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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: 1068401-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Tessa Ripka/Elisa Montgomery 651-431-6612 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) fell and had not received care until two days later and it was found that the VA had a broken arm. Date of Incident(s): March 7, 2025 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 21, 2025; from documentation at the facility and medical records; and through six interviews conducted with facility staff persons (SP1, SP2, P1, and P2), the VA, and the VA’s guardian (G). The VA enjoyed talking with his/her housemates and liked to make others laugh and have fun. The VA was diagnosed with diabetes, chronic kidney disease, and mild intellectual and developmental disorder. The VA received 24-hour supervision and did not have unsupervised time at the facility or in the community. The facility’s Incident Report stated that the VA was sitting in the living room watching TV when the phone rang. The VA stood up and went to pick up the phone and s/he slipped and fell. Staff assisted the VA up and asked the VA if s/he was okay and the VA said, “Yes,” but also stated that s/he was in pain. Staff administered medication for the pain and the VA went to his/her scheduled medical appointment. SP1 provided the following information: · On March 7, 2025, SP1 was working at the facility and around 10:00 a.m., SP1 was getting the VA’s medications and was able to see the VA. The phone was ringing, and the VA got up quickly and fell on his/her arm. SP1 noted that the VA was wearing shoes, and his/her shoelaces were untied. SP1 assisted the VA with getting up and asked the VA if s/he was okay, and the VA confirmed that s/he was okay but asked for medication for pain. SP1 administered the VA medication for pain. · Around 1:00 p.m., another staff had taken the VA to his/her medical appointment. When the other staff and the VA returned, SP1 asked the VA if s/he mentioned his/her arm pain to the doctors and the VA did not respond. It was found that the appointment was scheduled at another clinic and the VA had missed his/her appointment and it was rescheduled so s/he did not see the doctor. SP1 gave the VA his/her afternoon medications and the VA went to his/her bedroom. · Around 3:00 p.m., the VA came out of his/her bedroom and ate some food and went back to his/her bedroom. The VA did not complain of pain. · On March 8, 2025, SP1 worked at the facility and the VA took a shower. The VA did not ask for assistance and did not complain of pain and was in a good mood and was talking with SP1 and other staff. · On March 9, 2025, SP1 worked at the facility and the VA reported to SP1 around 10:00 a.m. when getting his/her morning medications that s/he was experiencing pain in his/her arm. · SP2 called P1 and was on speakerphone. P1 instructed SP2 to drive the VA to the hospital. The VA had gone to his/her bedroom and was sleeping. SP1 tried to encourage the VA to go to the hospital to have his/her arm checked by medical professionals but the VA declined and told SP1 that s/he would go to the hospital after his/her nap. SP1 and SP2 let the VA sleep. · A while later, around 6:30 p.m., SP1 went to the VA’s bedroom to wake the VA and ask if s/he wanted to go to the hospital. The VA declined and told SP1 that s/he would go later and that s/he wanted to sleep. SP2’s shift ended at 7:00 p.m., and SP2 left the facility. · At 10:00 p.m., P2 came to relieve SP1 and SP1 informed P2 that the VA’s arm was hurting, and that the VA did not want to go to the hospital. While SP1 was still at the facility, P1 called and asked how the VA was doing and SP1 reported to P1 that the VA declined to go to the hospital and that the VA was sleeping. SP2 provided the following information: · SP2 arrived at the facility on March 8, 2025, around 11:00 a.m., and the VA was in his/her bedroom sleeping. The VA came out of his/her bedroom to eat and take medications and then would go back to sleep. The VA did not complain about pain or mention to SP2 that s/he had fallen. · On March 9, 2025, the VA told SP2 that s/he fell on March 7, 2025. SP2 asked the VA if s/he mentioned this to the doctor during the VA’s medical appointment, and the VA said that due to going to the wrong clinic location, the VA did not make it to his/her medical appointment. SP2 asked the VA if s/he was okay, and the VA reported to SP2 that s/he felt okay but wanted pain medication. SP2 let SP1 know this. · Around 5:48 p.m., the VA expressed that s/he would like to go to the hospital, but s/he wanted to nap first and take more pain medication. SP2 let the VA know that his/her shift was ending at 7:00 p.m. and that if the VA wanted to go to the hospital close to that time, SP2 could not take him/her. The VA then laid back down in his/her bed. The VA remained in his/her bedroom until SP2 left the facility around 7:00 p.m. · P1 called SP2 after s/he left the facility and asked SP2 if s/he had taken the VA to the hospital and SP2 said that the VA laid back down and would not get up to go to the hospital. P1 then ended the call with SP2. P1 provided the following information: · On March 7, 2025, around 11:00 a.m., SP1 called P1 and said that the VA tripped over his/her shoelaces and fell. P1 asked SP1 if s/he called 9-1-1 and SP1 said that s/he had not, and that the VA declined to have 9-1-1 called and was getting ready for his/her appointment. P1 instructed SP1 to complete an incident report. · On March 9, 2025, SP1 and SP2 called P1 around 1:00 p.m. and said that the VA was crying and saying that his/her arm was hurting. P1 instructed SP1 or SP2 to take the VA to the emergency room or urgent care. SP1 did not have a car and SP2 did not have enough gas in his/her car to take the VA. P1 told SP2 to get the vehicle from another facility location not far from the facility and SP2 agreed. · Around 8:00 p.m., P1 received a call from P2. P2 said that the VA was crying and that SP1 and SP2 did not take the VA to the emergency room or urgent care. P1 called SP2 and asked why the VA was not taken to the emergency room or urgent care. SP2 said that the VA was sleeping and declined to go at that time. P1 informed P2 that s/he would be at the facility in the morning to take the VA to the hospital to have his/her arm checked. · On March 10, 2025, P1 arrived at the facility at 7:00 a.m. and P1 observed that the VA was not able to move his/her shoulder. P1 and the VA left the facility around 8:00 a.m. and went to urgent care. The VA received an MRI and an X-ray, and it was found that the VA had a fractured arm. · On March 19, 2025, the VA attended an appointment with an orthopedic doctor and was informed that due to the VA’s high blood pressure and high blood sugar, the VA would not be able to have surgery for his/her fractured arm nor was surgery needed. The VA was given a sling for his/her arm and was instructed to take Tylenol for pain as needed. · The VA did not have a history of falls but would not use his/her walker on a frequent basis. P2 provided the following information: · On March 9, 2025, P2 arrived at the facility around 7:50 p.m., the VA was in the living room sitting on the couch and verbalized to P2 that s/he needed help. P2 asked what the VA needed help with, and the VA expressed that his/her arm was hurting, and s/he wanted to go to the hospital, but s/he wanted to shower first but the toilet was clogged so s/he needed help unclogging the toilet. · P2 asked the VA what s/he wanted to do first and the VA expressed that s/he wanted to unclog the toilet first so P2 unclogged the toilet. The VA then wanted to shower so P2 assisted the VA with showering. P2 observed that the VA’s arm appeared swollen. · P2 called P1 and informed P1 that the VA’s arm appeared swollen. P1 asked if the VA had been to the hospital and the VA stated that they had not been to the hospital. P1 then told P2 that s/he would call P2 back. · When P1 called P2 back around 9:00 p.m., P2 was assisting the VA with getting dressed and putting on lotion. P2 assisted the VA into bed and called P1 back. P1 instructed P2 to give the VA Tylenol for pain and that P1 would be at the facility in the morning to take the VA to the hospital. P1 checked on the VA and the VA was sleeping in his/her bedroom. The VA provided the following information: On March 7, 2025, the VA was sitting in the living room and the phone rang. The VA got up and tripped and fell. SP1 helped him/her up. When s/he was seen at the hospital a few days later, the doctor gave him/her pain medication and a sling for his/her arm. The VA was not able to recall further details regarding the incident. The G provided the following information: The G was notified that the VA had fallen on March 10, 2025. The G was not sure if the VA was refusing medical care and that if the facility had notified the G sooner, the G might have been able to talk to the VA and VA might have been more inclined to go to the hospital sooner. Prior to this incident, the G did not have concerns with the facility. Medical records provided the following information: On March 10, 2025, the VA had an X-ray and a CT scan. It was noted that the VA had a nondisplaced fracture of his/her left proximal humerus. Notes stated, “This should heal without surgery or other special treatment. Continue with Tylenol for pain, wear sling for comfort. Follow up with orthopedics.” The VA was scheduled for a follow-up appointment with orthopedics on March 19, 2025. All staff person interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans and protocols. Conclusion: On March 7, 2025, around 10:00 a.m., the VA tripped and fell when trying to answer the phone. SP1 assessed the VA, administered medication for pain to the VA and the VA did not complain of pain in his/her arm further. SP2 worked with the VA on March 8, 2025, and the VA had showered and spent time in his/her bedroom. The VA did not express pain to SP1 or SP2 on March 8, 2025. On March 9, 2025, SP1 and SP2 called P1 around 1:00 p.m. and said that the VA was crying and saying that his/her arm was hurting. P1 instructed SP1 or SP2 to take the VA to the emergency room or urgent care. SP1 did not have a car and SP2 did not have enough gas in his/her car to take the VA. P1 told SP2 to get the vehicle from another facility location not far from the facility and SP2 agreed. Around 5:48 p.m., the VA expressed that s/he would like to go to the hospital, but s/he wanted to nap first and take more pain medication. SP2 let the VA know that his/her shift was ending at 7:00 p.m. and that if the VA wanted to go to the hospital close to that time, SP2 could not take him/her. The VA then laid back down in his/her bed. The VA remained in his/her bedroom until SP2 left the facility around 7:00 p.m. While SP1 was still at the facility, P1 called and asked how the VA was doing and SP1 reported to P1 that the VA declined to go to the hospital and that the VA was sleeping. P1 took the VA to the hospital on March 10, 2025, where s/he was diagnosed with a fractured arm and medical records stated that the VA’s fractured arm “should heal without surgery or other special treatment.” Although the VA fell on March 7, 2025, and was not medically evaluated until three days later, on March 10, 2025, when the VA was diagnosed with a fractured arm, given that staff persons continued to assess the VA and offer pain medication, that on March 8, 2025, the VA did not express any pain, that the VA’s arm was not swollen until March 9, 2025, and that when the VA wanted to seek care SP1, SP2, P1, and P2 attempted to convince the VA to go to the hospital but the VA declined and/or decided to sleep instead, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. It was not determined whether neglect occurred (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 policies and procedures were adequate but was not able to determine that SP1, SP2 or P2 had followed the facilities policy and procedure regarding medical emergencies. SP1, SP2 and P2 received retraining. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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