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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: 1071690-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scout Peterson 651-431-6578 Suspected Maltreatment Reported: A staff person (SP) refused to bring water to a vulnerable adult (VA), said “not nice things” to the VA, and did not reposition the VA which led to the VA developing pressure sores that needed medical care. Date of Incident(s): Ongoing prior to April 10, 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 2, paragraph (b), clause (2); and subdivision 17, paragraph (a): 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: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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 17, 2024; from documentation at the facility, medical records; and through five interviews conducted with two facility staff persons (P1 and the SP), two supervisory staff persons (P2 and P3), and the VA. The VA enjoyed going to the mall, talking on the phone, and listening to live music. The VA was not subject to guardianship. According to the VA’s Coordinated Services and Support Plan, “[The VA] has a 24-hour plan of care and lives in adult foster care. [S/he] has staff available at all times at home.” The VA moved to the facility in December 2023. Information obtained showed that at some point, the VA wore disposable briefs, used a condom catheter, and required repositioning. However, there was no information provided in the VA’s plans that addressed repositioning needs or condom catheter care needs. According to the VA’s Individual Abuse Prevention Plan (IAPP), “[The VA] had spastic quadriplegic cerebral palsy, which limited [his/her] physical abilities.” The VA used a wheelchair and had an automatic lift to assist with transfers into and out of bed that required the assistance of a staff person to use. Regarding emotional abuse, the VA’s IAPP stated, “[The VA] would likely be able to report abuse to the appropriate person. [S/he] was a strong advocate for [him/herself]. However, [s/he] may not always report events accurately.” Also, according to the VA’s IAPP, “[The VA] needed 24 hour plan of care” and “required overnight supervision,” however, “may not require supervision at all times but there is someone identified/assigned that is responsible and accessible to [the VA] in case of emergency.” On April 10, 2024, a facility nurse visited the VA and documented in a shift note, “sore was note to be ½ cm [centimeters] x ½ cm around in circumference. A 1st [sic] layer skin tear, skin pink in color, with no drainage or s/s [signs/symptoms] of infection” and “[the VA] was going to be seen by wound care this upcoming Friday.” On April 11, 2024, the nurse documented the size remained the same at about ½ cm x ½ cm, in circumference and the “color remains pink. No odor or drainage present.” The VA provided the following information: · For “the last few months” the SP talked “rudely” to the VA. The VA was not able to provide specifics regarding the SP’s rudeness but state that the SP refused to reconnect the VA’s condom catheter. When the VA told the SP it had come off, the SP replied, “What makes you think that?” . The SP stated that the SP also was rude because s/he refused to reposition the VA “a few times.” The SP also refused to assist the VA in changing clothes and did not assist the VA to sit up in bed before providing him/her water which the VA was concerned because it could cause him/her to aspirate. · The VA had a pressure sore on his/her buttocks that was in the process of healing. The VA stated that the sore was healed because the SP no longer worked with the VA, and if s/he did still work with the VA, the sore “would not be healed. It would be really bad” because the SP refused to reposition the VA. · On an unknown date, the VA told P2 that s/he did not feel “comfortable” working with the SP, so P2 went to the facility to work with the VA during the SP’s shifts. As of April 14, 2024, the SP no longer worked with the VA. · The VA did not have concerns with any other staff persons at the facility. P1 provided the following information: · The SP was “dirty,” and when s/he changed the VA’s disposable brief, the SP got feces “everywhere” including the light switches, light bulbs, the VA’s bed, sheets, wipes, paper towels, and the VA’s clothes. P1 stated, “I can’t explain how bad it is.” When P1 asked the SP to clean up after him/herself, the SP stated that s/he did not do it. · P1 stated that the VA’s pressure sore was “not horrible” when the VA moved to the facility in November 2024 (Note: The VA moved into the facility the beginning of December 2023). The pressure sore continued to improve, but there was no “set routine” for caring for the pressure sore or changing the VA’s disposable brief. The VA did not have the ability to tell when s/he urinated, so staff persons had to check and change the VA’s disposable brief when it was saturated. The pressure sore worsened because the SP “refused” to check and/or change the VA’s disposable brief. On multiple unknown dates when P1 arrived for his/her shift after the SP worked, the VA was “soaked” in urine and feces. There were also times when P1 found feces on the VA’s bed and in the VA’s hair. · The pressure sore worsened on weekends that P1 did not work and when the SP was the VA’s direct support staff person. At one point, the pressure sore was “so bad” that the bone was “almost” showing. P1 came up with a “system” to care for the pressures sores and to prevent additional sores, including repositioning the VA and using a catheter to keep the VA’s brief dry. After the SP worked, the VA’s brief would be wet and the catheter kinked. The SP “knew how to do it [care for a catheter]” because s/he “did it right for another resident,” and the SP “just doesn’t do it” for the VA. · P1 did not talk to the SP about the way s/he cared for the VA because “it would be a waste of time” and “[the SP] would yell.” After every interaction P1 had with the SP, s/he told P2 because it was “always unpleasant.” The SP “constantly” told P1 that P1 did things wrong and told the residents the same. The SP told P1, “I refuse to take care of [the VA].” The SP did not want to do “anything” other than take care of one resident at the facility. · P1 stated that each time s/he reported his/her concerns to P2 and P3, the SP was retrained on how to work with the VA. The SP knew how to care for the VA, s/he just refused and did not so. The SP told P1 that s/he never learned how to work with the VA, however the SP helped train P1 when P1 started working at the facility. P1 stated that s/he never net anyone as “negligent” as the SP. · P1 stated that the VA did not tell P1 that the SP was rude or said things that were not nice. P1 did not work the same shift as the SP so did not observe the SP’s interactions with the VA or any client. P2 provided the following in an interview: · The SP is “very rude and mean” to the VA and had “issues” with the VA for “a while.” If the VA asked for the SP’s assistance, the SP told the VA that s/he did not need anything and “all the time” told the VA that s/he was “being a baby.” On an unknown date, the VA hurt his/her finger and the SP told the VA s/he was being a “dramatic baby bitch.” P2 saw the SP say rude things “daily” and corrected the SP “all the time.” P2 reported this to P3, and they later spoke to administration about it. Administration told P2 and P3 to retrain and “have a talk” with the SP and they did so. · The VA told P1 that the SP “refused” to reposition the VA when the VA asked. The VA was supposed to be repositioned every two hours, though at times the VA often refused, so, staff waited until the VA rang his/her call button and asked to be repositioned. The SP would tell the VA that “[the VA] didn’t need [to be repositioned]” and “Why should I do that?” In response to the SP refusing to reposition the VA, P2 “cut back” the hours that the SP was scheduled to work at the facility. · On April 5, 2024, the VA called P2 and “begged” P2 to go to the facility because s/he did not “feel safe” at night with the SP and that s/he was going to leave and “go stay somewhere else during the night.” P2 agreed to go to the facility at night to care for the VA. That evening, P2 told P3 what the VA said and P2 told this investigator that the SP had already been written up by P2 and talked to about the situation. P2 and P3 had provided retraining to the SP, but the SP’s actions did not change. · The VA had a pressure sore on his/her buttocks when s/he was admitted to the facility. P2 said that s/he and P1 “had it healed and better,” but when the SP worked “it got bad again.” On an unknown date, the VA went to a wound clinic to have the pressure sore examined. At that time, the doctor said that “it looked good.”. On April 12, 2024, P2 documented in a shift note, “At 715 [a.m.] went to wound care they said it looked amazing and to keep doing what [s/he] is doing, no return visit needed.” (Note: medical records for this visit were requested but the facility nor the clinic had a record of this visit.) P2 then worked the night shifts at the facility so that the SP was no longer working overnights with the VA. · “About a month ago” the SP was the sole staff working at the facility due to heavy snowfall. The VA told P2 that the SP did not move or reposition the VA for 12-16 hours and the SP did not document repositioning the VA in his/her shift notes. P2 also stated that the VA’s sore worsened after this period. The SP told the VA s/he was “lazy” for staying in bed. · Due to the VA’s diagnoses of cerebral palsy, repositioning him/her was “not an easy thing.” P2 described the VA’s arms and legs as stiff and spread out. P2 got a gel cushion for the VA that went under him/her in bed, and prior to that s/he used bed wedges to reposition him/her. Due to the stiffness and positioning of the VA’s limbs, s/he could not lay on one of his/her sides and could not use pillows as cushioning. The VA could not move him/herself in bed. Shift notes from February 15 to April 15, 2024, written by P2 provided the following information: · March 24, 2024: “[The VA] up at noon [s/he] was very upset today when staff had put him to bed [the VA] asked [the SP] to change cath[eter], [the SP] refused and refused to take off [the VA’s] shirt so he was sweat[ing] really bad.” · April 4, 2024: “[The VA] is very upset with night staff.” · April 6, 2024: “[The VA] in room wanted to talk to me about staff and I said I will see what I can do.” · April 6, 2024: “I went in at 9 [p.m.] and talked to [the VA] and let [him/her know] I was going to be retraining [the SP] to make sure [s/he] knows how to do things [the VA] started crying and said no [and] refused [the SP as his/her staff person and] said not only was [the SP] not taking care of [him/her] [the SP] was so mean to [him/her] and [s/he] refused to let her take care of [him/her] at all.” · April 9, 2024: “[The VA] in bed was up on return mood . . . [the VA] was upset . . . I told [him/her] [s/he] needed to take care of [him/herself], [the VA] stated [s/he] could not handle being treated that way by [the SP].” · April 10, 2024: “[The VA} had meds and asked told me [s/he] would not feel safe or comfortable with [the SP] and asked what I could do and I said that I would call [a facility administrator]” and “[The VA] later offered to get a hotel tomorrow due to not feeling safe with [the SP] I said I would be here for [him/her] and [s/he] thanked me.” · April 12, 2024: “Let [the VA] know I was going to be retraining [the SP] to make sure [s/he] knows how to do things [the VA] started crying and said no refused [s/he] not taking care of [the VA] [s/he] stated [the SP] was so mean to [the VA] and [s/he] refused to let [the SP] take care of him at all.” · April 13, 2024: “I asked again if I could retrain [the SP] on how to work with [the VA] and [s/he] shook [his/her] head no and said please no.” P3 provided the following in an interview with this investigator: · P2 came to P3 one to two times a week to discuss issues/concerns regarding the SP. P2 told P3 that the SP was “breaking HIPAA” and not doing the VA’s cares. · P3 stated that the SP is “dismissive” and “not kind” to the residents. The SP “avoided” P3 when s/he tried to meet with the SP to retrain him/her. P3 stated that the SP was on a “corrective action plan” related to caring for the VA in April, 2024 [Note: this corrective action plan was not found in the SP’s personnel file nor provided by P3]. P3 also stated that the clients at the facility “suffered” for the way the SP acted. The SP did not provide the clients with the “cares needed” and did not treat them with respect. P3 moved the SP to a different facility because s/he was “concerned” for the clients and stated that the SP should be “fully dismissed” from the company but P3 did not have the ability to do so. P3 talked to administration about the concerns with the SP and they suggested that P3 again retrain the SP. The SP provided the following information in an interview and in the facility’s Internal Review:
· The SP denied having received disciplinary action or being put on a corrective action plan. The SP also denied raising his/her voice or yelling at the VA. · The SP stated that the VA did not have anything in his/her plans about being repositioned, and “sometimes” the VA sat in his/her wheelchair “all day” and did not need repositioning. Staff persons “don’t do anything” for the VA at night except repositioning him/her if s/he tells staff that s/he was “uncomfortable” and changing his/her disposable brief if it is soiled. The SP stated that s/he repositioned the VA whenever the VA asked. · The VA called staff persons on his/her personal cell phone from his/her bedroom when s/he wanted to be repositioned or needed assistance. · The SP stated that the VA had a pressure sore on his/her tailbone since s/he moved into the facility. The SP had not seen it recently but heard that it was “almost gone.” Staff persons were to put “some sort of ointment” on it and made sure that the sore was not rubbing on the VA’s bed. The SP could not recall a time in which the sore got “particularly bad,” and “sometimes it would look worse sometimes it would look better.” · The SP stated that when s/he gave the VA water in bed, s/he would raise the head of the VA’s bed. The SP stated that s/he brought the VA water whenever s/he asked. The SP stated s/he never gave the VA water when s/he was lying down. · There was an incident that occurred and after the VA “changed” towards the SP. On an unknown date, the VA told P2 that s/he asked the SP to shovel snow from a van belonging to the VA after a snowstorm and that the SP refused to do so. The SP stated that the VA did not ask him/her to shovel out the van, but also stated that s/he would not have shoveled out the VA’s van even if he had asked the SP to do so. The VA “changed” after that and became “real quiet,” the SP added that s/he and the VA used to get along “well” before the VA “lied” about the SP. Facility documentation showed that the SP received a verbal waring and was put on a Corrective Action Plan on January 14, 2024. Details of the SP’s performance issues were not related to this investigation. s There was no additional information provided by the facility that the SP was on any other corrective action plans or received disciplinary action or retraining related to the VA. Facility documentation showed that P1 and the SP were trained on the VA’s plans and on the reporting of maltreatment of Vulnerable Adults Act. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a), states that the license holder must provide services in response to the person’s identified needs, interests, preferences, and desired outcomes as specified in the support plan and the support plan addendum and in compliance with the requirements of this chapter. Conclusion: A. Maltreatment Regarding Neglect Information obtained showed that at some point, the VA wore disposable briefs, used a condom catheter, and required repositioning. However, there was no information provided in the VA’s plans that addressed these needs which was a violation of Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a). Although there were concerns that the SP did not reposition the VA which resulted in the VA’s pressure sore worsening and that the SP refused to help the VA with his/her cares including the VA’s condom catheter, given that the VA had the pressure sore prior to moving into the facility; that the condition of the VA’s pressure sore fluctuated throughout the time frame; and that the VA’s plans did not identify cares regarding the VA’s disposable briefs, condom catheter, and repositioning, there was not a preponderance of the evidence whether there was a failure to supply the VA with necessary care or services. 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). Regarding Emotional Abuse The VA and P2 each stated that the SP was “rude” but did not provide specific examples of what the SP said to the VA that they considered “rude” and there were no other witnesses or details regarding the SP’s verbal interactions. The SP also denied raising his/her voice or yelling at the VA. Therefore, there was not a preponderance of the evidence whether the SP spoke to the VA in a repeated manner which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. It was not determined whether emotional 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: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening). Action Taken by Facility: The facility completed an Internal Review and determined that the facility’s policies and procedures were adequate but not followed and there was a need for additional staff training. The SP no longer worked at the facility. The facility also implemented a Repositioning Protocol and created a Brief Change Tracker to ensure that the VA’s cares were being done and tracked. Action Taken by Department of Human Services, Office of Inspector General: On August 30, 2024, the facility was issued a Correction Order for the violation outlined above and for failing to report maltreatment as required. Minnesota Statutes, section 626.557, subdivision 3, requires mandated reporters at a facility to immediately report suspected maltreatment. The investigation determined that three individuals failed to report suspected maltreatment as required. A letter from DHS was sent to each of these individuals regarding their failure to report the suspected maltreatment and potential consequences for future such failures.
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