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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: 1081784-H_CRS (Home and Community-Based Services-Community Residential Setting)- Closed August 30, 2023 Investigator(s): Jason Pehler/Alice Percy 651.431.4830 Suspected Maltreatment Reported: It was reported that a staff person (P1) observed a red, swollen lump on a vulnerable adult’s (VA’s) head while bathing the VA. It was unclear what caused the injury. Date of Incident(s): May 10 – 11, 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 27, 2023; from documentation at the facility and medical records; and through six interviews conducted with two facility administrative staff persons (P1 and P2), a staff person (P3), the VA’s guardians (G1 and G2), and the VA’s case manager (CM). The VA enjoyed going on community outings, going out to eat, and spending time with his/her family members. The VA’s diagnoses included a traumatic brain injury (TBI), a seizure disorder, vascular dementia, left hemiparesis, tardive dyskinesia, chronic obstructive pulmonary disease (COPD), asthma, seborrheic keratosis (skin condition), and muscle weakness. The VA was legally blind and used a wheelchair for mobility. The VA was prescribed blood thinners. According to the VA’s Individual Abuse Prevention Plan (IAPP), the VA’s orientation to place and time might be inconsistent at times and s/he may have inaccurate recollections of events. The VA might talk about past abuse and believe it was more current. The VA was unable to identify potentially dangerous situations, but was able to call for help if necessary. Any discovered injury to the VA was to be addressed by the staff persons and they were to seek medical care for the VA when needed. P1, P2, P3, and the facility’s documentation provided the following information: · P1 stated that in April 2023, the VA was hospitalized because of swallowing issues and then had seizures while s/he was in the hospital. The VA also received a feeding tube while in the hospital. On May 8, 2023, the VA returned to the facility from the hospital. When the VA returned to the facility, s/he had eleven pressure wounds on his/her back, ankle, and calf. On the morning that the VA returned to the facility, the staff persons had a training at the facility on how to treat the VA’s pressure wounds and use the feeding tube. P1 checked on all of the VA’s pressure wounds and no injury to the VA’s head was observed at that time. The VA slept in a hospital bed placed in the facility’s living room. There were typically two staff persons working at the facility during the day and one staff person working the overnight shift. · On May 9, 2023, the staff persons documented that the VA slept most of the day and did not eat breakfast or lunch. The staff persons administered the VA’s medications and repositioned him/her every two hours. P2 stated that on May 9, 2023, a staff person (P4) worked at the facility and observed the VA have a seizure, but did not document or report the seizure activity that day because s/he did not realize it was a seizure. On May 10, 2023, the VA had another seizure, which was observed by a staff person (P5). The VA was sent to the hospital, where s/he was prescribed a new seizure medication. At 8 p.m., the VA returned to the facility. The staff persons documented that they fed the VA, administered medications to the VA, and repositioned him/her. On May 10 – 11, 2023, P3 worked the overnight work shift and documented that when s/he arrived at the facility at approximately 9:45 p.m., the VA was “leaning” on his/her bed. P3 gave water to the VA and repositioned him/her as required. The VA was awake for much of P3’s work shift and talked to P3. P3 did not observe any injury to the VA’s head during his/her work shift. · On May 11, 2023, the staff persons interacted with the VA throughout the morning and the VA had a Zoom call with a family member and then ate lunch. After lunch, P5 and another staff person (P6) gave the VA a bed bath and found a wound on the right side of the VA’s head that was the size of a silver dollar and was “scabbed with dry blood, red, swollen, and soft to the touch.” P6 asked the VA if s/he hit his/her head on something and the VA said, “No.” P6 then asked if someone hit the VA and the VA said, “Yes.” P1 stated that it was difficult to see the injury because the VA’s hair covered the area. P1 described the injury as having “definite redness” and was “raised.” The VA went to the hospital to be checked by a physician, but was not admitted to the hospital and returned to the facility. The VA was diagnosed with a “head abrasion and head injury.” A hospital staff person contacted P5 and told him/her that s/he believed the wound was from a “head trauma incident,” though it was not determined what the trauma was. · P5 told P1 that when s/he arrived at the facility for his/her work shift that day, s/he observed a paper towel in the bathroom with blood on it. She asked P3 what caused the blood and P3 told him/her that s/he had a bloody nose during his/her work shift at the facility and had placed a paper towel with his/her blood on it in the garbage can in the facility’s bathroom. There was no blood anywhere else in the facility, including the VA’s bedding and clothing. None of the VA’s clothing or bedding was missing. P3 stated that s/he sat next to the VA’s bed during much of the night and did not hit the VA or observe anything that might injure the VA. P3 did not know how the injury occurred, because there was nothing above the VA’s head while the VA was in his/her bed that the VA could bump his/her head on. The VA was not always a reliable reporter of events. · P1 stated that s/he did not talk to the VA’s physician about the VA’s injury, but read in the hospital documentation that the cause of the injury was referred to as “head trauma” and that is the information s/he shared with G1 and G2. G1 stated that on May 10, 2023, the VA sustained an injury to his/her head. G1 believed that the injury was caused by a staff person because P1 told G1 that the wound on the VA’s head was caused by an “assault” and was not a pressure would. The VA’s physician told G1 that it would take two to three months for the wound on the VA’s head to heal. Several days after the incident, G1 talked to the VA about the incident, but the VA was unable to tell G1 who caused the VA’s injury and only provided the gender of the person who injured the VA. G1 was uncertain how accurate the VA would be at reporting past events. G2 stated that after the incident, P1 expressed concerns to G1 and G2 that the wound on the VA’s head was caused by a staff person and was not a pressure wound. The CM stated that the VA had a history of pressure sores on his/her heel. The CM did not see the wound on the VA’s head. The VA was hospitalized for an unrelated matter prior to the incident. According to the hospital’s Imaging Results, on May 11, 2023, the VA was seen by a physician at the hospital for a head wound. The physician documented that there was “no evidence of acute intracranial hemorrhage or mass effect. The globes were unremarkable, and the partially imaged paranasal sinuses and mastoid air cells were unremarkable. The visualized skull base and calvarium were unremarkable.” The VA did not require medical care for the injury. Facility documentation showed that P1 – P3 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Conclusion: On May 11, 2023, P5 and P6 found a wound on the top of the VA’s head while bathing the VA. Several staff persons had worked with the VA over the previous two days and had not observed the wound and did not know what caused the wound. Although the VA told G1 and P6 that someone hit him/her, the VA did not provide any additional information about the incident. Consistent information was provided that the VA was not always a reliable reporter of events. Given that it was unclear how or when the VA’s injury occurred, there was not a preponderance of the evidence as to whether all of the staff persons’ actions were therapeutic conduct or whether the VA’s injury was caused by any means other than accidental. 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: The facility completed an internal review and determined that the facility’s policies were adequate, but did not determine whether the facility’s policies were followed because it was unclear when and how the VA sustained his/her injury. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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