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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: 1070059-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman/Alice Percy 641-431-6567 Suspected Maltreatment Reported: It was reported that a supervisory staff person (SP) found a vulnerable adult (VA) lying on the floor. The SP assisted the VA into a wheelchair, but did not document the incident or seek medical care for the VA. Several hours later, the VA was taken to a hospital, where s/he was diagnosed with a left femur fracture which required surgery. Date of Incident(s): August 24, 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 September 6, 2024; from documentation at the facility and medical records; and through seven interviews conducted with four facility staff persons (P1 – P4), an administrative staff person (P5), the SP, and the VA’s guardian (G). The VA enjoyed going on community outings and taking walks with the staff persons. The VA’s diagnoses included profound intellectual disability, obsessive-compulsive disorder (OCD), cataracts, and drug-induced secondary parkinsonism. The VA was non-verbal and used groaning, grunts, and burping as communication. The VA’s Individual Abuse Prevention Plan stated that the VA was unable to identify potentially dangerous situations and sometimes engaged in self-injurious behaviors when agitated. The VA’s Individual Support Plan stated that the VA could walk independently but was at risk of falling when s/he lost his/her balance. The VA enjoyed pacing and needed to be monitored by the staff persons when s/he walked to ensure that s/he did not lose his/her balance. The staff persons documented the following information in the T-Log Notes: · August 24, 2024, 9:43 p.m., completed by P2: [The VA] was reported not to have been walking sometime during the morning shift today. [The VA] was on the wheelchair when p.m. staff member arrived. This staff attempted to ambulate [the VA], but it was to no avail. [The VA] was pushy, not wanting to be touched. . . . [The VA’s] temperature was taken at about 9 p.m. and it was 98.5. No fever. · August 25, 2024, 10:08 a.m., completed by the SP: Staff heard a fall around 11:45 a.m. August 24, 2024 [the previous day], staff found [the VA] sitting on the floor in a small amount of vomit. [The VA] was looked over for injury none was found [s/he] was then helped to stand up and walked to the toilet where [s/he] could get cleaned up. [The VA] was then set in [his/her] transport chair, taken back to [his/her] bed and further checked for injury, none found. Staff were observing [him/her] to see if [his/her] situation changed. The overnight person called the house coordinator at 4 a.m. stating [the VA] had not slept through the night. [Staff person] had taken [the VA’s] temperature to find it was normal but [his/her] hip was tender. 9-1-1 was called and [the VA] was taken to Regions Hospital. · August 25, 2024, 10:57 p.m., completed by P5: Staff reported that [the VA] couldn’t sleep on overnight of August 24. This was due to the fall [s/he] had around 11:45 a.m. on August 24. 9-1-1 was called and transported to Regions Hospital at 4:55 a.m. on August 25. It was discovered that [the VA] must have fractured or broken [his/her] femur during the fall. . . . According to the nurse in charge, they need to do more scan/x-ray before proceeding to the surgery. · August 29, 2024, 8:30 p.m., completed by P5: [The VA] was discharged from Regions Hospital back to the house at 3:30 p.m., a Hoyer lift was delivered to the house at the time of arrival. [The VA’s] left femur wound extending to [his/her] hip, is dressed, leave it on for seven days and an appointment will be scheduled to remove the staples. P1, P2, P3, P4, P5, and the SP provided the following information: · Approximately one month prior to the incident, the VA sustained a fracture to his/her right ankle when s/he slid down the front of a chair. The SP stated that the VA’s physician told the SP that the VA’s injury was “possibly a spontaneous fracture.” Prior to the injury, the VA was pacing, spinning in circles, and walking around “at a good clip” because his/her OCD was “out of control.” · On the morning of August 24, 2024, the SP and P1 worked at the facility. At 10 a.m., the VA paced and spun around the living room, so P1 asked the VA to sit in his/her recliner or lie on his/her bed. At 11 a.m., P1 assisted the VA with using the toilet and shower. Afterwards the VA went to his/her bedroom. At approximately 11:45 a.m., the SP and P1 were doing paperwork in the facility’s kitchen when a client (C) told them that the VA had fallen. The SP and P1 went to the hallway outside the VA’s bedroom where the VA was sitting on the floor. The VA had vomited and the SP believed the VA slipped on the vomit. The C told the SP that the VA “landed on [his/her] butt” and did not hit his/her head. · The SP cleaned the floor while P1 completed a body check on the VA and did not find any injury. P1 stated that s/he checked the VA’s head and “all over [his/her] body” for injuries but did not find any. P1 asked the SP to get a gait belt and they used the gait belt to assist the VA into his/her transport chair and took him/her to the bathroom to change his/her clothing. At that time, P1 again checked the VA’s skin and legs and told the SP that s/he saw no injury, but they should continue to monitor him/her. P1 and the SP took the VA to his/her bed and did not allow the VA to stand as they assisted the VA into bed. P1 stated that s/he told the SP that s/he should complete an incident report, but the SP told him/her that s/he was not doing an incident report because there was no injury. P1 documented that the VA fell and that the staff persons “should keep their eyes on” the VA. At approximately 1:15 p.m., they assisted the VA out of bed, into his/her transport chair to take him/her to the kitchen where the VA ate lunch “like nothing was wrong.” After lunch, they took the VA back to his/her bed.
· At 2 p.m., P2 and P3 began their work shifts at the facility and the SP and P1 finished their work shifts. The SP said s/he planned to check on the VA the following morning to ensure that s/he had no injury. The SP stated that s/he told P3 that the VA fell and asked P3 to ensure that the VA was given liquids so that s/he did not become dehydrated like s/he had during his/her previous fall. The SP also told P3 to watch the VA to make sure that s/he was not injured and to not let the VA walk in case s/he was injured. The SP did not tell P2 that the VA fell, but assumed P3 would tell P2 what the SP had said. P3 stated that the SP told him/her that the VA was in the transfer chair because s/he was dehydrated and that the SP did not tell him/her that the VA fell. P3 then told P2 that the VA was in the transfer chair because s/he was dehydrated. P3 stated that s/he asked the SP if s/he documented what occurred during his/her work shift and the SP told P3 that P1 did the documentation. P3 stated that the VA remained in the transfer chair until after dinner, which was unusual for the VA because the VA typically paced around the facility. After dinner, P3 assisted the VA into his/her bed. P3 did not check the VA for injuries because s/he did not know that the VA had fallen earlier that day. P2 stated that the VA did not attempt to stand during P2’s work shift. The VA’s temperature was 98.5 degrees and the VA did not indicate that s/he was in pain. At 10 p.m., P2 left the facility and at 11 p.m., P3 left the facility. · At 10 p.m., P4 arrived at the facility for his/her work shift. P3 told P4 that the VA had been in the transfer chair that day and that P4 should monitor the VA that night. At 11 p.m. and at 12, 2, 3, and 4 a.m., P4 checked on the VA and changed his/her adult disposable brief when it was wet. P4 also took the VA’s temperature, which remained stable. At 4 a.m., P4 asked the VA to lift his/her legs while s/he changed the VA’s brief, but the VA struggled to raise his/her left leg. When P4 touched the VA’s left hip, the VA “shivered.” P4 called the SP and asked what happened to the VA earlier that day. The SP told P4 that the VA fell and P4 told the SP that s/he wanted to call 9-1-1 and the SP agreed. P4 called 9-1-1 and the paramedics arrived at the facility and took the VA to the hospital. · At 8 a.m., the SP went to the facility and called P5 to tell him/her that the VA had fallen the previous day and was in the hospital. The SP then completed incident reports about the incident. The SP stated that s/he did not complete the incident reports immediately after the VA fell because s/he had to prepare lunch and then it was the end of his/her work shift and P5 did not want the staff persons to remain at the facility past their scheduled work times. The SP did not have P2 or P3 complete the incident reports because s/he believed it was his/her responsibility since s/he was a supervisory staff person and planned to do them the following morning. P5 stated that P2 and P4 each checked the VA’s temperature during their work shifts, but did not check the VA’s blood pressure. · The SP visited the VA while s/he was in the hospital. The SP said that the VA’s physician told the SP that s/he reacted “appropriately” by keeping the VA in bed and off his/her feet, ensured s/he had fluids, had the staff persons observe the VA, and had them call 9-1-1 when they determined that the VA had a tender spot on his/her hip. On August 29, 2024, the VA was discharged from the hospital and returned to the facility. · The SP stated that s/he could have called 9-1-1 immediately after the VA fell, but s/he did not want to send the VA to the hospital if s/he was not injured. The SP was trained to check for fractures by palpitation and watching for any indication that there was pain and by checking for lumps or bruising. The SP stated that s/he did not receive adequate training at the facility and had not read the VA’s plans. The G stated that the VA’s mobility was declining due to aging. The staff persons told the G that the VA slipped and fell after vomiting and was not taken to the hospital until later. The VA tolerated “a lot” of pain and “never complained” about things. According to the facility’s Responding to and Reporting Incidents policy, the staff persons were trained to call 9-1-1 if they believed that a client was experiencing a medical emergency, unexpected serious illness, or significant unexpected change in illness or medical condition that might be life threatening. Facility documentation showed that P1, P2, P3, P4, P5, and the SP each received training on the Reporting of Maltreatment of Vulnerable Adults Act, and on the facility’s policies. There was no documentation to show that the SP was trained on the VA’s plans and the SP stated s/he was not trained on the VA’s plans which was a violation of Minnesota Statutes, section 245D.09, subdivision 3, paragraph (a) which states that the license holder must ensure that staff providing direct support, or staff who have responsibilities related to supervising or managing the provision of direct support services have the skills and knowledge training to meet the person’s needs as written in the person’s support plan or support plan addendum. Conclusion: On August 24, 2024, at approximately 11:45 a.m., the C told the SP and P1 that the VA fell and “landed on [his/her] butt” and did not hit his/her head. The SP and P1 went to the hallway outside the VA’s bedroom where the VA was sitting on the floor. The VA had vomited and the SP believed the VA slipped on the vomit. P1 checked the VA for injuries and did not find any and the VA did not indicate or demonstrate that s/he was in pain. They assisted the VA into his/her transport chair and took him/her to the bathroom where they changed the VA’s clothing. P1 documented that the VA fell and that the staff persons “should keep their eyes on” the VA. At approximately 1:15 p.m., they assisted the VA from bed into his/her transport chair to take him/her to the kitchen where the VA ate lunch “like nothing was wrong.” After lunch, they took the VA back to his/her bed. Neither the SP nor P1 called 9-1-1 after the VA fell. Although the SP stated that s/he told P3 that the VA fell and told P3 to watch the VA to make sure that s/he was not injured and to not let the VA walk in case s/he had an injury, P3 stated that the SP told him/her that the VA was using the transport chair because s/he was dehydrated and that the SP did not tell P3 that the VA fell. The VA did not attempt to stand during P2’s and P3’s work shift and they assisted the VA to his/her bed from the transport chair. That night, P4 checked on the VA hourly and changed his/her adult disposable brief when it was wet. At 4 a.m., P4 asked the VA to lift his/her legs while s/he changed the VA’s brief, but the VA struggled to raise his/her left leg and when P4 touched the VA’s left hip, the VA “shivered.” P4 called 9-1-1 and when paramedics arrived at the facility they took the VA to the hospital, where s/he was diagnosed with a broken femur. Although the VA fell and sustained a broken femur but was not taken to the doctor for approximately 18 hours, given that both the SP and P1 checked the VA for injuries more than once after the VA fell; that staff persons including the SP, P1, P2, P3, and P4 continued to check on and monitor the VA; that during the night, P4 checked on the VA multiple times and did not indicate that s/he was in pain at any point during the 18 hours until P4 checked on him/her at 4 a.m.; and that when the VA demonstrated s/he was in pain, P4 called 9-1-1 and the VA was taken to the hospital where the VA’s care received was likely the same had s/he been seen 18 hours earlier given that the VA was discharged back to the facility four days later, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services which were reasonable and necessary to maintain the VA’s physical health and 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 the facility’s policies were adequate, but were not followed by the SP. After the incident, all of the staff persons were retraining on documenting and reporting incidents and emergencies. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On September 24, 2025, the facility was issued a Correction Order for the violation outlined in this report.
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