The VA had a pad underneath his/her mattress that sounded an alarm if the VA began to get out of bed. The VA also had a video monitor in his/her bedroom and staff persons kept a remove video screen near them when the VA was in bed. The VA enjoyed magazines, puzzles, spending time with family, and ice cream. Documentation in the VA’s Progress Notes completed by the SP stated that on June 3, 2023, around 3 a.m., the VA’s bed alarm sounded, and the SP could see on the monitor that the VA was getting out of bed. As the SP walked to the VA’s bedroom, the SP heard the VA fall. When the SP entered the room, the VA was on his/her buttocks. The VA had fallen and hit his/her head on a dresser. The VA had a two inch long cut on the back of his/her head. The cut “did not bleed much” and the SP cleaned the cut with an antiseptic wipe. The VA did not show any signs that the cut was bothering him/her. An Incident and Emergency Report completed by a staff person (P1), who worked the morning following the fall, stated that the VA fell in his/her bedroom during the night resulting in 2.5 by .5 inch cut to his/her head. P1 took the VA to urgent care where they closed the cut with five staples. (The VA’s medical records stated that the VA was to rest and drink fluids and return in seven to ten days to have the staples removed. The VA left the hospital at about 12:30 p.m.) The SP provided the following information: · The SP worked awake overnights. During the night, the VA typically did not sleep all night. The VA would watch television, get out of bed to use the toilet or get up and look out his/her window. The VA had a history of falls so the VA had a bed alarm and a video monitor so the SP could monitor the VA at night. · On the night of the incident, between 3 and 4 a.m., the VA’s bed arm went off and on the monitor the SP saw the VA getting out of bed. The SP went back to the VA’s bedroom and on the way, the SP heard the VA fall. When the SP entered the bedroom, the VA was trying to get up from the floor. The SP walked with the VA to the bathroom and saw a “trickle” of blood going down the back of the VA’s neck. In the bathroom with the light on, the SP looked at the VA and initially could not find the cut as it was “hardly bleeding.” · When the SP found the cut, s/he measured it, and it was about one inch long. The cut was not deep, and it looked like the “surface skin” had split. The SP cleaned the cut. The SP took the VA’s vital signs and they were “fine.” The VA was acting normal like nothing had happened. The SP then brought the VA back to bed. · Later when the VA got up for the day, the SP gave the VA a shower, but did not wash the VA’s hair in the area of the cut. The VA was laughing in the shower. After the shower, the VA had breakfast. P1 arrived and at shift change, the SP told P1 what happened and showed P1 the cut. The SP then left. · The SP did not feel it was necessary to seek medical care for the VA because the cut was not deep, it hardly bled, and the VA’s actions did not indicate that anything was wrong with the VA. P1 provided the following information: · P1 arrived at about 6 a.m. and everything “seemed normal” as the VA was sitting at the table eating breakfast. The SP told P1 about the fall. The cut was hard to see as the VA’s hair was matted over the cut. At that time the cut was not bleeding and looked clean. P1 thought it was about two inches long. P1 went about his/her morning routine helping other consumers and at 9 a.m. a second staff person (P2) arrived to work. P1 and P2 looked at the VA’s cut and P2 thought that maybe the VA might need stitches because the cut was wide and they thought it might not heal, so they made the decision to take the VA to the emergency room. P1 also notified the facility nurse. · At the emergency room, they decided to use five staples on the cut and while they put in the staples, the VA ate ice cream and was happy throughout the procedure. P1 was instructed to make sure no one rubbed the VA’s head. The emergency room did not mention any concerns about a concussion. · Prior to going to the emergency room, the VA was not a “single speck different” that his/her normal self and did not indicate that s/he was in any pain. P2 stated that s/he arrived at 9 a.m. A couple hours after P2 arrived, P1 had P2 look at the cut on the VA’s head. Because of the size of the cut, P2 thought that the VA should go in to the emergency room and have it looked at. At that time, there was no blood, the cut was dry, and there was nothing out of the ordinary with the VA. P1 then took the VA to emergency room. A supervisory staff person (P3) stated that s/he did not have concerns about the staff persons’ actions regarding the cut on the VA’s head because staff persons followed through and took the VA in to be checked out. The FM stated that other than the incident, s/he did not have concerns about the care that the VA received at the facility. Facility documentation showed that P1, P2, P3, and the SP each received training specific to the VA and on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: On June 3, 2023, at about 3:30 a.m., the VA fell as the SP was walking to his/her bedroom after s/he saw the VA getting out of bed. The SP observed a cut on the VA’s head that was “hardly bleeding.” The cut was not deep, and it looked like the “surface skin” had split. The SP cleaned the cut and assisted the VA back to bed. Before the end of his/her shift the SP gave the VA a shower and gave the VA breakfast. During that time, the VA did not show any signs of anything out of the ordinary. The SP told P1 about the incident and left. When P1 looked at the cut, P1 did not see any blood on the cut and there was no indication that anything was wrong with the VA. A couple hours later, P2 arrived and at some point, P1 and P2 looked at the cut. At that time, there was no blood, the cut was dry, and there was nothing out of the ordinary with the VA. However, because of the size of the cut, P1 and P2 decided that the VA should go to the emergency room. P1 took the VA and the VA received five staples to close the cut and then was sent home. P1 said that there was no mention of a concussion and there was nothing out of the ordinary with the VA. (Information showed that VA likely went to the emergency room approximately 8 hours after the fall.) After the VA had an unwitnessed fall with an injury to his/her head, it would be reasonable to take the VA in for a medical examination sooner than eight hours after the incident. However, because the cut did not bleed, the VA did not show any signs of anything being out of the ordinary, staff persons monitored the VA’s cut, and there was no information that anything else was wrong with the VA other than the cut, there was not a preponderance of the evidence whether there was a failure to obtain timely medical care for the VA. 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, but not followed in that staff persons were to take any consumer with an injury to the head to be seen by a medical professional as soon as possible. The SP and P1 each received corrective action and on July 12, 2023, staff persons were retrained regarding actions to be taken in the event of a head injury. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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