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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: 1077681-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070806-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a staff person (SP) stapled a bandage to a vulnerable adult’s (VA) scalp prior to the VA being seen at a medical facility. Date of Incident(s): January 3, 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 (b): 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 14, 2024; from documentation at the facility; and through five interviews conducted with the VA, a facility supervisor (P3), the VA’s case manager (CM), the VA’s guardian (G), and the SP. Facility documentation showed the VA enjoyed going on walks, playing games, and was described as creative and kind. The VA enjoyed spending time with his/her family and dreamed of visiting the Memphis Zoo to see a giant panda. Prior to moving into the facility, the VA was at a hospital due to his/her “unique needs long-term.” The VA was diagnosed with autism, and requested to go to the hospital if s/he was having a “rough day.” The VA had a history of “severe” self-injurious behaviors (SIB) which included hitting him/herself until s/he was concussed or had broken his/her nose or jaw. The VA’s client specific programming showed that staff persons would transport the VA to the hospital if his/her SIB behavior included “damaging” his/her face. The VA’s SIB occurred for multiple reasons including but not limited to feeling overwhelmed, changes in routine, and difficulty having his/her sensory needs met. An interview was attempted with the VA; however, the VA did not provide information about the incident. The following is a summary of information from interviews completed by this investigator, the facility’s Internal Review (IR), and video footage: · The VA had an electroconvulsive therapy appointment (ECT) at 9 a.m. on January 3, 2024. At the appointment, a medical provider discovered the VA had a staple embedded in his/her scalp. The VA was seen at an emergency room for further evaluation. A nurse said s/he found a bandage stapled to both sides of the VA’s scalp, and took the staples out of the VA’s scalp. There was no other documented treatment the medical facility provided for the staples. · P3 said on the morning of January 3, 2024, the VA engaged in banging his/her head, which caused bleeding. P3 said the VA’s guardian was contacted and the guardian said the VA could be evaluated at the appointment scheduled for 9 a.m. · The SP told the DHS investigator and P3 that early on the morning of January 3, 2024, s/he was assisting another person served when s/he heard a loud sound. The SP found the VA on the floor banging his/her head, causing a wound. The SP assisted the VA up from the floor and verbally redirected the VA. The SP observed a pool of blood on the floor before going upstairs with the VA. The SP cleaned the VA’s wound and wrapped the VA’s head with a bandage. The SP attempted to use plaster to secure the bandage, however the bandage was loose, and the SP tried to fix the bandage. The SP asked the VA if it was okay for him/her to use a stapler, to which the VA agreed. The SP said s/he pulled the bandage away from the VA’s head and stapled the bandage together. The SP said s/he checked the staples to ensure they were not poking the VA’s head. The SP said the VA hit his/her head later on, but the SP was not aware of a staple becoming embedded into the VA’s scalp at that time. · A video recording from January 3, 2024, at 7:53 a.m., showed the SP cut off a bandage wrapped around the VA’s head and wiped the back of the VA’s head with paper towels. The paper towels appeared to have blood on them. At 8:04 a.m., the SP prepped a new gauze pad and bandage before wrapping it around the VA’s head. At 8:05 a.m., the SP pulled the bandage away from the VA’s head and used a stapler to secure the bandage together. The SP used the stapler a few times in different areas around the bandage as the VA sat on a chair. The recording showed the SP did not staple the bandage to the VA’s scalp, but rather the SP stapled different parts of the bandage to one another with the prongs of the staples on the inside of the bandage. The VA did not make any sudden movements while the SP stapled the bandage, the VA appeared calm throughout the recording, and the SP spoke calmly to the VA while providing the VA with first aid. · A staff person (P2) arrived at the facility after the SP had completed the first aid. P2 transported the VA to the scheduled medical appointment, and said the VA did not engage in any SIB while being transported. The ECT appointment could not be completed due to the wound on the VA’s head, and a nurse recommended the VA be seen at an emergency room. P2 took the VA to an emergency room. Due to behavior issues the VA completed a mental health evaluation and the VA was admitted to the hospital around 4 p.m., for mental health care. It was also noted the VA engaged in ongoing SIB while at the medical facility including but not limited to head banging and punching him/herself; physically aggressed towards a security guard; and displayed an increase in overall agitation. There was no information which showed the VA’s admission was directly related to the staples. · The SP said s/he was trained on basic first aid but was not trained to staple bandages together. However, the SP said s/he was trying to create a “quick fix” to cover the VA’s wound prior to the VA’s appointment. The SP denied stapling the bandage to the VA’s scalp and said s/he would not “intentionally” cause harm to the vulnerable adults s/he provided care and services. · Throughout the investigation there were no concerns related to the SP’s work performance or the SP’s interactions with the VA prior to the incident. Additionally, it was stated the SP and VA had “great rapport” with one another. · The facility determined the SP did not provide first aid as trained, and retrained all facility staff persons, including the SP, on first aid. The SP was transferred to a different home operated by Dungarvin. The CM and the G said the VA engaged on SIB on a daily basis, however they both expressed frustration with the level of supervision the facility provided as they felt the VA spent “a lot” of time by him/herself on the facility‘s lower level. Prior to the incident the SP was trained on the VA’s client specific information, first aid and CPR, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: On January 3, 2024, at 9 a.m., the VA was seen at an appointment and a nurse found the VA had a bandage stapled to his/her scalp, with the staple embedded in the scalp. An interview was attempted with the VA, however the VA did not provide information related to the incident. The VA had a history of SIB, including causing significant injuries to his/her head and face. The SP said that early on the morning of January 3, 2024, s/he found the VA engaging in SIB and attempted to provide first aid as the VA was bleeding. The video recording and the SP’s description each showed that the SP placed a bandage around the VA’s head, and used a stapler to secure the bandage to itself in several places. The recording showed the SP stapled the bandage with the prongs of the staples facing the VA’s scalp/head, but did not staple the bandage directly to the VA’s head. Based on the information obtained it was more than likely that the staples, without the SP’s knowledge, moved after the bandage was stapled, and thereafter the staples embedded into the VA’s scalp without the SP’s knowledge. The VA was seen at medical facility the same day as the bandage was placed around the VA’s head, where the staples were removed but no other care was provided for the staple injuries. Although the VA was hospitalized for mental health care, there was no information which showed the VA’s staple injuries required further medical care, nor that it did not return to his/her pre-existing condition. Minnesota Statutes, section 626.5572, subdivision 17, paragraph (c), clause (5), states, “ A vulnerable adult is not neglected for the sole reason that an individual makes an error in the provision of therapeutic conduct to a vulnerable adult that results in injury or harm, which reasonably requires the care of a physician; and: (i) the necessary care is provided in a timely fashion as dictated by the condition of the vulnerable adult; (ii) after receiving care, the health status of the vulnerable adult can be reasonably expected, as determined by the attending physician, to be restored to the vulnerable adult's preexisting condition; (iii) the error is not part of a pattern of errors by the individual; (iv) if in a facility, the error is immediately reported as required under section 626.557, and recorded internally in the facility; (v) if in a facility, the facility identifies and takes corrective action and implements measures designed to reduce the risk of further occurrence of this error and similar errors; and (vi) if in a facility, the actions required under items (iv) and (v) are sufficiently documented for review and evaluation by the facility and any applicable licensing, certification, and ombudsman agency. Given that the VA received necessary care in a timely fashion, that the VA’s injuries from the staples were reasonably expected to be restored to the VA’s preexisting condition, that there was no pattern of similar errors by the SP, that the incident was reported immediately and recorded, that the facility identified and took corrective action and implemented measures to reduce the risk of further occurrence of the same or similar errors, and that the facility sufficiently documented the incident, it was determined that the SP’s conduct constituted an error in the provision of therapeutic conduct and was not maltreatment. It was determined that neglect did not occur (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 policies and procedures were adequate, but not followed. The report was not similar to a past events, and the facility took corrective action to ensure the safety of the individuals that received services. The SP no longer worked at Dungarvin Skillman, but remained an employee of Dungarvin. The facility completed retraining with all staff persons, including the SP, on first aid and serious injury reporting requirements. Action Taken by Department of Human Services, Office of Inspector General: The SP was not substantiated as a perpetrator of maltreatment of the VA because the Department of Human Services found that the incident for which the SP was responsible met the criteria to be determined an error. The SP was notified by the Office of Inspector General that any future incident of possible neglect of a vulnerable adult for which the SP is responsible might not be considered an error.
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