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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: 1092999-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Henne 651-431-3444 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) went fishing with a staff person (SP) and sustained a sunburn on the VA’s foot that blistered and required a hospital visit and antibiotics. Date of Incident(s): May 27, 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 June 13, 2023; from documentation at the facility and medical records; and through eight interviews conducted with two facility staff persons (P1 and P2), a facility nurse (N), two supervisory staff persons (P3 and P4), the VA, the SP, and a healthcare professional who worked outside of the facility (HCP). The VA enjoyed fishing and catching a Walleye was on his/her “bucket list.” The VA had a history of stroke and was diagnosed with a brain injury and nephropathy and had difficulty maintaining balance due to weakness on his/her left side. The VA wore a leg brace and used a wheelchair but was able to move him/herself throughout the facility semi-independently and asked for assistance as needed. The VA’s dream was to be able to gain strength to walk and have his/her left leg working again so s/he could dance. The VA was not subject to guardianship and there was no information in the VA’s plans that addressed the application of sunscreen. The facility did not have a training policy on when and how to apply sunscreen. However, the facility’s sunburn policy stated that depending on the severity of the sunburn, the burns were “usually” first degree burns, but could be as severe as second degree. Symptoms of sunburn included red, swollen, painful skin and that sometimes blistered. If symptoms occurred, staff persons were to get the individual out of the sun, cool the burn with large amounts of cold running water, notify the nurse/physician/medical professional if the area is large or blistered, apply standing order topical medication and chart on medication records, and document the status of condition, care, and response in the individual’s medical notes. According to a facility Incident Report, on May 27, 2023, the VA went fishing with P2 and the SP. While fishing off a dock, the VA removed his/her shoes, socks, and leg brace to put his/her feet on a railing. Staff persons applied sunscreen to the VA’s feet, but the VA sustained a sunburn on the top of his/her right foot. (Note: Information from all other sources showed that the sunburn occurred on the VA’s left foot.) Staff persons used aloe vera gel on the VA’s foot and monitored the sunburn. On June 5, 2023, the VA went to an appointment and the physician who looked at the VA’s foot, sent the VA to the ER because the foot appeared infected. The VA was diagnosed with cellulitis and prescribed an antibiotic. Facility shift notes provided the following information: · On May 27, 2023, at 10:00 a.m., the VA went fishing with staff persons and sustained a “severe sunburn” so a staff person applied aloe vera. · On May 28, 2023, the VA said s/he was experiencing pain from the sunburn. It was also noted that the VA had a blister in his/her left foot and aloe vera was applied again. · On May 29, 2023, P1 wrote in the shift notes that the VA had a blister on his/her left foot that “needs attention.” Aloe vera was applied to sunburn on the VA’s foot. · On May 30, 2023, the overnight staff person documented that the sunburn on the VA’s foot “hurts real bad.” · On June 1, 2023, the VA’s blister “popped,” and the VA said it felt better. · On June 4, 2023, the VA said his/her foot hurt “really bad” that morning, so a staff person took the VA’s foot boot off. · On June 5, 2023, the VA had a doctor appointment for the ringing in his/her ears. While being examined, the VA was also seen for his/her skin rash (unrelated to the sunburn) and his/her left foot that was affected by the sunburn. The doctor told staff to bring the VA to the emergency room (ER) “right away” due to concern of “gas” or “fluid” inside the foot and was referred to an audiologist. The VA went to the ER and had an X-ray done and bloodwork completed. The VA was prescribed antibiotics for an infection found in his/her foot. The doctor also outlined the infected area for staff persons to be able to know what to look for if the infection worsened. Staff persons were directed to monitor swelling on left foot and apply cream to the affected area. The VA was to follow up with his/her primary medical provider in a few days to check on the infection and swelling. The VA said s/he had short term memory loss but remembered that the SP took the VA fishing “a couple of weeks ago” and P1 and P2 were also there. The VA was outside fishing for four hours and at some point, took his/her shoes off because s/he was hot. The VA’s shoes were off for about one hour and a half to two hours and during that time, the VA put his/her left foot up on a railing. The VA did not realize the sun was beating down on his/her foot and s/he did not feel anything at the time. That night or the next day, the VA realized s/he sustained a sunburn on his/her left foot. The next day, the VA told a staff person but could not remember who s/he told. Staff persons applied aloe vera to the sunburn daily and at some point, P3 sent the VA to urgent care with P1, and the VA was prescribed antibiotics. The sunburn was “not really” painful, but the VA got a “disgusting” blister that eventually “popped.” During the fishing trip, staff persons gave the VA sunscreen, but the VA did not put it on his/her foot because s/he did not think about it. The VA did not think staff persons applied sunscreen to his/her foot, but also could not remember for sure if they did. However, the VA said s/he did have sunscreen applied to the “top portion” of his/her body and the VA thought P2 applied it for him/her. The VA said s/he was “responsible” for him/herself to putting on sunscreen. The VA asked the staff to put sunscreen on his/her arms but did not ask to put it on his/her foot because it “didn’t dawn on me” and the VA “didn’t feel it.” The HCP and medical records provided the following consistent information: · The HCP said that the VA required assistance from staff persons for sunscreen application due to the VA’s left spastic hemiparesis and inability to move left arm and leg. On June 5, 2023, around 3:30 p.m. the VA, who was with P1, was seen at the clinic for ringing in the VA’s ears. Towards the end of the appointment, the VA asked the HCP to look at his/her sunburn that happened the prior weekend. The VA said s/he was out in the sun all day fishing and did not wear sunscreen. The VA sustained a peeling sunburn on his/her shoulders, upper arms, and top left foot that also blistered in an area that was incredibly painful to the touch. The HCP saw one blister on the VA’s left foot, but the VA also said that it “maybe” blistered on his/her shoulders as well. Since the visit was after hours the HCP recommended the VA go to the ER for labs and imaging. · Medical records from June 5, 2023, stated that the VA presented to the emergency department for concern of left foot redness and swelling. The VA reported that 10 days ago s/he went fishing and the foot was exposed to the sun for prolonged period of time. Because the VA had residual numbness and deficit in the left foot from a previous stroke, the VA did not realize s/he was experiencing sunburn. Following the sun exposure, s/he developed a blister and redness and now has an area of ruptured blister with skin sloughing, redness, and swelling throughout the foot. The VA was seen earlier in the day at a clinic and the HCP referred her to the ER for further evaluation. The VA denied fever, chills, systemic complain or other concerns. An X-ray and labs were completed, which were normal. The second-degree burn healed with old blister tissue remaining and surround area was red, swollen, and tender. Antibiotics were prescribed to cover any “potential component” of cellulitis and the VA was instructed to follow up with primary care within three days.
· On June 8, 2023, the VA had a follow up appointment with his/her primary health care provider. At the appointment, there were no open lesions on the VA’s foot, and it was no longer draining. The VA denied any fever, chills, chest pain, or shortness of breath. Swelling was present at the site, but not worsening. P2 provided consistent information during his/her interview and in the Internal Review that on May 27, 2023, around 11:15 a.m., s/he did not work but joined the VA and the SP on a fishing outing. The weather was “nice” and “sunny” and when they arrived at the fishing spot, the sun was “beating down” and there was no shade. The VA brought sunscreen and asked P2, “right away,” to apply it on him/her. P2 applied the sunscreen (SPF unknown) to the VA’s arms and legs and about a half hour later to the VA’s feet after the VA took off his/her shoes. The VA sat in his/her wheelchair while fishing on a dock and did not change positions. P2 left the dock around 3 or 4 p.m. and P2 thought the VA and the SP left soon after. Sunscreen was not reapplied while they were fishing and P2 did not know of any sunscreen protocol. Although sunscreen was applied, the VA still sustained a sunburn. P2 worked the following Tuesday and the VA told P2 his/her sunburn, was “pretty bad,” on his/her shoulders and later that day, P2 saw the VA’s sunburn on his/her foot when s/he helped the VA with a shower. The SP provided consistent information during his/her interview and in the Internal Review that on May 27, 2023, s/he and P2 took the VA fishing. Even though it was the SP’s “day off,” s/he wanted to take the VA fishing, so the SP drove the VA and P2 met them there. It was a “hot” day, and the VA wore shorts and a tank top. After spending some time looking for a spot to fish, they arrived at a dock around 1 p.m. Once they arrived at the dock, P2 applied sunscreen to “all the areas” of the VA including the VA’s feet and the SP thought that P2 applied it again one or two more times. While they were fishing, the VA had his/her foot on a railing because s/he needed to keep his/her left foot elevated. The SP was unsure how long the VA had his/her foot on the railing. Even though sunscreen was applied, the VA still sustained sunburn after the outing. The SP and the VA arrived back to the facility sometime that evening and the SP saw the VA’s shoulders and arms were red and sunburned. The SP said “someone else” treated the sunburn. The SP said that s/he would have been responsible to ensure the VA worse sunscreen as well as P2. P3 who knew in advance they were going fishing. P1, P3, P4, and the N provided information that was consistent with the information in the shift notes and the VA’s medical records and the following additional information: · The VA previously had a stroke and was unable to use the left side of her body and therefore required help from staff persons. P1 said sunscreen was usually applied every two hours and the VA typically asked for it. P1 believed that the VA had sunscreen with him/her that day and that it was applied because previously the VA asked for it when P1 took the VA fishing. · P3 heard that sunscreen was applied when they arrived at the fishing location and that the VA took his/her foot brace off to let it “breathe” and “air out” to allow for “circulation flow.” About three to four days after the incident, the VA’s foot (the foot that the VA wore a brace on) sustained a blister about half the size of a standard business card. Sunscreen application depended on if clients were outside for over five minutes and if so, was reapplied at least every two hours. Staff persons who were with the VA the day of the incident were responsible for the VA’s sunscreen application. For as long as P3 could remember, the VA had a “purple hue” on the foot that sustained the sunburn and P3 thought it was because the VA wore a foot brace and did not have “great circulation” anymore. · Neither P4 nor the N were contacted about the incident for over a week since the incident occurred. Staff persons knew to use sunscreen on the VA unless the VA declined. According to P4, the VA did not have any skin conditions that made him/her more prone to sunburn and was not on any medications that would have that side effect. All staff persons working at the facility during that timeframe would have known about the sunburn/blister and P4 did not know why any of them did not call the N. On June 13, 2023, the N was at the facility and addressed the sunburn to staff persons and reminded staff persons to contact him/her. · The N said that s/he was notified of the VA’s sunburn on June 12, 2023, and was told the VA went fishing and sustained a sunburn on his/her neck, arms, and top left foot and required medical treatment. The N visited the facility once or twice a month and did not know why s/he was not told about the incident when it occurred. According to the N, sunscreen was to be applied anytime the VA went outside. However, the VA was not subject to guardianship, so staff persons were required to suggest the use of sunscreen, but they cannot force the VA to use it. According to facility documentation that showed dates and hours staff persons worked, the SP clocked in in on May 27, 2023, at 10:00 a.m. and clocked out at to 6:25 p.m. and P2 did not work that day. According to John Hopkins Medicine (www.hopkinsmedicine.org/health/wellness-and-prevention/sunscreen-and-your-morning-routine), generally sunscreen should be reapplied every two hours, especially after swimming or sweating. All staff persons interviewed were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adult Act. Conclusion: Information was consistent that on May 27, 2023, the VA sustained a sunburn after fishing outside with P2 and the SP. P2 and the SP provided consistent information that P2 applied sunscreen on the VA when they arrived at the fishing location. The SP thought P2 reapplied the sunscreen but P2 said that sunscreen was not reapplied. Minnesota Statutes, section 626.5572, subdivision 17, paragraph (d), clause (5), states, A vulnerable adult is not neglected for the sole reason that an individual makes an error in the provision of therapeutic conduct to a vulnerable adult that results in injury or harm, which reasonably requires the care of a physician; and: (i) the necessary care is provided in a timely fashion as dictated by the condition of the vulnerable adult; (ii) after receiving care, the health status of the vulnerable adult can be reasonably expected, as determined by the attending physician, to be restored to the vulnerable adult's preexisting condition; (iii) the error is not part of a pattern of errors by the individual; (iv) if in a facility, the error is immediately reported as required under section 626.557, and recorded internally in the facility; (v) if in a facility, the facility identifies and takes corrective action and implements measures designed to reduce the risk of further occurrence of this error and similar errors; and (vi) if in a facility, the actions required under items (iv) and (v) are sufficiently documented for review and evaluation by the facility and any applicable licensing, certification, and ombudsman agency. Minnesota Statues, section 626.5572, subdivision 17, paragraph (f) states in part that if the findings of an investigation by a lead investigative agency results in a determination of substantiated maltreatment for the sole reason that the actions required of a facility under paragraph (d), clause (5), item (iv) were not taken then the facility is subject to a correction order. An individual will not be found to have neglected or maltreated the vulnerable adult based solely on the facility’s not having taken action. Although the VA sustained a second degree sunburn on his/her left foot that resulted in a prescription antibiotic, given that P2 applied sunscreen at the beginning and that staff persons continued to monitor the burn, applied aloe vera as necessary, and obtained medical care when directed; that the VA returned to his/her previous condition; that there were no past incidents with the SP and/or P2; and although the facility failed to report the incident as required which was a violation of Minnesota statutes section 626.557, subdivision 3, paragraph (a), the facility identified what corrective actions needed to be completed, provided retraining to staff persons, and sufficiently documented their actions for review and evaluation, the SP’s and P2’s actions of not reapplying sunscreen to the VA was an error in the provision of therapeutic conduct. Minnesota statutes section 626.557, subdivision 3, paragraph (a), states that “a mandated reporter who has reason to believe that a vulnerable adult is being or has been maltreated . . . . . . shall immediately report the information to the common entry point.” Action Taken by Facility: The facility completed an Internal Review and stated that their policies and procedures were not implemented, and additional staff training was needed. All staff persons reviewed what constitutes a serious injury report, reporting timeliness, and the change of condition tool. They also received retraining on incident reporting, reviewed the VA’s plans if they have not already done so and P3 received a written corrective action plan for not reading shift notes and preparing a plan for treatment for the VA. Additionally, P2, P3, and the SP were trained on “summer safety: sunscreen use and preventing heat related illnesses” after the incident. Action Taken by Department of Human Services, Office of Inspector General: The SP and P2 were not substantiated as a perpetrator of maltreatment of the VA because the Department of Human Services found that the incident for which each was responsible met the criteria to be determined an error. The SP and P2 were notified by the Office of Inspector General that any future incident of possible neglect of a vulnerable adult for which either is responsible might not be considered an error. On August 30, 2023, the facility was issued a Correction Order for the violation outlined above.
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