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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: 1086510-AFC (Adult Foster Care) Investigator(s): Lindsay Arth/Beth Virden lindsay.arth@state.mn.us Suspected Maltreatment Reported: It was reported that a vulnerable adult’s (VA) legs were swollen and “oozing,” and that staff did not provide or seek medical care. Date of Incident(s): Ongoing 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 14, 2025; from documentation at the facility and medical records; and through five interviews conducted with the VA, the VA’s case manager (CM), the VA’s care coordinator (CC), a facility staff person (P1), and a supervisory staff person (P2). Information was also provided by a licensor (L), which was included in this report. The VA’s Support Plan and Coordinated Service and Support Plan Addendum included the following: · In 2017, the VA moved into the facility seeking services and supports relating to his/her diagnoses, which included diabetes and lymphedema (tissue swelling). The facility provided the VA with a place to live and staff to help with meal preparation, personal hygiene, transportation, and household management. · The VA independently managed his/her healthcare and administered his/her medications and wanted to be “healthy and active.” The VA wanted to decrease his/her leg swelling, improve his/her overall health and mobility, and move into his/her own apartment someday. · The VA was not subject to guardianship. The VA lived with the SP at the facility, which was a single-family home. The SP was the VA’s primary caregiver. The VA, the CM, the CC, P1, P2, the L, and the VA’s medical records provided the following information: · Consistent information was provided that the VA had a history of frequently seeking care at an emergency room and to minimize the VA’s use of the emergency room, the VA’s primary care physician (PCP) scheduled a regular weekly appointment with the VA to review his/her medical conditions. In addition to this, a nurse from a home health agency visited the VA once per week at the facility to setup the VA’s medications and complete other “basic health checks.” The VA independently scheduled and attended his/her medical appointments and administered his/her own medications; however, the VA struggled to always take his/her medications as prescribed. On/around April 14, 2025, the PCP, the CM, and the CC each recommended, and the VA agreed, to let P2 takeover the VA’s medication administration. The plan was for the home health nurse to train P2 and then slowly discontinue the nursing visits. However, before this could be setup, on May 15, 2025, P2 traveled overseas for unrelated family matters and during that time, P1 lived at the facility and provided care and supervision to the VA. The home health nurse continued visiting the VA weekly while awaiting P2’s return and eventual takeover of the VA’s medications. While overseas P2 fell and sustained an injury, which prevented him/her from flying and delayed his/her return to the facility until July 21, 2025. · P1 and P2 each said that before P2 left, s/he trained P1 on the VA’s cares. P1 was responsible for helping the VA with various aspects of daily living, including providing reminders to take medications and attend medical appointments. P2 showed P1 the condition of the VA’s legs and explained that the VA might ask for help applying creams and wraps to his/her legs. P1 said that at that time, the VA’s right leg was “swollen badly” and “hard as a rock.” P2 said that the VA had lymphedema, which sometimes got worse and sometimes got better; and sometimes “leaked” fluids and sometimes did not. Everyone, including the PCP and the home health nurse, knew about the ongoing condition of the VA’s legs. · P1 said that while P2 was overseas between May 15 and July 21, 2025, more than once, P1 talked to the VA, P2, and “the nurse” about the VA’s legs and each said that the treatment was to apply creams, which P1 did when the VA asked for help. P1 said, “I used a lot of cream” and no one said to do anything more for the legs. The nurse did not seem worried and P1 never noticed any odors suggesting an infection. · The VA’s medical records stated that between May 15 and July 21, 2025, the VA attended eight appointments with the PCP. The PCP examined the VA’s legs and prescribed various creams but did not seek or recommend emergency medical care. After each appointment, the VA returned to the facility with his/her next appointment with the PCP scheduled for the following week. The home health nurse met with the VA at the facility weekly and did not seek emergency care for the VA’s legs. · On July 11, 2025, the PCP provided the following memorandum: To Whom It May Concern: I am the primary care physician for [the VA] and have been since 2016. This letter is to confirm that [the VA] possesses the cognitive and physical ability to take responsibility for [his/her] medication and self-administer. However, [s/he] does require [registered nurse] assistance with setting up [his/her] medications weekly. Please contact me with any questions or concerns. [Note: This memorandum was in response to the plan that the home health nurse would discontinue services once P2 took over the VA’s medications. The PCP believed that, if possible, the nurse should continue to provide some oversight.] · The L, the CM, and the CC provided consistent information that on/around July 18, 2025, the CM and the L each visited the facility. The L said that the VA was wearing sweatpants with the right pant leg “wet from the mid-calf down.” The VA was not in pain and told the L that the wetness was due to “leaking” from his/her edema, which was “common.” On July 21, 2025, P2 told the L that s/he was back at the facility, that the VA’s legs were “all better, not weeping,” and that the VA had an appointment on July 22. · The VA’s medical records stated that on July 22, 2025, the VA attended an appointment with the PCP, who examined the VA’s legs and noted, “Warm, dry to touch with trace 1+ pitting edema to the knees bilaterally, close to [his/her] baseline.” The PCP also noted, “During fluid overload states, [the VA] gets bilateral venous dermatitis/inflammation. In addition, [his/her] right lower extremity is larger compared to left at baseline and becomes profoundly larger compared to left.” The PCP did not order any changes. · At the time of the site visit, August 14, 2025, the DHS investigator observed the skin on the VA’s right leg was “peeling” and “weeping.” The VA said that both of his/her legs had been “bad” for “a long time.” P2 demonstrated the VA’s leg cares (e.g., washing, applying creams) for the investigator.
· On August 26, 2025, the PCP provided the following memorandum: To Whom It May Concern: This letter is to document that [the VA] has longstanding lymphedema of the lower extremities since 2009. This manifests with relapsing-remitting episodes of lower extremity swelling, fluid weeping, and pain. I understand that there was concern that this was a more recent health development, but it has been chronic and unchanged in its severity. Please contact me with any questions or concerns. The VA said that s/he managed his/her own healthcare and medications. Facility documentation stated the license holder did not provide annual training to P1 and P2 on Minnesota Statutes sections 245A.65 and 626.557 governing maltreatment reporting and service planning for vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. The license holder also did not provide training to P1 within 60 days of hire on the VA’s support plans as required in Minnesota Statute section 245D.07, subdivision 1a. [Note: On October 7, 2025, an Order of Conditional License was issued to the license holder, which included these citations.] Conclusion: Consistent information was provided that on/around July 18, 2025, the VA’s legs were swollen or weeping fluids and there was concern regarding the staff response. However, information was also provided that the VA’s leg condition was chronic, and that the PCP and the home health nurse were aware and monitoring during weekly visits, and there was never a recommendation to seek emergency care. Given that the VA was not subject to guardianship and managed his/her own healthcare, and that there was no information the VA’s legs worsened as a result of staff conduct, 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 for his/her 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 policies and procedures were adequate and followed and that there was not a need for additional training or corrective action. “[The VA] has a longstanding, chronic medical condition—lymphedema of the lower extremities. This condition is well documented in [his/her] medical history, and the recent event is consistent with [his/her] chronic health status, not program practices.” Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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