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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: 1071286-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was put to bed with his/her hand underneath him/her and woke up with blisters on his/her hands requiring hospitalization and surgeries. Date of Incident(s): April 12-13, 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 April 25, 2023; from documentation at the facility and medical records; and through five interviews conducted with three facility staff persons (P1, P2, P4), the VA’s case manager (CM), and the VA’s guardian (G). Due to his/her diagnosis the VA was non-verbal and unable to provide any information about the incident. This investigator made attempts to interview a staff person (P3), but attempts were unsuccessful. The VA was diagnosed with intellectual disabilities, autism, and hydrocephalus (excess fluid buildup in the brain) with a shunt. The VA enjoyed outings and listening to music. The facility was a single-story home. Through the front entrance was a large open kitchen and dining area. To the left was the VA’s bedroom. The VA’s bedroom contained a single hospital bed pushed against a wall. The wall had a large blue mat attached to it, along the side of the bed. There was another long blue mat that staff persons put on the floor along the other side of the bed at night. The hospital bed could be raised and lowered. The Coordinated Service Support Plan Addendum provided the following information: · The VA used a wheelchair that staff persons operated and was unable to bear weight. Staff persons used a Hoyer lift to transfer the VA. The VA’s mobility had been declining and s/he received staff person led stretches twice per day on his/her arms and legs. · The VA occasionally slid him/herself out of a chair, toilet, or bed. Staff persons lowered the VA’s bed to its lowest position and placed a cushion on the floor when the VA was in bed. · The VA lost the ability to use his/her left hand and no longer lifted the left hand as s/he did before. · The VA was non-verbal but was able to yell or vocalize during times of distress or if s/he was agitated. When the VA did not want something s/he moved his/her head away and made vocalizations to get staff person’s attention. The VA might cry or yell if uncomfortable or agitated. The facility’s Serious Injury Report showed that on April 12, 2023, at approximately 7:35 p.m., the VA was put in bed. P1 “unknowingly” placed the VA’s body on his/her left hand. P2 came in at 10 p.m. The VA was to be checked on/moved every two hours throughout the night. P2 said that s/he checked on the VA throughout the night but did not move him/her because P2 did not think the VA had been incontinent. At 8 a.m., P3 came in to get the VA up. The VA screamed in pain when s/he was moved off his/her hand. The VA had blisters on his/her hand and was taken to the hospital. P4 provided the following information: · There were two staff persons at night, one asleep staff person and one awake staff person. During the night shift, the awake staff person checked the individuals and changed absorbent undergarments every two hours and cleaned the facility. Staff persons went into the individual’s bedroom to ensure the individuals did not need to be changed, then repositioned them. · The VA went to bed between 7:30 and 8 p.m. each night. Overnight staff persons arrived at 10 p.m. The evening staff person completed a check before the overnight staff persons arrived. The overnight staff person checked and repositioned the individuals every two hours. · The VA was unable to use his/her hands but if s/he was mad was able to stretch his/her hands out. Otherwise, the VA’s hands were clenched in fists. Staff persons put a paper towel in the VA’s palms, so the VA’s fingernails did not dig into his/her palms. The VA’s hands were cleaned each morning and the paper towels were replaced. · The VA was non-verbal but did cry or scream. If was hard to tell if the VA was in pain. The VA had a sore in his/her underarm area that “goes and comes” and sometimes the VA got “weird tiny blisters” on his/her back, chest, or arms that would be gone the next day. P1 provided the following information: · When it was time for the VA to go to bed, P1 used a pivot transfer. P1 changed the VA and “tilted” him/her towards the wall. P1 placed a pillow under his/her bottom to stop the VA from falling out of the bed, then covered him/her with a blanket. The VA’s hospital bed was lowered down to floor level and a mat was put at the side of his/her bed for safety. P1 tilted the VA’s head, legs, and bed, then made sure the VA’s hands were up so P1 could see them. · On the day of the incident, P1 worked the evening shift and could see both of the VA’s hands before P1 covered the VA with a blanket. Before P1 left his/her shift at approximately 9:15 p.m., s/he checked on the VA. The VA was still awake because P1 could see that his/her eyes were open. P1 pulled back the covers to check if the VA was incontinent and saw that his/her hands were at his/her sides. · The VA’s right hand was tight and staff persons put a paper towel in the hand to prevent blisters. The VA often got sores or blisters in his/her underarm/arm pit area. Staff persons put pillows under the VA’s arms to prevent the sores. The VA made noises when s/he was incontinent or had a bowel movement and did not stop until s/he was changed. P2 provided the following information: · The VA had a special position that s/he slept in. P2 came in and rolled the VA over and checked him/her but did not wake the VA. The VA slept facing his/her wall. The VA’s bed was against the wall, and s/he laid on his/her right side. If the VA laid on his/her back or moved to his/her back at night, s/he made noises and staff persons came to put the VA back to his/her preferred sleeping position. The VA typically made noises when s/he was incontinent or had a bowel movement. · On the date of the incident, P2 arrived at the facility at 10 p.m. and checked on the VA. The VA was sleeping on his/her right side and had a dry absorbent undergarment. P2 checked on the other individuals in the facility and then started his/her assigned cleaning tasks for that night. · P2 checked on the VA at approximately 12 a.m. and 4 a.m. On both occasions the VA was sleeping and was dry. One of the checks, the VA had moved slightly and was “a little bit on [the VA’s] back side.” P2 did not notice where the VA’s arms were. · At approximately 6 a.m., P2 started getting two other individuals ready for the day. At approximately 8 a.m., P3 went to assist the VA with getting ready for the day. P2 received a phone call after s/he left that the VA had laid on his/her hands and had bruising on his/her hands. · Staff persons were “supposed to move” the VA every two hours but the VA liked to sleep on his/her side and when staff persons moved the VA, s/he made noises indicating s/he wanted to move back onto his/her side. The FM provided the following information: · The VA had a history of bed sores, and the facility was supposed to be turning the VA every two hours. This did not happen, and the VA’s hand was stuck underneath him/her, and s/he was incontinent. There were small blisters on his/her hands that got worse at the emergency room. · The skin detached from the VA’s hand and bacteria was eating his/her hand. The VA had two surgeries to clean out the infection. There was a possibility the VA could lose his/her hand. The medical professional said the blisters were from the VA’s hand being “where it was” for an extended time. The CM said the VA was prone to bed sores and was to be turned every two hours at night. Communication Book Notes showed that on April 13, 2023, P3 wrote that while waking the VA, P3 noticed that the VA was sleeping with his/her hand under his/her backside. When P3 removed the hand, all five fingers had blisters with lots of fluid. P3 called supervisory staff persons and the VA was taken to the hospital. Nursing Notes showed that on April 13, 2023, a staff person called to express concerns with “small blisters” on the VA’s hand. Staff persons said that the blisters were there when the VA woke up but not the night before. The VA appeared to be in pain that morning, but not overnight. Staff persons were instructed to take the VA to the emergency room as soon as possible to rule out infection and administer as needed medication for pain/discomfort according to his/her standing order medication list. The Tasks Record for April 2023, showed that reposition, check, and change incontinence absorbent undergarments checks were added to the record daily at 12 a.m., 2 a.m., 4 a.m., 6 a.m., and 9:45 p.m. at some point after the VA was admitted to the hospital. Medical paperwork showed the VA was seen on March 21, 2023, by his/her medical provider. It was noted that the area of irritation in his/her left armpit had not reopened but continued to appear “frail.” There were no other skin integrity concerns. Medical records provided the following information: · On April 13, 2023, the VA was seen at the emergency department for a right-hand injury. The VA “apparently slept on the top of [the VA’s] hand.” The VA’s hand had bullae (large blisters filled with fluid) and discoloration. The VA was transferred to another hospital for surgery for necrotizing fasciitis (rare infection that eats away the skin, fat, and muscle tissues in the body). During five hours at the emergency department, the bullae grew in size and wept/decompressed spontaneously. The hand and fingers were swollen, and new lesions developed. · The VA was admitted to the hospital due to elevated CK levels (creatine kinase-can indicate skeletal muscle, heart or brain damage) and lactate (can indicate lack of oxygen) levels and antibiotics were started. CK levels continued to increase, and the VA was taken to surgery for necrotizing fasciitis (bacterial infection that results in death of soft tissue) of the right hand. · The medical provider noted that the VA had right hand blistering/swelling concerning for necrotizing fasciitis “presumed” from laying on his/her hand in bed under his/her buttocks for several hours. Also noted “after lying on hand overnight; ischemic (restriction in blood supply) injury leading to secondary process here.” · On April 14, 2023, the VA underwent extensive debridement (removal of infected/dead tissue) and washout and his/her wounds were left open. On April 15, 2023, the VA underwent a second procedure to close the wound after right hand/wrist incision and debridement, down to and including bone, muscle, subcutaneous tissue, and skin. On April 18, 2023, the medical provided noted “This may all be ischemic from pressure/laying on hand, but [the VA] is clearly better than preadmission.” On April 19, 2023, a medical provider assessed the VA’s necrotizing fasciitis of hand as “unclear cause but possibly ischemic from pressure while lying on hand.” · On May 2, 2023, after 18 days of culture directed antibiotics, the wound was healing appropriately. All antibiotics were stopped, and the wound cares were continued. · On April 18, 2023, a Social Work Progress Note showed that the social worker asked the attending physician if any medical indicators of neglect or maltreatment were identified. The physician said that to the best of his/her knowledge, there were no clear indicators of suspected neglect and the direct cause of the VA’s hand injury remained unclear. All staff persons were trained on the Reporting of Maltreatment of Vulnerable Adults Act, the VA’s plans, and the facility policies prior to the incident. Conclusion: Information was consistent that on April 13, 2023, at approximately 8 a.m., P3 found the VA in bed with his/her right hand under his/her bottom. When P3 removed the VA’s hand, the VA “screamed” in pain and had blisters on his/her hand. The VA was taken to the emergency department and eventually admitted to the hospital. In that time the blisters continued to grow in size and wept. The VA’s fingers were also swollen, and new blisters developed. The VA started antibiotics for necrotizing fasciitis. On April 14, 2023, the VA had surgery to debride the hand and a second surgery the following day to debride and close the wounds. The VA continued on antibiotics to treat the infection until May 2, 2023. Medical records showed that the cause of the VA’s infection was “unclear” but “possibly ischemic from pressure while lying on [his/her] hand.” On April 18, 2023, a social worker noted that when s/he asked an attending physician, the physician stated that to the best of his/her knowledge there was no clear indicators of suspected neglect and the direct cause of the VA’s hand injury remained unclear. P1 said that on the evening of April 12, 2023, s/he put the VA to bed. At approximately 9:15 p.m. s/he checked the VA and could see that his/her hands were by his/her sides. P2 said that s/he came into the facility on the overnight of April 12-13, 2023, at approximately 10 p.m. and checked the VA. The VA was facing the wall laying on his/her right side which was typical and had a dry brief. P2 checked on the VA again at 12 and 4 a.m. and the VA was dry on each occasion but P2 did not move the VA. On one occasion, P2 noticed that the VA had moved slightly and was “a little bit on [the VA’s] back side.” P2 did not notice where the VA’s arms were when s/he checked on the VA. P2 said that staff persons were “supposed” to move the VA every two hours, but the VA liked to sleep on his/her side and if s/he was moved, made noise until returned to the position that s/he liked. Although the VA sustained a serious infection after laying on his/her hand, given that according to the attending physician the exact cause of the injury remained unclear, that while P2 did not reposition the VA every two hours, s/he did check on the VA but continued to let the VA sleep on his/her side and this was what the VA preferred, and that there was not documentation noted in the VA’s program plan that indicated that s/he was to be repositioned every two hours, there was not a preponderance of the evidence that there was a failure to provide the VA with care that was reasonable and necessary for his/her 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 policies and procedures were adequate but not followed when staff persons did not reposition the VA every two hours. Staff persons were retrained and received corrective action. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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