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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: 1067784-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Kimberly Anderson/Alice Percy 651-431-6553 Suspected Maltreatment Reported: It was reported that during a shower, a staff person (SP) left a vulnerable adult (VA) alone in the shower for approximately five minutes. The following morning, the VA had a large red burn along one side of his/her back and was taken to a hospital. It was believed that the burn occurred during the VA’s evening shower. Date of Incident(s): August 5, 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 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 August 22, 2023; from documentation at the facility and medical records; and through three interviews conducted with an administrative staff person (P1), the SP, and the VA’s guardian (G). While this investigator met the VA, the VA did not provide any information about the incident. The VA enjoyed watching movies, listening to music, spending time outside, and spending time with his/her friends and family members. The VA’s diagnoses included moderate intellectual disability, spastic diplegic cerebral palsy, and neuro-degenerative disorder. The VA went to a work program five days a week. The VA used a wheelchair for mobility. According to the VA’s Coordinated Services and Supports Plan (CSSP), the VA preferred to be as independent as possible when bathing, but due to a decline in mobility, more hands-on assistance was required. The staff persons were to transfer the VA in and out of the shower and check on the VA during his/her shower. The VA was unlikely to recognize abuse, neglect, or exploitation. The SP, P1, and the facility’s documentation provided the following information: · On August 5, 2024, the SP worked at the facility with a staff person (P2). At approximately 7 p.m., the SP assisted the VA with a shower. The VA had no burn marks on his/her back when the SP assisted the VA into the shower. The SP stated that s/he checked the water temperature with his/her hand and determined that it was “not hot.” The SP believed that the VA was only in the shower for approximately five minutes because another resident also needed to shower. The SP typically assisted the VA in the shower twice a day and often allowed the VA to sit in the shower alone for a few minutes and “steam.” The SP typically did not remain with the VA the entire time s/he was in the shower, but left the VA in the shower to have privacy for a short time before returning to monitor the VA’s shower. The VA was able to wash his/her face, hands, and the front of his/her body, but the staff persons typically washed the VA’s back. The VA did not complain of pain or indicate in any manner that s/he was in pain at any point during or after the shower. · When the VA was done with the shower, the SP used the Hoyer lift to move the VA out of the shower and then the SP dried the VA “the best I could” before dressing the VA in a t-shirt and an adult disposable brief. The SP did not see a burn on the VA’s back that night. The VA slept on his/her back in a hospital bed with an inflatable mattress. The SP stated that P2 was being trained on working at the facility but was working with another resident during the time the SP assisted the VA with the shower. · On the morning of August 6, 2024, the SP assisted the VA out of his/her bed and into the shower. At that time, the SP saw a red burn on the middle of the VA’s back that was approximately ten inches long. The SP “freaked out” and called the facility’s program nurse consultant (PNC) and sent the PNC a photograph of the VA’s burn. The PNC told the SP to have the VA taken to the emergency room so the SP telephoned 9-1-1 and paramedics arrived and took the VA to the hospital. · P1 stated that after the incident, s/he talked to the SP. The SP told P1 that s/he gave the VA a shower that lasted approximately five minutes. After the SP turned on the water, s/he checked the water temperature with his/her hand and then let the VA sit in the shower. The VA was in a shower chair during the shower. The VA was unable to adjust the water temperature and was also unable to tell a staff person if the water temperature was too hot or too cold. P1 stated that due to the VA’s diagnoses, s/he was unable to tell someone that s/he was in pain. P1 stated that prior to the incident, s/he had no concerns about the SP’s care of the residents. · The SP stated that during the week prior to the incident, the SP showered at the facility and found that the water became “super hot.” The SP documented the water being hot in the staff communication notes. The SP believed that s/he should have contacted a supervisory staff person to ensure that someone checked the water temperature at the facility, but s/he only documented it in the staff notes. The SP did not know who read the staff communication notes. The SP believed that during the VA’s shower the previous night, the water temperature “surged” and caused the burn on the VA’s back. The VA also had some skin deterioration and the SP believed that might have contributed to the VA sustaining the burn. · The facility’s water temperature was to be set no higher than 110 to 115 degrees Fahrenheit (F). After the incident, P1 tested the water temperature and after running the water for five minutes, the water temperature was 110 degrees F. According to the hospital’s Burn Surgery Discharge Summary, on August 6, 2023, the VA was diagnosed with a “6% partial thickness, second-degree burn on [his/her] back.” The VA had no open areas or signs of infection. The VA was initially prescribed Mepilex Ag foam dressings, but was transitioned to daily dressing changes. The VA was prescribed acetaminophen for pain. Because the facility was unable to assist with the VA’s dressing changes, the VA remained in the hospital until August 17, 2023, when the VA was discharged back to the facility. A review of several photographs of the VA’s back showed a long, red, blistered area extending on the right side of his/her back from the middle of his/her back onto his/her right buttock. The G stated that the SP telephoned the G after the incident and told him/her that the VA sustained the burn when the SP showered the VA. The SP told the G that s/he did not notice the burn on the VA’s back when s/he assisted the VA out of the shower and that it was not noticed until the following morning. According to the facility’s staff communication notes, on an unknown date between July 7 and 13, 2023, the SP documented, “Hot water is extremely hot. Perhaps the temp [sic} control is in need of maintenance. But be aware that can [sic] when giving showers.” Facility documentation showed that the SP 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. Minnesota Rules and/or Statutes: Minnesota Statutes, section 245D.25, subdivision 1, states in part that in community residential settings to prevent scalding, the water temperature of faucets must not exceed 120 degrees Fahrenheit. Conclusion: On the evening of August 5, 2023, the SP worked at the facility. At approximately 7 p.m., the SP assisted the VA into a shower chair so that the VA could shower. The SP tested the water temperature with his/her hand and determined that the water was “not hot.” The SP left the VA to shower in private for approximately five minutes and then returned to assist the VA out of the shower and into his/her bed. The SP did not see any burn marks on the VA’s back that evening. On the morning of August 6, 2023, the SP assisted the VA out of his/her bed and then to the shower. At that time, the SP observed a long red burn mark on the VA’s back. The SP sent a photograph of the burn to the PNC, who instructed the SP to telephone 9-1-1, which the SP did. The VA was taken to the hospital, where s/he was diagnosed with a “6% partial thickness, second-degree burn on [his/her] back.” While the burn was not observed until the morning of August 6, 2023, it was more likely than not that the burn occurred when the SP bathed the VA the previous evening. However, given that the SP checked the water temperature prior to leaving the VA in the shower; that the VA did not indicate that s/he experienced pain during the shower; that after the incident the water temperature was tested and found to be 110 degrees F which was lower than required by Minnesota Statutes, section 245D.25, subdivision 1; and that the staff persons typically left the VA to shower in privacy, 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 and were followed by the staff persons. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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