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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: 1075761-H_CRS (Home and Community-Based Services-Community Residential Setting) 1071829-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-6553 Suspected Maltreatment Reported: It was reported a staff person (SP) used a hair removal cream (Nair) on a vulnerable adult’s (VA) armpits. The VA developed oozing sores and was seen at a medical facility. Date of Incident(s): June 22, 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 July 16, 2024; from documentation at the facility and medical records; and through five interviews conducted with the VA, a facility supervisor (P), the VA’s case manager (CM), the VA’s guardian (G), and the SP. Facility documentation showed the VA dreamed of playing in an orchestra, and was described as helpful and kind. The VA liked having bonfires, going shopping, and going to the movies. The VA worked at a day program, and hoped to one day work at a deli or bakery. The VA was diagnosed with depression, anxiety, tardive dyskinesia, attention-deficit/hyperactivity disorder, intermittent explosive disorder, mood disorder, postural orthostatic tachycardia syndrome, and auditory hallucinations. The VA’s client specific documentation provided the following information: · If the VA “desired to shave, staff will assist [the VA] in using hair removal lotion.” · The VA was willing to participate in appointments and could communicate his/her medical concerns, but was unable to independently schedule appointments. According to an internet search and information from healthline.com, Nair was a depilatory cream that can be used at home to remove unwanted hair. Depilatory creams use chemicals to dissolve hair, and the hair can be easily wiped away. Depilatory creams burn the hair, and they could also burn the skin, especially if a person’s skin was sensitive. The bottle of Nair had instructions which said Nair could be used on legs, arms, underarms, and bikini area. Nair should be applied in an even layer over hair, and a small area should be checked after five minutes. Nair should be wiped off using a damp washcloth and then skin should be rinsed thoroughly. Thicker hair may require additional time, but users should not exceed ten minutes of total application time. A warning stated, “Irritation or allergic reaction may occur with some people, even after prior use without adverse effect. Therefore, test before each use by applying product to a small part of the area where hair is to be removed. . . wait 24 hours. If skin appears normal, proceed with full application.” The following is a summary of information from interviews completed by this investigator, facility documentation, and medical records: · On June 22, 2024, the SP assisted the VA in using Nair on the VA’s armpits and the VA was “yelling in pain.” The VA used an ice pack on his/her armpits and went to bed. · On June 23, 2024, the VA showed the SP his/her armpits, and the VA took a shower. A baking soda paste was used on the VA’s armpits to help with the pain. · On June 24, 2024, the G and the VA went to a medical facility where it was noted that the VA had blistering on both armpits. The VA was diagnosed with chemical dermatitis, and it was noted that, “[The VA] was being treated with baking soda which likely irritated it further.” The VA was prescribed hydrocortisone cream twice a day for a week. · The G first saw the VA’s armpits on June 24, 2024, and described them as “super raw” with oozing fluid. The G added the VA was “not safe” with a razor, and preferred “all natural” materials. · The VA said s/he wanted to use the Nair and asked the SP to assist him/her in the process. The VA said s/he had previously used Nair on his/her legs, however it did not cause the same skin discomfort on his/her legs as it did when it was applied to his/her armpits. The VA said the pain started right after the Nair was put on his/her armpits, and the SP wiped the Nair off as soon as the VA said s/he was in pain. Afterward, the VA used ice packs on his/her armpits, and his/her armpits were “red.” · The P said s/he had previously helped the VA use Nair on the VA’s legs and the VA never reacted to the Nair before. The SP told the P that the Nair “started to burn at the moment when [the SP] put it on [the VA], or a little bit after, so that’s when [the SP] took it off.” On June 23, 2024 (the day after the VA used Nair on his/her armpits), the VA showed the P his/her armpits and there was just a “little patch” of redness, but no broken skin or oozing fluid. The P used a baking soda paste on the VA’s armpits, applied an ice pack, and had the VA wear a tank top. The P said the baking soda paste was used because the G liked the VA to “use natural stuff,” and the VA had previously used baking soda paste for a bee sting. The P did not contact a medical professional after observing the VA’s armpits. · The SP had previously applied Nair to the VA’s legs "with no problem," however, the SP had not previously applied Nair to the VA’s armpits. The SP said the Nair was put on the VA’s armpits, and the VA started complaining of pain. The SP immediately wiped the Nair off the VA’s armpits and instructed the VA to take a shower to rinse off the Nair, which the VA did. The VA showed the SP his/her armpits after taking the shower, and they were red. The SP had the VA apply an ice pack to his/her armpits due to the pain, and then later used a baking soda paste. The SP did not contact a medical professional after observing the VA’s armpits. · The CM said the VA had used Nair previously, but the CM did not believe the VA understood the warning on the product. According to mayoclinic.org, “Chemical burns are tissue damage caused by strong acids, drain cleaners, paint thinner, gasoline and many other substances. Usually, you are aware of such a burn and its cause. But sometimes you may not immediately recognize a burn caused by a milder chemical. As with some sunburns, the damage may develop hours after the exposure.” The SP’s Job Description stated s/he would monitor persons served health, document health concerns, and communicate with nurse or supervisor as appropriate. The facility’s First Aid policy stated general triage and first aid practices would be available as a resource to staff persons. First aid practices were not to take the place of a doctor’s order or to delay seeking emergency medical care. If a vulnerable adult was displaying symptoms or had a need for first aid a staff person would use the first aid practices as a resource to treat or identify if outside medical professional care was required. · The following was found in the “Burns” section of the First Aid policy: o First degree burns: symptoms would include redness or discoloration, mild swelling and pain. 1. Apply cold-water applications or immerse the burn area in cool water. 2. Apply a sterile dressing and bandage loosely. 3. Document the status of condition, care, and response in the individuals’ medical notes. o Second degree burns: symptoms would include red or mottled appearance, development of blisters, considerable swelling over a period of several days, wet appearance of the surface of the skin due to damage of skin. 1. Immerse the burned part in cool water until pain subsides. 2. If immersion of burn was not practical; apply clean cloths that were wrung out in ice water. 3. Blot dry gently with clean towel. 4. Apply dry sterile gauze, or clean cloth as a protective bandage. 5. Do not break blisters or remove skin. 6. Do not use an antiseptic preparation, ointment, or spray. 7. If arms or legs were affected, keep them elevated. 8. Contact nurse/physician/medical professional to determine if medical attention was needed. 9. Document the status of condition, care and response in individuals’ medical notes. 10. Notify nurse, physician, medical professional if symptoms of infection develop. The P and the SP were trained on the VA’s client specific information, the facility’s policy and procedures, first aid, and the Reporting of Maltreatment of Vulnerable Adults Act. However, the SP did not fully complete training on the VA’s client specific information, as there was no record of the SP reviewing the VA’s CSSP. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.11, subdivision 1 stated a license holder providing intensive support services must establish, enforce, and maintain policies and procedures as required. Conclusion: It was reported that on June 22, 2024, the SP helped the VA use Nair to remove hair from the VA’s armpits. Information was consistent that the VA began to experience pain immediately after the Nair was applied. The VA told the SP s/he was in pain, and the SP then removed the Nair and the VA showered. The P and the SP said the VA’s armpits were red on June 22 and 23, 2024, but were not oozing fluid. The P and the SP had the VA use ice packs and a baking soda paste on his/her armpits. The VA was seen at a medical facility on June 24, 2024, where s/he was diagnosed with a chemical burn and was prescribed a hydrocortisone cream. Regarding the VA’s use of Nair on his/her armpits: Information was consistent that the VA asked to use the Nair on his/her armpits, had previously used Nair on his/her legs without any issues, and that Nair was intended for use on various body parts, including armpits. Additionally, the VA’s client specific documentation stated, “If [the VA] desires to shave, staff will assist [the VA] in using hair removal lotion.” The VA and the SP both said that after the Nair was applied to the VA’s armpits the VA began to experience pain, and the Nair was removed immediately. Given that the VA chose to use Nair, and the VA’s client specific documentation stated Nair could be used, there was a preponderance of the evidence that use of Nair on the VA’s armpits was not a failure to provide the VA with care or services which was reasonable and necessary to maintain his/her physical health or safety. Regarding the timeliness of the VA’s medical treatment: The Nair was initially applied to the VA’s armpits on June 22, 2024. After the Nair was removed from the VA’s armpits the SP instructed the VA to take a shower, and the SP and the VA each said the VA’s armpits were red. On June 23, 2024, the P observed the VA’s armpits and saw a “little patch” of redness, but the skin was not broken, and the VA did not have any oozing fluid. The G saw the VA’s armpits on June 24, 2024, and described them as “super raw” with oozing fluid. The VA was seen at a medical facility on June 24, 2024, and was diagnosed with a chemical burn. Although the VA was not seen at a medical facility until 24 to 48 hours after the initial incident, the SP and the P each said they did not observe broken skin or oozing fluid on the VA’s armpits on June 22 or 23, 2024. Once the VA’s armpits developed oozing and “raw” skin, the VA received medical attention. Due to the nature of chemical burns, it was reasonable that the injury might worsen over time. Therefore, there was not a preponderance of the evidence as to whether staff persons failed to provide the VA with health care or supervision which was reasonable and necessary to maintain his/her physical health or safety. Regarding the application of baking soda paste: Information was consistent that the SP and the P applied a baking soda paste to the VA’s armpits after Nair was used on June 22, 2024. The VA’s medical records from June 24, 2024, showed the use of the baking soda paste “likely irritated [the VA’s armpits] further.” There was no client specific documentation, facility policy, or first aid instruction which stated that baking soda paste should be used for a chemical burn. Use of a baking soda treatment was not documented in the VA’s plans, and was also inconsistent with the facility’s First Aid policy, which was a violation of Minnesota Statutes, section 245D.11, subdivision 1. However, there was no information provided to the DHS investigator that the SP’s and the P’s use of the baking soda paste was anything other than a good faith attempt by the SP and the P to provide therapeutic conduct to alleviate the VA’s pain and irritation. Therefore, there was not a preponderance of the evidence as to whether use of the baking soda paste was anything other than therapeutic conduct. 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 policies and procedures were adequate and followed. The report was not similar to a past events. The facility updated the VA’s client specific documents to reflect a negative reaction to Nair, and retrained the SP on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s client specific information. Action Taken by Department of Human Services, Office of Inspector General: On November 7, 2024, the facility was issued a correction order for failing to enforce and maintain policies and procedures, as well as failing to provide oversight of services provided as required.
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