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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: 1070600-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh/Alice Percy 651-431-3444 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was unable to walk, was not talking, and had a fever. The VA was taken to the hospital, where s/he was diagnosed with fractures to his/her left shoulder and lumbar vertebrae, fever, pneumonia, and weakness. Date of Incident(s): March 2, 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 March 11, 2024; from documentation at the facility and medical records; and through ten interviews conducted with six facility staff persons (P1 – P6), an administrative staff person (P7), a hospital social worker (SW), the VA, and the VA’s guardian (G). The VA enjoyed watching sports, playing bingo, going out to eat, and spending time with his/her friends. The VA’s diagnoses included mild intellectual disabilities, seizure disorder, Parkinson’s disease, hyperkyphosis, scoliosis, osteoporosis, mood disorder, and chronic back pain. According to the VA’s Community Support Plan (CSP), the staff persons scheduled the VA’s medical appointments and transported the VA to his/her medical appointments. The VA was vulnerable to abuse and might not be able to defend him/herself. The VA needed assistance and supervision to ensure his/her health and safety. According to the VA’s Self-Management Assessment, the VA wore a back brace every day and used a walker when in the facility or during short community outings. The VA used a wheelchair for longer distances. The VA’s diagnoses sometimes made it difficult for the VA to complete physical tasks. The VA’s physicians advised the VA to continue to try to perform mobility and physical tasks independently. The staff persons were to provide verbal encouragement and direction to the VA. In the past, the VA had fallen due to his/her back pain and shaking. According to the VA’s Falls Assessment, completed on June 22, 2023, the VA was at a “high risk” of falling. The VA’s bedroom was located next to the bathroom and the doors were approximately three feet apart. A grab bar was located on the wall between the two doors. The doors of both rooms opened onto the living room and a sofa was located in the living room a few feet from the two doors. The VA stated that on one occasion, in the middle of the night, s/he fell down three times onto his/her left shoulder. The VA fell near the bathroom and his/her bedroom. The VA did not recall who was working at the facility at the time of the incident and stated that the staff person did not assist the VA off the floor. The VA remained on the floor until 8 a.m. the following day, when another staff person arrived at the facility and helped the VA off the floor. The VA stated that s/he also fell a second night when another staff person was working at the facility. That staff person also did not help the VA off the floor. The SW stated that on March 2, 2024, at approximately 6:30 p.m., the VA was taken to the hospital emergency room. A facility staff person told the hospital nurse that at 11 p.m. the previous night, the VA fell and remained on the floor “all night” until a second staff person arrived at the facility at 8 a.m. At approximately 5 p.m., the VA was nonverbal, was unable to move on his/her own, and had a temperature of 102.7 degrees Fahrenheit. The VA was taken to the hospital by ambulance. P1, P2, P3, P4, P5, P6, P7, and the facility’s documentation provided the following information: · P1 stated that the VA sometimes needed assistance during the night to go to the bathroom. At those times, s/he would call for a staff person to assist him/her. On other occasions, the VA was able to get out of his/her bed or recliner and go to the bathroom without assistance. The VA had a trapeze bar above his/her bed that s/he could use to help him/her sit up in his/her bed. The VA typically used a walker when moving around the facility.
· On February 29, 2024, P1 worked at the facility from 10:30 p.m. to 8:30 a.m. on March 1, 2024. P1 stated that the VA had “a good night” and did not ask for assistance to get up during the night. At one point during the night, P1 saw the VA using his/her walker to go to the bathroom. P1 then encouraged the VA to walk to his/her bedroom. The VA sat on his/her walker and told P1 that s/he could not walk. P1 continued to encourage the VA to walk until the VA returned to his/her bedroom. The VA was “shaking” due to his/her Parkinson’s disease diagnosis. · On March 1, 2024, at 8 a.m., P2 began his/her work shift. When P2 arrived at the facility, the VA was sitting on the floor in the living room. P1 told P2 that the VA walked to the bathroom as s/he was in the kitchen making breakfast for another resident. P1 heard a “thump” and went to the living room and saw the VA on the floor. The VA told P2 that s/he was using his/her walker to go to the bathroom when the walker tipped over as s/he moved it over the threshold to the bathroom and the VA “tipped onto the couch.” The VA was lying on his/her left shoulder and told P2 that s/he fell onto the floor and his/her left shoulder hurt. P1 and P2 used a gait belt to assist the VA into his/her wheelchair. The VA used his/her arms to balance him/herself as they moved him/her and used both arms to take off his/her shirt when P2 took him/her to the bathroom. The VA did not complain of any pain throughout the remainder of P2’s work shift. · On March 1, 2024, at 12:30 p.m., P5 began his/her work shift at the facility. When P5 arrived at the facility, the VA was sitting at the table after eating lunch. The VA spent the afternoon in his/her bedroom and returned to the kitchen at 4 p.m. to eat dinner. The VA did his/her exercises and at 8 p.m., the VA walked to his/her bedroom. The VA walked to his/her bed and then “couldn’t walk anymore” so P5 assisted the VA into his/her bed. At 9 p.m., P5 administered the VA’s medications to the VA and then left the facility at 10:30 p.m. The VA did not complain of any pain during P5’s work shift. · On March 1, 2024, at 10:30 p.m., P1 began his/her work shift at the facility. When P1 arrived at the facility, the VA was in his/her bedroom. P1 did not recall if the VA was in his/her bed or in his/her recliner. At approximately 11 p.m., the VA went to the bathroom. When the VA saw P1 in the kitchen, the VA told P1 that s/he “could not do anything” even though s/he was walking with his/her walker back to his/her bedroom. P1 encouraged the VA to walk to his/her bedroom, but to take a break and sit on his/her walker if s/he needed to rest. The VA told P1 to push the VA’s back while s/he was walking, but P1 told the VA that s/he could not push him/her. The VA stopped walking in the hallway between the bathroom and his/her bedroom and “just stood” next to the wall until approximately 4 a.m. P1 stated that s/he never saw the VA behave in that manner “to that extent” and believed one of the VA’s medications caused the behavior. P1 stated that s/he was trained to “deescalate and motivate” the VA when s/he had a behavior, which is what P1 attempted to do. · On March 2, 2024, at approximately 4 a.m., the VA sat on the floor on his/her buttocks. P1 did not believe the VA sat hard enough to cause an injury, because the VA “instantly” asked P1 to assist the VA to his/her feet. P1 was unable to help the VA to his/her feet so s/he got a chair for the VA to try and pull him/herself up with, but the VA could not stand. P1 then used a gait belt to try to help the VA to his/her feet, but the VA told P1 that s/he could not stand and “wouldn’t try.” P1 brought a nightstand to the VA to use to stand, but the VA would not try to stand. At approximately 5 a.m., P1 brought a pillow and blankets to the VA and told the VA that when the morning staff person arrived at 8 a.m., they would assist the VA to his/her feet. P1 placed pillows under the VA’s body and under his/her head and covered him/her with the blanket. P1 stayed near the VA until 6 a.m., when s/he assisted another resident out of his/her bed. The VA did not complain of pain and “looked normal.” The VA did not appear to be ill. P1 believed that the VA was exhibiting a behavior and stated that s/he would have handled the situation differently if it was a fall. P1 did not call anyone for assistance getting the VA off the floor. · At approximately 8 a.m., P3 arrived at the facility for his/her work shift. P1 told P3 that the VA was on the floor and s/he was unable to assist him/her to his/her feet. P1 and P3 used a gait belt to assist the VA into his/her recliner. P3 took the VA’s vitals, which were normal. The VA told P3 that s/he fell and was unable to stand. Shortly after that, P1 left the facility at the end of his/her work shift. P3 asked the VA if s/he wanted breakfast and the VA told P3 that s/he did, but was unable to stand and walk to the table. P3 gave the VA his/her breakfast and s/he was “fine.” At lunch time, the VA wanted to eat and P3 gave the VA his/her lunch. The VA ate lunch and then watched television. When P3 returned 45 minutes later, the VA was sleeping in his/her recliner. P3 continued to check on the VA every 45 to 60 minutes and the VA continued to sleep. At 12:30 p.m., P4 arrived at the facility for his/her work shift. · At approximately 5 p.m., P3 and P4 assisted the VA into his/her wheelchair. P4 stated that the VA “didn’t look good.” P3 stated that the VA’s body was hot, so s/he took his/her temperature, which was 103 degrees. The VA did not want to eat dinner and was “breathing funny.” The VA told P3 that s/he was having a hard time breathing. P4 telephoned 9-1-1 and the paramedics arrived at the facility and took the VA to the hospital. P3 telephoned P5 and asked him/her who P3 needed to contact to inform them about the VA’s hospitalization. P5 told P3 that s/he would telephone the G, the CM, and an administrative staff person. P4 went to the hospital and stayed with the VA until 12 a.m. P4 stated that the VA’s temperature, pulse rate, and oxygen levels were “fine” when the VA was checked at the hospital. The hospital nurse told P3 that the VA’s Parkinson’s disease might be “throwing off [the VA’s] readings” and the VA was admitted to the hospital. The VA was later diagnosed with pneumonia. Neither P3 nor P4 noticed the VA coughing prior to when the VA was taken to the hospital. · P7 stated that on March 4 and 5, 2024, s/he talked to P1, P2, P3, P4, and P5 about their work shifts on March 1 and 2, 2024. None of the staff persons noticed any injury to the VA and the VA’s vitals were normal until March 2, 2024, at approximately 5 p.m. At that time, the VA had a high temperature and his/her breathing was labored, so they telephoned 9-1-1. P1 told P7 that on March 2, 2024, the VA “lowered” him/herself to the floor and P1 was unable to assist the VA to his/her feet so s/he brought pillows and a blanket to the VA and made him/her comfortable. P1 also stayed with the VA until P3 arrived at the facility and they assisted the VA to his/her feet. P7 believed P1 could have telephoned an on-call supervisor to request assistance getting the VA off the floor. · P1 stated that in the past, the VA told people that s/he fell even though s/he had not fallen. P2 stated that the VA was “in decline” and s/he was not able to walk as much as s/he had in the past. The VA “struggled” to walk to the bathroom without assistance and often refused to drink liquids. P3 stated that the VA sometimes “stretched the truth” and sometimes sat on the floor if s/he wanted the staff persons’ attention. P5 stated that the VA sometimes told the staff persons s/he was falling even when s/he was simply standing. The VA also sometimes slid against a wall to the floor. P5 stated that the VA sometimes “exaggerated” when s/he talked about events. P6 stated that the VA sometimes told the staff persons that s/he could not do something like get out of his/her bed, but was able to do it when a staff person encouraged him/her. P7 stated that the VA sometimes became “confused” and was not always an accurate reporter of events. · P2 stated that the staff persons recently learned that if they telephoned 9-1-1, the paramedics would “not do pick-ups anymore.” P2 believed that the training on what to do if a resident fell during the overnight work shift was a “very grey area.” In the past, when P2 telephoned another staff person when a resident fell, s/he was told to call 9-1-1. Another staff person told P2 to “use their best judgment.” P2 believed s/he could contact the on-call supervisor if the situation occurred again. P2 stated that the staff persons were to document when the VA fell if no one witnessed the fall. P7 stated that there were previous occasions when the VA sat on the floor and was unable to stand. P7 believed that because of the VA’s diagnoses, the VA’s physical abilities might be declining. · According to the facility’s Internal Review, in May 2023, the VA injured his/her L3 and L4 vertebra when s/he fell. The VA was seen by a physician at that time. The G stated that the VA had a history of having pneumonia. The staff persons told the G that the VA “lowered” him/herself to his/her bedroom floor and the staff person working at the time was unable to assist the VA to his/her feet. The VA was assisted to his/her feet when a second staff person arrived at the facility for his/her work shift three or four hours later. The G believed that the staff persons typically did a “fantastic” job working with the VA. According to the hospital’s ED to Hospital Admission form, on March 2, 2024, the VA was taken to the hospital because s/he was disoriented and had a fall. When the VA arrived at the hospital, s/he had no respiratory distress or fever, although the VA did develop a fever while in the emergency room. The VA’s principal diagnosis was sepsis due to pneumonia. The VA was also diagnosed with a “closed displaced fracture of coracoid process of left shoulder,” weakness, “closed fracture of transverse process of lumbar vertebra,” acute cough, and supraventricular tachycardia (SVT). An x-ray impression of the VA’s left shoulder showed no acute fracture or dislocation. It was documented that the VA had “age-related osteoporosis with current pathological fracture with routine healing.” It was also documented that the VA had an “age indeterminate new from September 2023 exam nondisplaced fractures of the left transverse processes L3 and L4; old multilevel vertebral body compression fractures.” On March 8, 2024, the VA was discharged to a transitional care facility. Facility documentation showed that P1 – P7 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: P1 stated that on March 2, 2024, at approximately 4 a.m., the VA sat on the floor on his/her buttocks. P1 did not believe the VA sat hard enough to cause an injury, because the VA “instantly” asked P1 to assist the VA to his/her feet. P1 was unable to lift the VA and the VA was unable to pull him/herself to a standing position, so P1 placed pillows under the VA and a blanket on top of the VA and then sat near the VA until 8 a.m., when P3 arrived at the facility. P1 and P3 assisted the VA into his/her recliner and checked his/her vitals, which were normal. The VA ate breakfast and lunch and then slept in his/her bedroom. P3 and P4 checked on the VA every 45 to 60 minutes. At 5 p.m., the VA “didn’t look good” and had a high temperature. The VA told P3 that s/he was having a hard time breathing. P4 telephoned 9-1-1 and the paramedics arrived at the facility and took the VA to the hospital, where s/he was diagnosed with sepsis due to pneumonia. While it was reported that the VA fell and sustained several fractures, information was provided that the VA had fallen several months earlier and was diagnosed with vertebrae fractures at that time. It was unclear when the VA’s shoulder fracture occurred. P1 stated that because s/he believed the VA did not fall, but instead sat on the floor while s/he was having a behavior, P1 did not attempt to telephone for assistance getting the VA off the floor. While information was provided that when the VA fell, s/he remained on the floor all night, given that the VA and P1 provided conflicting information about whether the VA fell or sat on the floor as well as on how long the VA remained on the floor; that P3 and P4 ensured that the VA was taken to the hospital when s/he appeared unwell; and that the VA’s principal diagnosis of sepsis due to pneumonia was unrelated to lying on the floor, there was not a preponderance of the evidence whether there was a failure to provide care or services to the VA which were reasonable and necessary to maintain the VA’s physical health and 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 policies were adequate, but the staff persons did not follow all of the facility’s policies. After the incident, all of the staff persons received additional training on the facility’s policies. Prior to the VA’s return to the facility, an updated fall assessment and protocol was to be completed and the staff persons were to be trained on the updated assessment and protocol. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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