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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: 1109826-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had a “controlled” fall from bed at 3 a.m. and although three staff persons (SP1-SP3) attempted to assist the VA from the floor, the VA remained on the floor until about 9 a.m. It was also reported that the VA’s knees and elbows were “raw.” Date of Incident(s): prior to April 29, 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 May 5, 2025, from documentation at the facility, from the VA’s medical records, and through eight interviews conducted with SP1-SP3, a facility management staff person (P1), two facility staff persons (P2 and P3), the VA’s guardian (G), and the VA’s case manager (CM). Although this investigator met the VA, the VA was unable to provide information in an interview due to his/her disability. This investigator contacted a medical doctor (MD) who treated the VA in an emergency room (ER), however the MD did not respond to requests to be interviewed. The VA’s Individual Information Sheet showed that some of the VA’s diagnoses included cerebral palsy, hypertension, bipolar disorder, and a moderate developmental disability. The VA’s My Plan stated that the VA enjoyed swimming, watching movies, and attending his/her day program. The plan showed that the VA used a walker and “transfer belt” for ambulation and that staff provided assistance as needed. The facility had a document that provided directions to staff persons to assist the VA with his/her activities of daily living. The VA could “walk around the house independently” and when the VA fell or was on the floor, staff persons were not supposed to lift the VA from the floor. Instead, staff persons were to offer the VA a “stable chair” and encourage the VA to stand. On occasion, the VA would not stand because the VA could “see staff.” When that happened, staff persons were trained to “move out of eyesight, but have eyes on” the VA. When the VA was on his/her knees, staff were trained to offer support, without lifting, as the VA lifted his/her body from the floor. A review of the VA’s plans did not identify a frequency in which staff persons were to check on the VA during the overnight shift or a specific timeframe in which staff persons were to call for direction when the VA was on the floor and was unable to get up. The facility had a Task Sheet for the VA, which stated that staff persons were to document how many milliliters (ml) the VA drank, but the target amount was not identified. The documentation for April 2025 was inconsistent. Some staff documented water consumption without an amount and some documented in ounces. The facility’s staffing schedule showed that on April 27, 2025, P3 worked from 8 a.m. until 9 p.m. and during the overnight shift between April 27 and 28, 2025, SP1 and SP2 had awake positions and SP3 had a sleep position. P2 worked the day shift on April 28, 2025. The facility’s Summary of Internal Review provided the following information: · At 9 a.m. on April 28, 2025, P2 got to the facility for his/her shift and was told, by an unspecified person, that the VA “slid to the floor in the middle of the night” and that SP1 and SP2 “had not been able to get [the VA] up.” P2 called P1, who told P2 to call 9-1-1. · First responders arrived at the facility at 9:30 a.m. and transported the VA to the hospital. · When SP1-SP3 were interviewed by management, they stated that the VA “slid out” of bed between 3 and 4 a.m. and that it was “not uncommon” for the VA to do that and then “refuse” to get up. SP1-SP3 each said that they tried a variety of methods to assist the VA from the floor, such as “the use of a chair” so the VA could use the chair as leverage to get up and giving the VA “space by stepping out [of the VA’s bedroom] for 15-20 minutes” while maintaining visual supervision of the VA. · As a result of the incident, management interviewed five staff persons, and all staff interviewed stated that it was “unusual” for the VA to refuse assistance for “long periods of time.” · While the VA was hospitalized, the VA was diagnosed with a urinary tract infection (UTI) and rhabdomyolysis (a condition that causes muscles to break down, which lead to toxins being released into the circulation system and kidneys). The VA was released from the hospital on May 2, 2025, and the facility began using a Hoyer lift on May 3, 2025, to assist the VA with transfers. · The review stated that it was not uncommon for the VA to “lower” his/her body to the floor and “refuse or seem to struggle” to get off the floor but the VA typically got up within 30-45 minutes. The website www.webmd.com stated that rhabdomyolysis was a “serious condition cause by a direct or indirect muscle injury. It happens when muscle fibers die and release their contents” into the bloodstream. The VA’s medical records provided the following information: · At about 3 a.m. on April 28, 2025, at the facility, the VA “lowered” him/herself to the floor from his/her bed and “was unable to stand up independently.” · While the VA was in the ER, the G told a doctor over the phone that previously the VA was unable to stand when s/he was dehydrated. The VA was admitted to the hospital and liquids were administered through intravenous therapy (IV). The VA was diagnosed with a UTI and prescribed ertapenem. The VA was also diagnosed with rhabdomyolysis and prescribed other medications for treatment. The records also noted, “abrasions noted on bilateral knees and elbows,” but no treatment was provided for those. The VA was discharged from the hospital on May 2, 2025. Pictures, taken by P2 on April 28, 2025, showed various scrapes and abrasions on the VA’s knuckles, elbows and knees. SP1 provided the following information: · On the night of April 27, 2025, SP1 began his/her awake shift at 11 p.m. At midnight, SP1 checked on the VA, who typically wanted to use the bathroom at that time, but the VA was sleeping. Because of that, SP1 did not wake the VA up to use the bathroom. · At 3:15 a.m., SP2 checked on the VA and the VA was “weak” and on the floor, which SP1 had previously seen on other nights. SP2 asked SP1 for assistance and for about an hour they tried to assist the VA from the floor by using a chair, but they were unsuccessful. · At about 4 a.m., SP1 sought assistance from SP3, and they tried to assist the VA from the floor, but they were also unsuccessful. · At about 5 a.m., SP1 returned to the VA’s bedroom and tried to verbally encourage the VA to stand up, but the VA did not get up. SP1 continued to try, at least twice per hour, to verbally assist the VA to stand up, but was not successful. SP1 did not think about calling 9-1-1 because SP1’s “main focus” was getting the VA up from the floor. · Beginning at about 6 a.m., SP1 offered water to the VA and the VA drank the water, but SP1 did not remember how much water the VA drank. · The VA seemed “okay” in the days leading up to the April 28, 2025, incident and SP1 did not have any concerns. SP1 did not have concerns related to the VA’s ability to breathe that night. · Prior to the incident, the VA typically had the ability to get up on his/her own. The VA normally got up within 20-30 minutes if the VA fell or lowered him/herself to the floor. SP2 provided the following information: · At about 3 a.m. on April 28, 2025, SP1 checked on the VA to assist him/her to the bathroom, but the VA was on the floor. SP2 did not hear the VA fall from the bed to the floor. SP1 asked SP2 to assist with getting the VA off the floor by using the chair, but that did not work. SP2 described the VA as being “very lethargic,” which SP2 had seen prior to that night. · Shortly thereafter, SP3, who had been sleeping, came to assist, but SP2 did not know who asked SP3 to assist in getting the VA up from the floor. · At least twice hourly, SP2 continued to try and encourage the VA to get up, but the VA remained on the floor and did not get up. However, there were times that the VA got partially up by being on his/her knees and having his/her hands on the chair, but even with assistance, the VA could not go further. When that happened, SP2 gently assisted the VA back to the floor so the VA could rest. SP2 did not have concerns related to the VA’s breathing. · SP2 noticed that the VA had some abrasions on his/her knees from trying to get up to the chair. When SP2 left his/her shift, s/he told P2. SP2 did not remember how much the VA was supposed to drink but stated that s/he did not have concerns that the VA was not drinking enough water in the days leading up to the incident. · Prior to the incident and when the VA fell or was on the floor, staff were trained to put a chair in front of the VA and once the VA was on his/her knees, staff provided some support and the VA would normally stand up and that “always works” within 20 minutes or so, but there were times that it could take the VA upwards of three hours to get off the floor. SP3 provided the following information: · At about 4 a.m. on April 28, 2025, SP3 heard “movement” coming from the VA’s bedroom so s/he got up and was told by SP1 and SP2 that the VA “slipped” onto the floor around 3 a.m. · For the next several hours, SP1-SP3 continued going into the VA’s bedroom at least a couple times per hour to assist the VA from the floor, but they were not successful. SP3 knew that at some point between 4-9 a.m., someone changed the VA’s adult absorbent undergarment, but SP3 did not remember who that was. · SP3 did not see any injuries on the VA when s/he left the facility at the end of his/her shift and did not have concerns related to the VA’s breathing. · Prior to the incident, SP3 described the VA as being “weak,” but SP3 did not think too much about that because that had happened in the past for unknown reasons. SP3 did not remember the volume of water the VA was supposed to drink but said that the VA almost always did well drinking water and SP3 did not have concerns related to the volume the VA drank. P2 provided the following information: · At about 9 a.m. on April 28, 2025, P2 got to work and learned from SP1 that the VA was on the floor in his/her bedroom and that SP1-SP3 were unable to assist the VA from the floor.
· At about 9:10 a.m., P2 went to the VA’s bedroom and the VA was still on the floor and that was the first time that P2 observed that the VA did not have the ability to get up. Typically, when the VA fell or lowered his/her body to the floor, the VA got up within 20 minutes. On occasion, the VA refused to get up. · At about 9:20 a.m., P2 called 9-1-1 and changed the VA’s adult absorbent undergarment. Paramedics arrived and transported the VA to the hospital. P2 stayed with the VA at the ER and subsequent hospitalization for most of the day. · P2 described the VA as being “fine” in the days leading up to the incident. P1 provided the following information: · At least weekly, P1 had responsibility to ensure that staff documented the VA’s liquid intake and that s/he made calls to staff if there were questions surrounding the amount of liquid the VA consumed and that the VA typically did well with water consumption. · When the VA fell, staff persons were trained to encourage the VA to grab onto a chair to lift him/herself from the floor and if that did not work, staff were trained to call P1. A specific timeline was not identified as to when staff should call P1. P1 did not receive a call from SP1-SP3 on the morning of April 28, 2025. The VA typically got up from the floor within 20-30 minutes. · P1 did not have concerns related to SP1-SP3. P3, who worked the day before the incident, stated that the VA had behavioral incidents that included grabbing at staff and clients. The VA “slumped to the ground” and did not initially get up independently but did so after 20 minutes when P3 “lifted” the VA to a wheelchair. Aside from that, P3 did not have concerns related to the VA on April 27, 2025. The VA’s case notes provided the following information: · On April 27, 2025, the VA went to get coffee with staff and when leaving the vehicle, the VA “went limp and laid on driveway for 20 minutes.” Staff assisted the VA into a wheelchair and when they got into the garage, the VA “went limp” and “slid out of the wheelchair” and laid on the garage floor for 20 minutes “repeatedly attempting to get [him/her] up and to get [him/her] into the house.” Another entry later that afternoon showed that a staff person was unable to take the VA swimming because the VA had “behaviors and exhaustion/inability to walk.” · At 8:41 a.m., on April 28, 2025, SP1 documented several abrasions on the VA’s body, such as on his/her hands, feet, and knees. The injuries occurred when the VA tried to get up but “failing to do so.” The CM stated that due to the VA having a history of UTI’s, the VA was supposed to drink a certain amount of water daily, but the CM did not know the volume of water the VA was supposed to drink daily. The CM also stated that the VA had the ability to get up on his/her own but could have difficulty as well. The G stated that the VA was supposed to be drinking three liters of water per day to prevent UTI’s. The G also stated that when the VA was hospitalized, the VA was diagnosed with dehydration and when the VA was previously dehydrated, the VA was “weak” and had difficulty getting up on his/her own. The facility’s training records showed that all staff interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to April 28, 2025. Conclusion: At about 3 a.m. on April 28, 2025, SP1 checked on the VA and found him/her on the floor in his/her bedroom. For the next hour or so, SP1 and SP2 made attempts to assist the VA from the floor, but those attempts were unsuccessful. Beginning at about 4 a.m., SP3 assisted SP1 and/or SP2 at various times between 4 a.m. and 9 a.m., but those attempts to help the VA off the floor were also successful. When P2 arrived at about 9 a.m., SP1 apprised P2 of the VA’s condition. Shortly thereafter, P2 called P1 and then 9-1-1 and first responders transported the VA to the hospital. While hospitalized, the VA was diagnosed with a UTI and rhabdomyolysis, which were treated with medications. In addition, some abrasions were noted on the VA’s knuckles, elbows and knees. The VA was discharged from the hospital on May 2, 2025. Although information showed that the VA typically got up from the floor within 20-30 minutes, SP2 stated that it could take up to three hours. SP1-SP3 provided mostly consistent information that the VA was in a weakened condition, but also that they had seen the VA previously experience weakness. Documentation showed that staff were supposed to document the volume of liquid the VA consumed each day, but the target range was not identified. The documentation provided inconsistent information in terms of whether the VA consumed enough liquid each day. Although it might have been reasonable for SP1-SP3 to seek earlier assistance when they were unable to assist the VA from the floor and six hours was a long time for the VA to be on the floor, the VA’s plans did not identify a set time in which staff were to seek assistance when the VA did not get up from the floor. In addition, during the six hours that the VA remained on the floor, SP1-SP3 made several attempts to assist the VA and offered water to the VA. Also, SP1-SP3 followed the guidance in the VA’s plans by encouraging the VA to stand up using a chair so the VA had leverage. Given those reasons, there was not a preponderance of the evidence whether SP1-SP3 failed to provide reasonable and necessary care and services to the VA. 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’s Summary of Internal Review also stated that although policies and procedures were adequate and followed, additional training was provided, specifically to SP1 and SP2, who were placed on “performance improvement plans” regarding expectations around being in communication with a supervisor “when people we support are struggling.” In addition, the facility revised the VA’s plan to include more techniques staff could follow when the VA was on the floor, as well as a “length of time [s/he] is allowed to try to get up either by [his/her] self or with staff assistance before calling the non-emergency number for assistance.” Action Taken by Department of Human Services, Office of Inspector General: No action taken.
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