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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: 1086323-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Anna Parkin 651-431-6225 Anna.parkin@state.mn.us Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) fell onto his/her floor during the night and had a bowel movement. Staff persons (SP1 and SP2) did not assist with getting the VA back into bed or with cleaning the VA until the following afternoon. Date of Incident(s): June 3 and 4, 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 June 23, 2025; from documentation at the facility; and through seven interviews conducted with a supervisory staff person (P1), three facility staff persons (P2, SP1, and SP2), the VA, the VA’s guardian (G), and the VA’s case manager (CM). This investigator contacted another staff person (P3) but P3 declined to provide information about the incident. The VA was diagnosed with a traumatic brain injury and resided at the facility for 13 years. Along a wall in the VA’s bedroom was a medical bed and a buzzer to alert staff persons. On the floor next to the bed was a mat that had a few inches of foam inside. Staff person used a sit to stand lift or Hoyer lift to move the VA from the bed to his/her wheelchair. The VA wore adult undergarments to bed and enjoyed long showers. On June 4, 2025, SP1 worked from 7 a.m. to 3 p.m. and SP2 worked the overnight starting at 11 p.m. and left at 5 p.m. the following day. P2 and P3 came in to work at the respective times. The VA provided the following information: · On a previous occasion, at an unknown time, s/he was upset with another staff person (P4) so the VA “thr[e]w” him/herself out of bed onto the mat. The VA was not injured and did not ask SP2 or P4 for assistance back into bed. The VA fell asleep “all night” and SP2 did not check on the VA. · At approximately 7:30 or 8 a.m., SP1 and SP2 came into the VA’s bedroom. SP1 told SP2 that s/he might have “smelled something” and the VA told them it was flatulence because s/he had been “gassy” all night. SP1 and SP2 did not check the VA’s adult undergarment. The VA did not have a history of bowel incontinence at night but had urinary incontinence approximately every two weeks at night. · SP1 and SP2 then used the Hoyer lift to move the VA to his/her bed. The VA fell back to sleep in his/her bed. SP1 and SP2 did not come back and check on the VA and the VA did not remember anything until P2 asked the VA about being incontinent. P2 provided the following information: · On June 4, 2025, at 3 p.m., P2 arrived at the facility and SP1 said that the VA was in the bathroom getting ready to shower. SP1 also said that the VA was in bed “awhile” during the day and missed his/her noon medication. SP2 was already assisting the VA so P2 went to assist other clients. · At 5 p.m., SP2 left the facility so P2 went into the bathroom to assist the VA with washing his/her hair. Once they were done, P2 went into the VA’s bedroom to get clean clothes and saw the VA’s bedding “severely soiled” with urine and feces and the sling of the Hoyer lift soiled. · P2 went back into the bathroom and asked the VA what happened and the VA responded that s/he rolled him/herself onto the floor. While on the floor, the VA had a bowel movement and slept on the floor before SP1 and SP2 got the VA back into bed. Once back in bed, the VA fell back asleep with the sling under him/her all day. SP1 got the VA into the bathroom using the sit to stand and the VA had not eaten or drank anything yet that day. P2 checked the VA and did not see redness or any injuries to the VA’s buttock or body. P2 cleaned the VA’s bedding and sling. · The VA had a history of incontinence with urine and bowel and a history of “when upset” rolling off his/her bed onto the mat. Staff persons waited until the VA “calm[ed]” and then moved him/her back into bed. It was “common” for the VA to lay in bed all day. P1 stated that staff persons were trained to do checks on the VA every 30 minutes while s/he slept. The VA had a buzzer near his/her bed to call staff persons if s/he was incontinent or needed to use the bathroom. There were no injuries or breakdown of skin from the incident. SP1 provided the following information: · When SP1 arrived at the facility at 7 a.m., s/he saw the VA asleep on the mat. SP1 assisted other clients for an hour until they left and at approximately 8 a.m., SP1 and SP2 used the Hoyer lift to get the VA back into his/her bed. SP1 denied smelling urine or feces at that time. · SP1 went to get the VA’s medication and by the time SP1 came back to the VA’s bedroom, the VA was asleep. Approximately every 15 to 30 minutes, SP1 stood in the doorway and visually checked the VA. The VA did not eat throughout the day because s/he was asleep. · At approximately 2:30 p.m., the VA used his/her buzzer to notify SP1 that s/he was awake. SP1 went into the VA’s bedroom and smelled urine and feces so s/he asked the VA if s/he wanted to use the bathroom. SP1 used the stander to get the VA out of bed, assisted the VA into the shower chair over the toilet, and cleaned the feces off the VA with soapy water. The shower chair and stander were clean but SP1 was not sure if the Hoyer lift was dirty. SP1 did not go back into the VA’s bedroom so was not aware if his/her bedding was soiled and could “only assume” it was. · At that point, it was almost time for SP1 to leave so s/he went and told SP2 that the VA was in his/her shower chair but still using the toilet so SP2 could assist the VA when s/he was ready to get into the shower. · The VA had a history of urinating and defecating in his/her adult undergarment through the day and night. Staff persons worked as a “team” to clean so at shift change, staff persons continued tasks that were not completed the prior shift. SP2 and progress notes provided the following information: · On the night of the incident, at 1 a.m., the VA ate a sandwich and drank liquids. At approximately 2 a.m., the VA said s/he needed to change his/her clothing so SP2 suggested that the VA go to the bathroom. The VA fell asleep before making it to the bathroom so SP2 assisted the VA with getting into bed. · At one point, the VA was on the floor but yelled and kicked at SP2 and another staff person (P4) so they left the VA on the floor because it was not safe to transfer the VA using the Hoyer lift if the VA was upset. SP2 gave the VA a pillow and blanket and at approximately 3 a.m., SP2 left the VA’s bedroom. The VA remained awake for at least the next hour while calling for staff persons and being verbally aggressive. The VA did not fall asleep until after 5 a.m. Every 30 minutes, SP2 checked on the VA on the mat to determine if it was safe yet to move the VA. · At an unknown time, SP1 and SP2 moved the VA from the floor to the bed using the Hoyer lift. During that time, SP2 thought s/he smelled feces but was unsure if it was the VA or another client. SP2 asked the VA if s/he defecated and the VA responded, “No.” After the VA was in bed, SP2 went and assisted two other clients. SP1 checked on the VA throughout the day and told SP2 that the VA was still asleep. · At some point in the afternoon, the VA woke up and SP1 assisted the VA onto the toilet. At 3:30 p.m., SP2 went into the bathroom and moved the VA from the toilet into the shower. SP2 did not remember seeing feces on the shower chair or the VA. SP2 assisted the VA with preparing for the shower and into the shower before assisting other clients. SP2 did not go into the VA’s bedroom so was not aware if items were soiled. · At approximately 4:45 p.m., SP2 went back into the bathroom and assisted the VA with some washing. SP2 then went into the kitchen and cooked food while the VA remained in the shower until after SP2 left at 5 p.m. The CM stated that the VA was independent with showering and changing his/her clothing. Facility documentation showed that all staff persons interviewed were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident.
Conclusion: P2 stated on June 4, 2025, after 5 p.m., s/he assisted the VA after his/her shower. During that time, P2 saw the VA’s bedding was “severely soiled” with urine and feces and the sling of the Hoyer lift soiled. The VA told P2 that s/he had a bowel movement while on the floor before SP1 and SP2 got the VA back into bed; the sling was underneath the VA the entire day; and s/he had not eaten or drank anything that day. Although the VA’s bedding and sling were soiled, given that when SP1 and SP2 assisted the VA into bed and might have “smelled something,” the VA told them it was flatulence because s/he had been “gassy” all night; that SP1 and SP2 visually checked on the VA throughout the day while s/he slept; and that once the VA woke up SP1 and SP2 immediately assisted the VA to the bathroom and to shower, there was not a preponderance of the evidence whether staff persons failed to provide the VA with reasonable and necessary care. 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 policies and procedures were adequate but not followed. Staff persons received additional training on documenting visual checks of the VA every 30 minutes. The checks included verifying any incontinent issues and ensuring the VA’s bedding was clean. SP1 was assigned to work at another facility location while the internal investigation was open. Action Taken by Department of Human Services, Office of Inspector General: No further action taken at this time.
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