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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: 1070634-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) came to the emergency department of a hospital with a laceration to the nose from a fall and had bilateral bruises on the forearms, upper arms, legs, feet, and toes. There was also a bruise on the inside of the VA’s left buttock, scattered scratches on his/her lower back, and blood on the VA’s inner thighs and inside the VA’s pants on the groin area. The VA previously resided at another facility (facility A) but began residing at his/her present facility (facility B) on May 16, 2023. Date of Incident(s): Prior to 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 2, paragraph (b), clause (1): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. Summary of Findings: Pertinent information was obtained during a site visit conducted on June 15, 2023; from documentation at facility B, and the VA’s medical records; and through three interviews conducted with facility B’s staff persons (P1, P2, and P3). The VA used gestures and one-word statements to communicate his/her wishes. However, the VA was hospitalized in a unit of a hospital that provided services to persons with mental illness when this report was received and at the time of the site visit and was not interviewed. Facility B’s documentation showed that the VA’s diagnoses included a developmental disability, autism, “psychosis,” diarrhea, and obsessive-compulsive disorder. On May 16, 2023, the VA was admitted to facility B, upon discharge from a hospital near facility A. Concerns regarding the VA’s care at facility A were investigated in report 202304172. Staff persons at facility B completed an admission screening of the VA which showed that s/he had “self-inflicted” scratches/abrasions near his/her right eye, right knee, right foot, left ankle, on the backs of both heels, on the backs of both shoulders, the back of the right elbow, and on his/her right hand. The VA might become agitated or confused and had a history of removing his/her clothing or lowering his/her pants at inappropriate times. The VA was encouraged to wear lightweight comfortable clothing inside the facility and his/her bowel medications were adjusted to lessen the likelihood of diarrhea. The VA liked spending time with persons s/he knew well and good days for him/her included spending time outside, going bowling, going to get tea, or visiting family members. Indications that the VA was upset included removing his/her clothing at inappropriate times/locations, physical aggression, or yelling. When the VA disrobed in common areas of the facility or when others were present, staff persons were to redirect the VA to wear clothing, move to a private area in the facility, or use a blanket to cover the VA. When the VA was evaluated at medical facilities, s/he might hit other patients, staff persons, health care professionals (HCPs), physicians, and security persons at the medical facilities. Incident Reports from facility A showed that the VA had recently been admitted to the units of hospitals that provided care to persons with mental illnesses in April and May of 2023. The VA moved to facility B to receive crisis services and was vulnerable to all forms of maltreatment. Facility B’s documentation, the VA’s medical records, and interviews with this investigator provided the following information: An Incident Report and a Serious Injury Report for the VA from facility B showed that at 8:45 a.m., on May 26, 2023, the VA was walking toward an office with his/her pants pulled down. P1 and P2 were walking directly behind the VA while encouraging him/her to pull up his/her pants, but the VA said, “No,” tripped on his/her pants, and fell forward, which caused his/her face to hit the floor. The VA did not appear to lose consciousness, but when s/he sat up, blood streamed from his/her nose then flowed onto his/her lap. P1 and P2 assessed the VA, then assisted him/her to sit, stand, and walk to the bathroom where s/he was given first aid and the blood was wiped from him/her. P2 called 9-1-1 and the VA was taken by ambulance to the emergency department of a hospital for evaluation where s/he was admitted and treated for his/her injuries. The VA’s medical records showed that on May 26, 2023, the VA was evaluated at a hospital for a fall, and it was initially determined that s/he had a change of mental status, injuries to his/her face, and a closed fracture of a right rib. The VA was admitted to the hospital and was very active and impulsive there. A computerized tomography (CT) scan and a physical examination of the VA’s entire body completed while s/he was sedated showed that s/he had an acute minimally displaced left nasal bone fracture, dislocation of the right clavicle (described as chronic), anterior right rib fractures, and knee abrasions “thought to be sustained in a fall.” Physicians were unable to determine when the VA sustained rib fractures which were described as non-displaced buckle fractures of the right seventh and ninth ribs and “old” fractures of the right fourth and fifth anterior ribs. In addition, the VA had various bruises and scratches on his/her extremities and bruising/swelling to both feet and the left ankle, and blood on his/her groin and the inside of his/her thighs. There were no fractures to the VA’s toes and the VA did not show signs of tenderness or pain in the areas around his/her injuries, but s/he was agitated, difficult to redirect, attempted to leave the hospital, pushed past HCPs, and hit him/herself on the head. “Soft restraints” were placed around the VA’s wrists and ankles and hospital employees consulted with the VA’s guardian (G) and an HCP who was part of a behavioral emergency response team that worked to de-escalate high risk behaviors in high-risk situations. The VA received treatment for the left nasal bone fracture secondary to a forward fall but it was determined that no surgical intervention was needed for the dislocated clavicle. His/her medications were adjusted to better manage the symptoms of mental illness experienced by the VA. Contact Notes from facility B showed that the VA removed his/her clothing at the facility daily and attempted to enter common areas of the facility unclothed and had a history of falls at facility A and in hospitals to which s/he was previously admitted. On May 25, 2023, at facility B, the VA opened and closed a door near his/her bedroom multiple times and one of the times, s/he opened the door on his/her foot, which became wedged under the door. P1 and P2 assisted the VA to move his/her foot from the door, but his/her left big toe was cut and bruised. Staff persons placed ice on the VA’s foot as much as s/he tolerated it and encouraged the VA to rest and elevate his/her foot. P3, a supervisory staff person, documented that on May 26, 2023, the VA was not wearing pants when s/he fell, and that after s/he fell and was assisted into an upright sitting position, his/her nose bled onto his/her thighs and groin. P2 called 9-1-1 and assisted P1 to wash the blood off the VA and apply pressure to the VA’s injuries before first responders arrived. P1 and P2 provided consistent information that they were right behind the VA when s/he fell on the date of the incident, and that they worked together to assess the VA for injuries and clean blood from the VA after s/he fell. P2 said that the VA fell forward and did not attempt to catch him/herself or use his/her arms to block his/her fall. The VA’s nose bled a lot, and s/he needed medical care, but a bloody nose was the only injury that was visible. P2 said that the VA sometimes suddenly dropped to his/her bottom, picked his/her skin, and slapped his/her head. P1 and P2 each denied that they caused injuries to the VA and were unaware of injuries to the VA on the date of the incident except those to his/her toe from the toe being wedged under the door and the injuries to his/her nose that were caused when the VA fell. P3 said that there were no concerns regarding P1 and P2. Facility B’s personnel and training records showed that staff persons interviewed for this report were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incidents. Conclusion: The VA had a history of falls and disrobing at inappropriate times and began residing at facility B on May 16, 2023. The VA was assessed for injuries on that date and had multiple scratches/abrasions including injuries near his/her right eye, right knee, right foot, left ankle, the backs of both heels, the backs of both shoulders, the back of the right elbow, and on his/her right hand. Information was consistent that on the morning of May 26, 2023, the VA was walking toward facility B’s office, with his/her pants lowered to the ankles. P1 and P2 walked behind the VA redirecting him/her but the VA fell forward and did not attempt to catch him/herself or use his/her arms to break the fall, which resulted in the VA’s face hitting the floor. The VA’s nose bled onto his/her legs and groin, P1 applied pressure to the VA’s bloody nose, P2 called 9-1-1, and both P1 and P2 assessed the VA for injuries, gave him/her first aid, and washed the blood from the VA. The VA was taken to the emergency department of the hospital where his/her injuries were treated, and s/he was admitted to the unit of the hospital that provided care to persons with mental illnesses. The VA’s medical records showed that s/he had a change of mental status, a nasal bone fracture, dislocation of the clavicle, anterior rib fractures, and knee abrasions thought to be sustained in a fall. It was unknown when the VA sustained rib fractures and s/he also had various bruises and scratches on his/her body, and blood on his/her groin and the inside of his/her thighs. No other injuries were noted, and the VA did not show tenderness/pain in the areas around his/her injuries, but s/he was agitated and had self-injurious behavior. “Soft restraints” were placed on the VA’s wrists and ankles and his/her team worked to de-escalate him/her. The VA was treated for the nasal bone fracture and his/her medications were adjusted. P1 and P2 each stated that they were right behind the VA redirecting him/her when s/he fell on the date of the incident and provided first aid to the VA after s/he fell. Each denied that they caused the injuries sustained by the VA and were unaware of other injuries the VA had except the ones s/he sustained when his/her toe was wedged under an interior door at facility B. There were no concerns regarding P1’s or P2’s conduct according to P3. Although the VA sustained a nasal fracture on May 26, 2023, had blood on his/her thighs and groin, and had unexplained injuries of unknown origin/age, given that P1 and P2 witnessed the VA’s fall, provided similar accounts of it, that the VA had a history of falling unexpectedly/suddenly, and received prompt medical care after s/he fell, there was a not a preponderance of the evidence whether the VA’s injuries were caused by anything other than by accidental means. It was not determined whether physical abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). Action Taken by Facility: Facility B completed an Internal Review which determined that its policies and procedures were adequate and were followed. When the VA was admitted to facility B, the facility was unaware of the frequency of the VA’s falls. The facility planned to evaluate the VA’s risk of future falls with assistance from the hospital upon his/her discharge from the hospital, which might include recommendations that staff persons use a walker or a gait belt to assist the VA with mobility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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