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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: 1067818-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that when assisting a vulnerable adult (VA) to get dressed for the day, a staff person (P1) observed the VA’s arm looked unusual and the VA showed anxiousness. 9-1-1 was called and the VA was transported to a hospital where hospital staff persons observed what looked like a handprint on the VA’s shoulder. The VA’s left arm was found to be dislocated with some broken bones. Date of Incident(s): August 6, 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 (1): 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. Summary of Findings: Pertinent information was obtained during a site visit conducted on August 19, 2024; from documentation at the facility and/or hospital medical records; and through seven interviews conducted with four facility staff persons (P1-P4), a case manager (CM), a hospital medical doctor (MD), and a guardian (G). This investigator met the VA; however, the VA was not able to be interviewed due to his/her diagnoses. Multiple attempts to contact a hospital social worker (SW) were unsuccessful. The VA enjoyed listening to the radio and the conversations of others. The VA liked receiving attention and enjoyed van rides and eating cookies. The VA did not like transition times or having his/her clothing changed. The VA’s diagnoses included autism, intellectual disability, and seizure disorder. The VA was nonverbal. The VA engaged in self-injurious behavior and had detached retinas resulting in blindness in his/her left eye and limited vision in his/her right eye. The VA’s Coordinated Service and Support Plan (CSSP) and Addendum (CSSPA) stated that the VA preferred consistent interaction with staff persons and received physical assistance when need. The VA engaged in self-injurious behaviors (SIB) that included hitting him/herself in the face, scratching him/herself, pulling his/her hair, stomping his/her feet, and biting his/her lips until they bled. The VA also engaged in aggression towards property (throwing or clearing items off tables, tipping furniture, and pounding on surfaces) as well as aggression toward others (hitting, scratching, and kicking). The VA had a physician’s order for “posey mitts” for his/her hands to prevent further damage to his/her vision due to SIB. The VA’s Self-Management Assessment (SMA) stated that due to the VA’s visual limitations and/or risk of falling, staff persons provided the VA with physical assistance by offering to hold his/her arm when walking. An Emergency Medical Services (EMS) Run Sheet showed that on August 6, 2024, at 2:28 p.m. an ambulance crew was dispatched to the facility regarding a report of a left shoulder dislocation. Upon arrival, the VA was observed sitting on the floor in a kitchen. A staff person (determined to be P2) stated s/he was assisting the VA and noticed the VA’s left shoulder was “inflamed and dislocated.” The VA was wearing soft gloves on his/her hands to protect him/herself from self-injurious behaviors. Bruising on the VA’s face from self-harm was observed. P2 assisted the VA onto a stretcher and once there, the VA started to “kick and punch” EMS persons. Once inside the ambulance, attempts to obtain the VA’s blood pressure again resulted in the VA kicking and punching the EMS persons. Upon arrival at the hospital at 3:12 p.m., the VA was moved from the stretcher to an emergency room bed and the VA kicked and punched EMS persons and hospital personnel. The VA also attempted to “climb out” of the bed. While placing the VA in “soft restraints,” an EMS person was punched and bit by the VA. A hospital record dated August 6, 2024, stated that during the VA’s health and physical exam, the VA was “intermittently yelling” and attempted to hit hospital staff persons and him/herself. Several components of the exam were not completed due to the VA being “combative and agitated.” However, observations of the VA’s skin showed “scattered contusions and abrasions” over the VA’s bilateral upper and lower extremities, a “contusion that appears to be a handprint” over the left shoulder. (A photo provided by the hospital showed significant swelling of the shoulder with discoloration of the entire shoulder from the top of the shoulder that continued down the VA’s arm several inches.) The VA also had a small wound near the middle of his/her back on the right side that was covered with Mepilex (bandage type dressing). There was an “obvious deformity” to the VA’s left shoulder. The cause of the injury to the VA’s left shoulder was unknown and there were no reported falls. An ex-ray showed an “acute displaced fracture of the surgical neck of the humerus.” (Internet searches of the National Institute of Health and/or Johns Hopkins Medicine showed that humeral neck fractures were usually caused by traumas like car accidents or falls with an outstretched hand, that the surgical neck was the “weakest region of bone” located below the humeral head, and that symptoms included swelling, bruising, and “deformity” of the shoulder.) On August 8, 2024, the VA underwent surgery described as “open reduction internal fixation of the left proximal fracture” and “biceps tenodesis” (repair of the tendon that connects the bicep muscle to the shoulder). The VA was discharged back to the facility on August 19, 2024. P1 was interviewed by a law enforcement officer (LEO) and this investigator and provided the following information: · P1 worked with the VA for many years and said the VA had an “unsteady gait,” his/her “coordination was poor” and s/her needed physical assistance with eating, changing clothing, and other activities of daily living. · On August 5, 2024, P1 and P3 worked together at the facility. P1’s shift ended at 7 p.m. and at that time there was no indication of an injury to the VA. P3 remained at the facility that evening until P2 arrived to work the overnight shift. · On August 6, 2024, P1 arrived at the facility around 11 a.m. P2 was working with the VA when P1 arrived. The VA was sitting at a kitchen table and “seemed happy.” The VA was wearing shorts and a t-shirt. While P1 assisted the VA with eating lunch, P2 left the facility. At approximately 12:45 p.m., P1 knew the VA needed his/her absorbent adult undergarment changed and at that same time, s/he also changed the VA’s shirt. As P1 was removing the VA’s shirt and raising the VA’s arm, P1 observed the VA’s arm “socket was lower than where it should have been.” P1 “suspected” the VA’s shoulder was “dislocated” so P1 telephoned a facility health care professional (HCP) who stated the VA needed to go to an emergency room. At that time, P1 did not observe any discoloration but said that the VA’s shoulder “started to swell.” P1 also called P2 to inform him/her about the VA’s shoulder. · The VA had a “high pain tolerance” and “did not give any indication” of the injury prior to P1 removing the VA’s shirt. · The day after the VA went to the hospital, P1 observed that a piece of wood on a coffee table in the living room was cracked. P1 “wondered” if another client (C) pushed the VA out of the C’s “personal space” resulting in the VA falling onto the coffee table. P1 said that on prior occasions s/he saw the C “get angry” with the VA and/or saw the C “move” the VA out of the C’s way; however, the C did not act aggressively in those circumstances. P1 said for the most part, the VA and his/her housemates “keep to themselves.” · P1 did not know what caused the VA’s injury and denied doing anything to cause the injury. P1 did not believe any of the facility staff persons would “hide or try to obscure” knowledge about the VA’s injury. The following information was obtained from the facility’s Internal Review or from P2 when s/he was interviewed by the LEO and this investigator: · The VA’s gait was unsteady and s/he needed physical assistance when ambulating. · P2 worked from 10 p.m. on August 5, 2024, until approximately 1:30 p.m. on the afternoon of August 6, 2024. P2 believed that when s/he arrived at 10 p.m., the VA was either awake or sleeping on a couch in the living room. Around 2:30 or 3:30 a.m., the VA was stomping around the living room and hitting him/herself, and those actions sometimes indicated the VA was in pain. P2 asked the VA if s/he was in pain and the VA indicated “yes,” so P2 administered acetaminophen. The VA had a snack and remained awake for approximately 45 minutes before going back to sleep. During the night, P2 checked the VA’s adult absorbent undergarment and it was not wet and did not need to be changed. · When P2 left the facility on August 6, 2024, P1 was working, and the VA was at the table eating lunch. P2 became aware of the VA’s injury after shortly after leaving the facility when s/he received a call from P1 who said s/he suspected the VA shoulder was dislocated. · An unidentified hospital physician told P2 that the VA’s injury was “extreme,” and an unidentified hospital nurse told P2 that the VA’s injury was to the “degree of someone grabbing [the VA’s arm] and pulling to the ground.” · When asked about the VA’s unsteady gait, P2 demonstrated that s/he assisted the VA by standing next to the VA and offering an arm bent at the elbow. The VA then reached his/her arm under and around P2’s arm with contact at the crook of the arms/elbows. P2 said that other staff persons assisted the VA by walking next to the VA while holding the VA’s upper arm with their hand. P2 said in either instance, the “amount of force or pull is minimum” and therefore not likely the cause of the VA’s injury. P2 denied causing the VA’s injury.
P3 was interviewed by the LEO and this investigator and provided the following information: · P3 worked with the VA on August 5, 2024. During that afternoon and evening, P3 worked with P1 and during their time together they changed the VA’s wet adult absorbent undergarment prior to dinner. P3 recalled the VA was “calm” that evening and remained seated at a kitchen table during dinner. Later that evening, the VA received his/her medications, had an evening snack, and then went to sleep on a couch in the living room. The VA slept in his/her clothing and his/her shirt was not changed prior to bedtime. The VA was sleeping when P2 arrived for the overnight shift. P3 said there were “no tantrums” that day and s/he was not aware of anything that could have caused an injury to the VA’s shoulder. · P3 said that the VA sometimes needed physical assistance when s/he was unsteady and described how s/he offered the VA his/her arm bent at the elbow for the VA to wrap his/her arm around, similar to the description given by P2. P4 did not have information specific to the VA’s injury but stated the VA had a “high pain tolerance” and engaged in SIB. Several years ago, the VA fractured his/her arm by hitting it on a table. The VA’s T-Logs and/or Medication Administration Record from August 2-6, 2024, were reviewed and showed: · August 2, 2024: The VA was not sleeping at 10 p.m. and “did not have a good night.” · August 3, 2024: The VA was “restless” at 10 p.m. and unable to sleep. The VA moved from “place to place” and was “pushing and tipping” objects. · August 4, 2024: The VA napped on the couch during the day. A staff person observed a three inch “bruise or cut” on the VA’s back while changing the VA’s absorbent adult undergarment/clothing. The cause of the injury was not known. That night, the VA “refused to sleep” and had a “sleepless night.” · August 5, 2024: The VA did not sleep much and woke up at 7 a.m. During the day the VA spent time in the living room, watched TV, and “no concerns” were documented. · August 6, 2024: At 3 a.m., P2 documented that the VA was administered acetaminophen. Later that morning the HCP documented s/he received a call (determined to be from P1) regarding the VA being “unwilling to use [his/her] left upper extremity and [his/her] left shoulder has some swelling.” The VA was transported to a hospital via ambulance. The G said that a hospital social worker (SW) told the G about a “handprint” on the VA’s shoulder and the SW said that s/he took a picture of the handprint. The G did not know when the picture was taken. The G said that prior to this incident, s/he did not have concerns regarding the VA’s care and services, however, the G gave the facility “a lot of leeway” and the VA “has had some injuries.” The MD told this investigator that s/he “did not recall any handprint” on the VA’s shoulder and there was “no scientific literature” to support that it “takes 12 hours or 10 minutes” after an injury for a bruise to show up. Regarding the cause of the injury, the MD stated this type of fracture can occur from a “ground level” fall such as when a person puts their arm out to catch or brace themselves from a fall, or from a “twisting injury.” The MD said there were many “different factors” so s/he was not able to determine if it was from “a non-accidental trauma.” The CM did not have information specific to the incident. Law enforcement ended their investigation with no charges pending. Staff persons were trained regarding the VA’s program plans and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: On August 6, 2024, around 12:45 p.m., P1 assisted the VA with changing his/her shirt and when the VA’s arm was raised, P1 observed an injury to the VA’s arm socket and suspected it was dislocated. The VA was diagnosed with a left humerus fracture and required surgery. Several staff persons worked with the VA over the previous four days and had not observed an injury or a fall and did not know what caused the injury. Although there were some initial concerns about a “handprint” bruise on the VA’s injured shoulder, given the VA was not able to provide any information due to his/her diagnoses, that information showed the VA was very combative in the ambulance and in the emergency room requiring multiple people to hold/restrain him/her, and that the bruising later developed over the VA’s entire shoulder, the cause of what initially looked like a “handprint” was not known. Given that it was unclear how or when the VA’s fracture occurred, that the MD was not able to determine if the injury was from ‘”non-accidental trauma,” and that staff persons said they did not do anything to cause the VA’s injury, there was not a preponderance of the evidence whether all the staff persons’ actions were therapeutic conduct or whether the VA’s injury was caused by any means other than accidental. It was not determined whether physical 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). Action Taken by Facility: The facility completed and submitted a Serious Injury Report. The facility also completed an internal review and determined that policies and procedures were adequate, were implemented as written, and there was no need for additional staff person training. It was also determined that the incident was similar to a past incident with the VA when there was an incident years ago where the VA fractured his/her arm from striking a table resulting in an emergency room visit and orthopedic casting. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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