|
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: 1071289-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that a staff person (SP) did not use a mechanical lift to transfer a vulnerable adult (VA) and that the VA fell, which resulted in the VA sustaining a fractured right femur. Date of Incident(s): November 15, 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 November 25, 2024; from documentation at the facility and the VA’s medical records; and through six interviews conducted with the SP, two facility staff persons (P1 and P2), a facility management staff person (P3), a staff person from the VA’s day program (DP), and the facility’s health care practitioner (HCP). Although this investigator contacted the VA’s guardian (G), the G did not respond to requests to be interviewed. This investigator met the VA, but the VA was unable to provide information in an interview. The VA’s Face Sheet document stated that some of the VA’s diagnosis included hypothyroidism, osteoporosis and a seizure disorder. The VA’s support plan showed that s/he enjoyed accessing the community and being “connected” to his/her family and friends. The VA used a manually operated wheelchair for mobility, equipped with foot pedals and straps to secure the VA’s feet. Staff persons were to use a Hoyer lift for all of the VA’s transfers. The Hoyer lift had a sling that the VA was to sit in and four straps that were to be secured to the lift when transfers occurred. The facility’s Incident Report provided the following information: · At about 7 a.m. on November 15, 2024, the SP put the Hoyer sling under the VA, who was on his/her bed, but did it “incorrectly” and “lifting didn’t work.” As a result, the SP attempted to lift the VA, instead of using the Hoyer lift, but because the VA was “heavy,” the SP could not transfer the VA and “set” the VA on the floor. · The SP then called P3, who “explained” to the SP “how to fix the sling.” After that, the SP transferred the VA, using the Hoyer lift, from the floor to his/her wheelchair. The facility’s Serious Injury Report stated that later that day, the VA was taken to an emergency room (ER), diagnosed with a “broken right femur,” and admitted to the hospital. The SP provided the following information that was consistent with information provided in the facility’s Incident Report: · The SP worked from 10 p.m. on November 14, 2024, until 10 a.m. the following morning. At about 7 a.m., on November 15, 2024, the SP went to wake the VA up for the day. While the VA remained in his/her bed, the SP assisted the VA with taking off the VA’s nighttime clothes, changing the VA’s adult undergarment, and then dressing the VA for the day. · The SP was going to transfer the VA to his/her wheelchair so placed it next to the bed. Then, the SP attempted to put the Hoyer sling under the VA and secure the straps, but the SP was not certain that s/he did it correctly. As a result, the SP decided to lift the VA from the bed to the wheelchair without the Hoyer. There were no other staff persons working to assist the SP. · The SP put his/her arms under the VA’s arms and as the SP lifted the VA from his/her bed to go to the wheelchair, the SP realized that s/he was not going to be able to complete the transfer due to the VA’s weight. As a result, the SP “slowly” guided the VA to the floor. The VA ended up on the floor on his/her buttocks with his/her legs stretched out in front of him/her. The SP then called P3 and stated that s/he tried to use the Hoyer lift to transfer the VA, but ended up lifting the VA but could not complete the transfer so the VA was now on the floor. P3 and the SP communicated via video and P3 told the SP how the sling straps should be connected to the Hoyer lift. The SP did as P3 told him/her to do and then the SP successfully transferred the VA from the floor to his/her wheelchair using the Hoyer lift. After the transfer was completed, the VA did not have any complaints of pain. The VA did not show signs of pain at any time that morning and ate well before leaving to attend his/her day program. · In the days leading up to the incident, the SP received training from P3 on how to use the Hoyer lift. P3 provided the following information: · At about 7 a.m. on November 15, 2024, the SP called P3 and said that the VA laying on his/her back on the floor. P3 thought that the Hoyer lift malfunctioned, but the SP told P3 that s/he lifted the VA and did not use the Hoyer lift. P3 reminded the SP that was not how s/he was trained. · P3 told the SP that the Hoyer lift would need to be used to transfer the VA from the floor to his/her wheelchair. P3 and the SP used Facetime to communicate so P3 could see how the SP hooked up the sling to the Hoyer lift. P3 saw the VA on the floor on his/her back. P3 helped the SP to use the sling and Hoyer to transfer the VA so then the SP successfully transferred the VA to the wheelchair. · When new staff persons were hired, they watched a video on how to use the Hoyer lift. On November 13 and 14, 2024, P3 was on site at the facility and provided in person training to the SP on using the Hoyer lift. P1 stated that when s/he arrived at the facility for his/her shift the morning of the incident around 8 a.m., the VA was dressed and in his/her wheelchair ready to leave for his/her day program. After the SP told P1 what had happened earlier, P1 asked the VA if s/he wanted to still go to his/her day program and the VA said, “Yes,” and seemed “fine.” The DP stated that the VA did not demonstrate any signs of pain the day of the incident and appeared to be “happy.” The DP also stated that when the VA’s adult undergarment was changed at day program, that a Hoyer lift was used. There was nothing out of the ordinary for the VA that day. P2 said that when the VA arrived back at the facility from his/her day program around 4:30 p.m., P2 unstrapped the VA’s left foot strap from the wheelchair pedal as normally done. However, when P2 did the same on the VA’s right foot, the VA “screamed in pain.” When P2 asked the VA where s/he had pain, the VA pointed to his/her right leg. P2 then called the HCP, who suggested that the VA be brought in for medical evaluation. At about 5:30 p.m., another staff person (P4) came to the facility and transported the VA to the ER. The VA’s medical records showed that the VA was admitted to the hospital on November 15, 2024, diagnosed with a “right distal femur fracture,” and that “given [the VA] is not ambulatory, the decision was made to apply a splint and try a non-surgical approach.” The VA was discharged from the hospital on November 18, 2024. The HCP stated that the VA had “osteoporosis” and was “more prone” to injuries, but based on the VA’s injuries, the HCP did not believe that the VA was “lowered gently to the floor” by the SP. The HCP stated that P3 provided training, prior to the incident, to all staff persons on using the Hoyer lift. The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to November 15, 2024. Regarding the SP’s training on using the Hoyer lift, the SP’s personal training form stated, “Not started.” Conclusion: Information showed that at 7 a.m. on November 15, 2024, the SP attempted to use the Hoyer lift to transfer the VA from his/her bed to his/her wheelchair, but the SP was unsure if s/he secured the straps correctly. So, instead of using the Hoyer lift, the SP lifted the VA, but when the SP realized that s/he could not complete the transfer because of the VA’s weight, the SP stated that s/he “slowly” moved the VA to the floor. The SP stated the VA was on the floor on his/her buttock with his/her legs straight out in front of him/her. After that, the SP called P3 and P3 told the SP how to secure the straps. The SP then used the Hoyer lift to transfer the VA from the floor to his/her wheelchair. The VA did not show signs of pain. P1 said that when s/he arrived at the facility that morning around 8 a.m., the VA was dressed and waiting to go to his/her day program and that the VA did not show signs of pain. The SP told P1 what happened and P1 asked the VA if s/he still wanted to go to day program and the VA said, “Yes.” The DP stated that the VA seemed happy at day program and did not show signs of pain there either. Day program staff persons also used a Hoyer lift to transfer the VA during the day to change the VA’s adult undergarment. There was nothing out of the ordinary for the VA. P2 said that when the VA arrived back at the facility that day around 4:30 p.m., P2 moved the VA’s right foot from the wheelchair pedal and the VA “screamed in pain.” P2 called the HCP who recommended the VA be medically evaluated. Soon after, P4 took the VA to the ER, where it was determined that the VA had a right femur fracture. The VA was admitted to the hospital from November 15-18, 2024, and a splint was used. Although the SP did not transfer the VA as trained with the Hoyer lift and instead lifted the VA, resulting in the VA being on the floor when the SP could not move the VA to his/her wheelchair, given that at that time and up until the VA went to day program, the VA did not show signs of pain; that at day program the VA did not show signs of pain; and that nine and a half hours elapsed between the time the SP manually lifted the VA to the floor and when the VA expressed pain at 4:30 p.m. when P2 moved the VA’s foot from the wheelchair footrest, there was not a preponderance of the evidence whether the VA’s injury was sustained by the SP moving the VA to the floor or by any other action of a staff person, or whether the SP failed to provide the VA with reasonable and necessary care and 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). Action Taken by Facility: The facility completed an Internal Review and determined that although policies and procedures were adequate, they were not followed by the SP because the SP had been trained on using the Hoyer lift before the incident but did not use the Hoyer lift and transferred the VA by lifting the VA. The review also stated that additional training was provided. The SP was no longer employed by the facility. Action Taken by Department of Human Services, Office of Inspector General: No action taken.
|
