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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: 1070052-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Alice Percy Minnesota Department of Human Services 651-431-3970 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was outside in the sun for several hours without the staff persons having applied sunscreen to the VA. The VA sustained sunburn on his/her face, neck, ears, and hands. The following day, the VA’s hands were swollen and s/he had blisters on his/her face. Date of Incident(s): June 10, 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 27, 2023; from documentation at the facility; and through four interviews conducted with a facility administrative staff person (P1), two staff persons (SP1 and SP2), and the VA. The VA enjoyed playing video games, watch television, go out to eat, go to the movie theater, and spend time with his/her family members and friends. The VA’s diagnoses included Duchenne muscular dystrophy, dilated cardiomyopathy, mild intellectual disabilities, and major depression. The VA was not subject to guardianship. According to the VA’s Support Plan, the staff persons were trained to offer the VA fluids every 30 minutes in order to keep the VA hydrated. According to the VA’s Coordinated Service and Support Plan (CSSP), the VA might be susceptible to abuse due to his/her inability to care for his/her self-help needs, but was able to identify abuse. The staff persons assisted the VA with choosing weather-appropriate clothing. The VA used a motorized wheelchair for mobility. According to the General Event Report (GER), on June 10, 2023, the VA sat outside with the staff persons at an outdoor community event for several hours without the staff persons applying sunscreen to the VA. The staff persons also failed to pack a straw for the VA to drink fluids while at the community event. When the VA and the staff persons returned to the facility, sunburn was noticed on his/her face, neck, ears, and hands. The VA refused to have aloe vera lotion applied to his/her sunburn and also refused to be seen by a physician. Later, the VA agreed to allow the staff persons to apply aloe vera lotion to his/her hands and nose. The staff persons continued to provide fluids to the VA for the rest of the day according to the VA’s care plan. The following day, the VA had a small blister on his/her nose. Later that day, the VA’s hands became swollen and more blisters appeared on his/her face. The VA’s family member (FM) visited the VA and the VA agreed to allow the FM to apply aloe vera lotion to his/her sunburn, but continued to refuse to be seen by a physician. The VA stated that s/he did not like the way that sunscreen felt on his/her face. On the day that s/he and the staff persons attended a community event, the VA was sunburned. The VA did not recall if the staff persons asked if they could apply sunscreen to the VA, but assumed that if they did ask to apply sunscreen the VA would have declined because s/he does not like how sunscreen feels. The VA also did not like to have aloe vera lotion applied to his/her skin, but “had to do it” after the community event because of the sunburn. The sunburn “was a little uncomfortable” for four to five days. The VA was unable to drink fluids at the community event because the staff persons did not bring a straw for the VA to use. The staff persons asked some of the vendors at the community event for a straw, but were unable to obtain any for the VA to use. The VA stated that the staff persons “treat me well.” P1, SP1, SP2, and the facility’s documentation provided the following information: · P1 stated that the VA rarely wanted to go to community outings that were held outside, so the staff persons were not properly prepared for an outdoor event. On June 10, 2023, four staff persons and three residents went to an outdoor community event. SP2 met them at the community event. The group arrived at the community event at approximately 2 p.m. Soon after they arrived, one of the residents wanted to go back to the facility and two staff persons took that resident to the facility, leaving SP1, SP2, and another staff person (P2) at the community event with the VA and another resident (R). SP1 was assigned to work with the R and SP2 was assigned to work with the VA. · SP1 stated that because the VA rarely went on community outings, the day of the incident was the first time that SP1 accompanied the VA on an outing. SP2 stated that it was the first community event the VA attended that year. The VA wanted to go because they were serving ribs at the event. There was sunscreen in the staff persons’ “go bag,” which they took on the outing, but the staff persons did not use it because it was past its expiration date. SP2 stated that s/he did not know that sunscreen was not applied to the VA prior to leaving the facility to go to the community event. There were no straws in the go bag so the VA was unable to drink anything during the outing. SP2 stated that s/he told the VA that s/he could not give him/her a drink because s/he did not have any straws, but the VA still wanted to eat food while at the event. SP1 stated that the house supervisor typically told the staff persons what they needed for an outing, but the supervisor recently started working at the facility and “nothing was planned.” · While they were at the event, the staff persons took the residents around the area to get food and then sat together under a tent. The VA’s wheelchair did not totally fit under the tent, so the VA sat “facing out” from the tent and was only partially in the shade. SP1 stated that s/he asked the VA several times if s/he was comfortable and the VA did not complain about the sun. The VA wore pants and a long-sleeved shirt. They left the community event between 3:30 and 4 p.m. · After they arrived at the facility, SP2 observed sunburn on the VA’s hands and asked SP1 to look at the VA’s sunburn. When they asked the VA if s/he ever had a sunburn before, the VA told them that it “happens a lot, but it goes away.” The VA did not want aloe vera lotion applied to his/her face, but eventually allowed the staff persons to apply it to his/her hands. SP1 stated that since the VA was not under guardianship, the staff persons were told to “do what [the VA] wants to do.” SP2 stated that s/he gave the VA a drink as soon as they arrived back at the facility. The staff persons notified the FM of the VA’s sunburn and the FM arrived at the facility and applied aloe vera lotion to the VA’s sunburn. The VA did not want to be seen by a physician. · After the incident, the staff persons were trained to ensure that there was sunscreen and straws in the go bag prior to going on any community outing and to apply sunscreen prior to each resident prior to going on community outings where they would be outside. A review of three photographs taken of the VA by the FM on June 11, 2023, showed the VA’s hands looking slightly red and swollen, the top of the VA’s right ear looking slightly red, with a small blister on the top, and the VA’s face looking red. According to Weather Underground, (“Weather history for Fargo, ND”), on June 10, 2023, at 2:53 p.m., the temperature was 77 degrees Fahrenheit and it was partly cloudy. The facility’s documentation showed that SP1, SP2, and P1 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies, and the VA’s plans prior to the incident. Conclusion: On June 10, 2023, at approximately 2 p.m., SP1, SP2, P2, the VA, and the R went to an outdoor community event. SP1 was assigned to work with the R and SP2 was assigned to work with the VA, but all of the staff persons worked together with the VA and the R. While they were at the event, the staff persons checked their “go bag” for sunscreen, but since the sunscreen had passed its expiration date, they did not apply any to the VA. They also did not have a straw in the go bag, so they were unable to provide the VA with a drink while they were there. During part of their time at the event, they sat under a tent, but the VA’s wheelchair did not completely fit under the tent. They left the event between 3:30 and 4 p.m. When they arrived back at the facility, SP2 gave a drink to the VA and observed sunburn on the VA. The VA did not want aloe vera lotion applied to his/her face, but eventually allowed the staff persons to apply it to his/her hands. Consistent information was provided that the VA rarely went on community outings and this was the first outdoor event that the VA attended in 2023. The house supervisor recently began working at the facility and did not provide information to the staff persons on what they needed to have with them on the outing, as had been done in the past. On previous occasions, the VA typically refused to allow the staff persons to apply sunscreen to his/her skin and on this occasion, s/he initially refused to allow them to apply aloe vera lotion to his/her sunburn. SP2 stated that s/he did not know that sunscreen was not applied to the VA prior to leaving the facility to go to the community event, since s/he met the group at the community event. The VA was in the sun for less than two hours and sat in the shade for part of that time. While the VA did not get a drink while s/he was at the community event, the staff persons attempted to get a straw from the vendors, but were unable to find one and s/he was given a drink when they returned to the facility. The VA refused to be seen by his/her physician. Although the VA sustained a sunburn on his/her face, ears, and hands and did not have a straw to drink, given the VA’s history of refusing sunscreen, that there was sunscreen along but later learned to be expired, that the VA was in the shade for a portion of the two hours, and that staff persons made attempts to obtain a straw for the VA, there was not a preponderance of the evidence whether there was a failure to supply the VA with care and services which was reasonable and necessary to maintain the VA’s physical health or safety. 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 facility’s polices were adequate, but were not followed by the staff persons. The staff persons were re-trained on the need to apply sunscreen every time the residents left the facility and to regularly offer the VA liquids. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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