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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: 1107968-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman/Alice Percy 641-431-6567 Suspected Maltreatment Reported: It was reported that a supervisory staff person (SP) gave a homemade rice-filled heating pad to a vulnerable adult (VA) to apply to his/her leg for pain. The VA later had blisters on his/her leg and stomach, which began bleeding. The VA was seen by his/her physician, who diagnosed a second-degree burn. Date of Incident(s): November 10, 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 December 19, 2023; from documentation at the facility and medical records; and through three interviews conducted with a facility administrative staff person (P1), the SP, and the VA. The VA enjoyed going out to eat, shopping, playing Bingo, doing craft projects, and spending time with friends and family members. The VA’s diagnoses included spina bifida, syringomyelia, pulmonary hypertension, abdominal fistula, major depressive disorder, anxiety disorder, and mild developmental disabilities. The VA used a wheelchair for mobility. The VA went to his/her community job site two days each week. According to the VA’s ISSA Assessment Detail, the VA did not have feeling from the waist down so s/he would not be able to tell if a heating pad was too hot. The VA stated that the SP had a rice pack that the SP used as a heating pad. The VA and the SP talked about the VA using the rice pack on his/her stomach and leg because the VA was experiencing pain in those areas. The VA believed the rice pack was heated in the microwave for two minutes and was on the VA’s body for 15 to 20 minutes. The SP placed the heated rice pack on the VA’s stomach and leg over the VA’s shirt and pants. The VA did not feel it burning him/her because s/he was unable to feel anything from the waist down. The following day, a staff person saw a blister on the VA’s skin. The VA’s physician prescribed a cream to use on the burn. P1 and the SP and the facility’s documentation provided the following information: · On the morning of November 10, 2023, the VA complained of pain in his/her shoulders and leg spasms, so the SP told the VA that s/he sometimes used a homemade rice pack for pain and that s/he had it in his/her car. The SP stated that s/he did not think about the rice pack being a “medical device,” but instead thought of it as being a “soothing comfort item.” The SP brought the rice pack in and heated it in the microwave oven for one minute prior to placing it on the VA’s shoulders. The SP stated that s/he “kept close watch” and did not notice any skin irritation on the VA’s shoulders. The rice pack was on the VA’s shoulders for “less than an hour.” At that time, the VA placed the rice pack on the kitchen counter. · At approximately 3 or 4 p.m., the VA told the SP that s/he had “felt some relief” from the rice pack that morning and wanted to use it for his/her leg spasms, so the SP rewarmed the rice pack in the microwave for one minute and placed it under the VA’s stomach and on the top of the VA’s right thigh on top of the VA’s clothing. After the rice pack was placed on the VA’s leg, the VA showed no signs of irritation or discomfort. The SP saw the VA take the rice pack off his/her leg and place it on the counter “a couple of times” and then put it back on his/her leg. The SP stated that while the rice pack was placed over the VA’s clothing, due to the VA’s movements, the rice pack may have come in direct contact with portions of the VA’s skin. · At approximately 7:30 p.m., the SP assisted the VA to bed and saw that the area on the VA’s leg where the rice pack was placed had a “slight redness.” The SP did not know if the redness was caused by “warm skin contact or if something else happened.” At that time, the rice pack was “slightly warm.” The SP believed that it was “unlikely” that the rice pack would still be warm after four hours, but stated that s/he did not re-heat the rice pack and believed that the VA might have re-heated the rice pack at some point during the evening. P1 provided information that the VA was able to independently use the microwave oven. The SP told the VA that there was “some redness” on the VA’s leg and that they should “keep an eye on it.” · On November 11, 2023, at 7:40 a.m., a staff person (P2) texted the SP and told him/her that there was a red spot on the VA’s stomach and leg and sent photographs of the red spot to the SP. The SP told P2 to treat the area as a burn and apply burn cream to the area. The SP knew that the VA had an appointment with his/her wound care specialist the following week, who could check on the burn at that time. · The SP stated that on November 14, 2023, the facility’s health care professional (HCP) saw the VA’s burn and recommended that the VA “follow up” with his/her wound care specialist to see if they had any recommendations for care. On November 15, 2023, P1 saw the VA’s burns on the VA’s stomach and leg and described them as light pink around a center area that was “dark red and open.” P1 stated that the burn on the VA’s stomach was “slightly bigger than a quarter but longer.” On November 15, 2023, the VA was seen by his/her wound care specialist, who diagnosed a second degree burn and ordered a cream to be applied to the VA’s burns. · P1 and the SP each stated that at the time of the incident, there was no written policy about the use of heating devices. The SP stated that prior to the incident, s/he was aware that the VA “had some lack of feeling” in his/her legs. The SP stated that during his/her first aid training when s/he began working at the facility, s/he was told that the staff persons could use the over-the-counter burn cream for “up to second degree burns.” According to the facility’s Serious Injury Report, on November 10, 2023, the area of the VA’s burn had “red shiny skin.” On November 11, 2023, a blister formed, which popped and then became open. On November 12 and November 14, 2023, there was bleeding on the burn area. On November 15, 2023, the VA had a wound care appointment. According to the facility’s Triage General First Aid Policy, when a resident had a second-degree burn, which was indicated by a red or mottled appearance, development of blisters, or considerable swelling, the staff persons were to use cold water to help reduce pain, apply a protective bandage, and contact a medical professional to determine if medical attention was needed. Facility documentation showed that the SP and P1 each 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. Conclusion: On the morning of November 10, 2023, the VA complained of pain in his/her shoulders and leg spasms, so the SP heated a rice pack in the microwave oven for one minute prior to placing it on the VA’s shoulders. The SP did not notice any skin irritation on the VA’s shoulders. At approximately 3 or 4 p.m., the VA told the SP that s/he had “felt some relief” from the rice pack that morning and wanted to use it for his/her leg spasms, so the SP reheated the rice pack in the microwave for one minute and placed it on top of the VA’s clothing under the VA’s stomach and on the top of the VA’s right thigh. After the rice pack was placed on the VA’s leg, the VA showed no signs of irritation or discomfort. The SP saw the VA take the rice pack off his/her leg and place it on the counter “a couple of times” during the afternoon and then put it back on his/her leg. The SP stated that s/he did not reheat the rice pack any additional times. At approximately 7:30 p.m., the SP assisted the VA to bed and saw that the area where the rice pack was placed had a “slight redness.” The SP did not know if the redness was caused by “warm skin contact or if something else happened.” At that time, the rice pack was “slightly warm.” The following morning, P2 told the SP that there was a red spot on the VA’s stomach and leg and the staff persons applied burn cream to the injury. On November 14, 2023, the VA was seen by his/her wound care physician and was diagnosed with a second degree burn and give cream to put on the burn. 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. Although the VA sustained a second degree burn on his/her leg and stomach, given that the SP stated that s/he heated the rice pack one time each prior to placing it on the VA’s stomach and leg; that the SP stated s/he did not reheat the rice pack to be placed in the same spot; that the VA was able to use the microwave independently and possibly reheated the rice pack him/herself and continued to use it on his/her stomach and leg; and that the VA was able to remove the rice pack without assistance, the SP’s conduct constituted an error in the provision of therapeutic conduct rather than neglect for the following reasons: (i) When it was observed that the VA had a burn, staff persons provided care to the VA’s burn by using a burn cream and monitoring it. The VA was then seen by his/her wound care physician who solely ordered cream for the burn; (ii) The health status of the VA returned to normal and the VA had no lasting injury as a result of the burn; (iii) The SP did not have a pattern of errors; (iv) The facility reported the incident as required; (v) The facility completed an internal review and implemented corrective action. (See Action Taken by Facility); and (vi) The facility’s actions as required by (iv) and (v) were sufficiently documented for review.
Given the aforementioned, it was determined that the SP’s actions constituted an error in the provision of the therapeutic conduct and were 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 facility’s policies were adequate, but were not followed by the SP. After the incident, the SP received additional training on the facility’s policies. The facility added information in their policies to not allow homemade heating or cold packs to be used in the facility. 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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