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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: 1105981-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: Allegation One: It was reported that during a bath, a staff person (SP) used water that was too hot and poured water on a vulnerable adult (VA) to rinse his/her hair resulting in burns on the VA’s face, ears, cheeks, neck, chin, and chest. Allegation Two: The SP used furniture/objects and/or door locks to keep the VA in his/her room or out of other areas. Date of Incident(s): Allegation One: April 26, 2024 Allegation Two: April 3, 2024, and other unknown dates 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), clauses (3) and (4); and subdivision 17, paragraph (a): 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: · Use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and · Use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825. 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 for this investigation was obtained remotely, including documentation from the facility and hospital medical records; and through 10 interviews with facility staff persons (the SP, P1, P2, P6, P7, and P8), a case manager (CM), a county licensor (CL), two guardians (G1 and G2), and/or documentation from a law enforcement officer (LEO1). The VA resided at the facility since June 2020. The VA loved sitting in the sun, playing in the water, taking bubble baths, receiving foot/back rubs, and swinging on his/her swing in a sensory room within the facility. The VA was not able to communicate verbally and did best when s/he received one-to-one attention. Due to the VA’s sensitive skin, only unscented and dye free shampoo, soap, and lotion were used. The VA had some hearing and vision loss. The VA engaged in self-stimulation such as rubbing a vacuum hose, touching objects that had different textures, and pulling on items such as blinds or shades. The VA’s diagnoses included severe developmental disability, chromosome abnormality, and celiac disease. A Self-Management Assessment stated that the VA was not able to regulate water temperature. The VA was “willing” to take a shower or a bath but preferred a bath. Because the VA was non-verbal, s/he was not able to inform staff persons if the water was too hot or cold and was not able to turn the faucet for him/herself. Staff persons were supposed to “test the water to ensure it is at a comfortable temperature prior to [the VA] having contact with the water.” A list of Individual Absolutes/Specific Instructions for the VA stated, “All new staff [persons] MUST read through [the] attached instructions, specific to [the VA], prior to work[ing] with [him/her] alone.” The list identified the VA ate a gluten free diet of only soft foods, medications were administered in yogurt or applesauce, and s/he needed to be assisted with using the bathroom “every two hours and changed as needed.” The VA required physical assistance with bathing. Facility documentation showed that staff persons were trained regarding the VA’s Support Plan, the VA’s Individual Abuse Prevention Plan, skills necessary to provide appropriate support for individual activities of daily living, responding to and reporting incidents/emergencies, the facility’s policies and procedures, resident rights, basic first aid, restricted and permitted actions and procedures under Minnesota Statutes, section 245D.06, and the Reporting of Maltreatment of Vulnerable Adult Act. During the course of the investigation there was also a concern that on April 2, 2024, the VA pulled on a cord on a small appliance that was stored on top of a refrigerator. P1 and P2 each stated that an electric can opener was placed on top of the refrigerator, out of the VA’s reach but an electrical cord was visible over the side of the refrigerator and when the VA pulled the cord, the appliance fell on the VA causing an injury to his/her right eyebrow and forehead near his/her hairline. A staff person (determined to be P2) was near the VA but unable to stop the appliance from hitting him/her. The VA’s guardians and a facility health care professional were notified that same day. Information showed no medical care was needed and the appliance was no longer stored on top of the refrigerator. No further investigation regarding this incident was completed by this investigator. Allegation One: It was reported that on April 26, 2024, during a bath, the SP used water that was too hot and poured water on the VA to rinse his/her hair resulting in burns on the VA’s face, ears, cheeks, neck, chin, and chest. Hospital records showed that on April 27, 2024, upon admission to Regions Hospital, the VA was diagnosed with second degree burns on his/her forehead, bilateral ears, cheeks, neck, and chin. The VA had “acute pain due to trauma.” The VA remained hospitalized into May 2024. (The exact discharge date was unknown as hospital records sent to this investigator ended on May 21, 2024.) G1 and G2 stated that on Saturday morning, April 27, 2024, they received a text message from P1 stating that the SP thought the VA was having an allergic reaction and needed to go to an emergency room. While immediately driving to the facility, G1 and G2 also received a telephone call from the SP who stated the VA’s skin was “peeling off” and s/he “needed to be seen.” Upon arrival at the facility, G1 and G2 “knew it was not a reaction to something” and observed the VA had facial burns. G1 and G2 said that the VA had a “high threshold” for pain and did not “process pain like others.” The SP told G1 and G2 that on Friday evening, April 26, 2024, s/he assisted the VA with a bath and when the VA got out of the tub, the SP “put [the VA] back in” but the water was “cool,” so the SP added more hot water to the tub and proceeded to wash the VA’s hair and rinse it. The VA got out of the tub “three to five times” as the SP kept rinsing the top of the VA’s head to get the shampoo out. When the VA went to bed, the SP noticed a “small spot” on the VA’s forehead was peeling. G1 and G2 transported the VA to a local emergency room where the VA was transferred to Regions Hospital Burn Center for further evaluation. LEO1 provided the following information: · P2 said that on April 26, 2024, s/he drew the water for the VA’s bath, and it was an appropriate temperature and level. The VA was not ready to get into the bathtub and when the SP arrived at approximately 8:30 p.m., the SP was able to talk the VA into getting into the tub. P2 left the bathroom and was filling out paperwork while the SP assisted the VA with bathing. P2 heard a “loud commotion” and walked into the bathroom and saw the VA on the floor. The VA’s hair was wet, and his/her face was “red,” and the SP said that s/he attempted to wash the VA’s hair; however, the SP did not indicate how. P2 assisted the VA by toweling him/her off and getting the VA dressed. P2 clocked out at 8:40 p.m. · The SP told LEO1 that s/he bathed the VA on Friday, April 26, 2024. The SP wore gloves while bathing the VA so only his/her fingers touched the water. When the VA got out of the bathtub, s/he “fell to the ground” and was “throwing a fit essentially.” When the SP observed that some of the VA’s skin was peeling, the SP brought it to P2’s attention. The SP said that s/he was not trained in bathing procedures. The SP denied using a showerhead or using water from the faucet and only used water from the bathtub. · P1 said that after the incident, s/he spoke to the SP who told P1 that s/he used the little cup generally used by the VA in the tub to rinse the VA’s hair. The SP said that s/he placed the cup under the bath spout/faucet to fill it up with water in order to rinse the VA’s hair after washing it. The SP said s/he used one hand on the VA’s forehead to redirect the water and soap and noticed a “little part” of the VA’s forehead was “peeling,” but the SP believed it was due to “dry skin.” · After the incident, on an unspecified date, a plumber measured the water temperature at the facility and it was 131 degrees Fahrenheit. · LEO1’s report documented that at the time of the incident, the facility’s water heater dial was set at “hot.” (Investigator’s note: On April 27, 2024, P1 took a picture of the water heater dial upon arrival at the facility that showed it was set on “low.”) According to the CM, an unidentified physician at Regions Hospital Burn Center confirmed the VA’s burns resulted from “a water scald.” P6 and P7 each stated that prior to the incident they provided the SP with training specific to assisting the VA with bathing that included checking the water temperature. P6 and P7 each demonstrated to the SP how to bathe the VA. When washing and rinsing the VA’s hair, P6 and P7 rinsed the VA’s hair with water from the tub faucet, checking the water temperature each time the faucet was turned on. The SP provided the following information when interviewed by this investigator: · On April 26, 2024, P2 ran the VA’s bath water. The VA was already undressed and got into the tub. The SP said the water in the tub felt “warm” through the gloves s/he was wearing. After the VA played in the water, the SP “gabbed a cup” and poured water over the VA’s head, “detangled” the VA’s hair, and “did it again.” The VA “freaked out” and got out of the tub and sat down. The SP said that s/he used water from the tub to pour over the VA’s head and denied using water from the faucet or showerhead. · After the VA’s bath, the SP noticed the VA’s skin on his/her forehead was “peeling a little bit.” The SP did not think it was a “big deal.” Before P2 left the facility, the SP asked P2 if it was “okay” and the SP said it “looked like a white mark.” The SP did not do anything about it, despite the VA not having the peeling prior to the bath. (The SP told LEO1 that s/he did not see the VA the rest of the night. The next morning the SP saw “yellow” on VA’s face.) · The SP denied ever being trained assisting the VA with bathing and said that s/he never observed anyone assisting the VA a bath. When asked about signing off on documents indicating s/he was trained, the SP said that s/he “just signed everything off.” When asked if s/he understood that signing those documents verified s/he had that training, the SP said s/he understood that. · The SP said on other occasions when s/he either had bare hands or wore gloves, the water did not burn him/her. On November 14, 2024, a District Court Petition showed that the SP pled guilty to criminal neglect of the VA. An internet search showed that second-degree burns appeared “red, blistered, and may be swollen and painful.” A burn chart showed that water of 131 degrees Fahrenheit was able to cause second degree burns in 17 seconds. The facility’s Internal Review stated that from January-March 2024, a thermometer was used to check the water temperature monthly. Documentation showed readings between January and March 2024 to be 114-115.1 degrees Fahrenheit. (At the time of the incident, an April 2024 reading was not yet documented.) On May 1, 2024, the facility had a licensed plumber come to the facility and the water temperature was 115 degrees Fahrenheit and the heater was set at the “lowest setting.” The county licensor (CL) stated that when s/he was at the facility on May 18, 2023, (almost a year prior to the incident) s/he tested the water temperature, and it was 110 degrees Fahrenheit. However, when law enforcement officers tested the water on April 29, 2024, the water was 131.8 degrees Fahrenheit. A Minnesota Department of Human Services Home Safety Checklist for Adult Foster Care (AFC) and Community Residential Setting (CRS) showed that water temperature was not to “exceed 120 degrees Fahrenheit in order to prevent scalding.” A plumbing Invoice dated November 1, 2023, showed that a new 40-gallon natural gas atmospheric water heater was installed. A plumbing Proposal dated May 1, 2024, showed that the same plumber came to facility and documented “there is a mixing valve above the water heater, but it is out of date and isn’t plumbed in correctly.” A new mixing valve was recommended where the temperature could be set. (The Internal Review stated there was no record of the installation or repair of a mixing valve, so it was unknown at the time the facility was purchased that it was plumbed incorrectly. In addition, the plumber likely did not notice the mixing valve being out of date in 2023 when the water heater was replaced.) Conclusion for Allegation One: A. Maltreatment: Information showed that on April 26, 2024, P2 ran the VA’s bath water, and the SP took over and assisted the VA with a bath and washed his/her hair. Although P2 did not witness the SP bathing the VA, prior to leaving at 8:40 p.m., P2 heard a “loud commotion” and walked into the bathroom and saw the VA on the floor. The VA’s hair was wet, and his/her face was “red,” and the SP said told P2 that s/he attempted to wash the VA’s hair. The following day the VA was hospitalized with second degree burns on his/her forehead, bilateral ears, cheeks, neck, and chin and treated at a burn center where s/he remained for approximately three weeks. Although there were discrepancies about the water heater’s setting at the time of the incident, following the incident, when the water temperature was set to “low” it measured as high as 131.8 degrees Fahrenheit. Information showed that second degree burns at that temperature could result in 17 seconds. The SP provided inconsistent information regarding where the water came from that s/he poured over the VA’s hair. However, it was evident the water did not come from the bathtub water the VA was sitting in since his/her submerged body was not affected/burned by that water. The water poured over the VA’s head caused burns to the VA’s face, ears, neck, and chest. Despite a faulty mixing valve, a reasonable person would check the water temperature prior to pouring water on anyone, including themselves. Given that a District Court Petition showed that the SP pled guilty to criminal neglect of the VA the day of the incident, there was a preponderance of the evidence that there was a failure to supply the VA with care and services which were reasonable and necessary to maintain the VA’s health or safety. It was determined that 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).
B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. Although the facility’s monthly checklist showed the water temperature was not checked yet in the month of April 2024, documentation showed the water temperature was below the recommended 120 degrees Fahrenheit when checked each of the three months prior to the incident. The’s VA plans showed that s/he could not regulate water temperature and that staff persons were to test the water to ensure it was a “comfortable” temperature prior the VA having contact with the water. In addition, despite a faulty mixing valve on the water heater, the SP’s actions were not mitigated because facility documentation showed, and the SP stated, that s/he signed his/her training documents indicating s/he was trained regarding the VA’s Support Plan and Individual Abuse Prevention Plan, skills necessary to provide appropriate support for individual activities of daily living, responding to and reporting incidents/emergencies, basic first aid, and the Reporting of Maltreatment of Vulnerable Adult Act. The SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the SP was responsible was not “recurring” because it was a single incident; however, was “serious” because it resulted in serious injury that required the care of a physician. Allegation Two: The SP used furniture/objects and/or locks to keep the VA in his/her room. Regarding April 3, 2024: Interviews and facility documentation provided the following information: · On April 3, 2024, the SP worked the overnight shift that ended at 7 a.m. The SP documented that “around 5 a.m.,” the VA was “given breakfast and [s/he] accidentally locked [him/herself in his/her room.] I don’t know if [s/he] did or [illegible word].” · On April 3, 2024, P2 documented that when s/he arrived at 7 a.m., the VA was in his/her bedroom with the door locked from the inside. (A photo of the VA’s bedroom doorknob showed there was a lever that pulled down to open the door. A locking device was on the inside of the VA’s bedroom doorknob and required a turn or twist. This type of lock required a key to unlock the door from the other side.) When the VA awoke, staff persons (the SP and P2) attempted to see if the VA was able to open the locked door; however, the VA did not and/or was not able to. P2 needed to use “force” to get the door opened. · The SP told P1 that on April 3, 2024, the VA was locked in his/her bedroom for “a few hours” because the SP was not able to find a key to unlock the door. · P8 said that a key to unlock the door was inside the office; however, staff persons panicked and “shouldered through the door.” · P1-P3, G1, and G2 each provided information that they did not believe the VA had the dexterity to lock his/her bedroom door. · The SP said that s/he “never touched the lock” and did not know how it became locked. Regarding other times the SP blocked the VA’s access in the facility: P1 said that another staff person (P4) told P1 that on unidentified dates, P4 arrived for his/her shift and furniture was moved from its usual place in what appeared to be an attempt by the SP to block the VA’s access to certain areas of the facility. P4 saw the SP moving the furniture back to its original place. P1 sent a text message to the SP asking if s/he “barricaded” or blocked areas of the facility and the SP said it was his/her understanding that it was okay to use furniture to block the VA from access to a kitchen for safety reasons. The SP said that s/he was “taught” to use a recliner to block access to the kitchen. The SP told this investigator that “at first” s/he used furniture to keep the VA in his/her room because s/he observed a former (unidentified) supervisory person use furniture to keep the VA out of the kitchen. P1 documented that on April 3 and 15, 2024, s/he addressed the SP’s use of furniture and/or objects to keep the VA in his/her room. The Internal Review stated that the VA’s bedroom door was “always open;” however, it would be closed during the SP’s shift. “None” of the staff persons believed the VA was able to open the door without assistance, nor would s/he close his/her door. It was believed that the SP shut and locked the VA’s door because the SP “did not want to be bothered” on his/her overnight shift. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.06, subdivision 2, clause 1, item 3 states that the license holder must ensure doors are locked from the inside to prevent a person from exiting only when necessary to protect the safety of a person receiving services and not as a substitute for staff supervision or interactions with the person. Conclusion: Documentation showed that on April 3, 2024, the VA ate breakfast around 5 a.m. and returned to his/her bedroom. P2 arrived at the facility at 7 a.m. and was told by the SP that the VA was locked inside his/her bedroom. A key was needed to unlock the door but neither the SP nor P2 were able to locate it and P2 needed to “force” the door open after attempts were made to see if the VA was unable to unlock the door from inside. Consistent information from P1-P3, G1, and G2 showed that the VA did not have the dexterity to lock or unlock doors and the Internal Review stated that the VA was not known to close his/her own bedroom door. The SP denied locking the VA’s door. Although the VA’s door was somehow locked from the inside, the VA was unable to provide information regarding the incident, and the SP denied locking the doorknob. The VA’s bedroom door being locked from the inside while the VA was in his/her bedroom was a violation of Minnesota Statutes, section 245D.06, subdivision 2, clause 1, item 3. On other occasions there was documentation that the SP used furniture to prevent the VA’s access to areas within the facility. Although the SP had reason to deny locking the door, there was no information that the VA was aware that his/her bedroom door was locked given that P2 said they waited for the VA to wake up to see if s/he was able to unlock the door. In addition, there was no information that the VA attempted to go to the kitchen and was not able to when the SP moved furniture to “block” the VA. Therefore, there was not a preponderance of the evidence whether the VA was unreasonably confined or involuntarily secluded in his/her bedroom or that the actions produced or could reasonably be expected to produce physical pain or emotional distress. It was not determined whether 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: Use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and Use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825). Action Taken by Facility: The facility completed an Internal Review and determined that policies and procedures were adequate but were not followed. Specific policies not followed included: incident/emergency responding, reporting and review, prohibited procedures, maltreatment of vulnerable adults reporting, and employee conduct. A new “mixer” was installed to prevent the water temperature from exceeding 120 degrees and a new digital thermometer was provided to the facility. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for serious maltreatment and that any future background studies for facilities, programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal. The facility was not issued a correction order for the violation outlined in this report because they took immediate corrective action.
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