|
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: 1072540-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Brittany Dolen 651-431-6701 Suspected Maltreatment Reported: It was reported that a staff person (SP) did not check on a vulnerable adult (VA) as required which resulted in the VA being found hanging halfway off his/her bed, soiled with feces. Date of Incident(s): August 13, 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 August 1, 2025; from documentation at the facility; and through five interviews conducted with the VA’s guardian (G) who was also the VA’s family member, two facility supervisory staff persons (P1 and P2), and two facility staff persons (P3 and P4). Attempts were made via telephone and certified mail to contact and interview the SP, but the SP did not respond. The SP provided information during the facility’s internal review and that information is included below. Due to the VA’s diagnosis, s/he was unable to provide information relevant to this investigation. The VA was diagnosed with multiple sclerosis, epilepsy, diabetes, neurogenic bladder, and intracranial injury. The VA was unable to care for his/her needs and required assistance with all activities of daily living (ADL’s) including bathing, grooming, dressing, mobility and transfers, medication management, and incontinence care. The VA enjoyed watching television, spending time with his/her pet, and speaking with the G. The VA’s Individual Abuse Prevention Plan (IAPP) said that the VA “may not identify his/her inability to complete self-care tasks or the risks associated with attempting to do them independently.” The VA was at risk of “harm and injury” if s/he attempted to transfer him/herself due to risk of falls and/or being incorrectly placed in his/her bed. The VA had a call light in his/her bedroom to alert staff persons if s/he needed assistance, and staff persons were responsible to check the VA’s call light every hour to ensure the VA could access it, to reduce the chance of the VA self-transferring. Staff persons were also responsible to check the VA’s absorbent undergarment every two hours to ensure it was clean and dry. P3 provided the following information: · On July 13th, 2025, at 11 p.m., P3 arrived at the facility for the start of his/her shift. The SP was sitting at the table watching movies on his/her laptop. P3 asked the SP about the residents, and the SP told P3 that everyone was in bed and “good” and then left the facility because it was the end of his/her shift. · P3 then checked on the residents, and when P3 went into the VA’s bedroom, s/he saw the VA on his/her bed in a “very dangerous” position. The VA was “halfway slipping off” the bed and when P3 tried to maneuver the VA back onto the bed, s/he noticed the VA had “soiled” him/herself and there was a “noticeable” smell. The VA looked like s/he was “weak, tired, in pain, and a little scared.” The VA was normally “very enthusiastic” when s/he talked to P3 but at that time the VA spoke like s/he was “out of breath, like a whisper.” · P3 thought the VA had been sitting in his/her own “filth” for “quite a long time.” The VA’s entire genital area was full of fecal matter, including his/her catheter. The stool was “very liquidy” and the VA’s skin was “red and irritated.” [Note: There was no information provided that the VA’s skin was red or irritated prior to this.] P3 then changed and cleaned the VA, which took “a few hours.” While P3 cleaned the VA, the VA was “very tired” and when P3 finished, the VA seemed “relieved” and fell asleep. After cleaning the VA, P3 notified P1 of the incident via email and P4 via text message. P3 did not receive a response until the following morning. · The VA wore absorbent undergarments and required a Hoyer lift, which was connected to the ceiling above the VA’s bed, for transfers as well as to be changed in bed. Staff persons used an electric remote to adjust the Hoyer and “lift” the VA with a sling. After the VA was lifted, staff persons prepared the area underneath and then lowered the VA back onto the bed to change him/her. P3 found the VA’s sling, in the washing machine damp and soiled and stated staff persons were supposed to clean the sling after each use. · P3 was unable to ask the SP regarding why the VA was in the condition s/he was in because the SP left before P3 had checked on the VA. P1, P2, and P4 provided the following consistent information: · On July 14th, 2025, at 2:38 a.m., P3 submitted a General Event Report (GER) which stated that when P3 arrived at the facility, around 11 p.m. on July 13, 2025, the SP was working and told P3 that all of the residents were “good.” The SP then left the facility and when P3 checked on the VA in his/her bedroom, it appeared that the VA “had not been taken care of” during the SP’s shift. P3 noted the VA was half out of bed, wet, and had diarrhea “all over.” Additionally, the VA’s catheter bag was full to 1000 cc’s (cubic centimeters) and had fecal matter on it. P3 took photographs of the VA and submitted them with the GER. · After reviewing the GER, P1, P2, and P4 discussed the incident and it was determined that the SP had not cared for the VA appropriately, and that s/he would be removed from the schedule. · On July 15, 2025, P1 notified the VA’s case manager and the G of the incident via email. · Staff persons were required to administer medications, bathe, dress and empty the VA’s catheter. The VA required hourly checks to ensure that his/her call light was accessible, and staff persons completed safety checks six times per day. Staff persons also checked on the VA hourly during the overnight shift and the VA had a nursing service that was responsible for changing his/her catheter tubing. The VA was unable to reposition him/herself in bed safely without assistance from staff persons. · The VA did not always provide accurate information due to his/her diagnosis and typically had a “jovial” disposition. The VA voiced if s/he was in pain, but P1, P2 and P4 did not think the VA had the capacity to recall the incident or provide accurate information. P1, P2, and P4 did not have prior concerns with the SP’s care of the VA. The G was not aware of the allegations and had concerns with the change in staff persons as well as the VA moving rooms but did not speak with the facility regarding these concerns. The facility primarily communicated with the G via email, however the G did not have a job where s/he could check his/her email every day. The G had not been at the facility for “a number of months” but was aware that the VA’s condition had “declined” over the last few months and s/he was no longer able to transfer him/herself. Three photographs of the VA taken by P3 provided the following information: · One photograph showed the VA lying on his/her back, with his/her legs off the bed. The VA’s upper body was diagonal across the bed and the VA did not appear to be in a stable position. · A second photograph was a zoomed in on the VA’s groin area which showed a large wet area on the left side of the VA’s genital area and upper left thigh. The VA was wearing sweatpants and had a towel beneath his/her leg and buttocks. · A third photograph was taken after the VA’s sweatpants had been removed. The VA had loose fecal matter that had come out of the VA’s absorbent undergarment and was on the inside of the VA’s thigh and catheter, as well as on his/her sweatpants. The VA’s left thigh appeared red and irritated. The Internal Review stated that the SP worked from 3-11 p.m. on July 13, 2025. An unidentified staff person spoke with the SP on an unknown date, and the SP stated s/he completed “all necessary” checks on the VA, and that around 10 p.m., the SP found the VA “hanging partially off the bed.” The SP asked the VA if s/he was “OK” and the VA stated s/he was “fine,” so the SP left the VA’s bedroom. The SP denied knowing that the VA had been incontinent, and stated it was “difficult” for the SP to change the VA by him/herself. The SP stated s/he emptied the VA’s catheter bag at 10 p.m. and was “unsure” why it was so full. The facility’s personnel files showed that all staff persons interviewed, and the SP, were trained on the VA’s plans and the Reporting Maltreatment of Vulnerable Adults Act. Relevant Rules/Statutes Minnesota Statutes, section 245D.07, subdivision 1a states that the license holder must provide services in response to the person's identified needs, interests, preferences, and desired outcomes as specified in the support plan and the support plan addendum, and in compliance with the requirements of this chapter. Conclusion: A. Maltreatment: Information obtained showed that the VA required assistance with ADLs, transferring, and repositioning, as well as hourly checks to ensure his/her needs were met. On July 13, 2025, prior to leaving, the SP told P3 that the VA was “good.” However, the SP provided information for the facility’s Internal Review that around 10 p.m., s/he saw the VA halfway off the bed and did not assist the VA because the VA said s/he was “fine.” When P3 arrived at 11 p.m., s/he found the VA in an “unsafe” position on his/her bed with an absorbent undergarment full of and leaking feces. Although the SP provided information in the Internal Review that s/he was not aware the VA was soiled, s/he did not request assistance from P3 to reposition the VA when P3 arrived at the facility and allowed the VA to remain in an unsafe position without his/her needs being met which was a violation of Minnesota Statutes, section 245D.07, subdivision 1a. Given that the VA required staff person assistance with all ADLs; that the SP saw the VA in an unsafe position and allowed the VA to remain in the unsafe position; and that allowing the VA to go unchanged sitting in his/her excrement for an undetermined amount of time was inconsistent with the standards of a professional caregiver in a facility licensed by the Minnesota Department of Human Services and was not accidental or therapeutic conduct which most likely caused the VA’s skin to be “red and irritated,”, there was a preponderance of the evidence that there was a failure to supply the VA with care or services which were reasonable and necessary to obtain or maintain the VA’s physical or mental health or safety. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on the VA’s plans and the Reporting Maltreatment of Vulnerable Adults Act. At the time of the incident, the SP was responsible for providing necessary cares to the VA to ensure the VA’s health, safety, and wellbeing. The SP was responsible for the maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the SP was responsible did not meet statutory criteria to be determined as “recurring” or “serious” because it was a single incident and the VA did not require the care of a physician. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. Given that the facility took immediate corrective action, a Correction Order was not issued for the violation outlined in this report.
|
