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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: 1086655-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Kim Huettl Anderson 651-431-6553 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) fell asleep while using a heating pad and sustained 2nd degree burns with blistering. Date of Incident(s): unknown prior to March 12, 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 March 28, 2024; from documentation at the facility; and through four interviews conducted with the VA, a facility management person (P1) and two staff persons (P2 and P3). Attempts to contact the VA’s guardian (G) via telephone were unsuccessful. The VA’s Coordinated Services and Supports Plan stated that the VA enjoyed being by a river, going for walks, going out to eat and shopping, and participating in community activities. The VA experienced ongoing pain from arthritis. The VA’s Identifying Information and Individual Abuse Prevention Plan stated that the VA was diagnosed with intellectual disability, schizoaffective disorder, personality disorder, diabetes, and bilateral lateral bursitis. The VA was supported with one-to-one staffing with auditory and/or visual supervision. When the VA wanted alone time at home, staff persons were to visually check on him/her every two hours. The VA’s Coordinated Service and Support Plan Addendum stated that the VA wanted to be as independent as possible, but staff persons were encouraged to verbally prompt the VA when necessary. The facility’s Incident Report Form -Detail dated March 12, 2024, stated that on an unspecified date, the VA asked P1 for assistance with his/her pants and P1 noticed a blister on the VA’s right buttock. P1 followed the “flip chart” on treating blisters and prompted the VA to not pop the blister. The next day, the VA had a blister on his/her right hip. The blisters were covered and treated with ointment. On March 14, 2024, the VA had an appointment with his/her primary physician who looked at the blisters and prescribed an antibiotic ointment. The VA stated that when s/he sustained the burns on an unspecified date when s/he fell asleep with the heating pad on his/her lower back near his/her buttocks. The VA thought that the cover of the heating pad had come off and staff persons were not checking on the VA to see how long s/he was using the heating pad. The VA did not know when the burns occurred, how long s/he had the heating pad on, or who was working at the time. The VA went to the doctor for the burns and was prescribed an ointment to put on the burns. Interviews with P1, P2, and P3 provided the following information: · The VA had his/her own heating pad and used his/her heating pad independently. There were times that staff persons were not aware that the VA was using his/her heating pad because the VA would use the heating pad in his/her bedroom. · P1 stated that the VA had three burns, one was on his/her buttock and two on the middle of his/her back. According to P1, the date the burns occurred was unknown. The VA did not tell anyone about the burns for a “few” days so P1 did not know if they occurred when the VA fell asleep in his/her recliner in the living room or when s/he used the heating pad in his/her bedroom. P1 was not sure which staff persons were working when the burns occurred or how long the heating pad was on the VA before the burns occurred. · The VA independently bathed and dressed him/herself and staff persons would not have seen the burns unless the VA told someone. The day after the burns were discovered, the VA had an appointment with his/her doctor and the burns were addressed at that appointment. The VA was diagnosed with second degree burns and prescribed an ointment. · After the incident, P1 bought a timed switch for the heating pad so in the event that the VA fell asleep with the heating pad and staff persons did not check on the VA, the heating pad would automatically turn off after 20 minutes of use. · P2 noticed a burn blister on the VA’s buttock when the VA asked P2 for assistance in the bathroom. P2 applied bacitracin to the blisters and documented the burn blisters in the VA’s Progress Notes. (Note: although P2 said this happened on March 7, 2024, P2’s corresponding Progress Notes entry was dated March 8, 2024.) · P2 stated that the VA was allowed to use his/her heating pad for 20 minutes at a time, but that staff persons were not required to monitor the VA’s usage. The VA “typically” used the heating pad while sitting in his/her chair in the living room. The VA “rarely” sat still for longer than 30 minutes at a time. · P3 did not see the VA using the heating pad on the days leading up to the burn blisters. The VA’s Progress Notes and the facility’s Internal Review provided the following information: · On March 7, 2024, at 10 p.m., the VA was asleep in his/her bedroom in his/her recliner. · On March 8, 2024, the VA asked P2 to look at the VA’s buttock because there was a blister that formed the previous day. P2 applied bacitracin. · On March 9, 2024, the VA showed a staff person a “new” sore on his/her right hip that was a blister that had popped. The staff person noted the blister was “possibly” from using a heating pad. The staff person applied bacitracin to the VA’s hip and buttock. · On March 14, 2024, the VA saw his/her primary doctor, who diagnosed the VA with second degree burns. The VA was prescribed a prescription antibiotic ointment. · On March 16, 2024, the bandage on the VA’s hip and buttocks was changed and appeared to be healing. · On March 20, 2024, a facility healthcare professional found two additional burns, one on the VA’s buttocks and one on his/her back. · Also on March 20, 2024, the VA had a “new” protocol for using his/her heating pad. Staff persons reminded the VA that with his/her neuropathy and diabetes that staff persons needed to monitor his/her heating pad usage. The facility’s personnel files showed that P1, P2, and P3 were trained on the VA’s plans for the 2023 – 2024 year and on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: On March 8, 2024, P2 saw a burn mark on the VA’s buttock and applied bacitracin. The next day the VA had a blister on his/her right hip. On March 14, 2024, the VA saw his/her primary doctor who diagnosed the VA with 2nd degree burns. On March 20, 2024, two additional burns were found on the VA’s buttocks and back. According to the VA, P1, and P2, the VA independently bathed and dressed him/herself and only asked for help when needed. The VA did not tell anyone about the blisters for a “few days” so it was not determined when the burns occurred or who was working at the time. In addition, information showed that the VA used the heating pad independently in his/her bedroom and in the living room, and that staff persons were not required to monitor the VA’s use of the heating pad. Although the VA sustained burns to his/her buttocks, back and hip that were likely from a heating pad, given that staff persons were not required to monitor the VA’s heating pad use and that it was undetermined when the burns occurred, and when or for how long the VA used the heating pad, there was not a preponderance of the evidence whether there was a failure to provide the VA with care that was reasonable and necessary to obtain or maintain his/her health or safety. 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 their policies were adequate but not followed for this incident. The facility created a written procedure for the VA’s usage of his/her heating pad, purchased a heating pad with an automatic timer, retrained staff persons on reporting promptly and documenting medication on Medication Administration Records. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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