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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: 1070046-H_CRS (Home and Community-Based Services-Community Residential Setting) 1069963-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a vulnerable adult (VA) was left outside during shift change for staff persons (SP1-SP2). The VA was found muttering and incoherent outside after four hours. The VA was seen at a medical facility and diagnosed with heat stroke and dehydration. Date of Incident(s): July 19, 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 August 29, 2023; from documentation at the facility, and medical records; and through four interviews conducted with a facility supervisor (P), the VA, the VA’s guardian (G), and SP1-SP2. Facility documentation showed the VA had a good sense of humor and joked around often. The VA enjoyed watching television, and eating lobster and shrimp. The VA was diagnosed with a traumatic brain injury, and had multiple physical health issues. The VA used a walker, and required prompting for hygiene tasks, and often needed reminders to drink water. According to the VA’s doctor, s/he needed to “drink more water to stay hydrated,” and did not get “close” to consuming the amount recommended. Additionally, the VA “dehydrates easily,” and was supposed have a “big bottle of iced water.” The VA was less “dizzy” and fell “less frequently” when s/he was hydrated. This investigator observed the facility during a site visit. The facility had a deck in the backyard, and the VA enjoyed sitting outside on the deck. According to internet weather data on the date of the incident, July 19, 2023, the high temperature was 89 degrees Fahrenheit (F) at 4:53 p.m. Additionally, the temperature was 82 to 88 degrees F between 1 and 4 p.m. The description of the weather was “sunny” with winds between 6 and 12 miles per hour. Center for Disease Control and Prevention website stated: · Heat stroke was the most serious heat-related illness. It occurred when the body could no longer control its temperature: the body’s temperature rises rapidly, the sweating mechanism fails, and the body was unable to cool down. When heat stroke occurred, the body temperature could rise to 106 degrees F or higher within 10 to 15 minutes. Heat stroke could cause permanent disability or death if the person did not receive emergency treatment. · Symptoms included, but not limited to; confusion, altered mental status, slurred speech, hot/dry skin or profuse sweating, and seizures. Medical Records provided the following information: · The VA was admitted to the medical facility on July 19, 2023, and the VA’s discharge diagnosis was “metabolic encephalopathy” (brain dysfunction caused by problems with metabolism) and “heat apoplexy,” (heat stroke). The VA was “stabilized in discharge” on July 21, 2023. · Within the medical records there was a note which stated that the VA was “outside all day,” and had a temperature of 105.7 degrees F. The VA was noted as “quite confused,” and his/her mental status improved with “rapid cooling.” SP1 provided the following information: · SP1 was working with the VA on July 19, 2023, and said the VA went outside to the deck around 1:45 p.m. SP1 was with the VA outside until his/her work shift ended at 2 p.m. SP2 said SP1 relieved him from working at 2 p.m., and SP1 informed SP2 the VA was outside. · SP1 said the VA had water outside on the day of the incident. SP1 offered to assist the VA back inside before SP1 left the facility, but the VA declined. · SP2 contacted SP1 around 3:45 p.m., and SP2 said 9-1-1 was contacted due to concerns with the VA. SP1 said the VA was outside for approximately an hour and a half prior to 9-1-1 being contacted. · SP1 said some days were easier to get the VA back inside than others, but SP1 always offered the VA multiple verbal prompts and/or assistance to go inside. SP2 provided the following information: · SP2 said s/he arrived at the facility at 2 p.m., and SP1 informed him/her the VA was outside. SP2 checked on the VA approximately every 15 minutes, while also providing care and supervision to the other persons served at the facility. SP2 said s/he offered to assist the VA inside the facility multiple times, however the VA declined. SP2 believed the VA had a water bottled while s/he was outside. · SP2 was unsure how long the VA was outside prior to his/her arrival at the facility at 2 p.m., but believed the VA was outside for a total of two hours. · SP2 said after arriving at the facility at 2 p.m., s/he did not notice any concerning behaviors or symptoms until the VA was unable to speak, at which time SP2 contact 9-1-1 at that time. SP2 was unsure what time s/he contacted 9-1-1.
The VA provided the following information: · It was noted during the interview the VA was unable to provide an accurate timeframe related to when s/he moved into the facility. Additionally, during the interview the VA said it was colder outside today because there was a cold wind coming off of Lake Superior. · The VA was unable to provide any specific details to the incident that occurred on July 19, 2023. The VA said s/he enjoyed being outside in the warm weather, and staff persons would sit and talk with the VA while s/he was outside, and/or staff persons would check on the VA while s/he sat outside. · The VA said s/he did not need water while s/he was outside, but staff persons offered water to him/her. The VA also said the staff persons would offer to assist the VA inside, but the VA refused their assistance. The VA said s/he did not use sunscreen and would normally wear a t-shirt and shorts while sitting outside. The G provided the following information: · The G said s/he was informed the VA was outside in the sun for four or five hours, and the VA had refused to go back into the facility. The G said the VA was hospitalized from July 19 to 21, 2023. While at the medical facility, the VA was “pack[ed]” with ice and provided intravenous (IV) fluids. · The G visited the VA once a week and described the VA as “stubborn” and “vocal.” The VA also did not like to “move.” The G did not believe the incident was “intentional abuse” or “neglect.” The G did not have any concerns with the facility. The P was not present for the incident but did not have any previous work performance concerns for SP1-SP2. The P said the description of the VA being stubborn and non-cooperative was “accurate.” The P had been told the VA was offered water and assistance back into the facility, but the VA declined. SP1 and SP2 were provided training on the VA’s client specific information, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: It was reported that on July 19, 2023, the VA was left outside for multiple hours. The VA was seen at a medical facility due to dehydration and heat stroke. The VA was not able to provide any specific details from the day of the incident. SP1 said the VA went outside at approximately 1:45 p.m., and SP1’s shift ended at 2 p.m., but SP1 informed SP2 the VA was outside. SP1 said SP2 contacted him/her around 3:45 p.m., and said s/he contacted 9-1-1 because of concerns with the VA. SP2 said s/he observed the VA approximately every 15 minutes, and offered the VA assistance into the facility, but the VA refused to go back into the facility. SP2 did not notice any concerning symptoms until the VA was unable to talk, at which time SP2 contacted 9-1-1. The VA was described as “stubborn,” and although the VA was unable to provide any specific details to the incident that occurred on July 19, 2023, s/he stated the staff persons would check on the VA while s/he sat outside, offered him/her water, and offered him/her assistance back inside the facility. The VA said s/he refused staff persons assistance. Although the VA was hospitalized with heat stroke and it was originally reported that the VA was outside for four or five hours, given that SP2 stated s/he checked on the VA every 15 minutes and was also caring for other facility residents in between checks, that the VA had water, that the VA refused assistance to go inside the facility, that it was likely two hours the VA was outside, and that when SP2 noticed the VA could not talk, s/he immediately called 9-1-1, 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 completed an internal review and determined that the policies and procedures were adequate and were followed. The report was not similar to past events, and the facility completed additional staff person training and corrective action to ensure the safety of the individuals served at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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