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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: 1071910-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady 651-431-6557 Suspected Maltreatment Reported: Allegation one: It was reported that a vulnerable adult (VA) fell on January 19, 2024, and on January 23, 2024, was taken for medical care and was diagnosed with a fractured right hip. It was reported that the VA was in pain after the fall and that the VA was not taken in for medical care in a timely manner. Allegation two: It was also reported that there were concerns regarding that the VA was not being showered, groomed, and changed daily; that the VA was left in bed; that the VA had multiple falls that were not being reported, and that the VA had unexplained bruises. Date of Incident(s): Ongoing, prior to January 23, 2024 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 February 8, 2024; from documentation at the facility; and through interviews conducted with four facility staff persons (P1- P4), a facility health care professional (HCP), and the VA’s guardian (G). This investigator met the VA, but the VA was not able to provide detailed information pertinent to the investigation. The VA’s support plans stated: · The VA was diagnosed with an intellectual disability. · The VA was at risk for falls. The VA was able to walk around his/her home. In the community, the VA needed assistance with curbs and uneven surfaces. The VA tended to “shuffle” his/her feet which caused the VA to trip over items while walking at home or in the community. · The VA had a high pain tolerance. Because of the VA’s pain tolerance, it might be difficult for the VA to assess how s/he was feeling and the VA might not report to staff person when s/he was feeling ill or if s/he was in pain. Staff persons were to observe the VA for any signs of illness or injury such as tiredness or refusals to get up and participate in his/her normal routine as well as look for visible signs of injury. · The VA enjoyed going to movies, shopping, out to eat, and playing with ropes. The VA enjoyed spending time with the G. Allegation one: It was reported that the VA fell on January 19, 2024, and on January 23, 2024, was taken for medical care and was diagnosed with a fractured right hip. It was reported that the VA was in pain after the fall and that the VA was not taken in for medical care in a timely manner. A facility internal review stated that on January 23, 2024, the VA had a medical appointment to evaluate his/her left leg due to having a limp when walking. At the appointment, it was discovered that the VA had a left hip fracture which require surgery to repair. The VA fell on January 19, 2024, but declined medical treatment and continued to ambulate as normal with a slight limp on his/her left side. It was unknown if the fall was the cause of the fracture. The VA had also been recovering from the flu for the last week and appeared to be weaker while recovering from the flu, but showed improvement leading up to the appointment. On January 23, 2024, the HCP documented the following in the VA’s progress note: On Friday, January 19, [2024], staff at Woodland called nursing at 3:52 p.m. and stated that [the VA] had a fall. I asked for details of the incident, and [s/he] stated, “We were walking and [the VA] just sat down. [The VA] didn’t hit [his/her] head or nothing, should I call 9-1-1?” I asked if [the VA] was complaining of pain, or showing any signs of distress, and staff reported that [the VA] was not complaining of pain and was able to get up on [his/her] own. Nursing recommended that staff notify [P1] and start a seven-day watch and monitor and notify if any changes. No updates were given the rest of the weekend. Today, January 23, [2024], [the VA] has an appointment with [the G] to check on [his/her] pain, and it was found that [s/he] had a broken hip and will require surgery. P1-P4 and the HCP provided information in the facility internal review, in an interview with this investigator, and/or in documentation in the VA’s progress notes. The G also provided information about the VA. Regarding the VA prior to January 19, 2024: · P1 stated that on January 16, 2024, the VA had “diarrhea type flu” that was going through the facility. The VA did not get out of bed that day and the VA was weak after having the flu. · The HCP stated that s/he was aware that the week prior to the fall, the VA and other consumers at the facility, had a stomach “bug.” The VA had diarrhea, was lethargic, and was weaker than normal. · P3 stated that s/he worked with the VA the week prior to the VA’s fall. During that time the VA was unsteady when walking. P3 noticed that prior to the fall, the VA’s leg was not moving as normal. The VA was not as weak as the last few days prior to January 19, 2024. P3 contacted P1 about his/her concerns with the VA and P1 said that s/he would get a wheelchair for the VA. P3 was not aware of the VA falling the week prior to the fall on January 19, 2024. Regarding the VA on January 19, 2024: · P4 stated that s/he arrived at 3 p.m. Prior to that, the last time P4 worked with the VA was two weeks prior. When P4 arrived, the VA was in bed. P4 was sent an email saying that the flu was going through the facility and that the VA was recovering. P4 got the VA up and out of bed and they walked to the bathroom together. P4 walked beside the VA because the VA was unsteady from the flu and P4 did not want the VA to fall. When the VA was done in the bathroom, P4 and the VA walked to the dining room and on the way, the VA fell on his/her buttocks on the floor. As the VA fell, s/he hit his/her elbow on a chair. P4 did not want to assist the VA back up in case s/he was injured so P4 called the HCP. The HCP asked P4 some questions including did the VA hit his/her head which s/he did not. After talking to the HCP, P4 assisted the VA up off of the floor and the VA went and sat at the table. At that time there were no noticeable bruises on the VA. · P4 stated that after dinner, the VA sat in a chair and then walked to bathroom. P4 walked next to the VA. At 7 p.m., the VA wanted to go to bed and then later came out for a snack and medications. The VA watched television for a little while and then at 8 p.m. used the bathroom and went to bed. P4 was able to sleep at night but P4 was a “light sleeper” and heard the VA when the VA got up at night so s/he was able to walk with the VA to the bathroom. The VA got up six times. When the VA walked, the VA appeared to drag his/her left leg. The VA usually walked on his/her tippy toes and shuffled when s/he walked, but in the morning s/he was dragging his/her leg but still refused to use his/her walker. · P4 stated that s/he also contacted P1 who contacted the G about the fall. P4 was told that on January 20, 2024, the G was planning on coming to take the VA shopping at 11:30 a.m. · P3 stated that s/he worked during the day with the VA and that P4 arrived to work in the afternoon. P3 was scheduled to go to the store and after P4 arrived, P3 went outside and started the VA. When P3 came back inside the VA was on the floor. The VA was sitting down with his/her legs out in front of him/her. P3 heard P4 ask the VA if s/he was okay and P4 was already on the phone about the VA. P4 told P3 that s/her should go the store. At that point, the VA looked scared and looked to be in pain. P3 went to the store and when s/he came back, the VA was in his/her bedroom and looked “just fine.” P3 left around 5:30 p.m. and did not see the VA again until January 23, 2024, the morning of his/her appointment. · The G stated that s/he was notified that the VA had a “light fall.” Regarding the VA on January 20, 2024: · P4 stated that s/he got the VA out of bed and the VA ate and took a shower. The VA did not have any bruising on him/her. The G came and brought the VA lunch and P4 asked if the G wanted P4 to make a doctor’s appointment for the VA and the G said that s/he was going to schedule one for him/her on January 22, 2024. · P4 stated that after the G left, the VA watched television, went back to his/her bedroom, and completed his/her evening routine. Every time the VA got up to walk, P4 walked with the VA. The VA got up four times during the night. The VA appeared to be unsteady. P4 left in the morning. · The G stated that s/he brought food to the VA. The G noticed the VA appeared to be weak, was shuffling when walking, and his/her vocalizations were higher pitched than normal. When the VA went to sit down, the VA would not let the G touch his/her leg. The G wanted P1 to notify him/her if the VA’s condition changed. The G did not hear from anyone until January 22, 2024. Regarding the VA on January 21, 2024: · P2 stated that s/he occasionally worked at the facility when they needed him/her, otherwise s/he did not work regularly with the VA. P2 arrived at work the morning. At that time, P4 was working and told P2 that the VA fell on January 19, 2024, but the VA did not have a serious injury or a concussion or contusions. At about 9 a.m. the VA got out of bed, but the VA was weak and was not walking on his/her tippy toes as s/he usually did. P2 asked the VA to use his/her walker but the VA did not want to so P2 held the VA’s hand when s/he walked. The VA went the bathroom, had breakfast, and went back to bed. · P2 stated that at lunch time, the VA got out of bed and ate lunch. The VA ate normally then went back to bed. The VA came out of his/her bedroom again for dinner. When the VA walked, P2 either held the VA’s hand or the VA leaned on the wall. P2 worked until the morning of January 22, 2024. P2 did not remember which staff person came into work that morning. The VA was asleep when P2 left. Regarding the VA on January 22 and 23, 2024: · A staff person (P5) who worked during the day on January 22, 2024, did not document any concerns about the VA in the VA’s progress notes. · P1 stated that on January 22, 2024, the G called P1 and told him/her that the VA had an appointment on January 23, 2024, at 8:10 a.m. P1 worked the Monday night overnight. The VA was in bed when P1 arrived, but got up about six times during the night to use the bathroom. The VA was gassy and had bowel movements. The VA did not want to use his/her walker so P1 held his/her hands when s/he went to the bathroom. While walking the VA was shuffling his/her left leg and swinging the leg out. The VA tended to walk on his/her tippy toes, but at that time the VA did. P1 did not think about that until later. P1 never noticed the VA “grimace” or indicate that s/he was in pain. · The G said that P1 told the G that the VA had gone several times to the bathroom. The G said that s/he made an appointment for the VA on January 23, 2024. The G was concerned that the VA could barely walk and was apparently in pain, but was not given any pain pills. · P3 stated that on the morning of January 23, 2024, prior to the VA’s appointment, P3 gave the VA a sponge bath and got him/her ready to go the appointment. The VA was in good spirits and did not appear to be in pain, but did say “owe” when P3 put on his/her right shoe. P1-P4 provided the following additional information: · P4 stated that the VA would not tell staff persons if s/he was in pain. If staff persons asked the VA if s/he was in pain the VA would say no. P4 did not believe that the VA needed medical care sooner because although the VA was not walking regularly, P4 thought it could be from the VA being weak from being sick. The VA also did not have any noticeable injuries from the fall. · P2 stated that s/he did not believe that the VA needed medical care on January 21, 2024, because P2 believed that the VA was weak because s/he had stomach flu the prior week. P2 did call P1 at the end of the shift and said that the VA was weak. The VA was able to communicate if s/he was not feeling well and if his/her stomach hurt s/he would show staff person his/her stomach. P2 did not see the VA indicate that s/he was in pain. · P1 stated that the VA was not taken in for medical sooner as the G and P4 were at the facility January 20, 2024, and did not decide to take him/her in and the VA was weak from having the stomach flu. · P1 stated that staff persons received training on the VA’s support plans. P2, P3, and P4 each stated that they received training on the VA’s support plans. Facility documentation showed that P1, P2, P4, and the HCP each received training on the VA’s support plans and that P1-P4 and the HCP each received training on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion allegation one: On January 19, 2024, the VA fell when walking with P4. The VA fell on his/her buttocks onto a sitting position on the floor. P4 contacted the HCP and assessed the VA for injuries which at that time there were none apparent. After the fall the VA showed signs of weakness and was not walking normally, but did not show signs of being in pain. The day prior to the fall the VA was weak from being sick with the flu and P3, who worked with the VA the days prior to his/her fall, had concerns that the VA was unsteady when walking. The G was notified about the fall and saw the VA on January 20, 2024. On January 22, 2024, the G notified P1 that s/he made a medical appointment for the VA on January 23, 2024. At that appointment, the VA was diagnosed with a fractured hip which required surgery to repair. Staff persons were aware that the VA was sick the week before s/he fell so it was reasonable for them to think that the VA was weak from being sick. In addition, P3 said that s/he had some concerns about the VA’s mobility prior to the fall. Because after the fall on January 19, 2024, staff persons were in contact with the HCP and the G, that between the fall and when the VA went to the doctor, staff persons assisted the VA with walking and the VA did not indicate that s/he was in pain, and on January 22, 2024, staff persons were aware that the G made an appointment for the VA to see the doctor the following day, there was not preponderance of the evidence whether there was failure to obtain medical care for the VA in a timely manner. 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). Allegation two: It was also reported that there were concerns regarding that the VA was not being showered, groomed, and changed daily; that the VA was left in bed; that the VA had multiple falls that were not being reported, and that the VA had unexplained bruises. The G provided the following information: · The G visited the VA weekly. The G was concerned that the VA was not being groomed, showered, or changed regularly. The VA was also not getting out of bed. The VA became weak and fell as a result. The G did unannounced visits to see the VA and found him/her with a four-day beard and the VA smelled like urine. Staff person told the G that they could not get the VA out of bed. The G told staff persons that if they were having trouble getting the VA out of bed, they could call the G to help, but the G never got a call. · Each time the G visited the VA, the G did body checks. On one occasion, the VA had 12 inch long by 6 inch wide bruise on his/her back. The bruise was purple and yellow. On another occasion the VA had a “giant” bruise on his/her buttocks and a bruise on the right side of his/her head. The G requested to be notified of any falls by the VA, but was not notified. · The VA was to have a bed alarm and it took almost four months to have the alarm installed. · In October or November in 2023, the VA was placed on a nutritional supplement (Ensure) by a doctor twice a day because the VA lost 20 pounds in a year. The Ensure was not listed as a medication. The G was not notified when the VA ran out of Ensure. P1 provide the following information: · The VA had a history of falling but never broke any bones. The VA’s physical health had been declining for six or seven months. Staff persons struggled with the VA and the VA did not want to get out of bed. · To get the VA out of bed, staff persons would engage the VA and offer him/her coffee and to come out in common areas and play with his/her ropes. The VA also had an increase in refusing hygiene activities. There were some new staff persons working with the VA and the VA was not as cooperative with the new staff persons. · In mid-December 2023, the VA had a “good” sized bruise on his/her back. Staff persons did not know how it occurred. P1 was not aware of any bruises on the VA’s buttocks or the VA’s head. · In December the VA got a pad for his/her bed which was an alarm to alert staff persons if the VA got up. The alarm was not set up right away when it arrived. When staff person began using it, the VA pulled it off of the bed as s/he did not want it on his/her bed. If staff persons placed the alarm pad under the VA’s sheets, the VA “basically” was not aware that it was on his/her bed. · The VA was given Ensure twice a day. P1 did not believe that it was ordered by a doctor. If the supply of Ensure got low, staff person would let the G know and the G would bring more Ensure. · P1 said that staff persons provided the VA with care consistent with his/her support plans. P4 provided the following information in the internal review and in an interview: · P4 was aware that the VA had a history of falling, but the VA never fell when P4 was working with him/her. P4 was aware of a bruise on the VA’s back “a while ago,” but did not know about a bruise on the VA’s buttocks or the VA’s head. · Staff persons assisted the VA with shaving, showers, and laundry, but encouraged him/her to be more independent. The VA ate and used the bathroom independently. · The VA liked to sleep during the day. When P4 worked with the VA, P4 tried to keep the VA engaged in activities so the VA did not spend time in bed. P4 offered the VA to play with his/her ropes in the common areas. The VA sat on common area with the television one but most of the time played with his/her ropes. P4 also offered snacks and cola to get the VA to come out of his/her bedroom. · The VA had a bed alarm that the VA did not like to leave on his/her bed. The bed alarm was at the facility in November or December 2023 and was not put on the bed right away, but P4 did not know why. · The VA received Ensure every day. P4 believed that it was a recommendation as opposed to a doctor’s order. Ensure was always available for the VA. P2 provided the following information: · P2 believed that the VA had a history of falling, but the VA never fell when P2 worked with the VA. P2 was not aware of any bruises on the VA. · The VA liked to spend most of the time in bed. Cola was the “best” motivation for the VA to get out of bed. The VA also liked to sit in the common area and play with his/her ropes. · The VA did not like to accept assistance from staff persons. P2 did not work with the VA often enough to say whether the VA was regularly cooperative with his/her grooming routine. · The VA had a bed alarm that the VA did not like. One time the VA took apart of his/her bed and threw the alarm. · The VA drank Ensure twice day and there was always Ensure available at the facility. P3 provided the following information in the internal review and in an interview: · On time P3 came back to work after a weekend and the VA had a large bruise on his/her right thigh. The VA was not able to say what happened and P3 did not how the VA got it. P3 said that before the VA went for surgery s/he had a bruise on his/her back. P3 was not aware of any bruises on the VA’s head. · The VA liked to stay in bed. P3 offered the VA soda and to play with his/her ropes to get the VA to come out of his/her bedroom. · P3 never had issues with the VA cooperating with hygiene tasks. · The G got the VA a bed alarm and for some reason a supervisory staff person delayed putting it on his/her bed. P3 believed that they might have waiting for approval from a health care professional. · P3 typically worked during the day with the VA. The VA got Ensure in the morning. P3 believed that s/he got it one time a day. The VA ate less when s/he drank Ensure. P3 did not believe that there was a doctor’s order for the Ensure. A review of progress notes dated December 1, 2023, though February 3, 2024, stated: · On December 3, 2023, a bruise on the lower left side of the VA was noted but the VA indicated that it was not painful. On January 10, 2024, the HCP did a body check of the VA and documented that the VA did not have any new bruises. · The VA occasionally refused to shower. · There was one entry where the VA did not want the alarm pad on his/her bed. · The VA often used the bathroom multiple times during overnights. · The VA spend a lot of time in his/her bedroom during the day. Conclusion allegation two: The G had several concerns about the VA’s care that the VA received at the facility including that the VA was not being groomed, showered, or changed regularly. Staff persons were also not getting the VA out of bed. The VA became weak and fell as a result. Information from staff persons showed that the VA did have a history of falling and P1 said that the VA’s physical health had been declining for several months. Information from staff persons and documentation showed that the VA spent a lot of time in his/her bedroom and that the VA was not always cooperative with grooming and hygiene tasks. Staff persons provided examples of actions they took to encourage the VA to come out of his/her bedroom. However, based on the G’s descriptions of when s/he observed the VA, it was not determined whether staff persons were always taking adequate action to ensure that the VA did not stay in his/her bedroom and that his/her personal needs were always being met. Each time the G visited the VA, the G did body checks. On one occasion, the VA had 12 inch long by 6 inch wide bruise on his/her back. The bruise was purple and yellow. On another occasion the VA had a “giant” bruise on his/her buttocks and a bruise on the right side of his/her head. P1, P3, and P4 were aware of a bruise on the VA’s back, P3 was also aware of a bruise on the VA’s thigh, and no staff persons were aware of a bruise on the VA’s head. Staff persons did not know how the bruises were caused. Without knowing how the bruises were caused, it was not determined whether they were caused other than by accident or therapeutic conduct. The G said that the VA was to have a bed alarm and it took almost four months the VA to have the alarm installed. Staff persons stated that there was a delay in getting the alarm in place but did not know why. Staff persons also stated that the VA did not like the alarm. There was no information whether the VA was harmed as a result of the bed alarm not being in place sooner. The G stated that in October or November 2023, the VA was placed on Ensure by a doctor twice a day because the VA lost 20 pounds in a year. The Ensure was not listed as a medication. The G was not notified when the VA ran out of Ensure. Staff persons stated that Ensure was not doctor’s order and no staff persons were aware of a time when there was not Ensure available at the facility. With the conflicting information, it was not determined whether the VA always received his/her Ensure twice a day or what affect it had on the VA if s/he occasionally missed a serving of Ensure. Given the above, although there were concerns that the VA’s personal needs were not always being met, there was not a preponderance of the evidence whether there was failure to provide the VA with care or services that were reasonable and necessary to maintain the VA’s physical or mental 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 their policies and procedures were adequate but not followed. Staff persons were retrained regarding what to do when changes in medication condition occur. In addition, the VA’s support plans were revised to show the VA’s current use of adaptive mobility equipment and staff persons were to receive training on the revisions. Action Taken by Department of Human Services, Office of Inspector General: On May 15, 2024, the facility was issued a Correction Order for the failure to have documentation that P3 received training on the VA’s support plans.
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