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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: 1113826-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) became unresponsive after a hike with two clients (C1 and C2) and a staff person (SP). It was also reported that the VA’s temperature was 104 degrees Fahrenheit (F), that the VA’s renal levels were high, and that the VA had a burn on his/her front thigh. Date of Incident(s): May 29, 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 16, 2023, from documentation at the facility, from law enforcement records, from the VA’s medical records, from the VA’s ambulance report, from the medical examiner’s (ME) report and through 13 interviews conducted with the ME, a facility health care professional (HCP), a staff person (DTH) from the VA’s day training and habilitation program, the VA’s legal representative (G), two facility staff persons (P1 and P2), the SP, the VA’s case manager (CM), the VA’s emergency room doctor (MD), a park ranger (PR), and three management staff persons (P3-P5). C1 and C2 were not able to provide information due to their respective disabilities so were not interviewed by this investigator. The facility had a van that was equipped with two captain’s chairs in the front, two captain’s chairs in the middle row, and one long bench seat in the back that could seat two people. The VA’s ISSA Assessment Detail showed that the VA enjoyed drawing, participating in arts and crafts, and watching movies. The plan showed that the VA did not have mobility concerns and there was no information in the document that the VA was to refrain from physical activity. The VA’s support plan showed that the VA needed assistance with bathing. The VA’s Risk Assessment Detail showed that s/he had ten minutes of unsupervised time in the community. The facility’s Report Form for Internal Investigation and an interview with the SP provided the following information: · When the SP was interviewed, the SP stated that when s/he began his/her shift at 8 a.m. on May 29, 2023, the VA was “laying on the couch in the living room like normal” and that the VA had already taken his/her morning medications and had breakfast. At 9 a.m., the SP called P5 to say that s/he was taking the clients on a “hike and picnic” and that they were going to “Taylors Falls.” The SP and the clients arrived at “Taylors Falls” at about 10:45 a.m. While the SP and the clients walked “not even a mile,” they “took multiple breaks because the terrain was rough and that when they took a break, they either stood or sat on the rocks” and that the SP “did not apply sunscreen to the persons being served as the area was very shaded and [s/he] was not concerned they would get sunburned.” The group walked for about one to one and a half hours total and “halfway” through the walk, the VA “started slowing down” so the group “turned around and headed back to the van.” During the walk, the VA drank one and a half bottles of water. When they got back to the van, the VA was “slow to get into the van.” As a result, the SP “helped” the VA to get into the van (the VA sat in the captain’s chair right behind the driver’s seat). When the SP went to hand out water and sandwiches, the SP stated that the VA “took the sandwich, put it in [his/her] mouth and then just slumped over in [his/her] seat.” When that happened, the SP “got out and tried to wake [the VA], but [s/he] would not move” so the SP asked “bystanders for help.” The SP checked the VA for a pulse and “could not find a pulse.” One of the bystanders called 9-1-1 and assisted the SP with getting the VA out of the van and “laying” the VA “on the ground.” At that time, the PR arrived and did cardiopulmonary resuscitation (CPR) on the VA until paramedics arrived. The SP denied that the VA “was left alone in the car.” In addition, the SP stated that the VA drank “a bottle and a half of water while on the walk” and that when the VA, who was wearing “pants,” was placed on the ground after the VA was unresponsive, the VA was placed on “asphalt,” which might have contributed to the VA’s elevated body temperature (104 F.). · P5 stated that at about 9:30 a.m. on May 30, 2023, (information from the investigation showed that the incident occurred on May 29, 2023) the SP called P5 to say that s/he was taking the VA, C1, and C2 on a “walk and picnic,” but the SP did not say where they were going. At about 12:30 p.m., the SP called P5 because there “was an emergency” and that they were in “Taylors Falls” at a state park (information from the investigation showed that the incident happened at Interstate State Park in Wisconsin). The SP told P5 that while they were on the walk, the VA began “slowing down” on the way back to the van. As a result, they took “several breaks.” When the SP, the VA, C1, and C2 got back to the van, the SP handed out sandwiches and noted that the VA was “slumped over and unresponsive.” The SP called a “couple of bystanders,” who helped the SP “get [the VA] out of the van.” · At some point, the PR came to the scene (the internal review did not indicate who called the PR). When the PR got to the scene, the PR performed (CPR) on the VA and used a “defibrillator,” and the PR was able to get the VA’s pulse. The VA was transported to a hospital by ambulance and passed away around 3:30 p.m. that day. The website, www.mapquest.com showed that the distance from the facility to the state park in Wisconsin was 44 miles and would take about 50 minutes to drive. The SP provided information to this investigator that was similar to the information s/he provided in the facility’s Report Form for Internal Investigation, but added the following additional information: · On the day of the incident, one of the clients sat in the front seat by the SP, who drove the van to the park. Another client and the VA sat in the back seat (in the facility’s Report Form for Internal Investigation, the SP stated that the VA sat in the captain’s chair right behind the driver’s seat). · When they got to the park, the SP brought eight water bottles (16.9 ounces each) along. The SP used his/her watch to identify the temperature and to calculate the distance they walked. The watch showed the SP that it was 73 degrees Fahrenheit (F), and that they walked a total of .74 miles. The group took “multiple breaks” while walking but that halfway through the walk, the VA began to “slow down,” so they turned around and went back to the van. During the walk, the VA drank 1.5 bottles (16.9 ounces each) of water. · When the group got back to the van, everyone sat in the same place in the van as they sat when they drove to the park. The SP gave a sandwich to the client sitting next to the driver’s seat, then the SP gave a sandwich to the client that was seated next to the VA. The SP provided different information regarding handing the VA a sandwich next. The SP told this investigator that when the SP attempted to give the VA his/her sandwich, the VA was slumped over and unresponsive. When the SP was interviewed as part of the facility’s Report Form for Internal Investigation, the SP stated that the VA took the sandwich when the SP handed it to him/her and put it in his/her mouth taking a bite and then “slumped over,” and was unresponsive. The PR provided the following information: · The PR did not remember the date, but heard a call for help on a scanner at about 12:30 p.m. When the PR got to the scene about one minute later, the VA, who looked “pale,” was laying on the ground by the van. The PR did not remember what the VA was wearing at the time but thought that the VA was wearing long pants. The PR began performing CPR on the VA “immediately” because the PR did not find a pulse on the VA and the VA was not breathing. · For about five to ten minutes, the PR continued performing CPR on the VA until paramedics arrived and took over. · The PR did not remember seeing any burns on the VA. The park did not have surveillance cameras. The law enforcement report, dated May 29, 2023, provided limited information, but stated that the call for service came in at 12:32 p.m. The 9-1-1 transcript stated that the VA “aspirated” and there was a “registered nurse on scene.” The VA’s ambulance report, dated May 29, 2023, provided the following information: · The call for service came in at 12:29 p.m. · At 12:31 p.m., the VA was in the vehicle. · At 12:32 p.m., the VA was out of the vehicle and was “unresponsive.” · At 12:33 p.m., the PR was performing CPR on the VA. · At 12:37 p.m., the ambulance arrived on scene. · At 12:41 p.m., the ambulance left the scene with the VA. · At 1:13 p.m., the ambulance arrived at the hospital with the VA. The VA’s medical records showed that the VA got to the emergency room (ER) at 1:20 p.m. on May 29, 2023, and passed away at 1:51 p.m. The records also stated that the VA was “brought in with an out of hospital cardiac arrest” and the “chief complaints” were “cardiac arrest” and “trauma.” The records included a photo of a burn on the VA’s thigh, but no dialogue describing the photo. The MD, who saw the VA in the ER, provided the following information: · The MD was not certain but thought that shortly after the VA got to the ER, the VA had a pulse, but shortly thereafter, the pulse was “lost.” · The MD did not remember what the VA was wearing at the time but remembered that the VA had “superficial” burns on his/her right thigh. The MD did not remember specific information about the burns. The ME report and an interview with the ME, provided the following information: · At 1:58 p.m., the ME was called to review the incident. Shortly thereafter the ME got to the hospital and talked to P5, who told the ME that while the VA was “hiking,” the VA began to “slow down.” As a result, “the group slowed down and took a water break” and when the VA was found to be “unresponsive,” 9-1-1 was called.
· The VA had a “rectal” temperature of 104 degrees F (normal would be 99.6 or 99.8 degrees F) and had an “older first degree with small second degree burn anterior aspect right thigh” that “looks clean and not infected.” The burn mark found on the VA’s body was a “couple of days” old. “This is what appears to be an older burn. This was on [the VA’s] right thigh anterior. Small area of blistering noted. No infection. The rest was increased erythema consistent with a first-degree burn. No other concerning bruises or burns. No direct connection of this burn to [the VA’s] death. This still appears to be a death related to heat exposure/heat stroke. Contributing factors include [the VA’s] Down syndrome, Alzheimer's dementia, and current medications.” · The report stated, “No mention of any congenital heart disease given [the VA’s] Down syndrome history.” · The report also indicated that the VA’s “creatinine is elevated at 2.63 (information from www.webmd.com showed that creatinine was a blood test used to determine kidney functionality), potassium is elevated at 5.00 (the website, www.webmd.com, stated that the normal range for potassium was 3.5-5.5 millimoles per liter), sodium is elevated at 148 (the website, www.webmd.com stated that sodium was found in “many foods” and that a person should have a pinch of salt a day; about a teaspoon and “too much salt affects your body’s fluid balance and an lead to serious health problems, including high blood pressure and kidney disease”).” The ME stated that hospitals used varying ranges to determine normal limits, but that .051 to 1.19 would be the normal range for Creatine, and that the normal range for potassium would be 3.5-4.5 and that “renal failure” might cause elevated potassium and that “dehydration” could cause elevated creatine levels. · Although an autopsy was not performed, the report stated that the cause of death was “sudden CV (cardiovascular) event due to or a compilation of environmental hyperthermia,” and the “significant contributing factors” were “Alzheimer’s dementia and Down syndrome.” · When the ME was asked to describe symptoms one could experience with “heat stroke,” the ME said that fatigue, minimized energy level, and sweating could be symptoms one could experience and that the onset could be within “minutes.” · The VA’s medications, or a combination of medications, could cause “problems with thermal regulation, body regulating, or higher risk of hyperthermia.” The ME provided a photo of the burn on the VA’s right thigh. The photo showed a large, reddened area and within that area, a section of the VA’s skin that was peeling. Photos of the VA’s burn, provided by the hospital, showed a large (four to five inch) darkened area on the lower part of the VA’s stomach and an abrasion/burn under the VA’s kneecap (did not identify which knee). The facility completed a second internal review for the burn marks on the VA and determined that policies and procedures were adequate and followed. The review stated that P1 “did not notice any unusual marks” on the VA and P2 stated that s/he “did not see any marks on [his/her] legs,” but that the VA had an area that was “brown in color and maybe was a callus or birthmark” and that s/he had not seen any changes in the mark. The VA’s Medication Administration Record showed that the VA received the following medications: · 25 milligrams (mg) Vitamin D every day (QD). · 10 mg. memantine (a medication used to treat patients with Alzheimer’s disease) two times daily (BID). · 2 mg. risperidone (a medication used to treat manic depression) BID. · 10 mg donezepil (a medication used to treat patients with Alzheimer’s disease) QD. · 1000 mg fish oil QD. · .1 mg clonidine (a medication used to treat high blood pressure) QD and .2 mg. QD. · 10 mg cetirizine (a medication used to treat allergies) QD. · 50 micrograms (mc g) nasal spray QD. · 100 mg vitamin C QD. · .2% olopatadine (eye drops) QD. · The VA also had a number of as needed (PRN) medications, such as Acetaminophen. The facility’s Report Form for Internal Investigation provided the following additional information: · The VA’s “annual physical,” dated February 24, 2023, stated that the VA was “in overall good health and has no limitation on [his/her] activities.” · P2, who worked the day before the incident, stated that s/he “did not witness any bruising/burn on [the VA] the night prior when [s/he] helped [the VA] with [his/her] shower or that morning when [s/he] was helping [the VA] get ready for the day.” P2 also said that when the SP returned to the facility after the incident, the SP stated that they had gone to “Cambridge” and when they got to “Cambridge, two of the persons served got out of the van and came down, but [the SP] didn’t see [the VA], so [s/he] asked the other two persons being served where [the VA] was” and that when the SP “went back to look for [the VA], [s/he] was slumped over in the van and was unresponsive.” P2 stated that the SP “made it sound like this happened right away when they arrived at the park.” (P2 stated that staff persons were not required to log mileage when they took clients out for community outings). · P1, who was called to the facility due to the emergency, stated that when the SP returned to the facility, the SP also told P1 that the SP “took the [guys/gals] to Cambridge for a picnic” and that when “they got there,” the two other clients “came down from the van. They were also going and [the SP] looked back and saw that [the VA] was still in the van. So [the SP] went to help [the VA] get out of the van but realized that [s/he] looked weak and kind of laid backward.” · On the day of the incident, the temperatures for “Taylors Falls” were 80 degrees F and sunny at 11:15 and 11:35 a.m., 81 degrees F and sunny at 11:55 a.m., 82 degrees F and sunny at 12:15 p.m., and 83 degrees F and sunny at 12:35 p.m. (Investigator’s note: Information from www.weatherunderground.com showed actual temperatures to be 76 degrees F at 10:53 a.m., 78 degrees F. at 11:53 a.m., and 80 degrees F at 12:53 p.m. for the zip code specific to Interstate State park where the incident occurred). · The facility’s interview with the PR provided information that was similar to the information that the PR provided to this investigator. · The SP denied telling P1 that the group went to Cambridge and denied any knowledge of the VA having burns. · When the ME was interviewed by an unspecified facility staff person, the ME stated that the VA’s “temperature was 104 degrees, that [the VA] was in kidney failure which suggests dehydration and heat stroke” and that the VA had a “burn on [his/her] leg consistent with the seat belt buckle.” Photos, taken by this investigator on June 16, 2023, showed a backpack that was used by the SP on the day of the incident to carry water and food, as well as a photo of the water bottles (16.9 ounces) brought on the outing by the SP. The CM stated that the VA’s “day program” had “reported” that for about four to six months prior to the incident, the VA had been showing signs of getting “worked up” after lunch, “pacing and swearing,” and being “agitated and throwing things away.” The CM stated that these types of behaviors were not typical for the VA and although they occurred at the day program, they occurred on occasion, but not daily. The DTH stated that on occasion, for about five to six months prior to the VA’s death, staff persons at the day program noticed that the VA periodically had episodes of “excessive sweating,” and a “lot of pacing” that typically happened shortly after the VA had lunch, but that the VA’s foods were typically the same so the DTH was not able to correlate a particular food items with the changed behavior. The DTH described the change in behavior as “not really [acting like the VA].” The HCP stated that s/he had not noticed any changes in the VA in the past six months or so and that no staff person brought concerns forward that the VA’s behavior had changed. P1 provided information to this investigator that was similar to the information s/he provided in the facility’s Report Form for Internal Investigation, but added that the VA was generally “healthy,” but that the VA had periods in which s/he would “sweat” when the VA was “anxious.” P1 did not see an increase and that the VA typically did that when his/her peers were away from the facility. P1 did not notice any changes in the VA’s breathing, appetite, or sleeping patterns before the VA’s death and did not have knowledge of the VA having any burns. P2 provided information to this investigator that was similar to the information s/he provided in the facility’s Report Form for Internal Investigation and similar to the information provided by P1 in his/her interview with this investigator. In addition, P2 did not have any knowledge of the VA having any burn marks. The G stated that s/he had not heard any concerns related to the VA before his/her death. The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to May 29, 2023. Conclusion: According to the SP, the SP took the VA, who did not have any physical activity restrictions, and two clients to Interstate State Park in Wisconsin on May 29, 2023, and they arrived at about 10:45 a.m. When they arrived, the temperature was between 76-80 degrees F. According to the SP, they walked about .74 miles, took frequent water breaks and when the VA began to slow down, the group turned around and returned to the van. Shortly after they returned to the van, the SP noticed that the VA was not responsive. The SP called for assistance and the PR arrived shortly thereafter. The SP and two bystanders assisted the VA from the van and then the PR performed CPR on the VA. Shortly thereafter, an ambulance arrived and took the VA to the ER, but the VA passed away after arriving to the ER. Although an autopsy was not performed, the ME’s report stated that the cause of death was “sudden CV (cardiovascular) event due to or a compilation of environmental hyperthermia” and the “significant contributing factors” were “Alzheimer’s dementia and Down syndrome.” The VA had a rectal temperature of 104 degrees F. The ME stated that the onset of a heat related death could occur within “minutes” and that the VA’s medications, or a combination of medications, could cause “problems with thermal regulation body regulating or higher risk of hyperthermia.” Although concerns were raised that the VA’s demeanor had changed somewhat in the months leading up to his/her death and information from the investigation did not show significant changes and information from the VA’s annual physical, dated February 24, 2023, showed that the VA was “in overall good health and has no limitation on [his/her] activities.” Concerns were also raised that the VA had a burn on his/her right thigh, but the cause of the burn was not established. The facility’s internal review noted that the ME indicated the burn was consistent with a seat belt buckle, and photos provided by the hospital showed a darkened area on the VA’s stomach. However, the ME provided information in his/her report and during an interview that the burn on the VA’s thigh may have occurred a couple days before the VA’s death and did not contribute to the VA’s death, and no other information was provided about the mark on the VA’s stomach. P2 who worked the day before the incident, stated that s/he did not see any bruising or burns on the VA’s body when s/he helped the VA shower and get ready for the day. Additionally, there were some inconsistencies noted during the investigation regarding the SP’s account of the incident. P1 and P2 stated in the internal review that the SP told them the group went to Cambridge for a picnic (not the park for a walk) and indicated that the incident happened as soon as they arrived when the VA did not follow others as they got out of the car. However, the SP denied telling them that they went to Cambridge and denied leaving the VA in the car alone. Regarding the sandwich, the 9-1-1 transcript stated that the VA had aspirated, and the SP stated during his/her interview with the facility that the VA took the sandwich and ate it, but the SP told this investigator that the VA was unresponsive before the SP was able to hand the sandwich to the VA. Although the inconsistencies of when and how the incident happened were concerning, given that the VA did not have physical activity limitations; that the ME stated the onset of heat stroke could happen within “minutes;” that the SP stated the VA had access to water during the hike, that the group took frequent breaks to rest, and that when the VA slowed down, the SP took the group back; and that when the VA was unresponsive, the SP took immediate action to seek medical care for the VA, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. 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’s Report Form for Internal Investigation showed that policies and procedures were adequate, but not followed (the review did not say what was not followed) and that additional training was provided to “all staff [persons]” pertaining to “signs and symptoms of heat stroke, sun stroke, and dehydration.” The SP was no longer employed by the facility. Action Taken by Department of Human Services, Office of Inspector General: No action taken at this time.
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