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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: 1069980-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) had pressure ulcers for an unknown amount of time. Date of Incident(s): Prior to August 30, 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 September 12, 2025; from documentation at the facility and medical records; and through nine interviews conducted with a supervisory staff person (P1), six facility staff persons (P3-P8), the VA’s case manager (CM), and the VA’s guardian (G). Attempts were made via telephone and certified mail to contact and interview a supervisory staff person (P2), but P2 did not respond to the requests. A staff person (P9) was contacted via phone and a time to interview P9 was scheduled. At the predetermined time, P9 did not answer the telephone and then did not respond to a voicemail left for P9. A follow up phone call to P3 to obtain additional information was not returned. The VA was diagnosed with spastic quadriplegic cerebral palsy and a severe developmental disability. The VA used a wheelchair to ambulate and was not able to verbally communicate. The VA attended a day program throughout the weekdays. According to the VA’s Intensive Support Self-Management Assessment: · The VA was unable to schedule medical appointments and relied on staff persons to communicate his/her needs and medical history to doctors. · Staff persons repositioned the VA, transferred the VA, and monitored the VA’s skin for “breakdown.” Staff persons completed all activities of daily living such as dressing, bathing, and personal hygiene. [Note: There was no information regarding what staff persons were to do if they noticed skin breakdown.] According to the facility’s Health Service Policy, a supervisory staff person in P2’s position deferred judgement to a facility nurse or medical professional for medical care or health related concerns. The facility ensured “prompt” notification to the G and the CM of any changes to the client’s mental and physical health needs that may affect the health service needs assigned to the facility in the client’s plans. Staff persons documented the information in the client’s health records. The supervisory staff person in P2’s position along with the G and the CM determined how the client’s health condition was monitored, including the written instruction of a health care professional. The VA’s medical records provided the following information: · On August 30, 2025, the VA was seen at the emergency room for an evaluation of “altered mental state.” A staff person (later determined to be P3) told the doctor that the night before, the VA had been “crying out” which was “unusual” for the VA and said that the VA had an ulcer on his/her lower back. For approximately one week, the facility had been treating the VA’s ulcer with cortisone cream and dressing, but the ulcer now appeared infected. · The doctor took the VA’s vitals and the VA had a fever and high heart rate but did not appear in distress. The doctor then completed a full skin check and saw a pressure ulceration on the VA’s right lower back and right ankle without cellulitis (visible signs of infection), abscess, or crepitus (popping or crackling sound). Photos taken on August 30, 2025, showed a pink and white ulcer on the VA’s lower back and a red ulcer (that was not scabbed) near one of the VA’s ankles. [Note: The photos did not have sizing and therefore it was difficult to determine the size and location of each ulcer.] · Urine testing was completed and was consistent with a urinary tract infection and a “recently passed” kidney stone. Blood testing was completed and nothing notable was found. · The doctor administered Tylenol and wanted to monitor the VA to ensure the VA had no new fevers or obstructions occur. The VA was admitted and administered antibiotics and discharged on September 2, 2025, with a diagnosis of complicated urinary tract infection, kidney stones, left hydronephrosis (swollen kidney), and skin ulcers. The VA was scheduled with follow up appointments for urology for stone prevention. · The discharge notes indicated a right sacral pressure ulcer and a left medial malleolar ulcer. Pain in those areas might have contributed to “behavioral changes.” P3 told medical personnel that the VA was seen approximately once per month by a facility nurse for cares and had not seen wound management for the ulcers. There were concerns because of multiple areas of pressure ulcers. · The VA’s after visit summary stated that the doctor ordered home health care services for wound assessment and care. · On September 5, 2025, the VA was seen for wound care. The nurse instructed staff persons to clean the stage three pressure ulcer on the VA’s back with wound cleanser and apply foam dressing. The dressing was changed every other day or “as needed.” For the stage two pressure injury on the VA’s right ankle, staff persons cleaned it with mild soap and water daily and left open to air dry.
There was no documentation of the VA’s ulcers in the VA’s facility medical/progress notes prior to him/her going to the hospital. According to Mayoclinic.org, for persons in wheelchairs, ulcers often occurred on skin over the tailbone or buttocks; shoulder blades and spine; or backs of arms and legs were resting against the chair. For persons in bed, ulcers occurred on the back or sides of their head; shoulder blades; hip, lower back, or tailbone; or heels, ankles, and behind the knees. If a person had an ulcer, position changes eased areas of pressure. If the ulcer did not improve within 24 to 48 hours, contact a medical professional. P1 provided the following information: · On August 30, 2025, P1 received a phone call from the VA’s primary doctor who said that the VA was admitted to the hospital. P1 then texted P2 asking for more information on why the VA was admitted to the hospital. P2 told P1 that s/he was not working at the time and referred P1 to P3. · P1 then texted P3 who responded saying that there was an ulcer on the VA’s lower back that was possibly causing the VA pain. After the VA returned from the hospital, P1 saw an ulcer on the VA’s lower back that was approximately “pea size.” There was another ulcer near it that was just starting to come through the VA’s skin. P1 was not aware of the ulcer on the VA’s ankle. · Staff persons were trained that when giving the VA a bath or changing his/her adult undergarment they should “always” check for ulcers. Staff persons were also trained to reposition the VA every two hours. Staff persons did not document these checks and/or the repositioning but any concerns were documented in the VA’s progress notes. P1 thought that the ulcers were because the VA had an old mattress and staff persons were not repositioning the VA every two hours as trained. · P1 did not typically provide direct care to the VA but worked with the VA for three years prior and the VA did not have a history of ulcers. Approximately one week prior to the VA’s hospitalization, during a staff meeting, it was mentioned that the VA should get a new bed mattress but there was no reason provided why. · When interviewing staff persons for the internal review, P2 told P1 that after P2 noticed an ulcer and s/he put ointment and bandages over the ulcer and told staff persons to do the same. P3-P8 provided the following information: · Staff persons assisted the VA with a shower every other evening before bed, administered a suppository in the evening, changed the VA’s adult undergarment every two hours, and repositioned the VA every two hours in bed. · Staff persons were not aware of any ulcer on the VA’s back until approximately one week prior to August 30, 2025, when P2 told P3 that the VA had an ulcer and to apply cream and bandages over it and reposition the VA “more often” when in bed. P3-P8 did not have concerns with staff persons repositioning every two hours. · P4 was not aware of the ulcer until approximately August 29, 2025, when P3 told P4 that the VA had an ulcer on his/her buttocks and that P2 was aware of it and said to apply an over-the-counter ointment. P4 then told P5 at shift change about the ulcer and to apply the ointment. · In the morning of August 30, 2025, P3 arrived at the facility and the VA was “making funny noises.” P3 texted P2 and said s/he thought the VA was possibly in pain because of the noises and P3 was unsure if it was because of the ulcer. P2 told P3 to bring the VA to the hospital so P3 did. While at the hospital, the doctor told P3 that the ulcer was not infected so it was possibly something else causing the VA pain. The doctor did more tests and found that the VA had a urinary tract infection and a kidney stone. · On a previous unknown date, P6 saw a spot on the VA’s back that looked like “ringworm.” P2 told P6 to clean it and put ointment on it. P6 was then off work for seven days and when s/he returned, P4 told P6 that the VA had been in the hospital for the ulcer. When P6 saw the ulcer it was “big” compared to the previous time s/he saw it. · P7 stated that s/he worked twice in a two-week time period and P7 left the facility around the time the VA arrived home from his/her day program. P8 did not work from August 28 to September 1, 2025. On September 1, 2025, P7 and P8 returned to work. P3 told P7 about the VA’s ulcer and that s/he had been in the hospital. P7 and P8 were not aware of any ulcers prior to the hospitalization. · P7 and P8 each stated that the VA had a scar on his/her back from a previous pressure ulcer that had occurred prior to the VA residing at the facility. P3-P8 each stated that the VA did not have a history of ulcers while living at the facility. P6-P8 was not aware of the ulcer on the VA’s ankle. P3-P8 each said that they repositioned the VA every two hours as required. The G stated that s/he was not aware of the ulcer on the VA’s back until after s/he was brought to the hospital but was not aware of an ulcer on the VA’s ankle. The facility notified the G “often but not always” when the VA had an injury. The G asked multiple times to be notified of changes in the VA but it was dependent of which staff persons were working. It was usually P2 who notified the G. The VA received pressure ulcers “probably every couple of months” from the amount of time spent in his/her wheelchair or bed. The CM stated on October 6, 2025, s/he called the facility and a new supervisory staff person (P10) notified the CM that the VA had ulcers. The CM was not notified of the ulcers prior. The CM was not aware of the VA having a history of ulcers. Facility documentation showed that staff persons were trained on the VA’s plans, the facility’s Health Service Policy, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (a) states in part that the licensed holder was responsible for promptly notifying the person’s legal representative and the case manager of changes in a person’s physical and mental health needs when discovered by the license holder. Minnesota Statutes, section 245D.05, subdivision 2, paragraph (c), clause (6) states that the license holder must ensure notation in the person’s medication administration record of when a medication or treatment is started, administered, changed or discontinued. Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b), clause (3) states that the license holder must maintain health information when the licensed holder is assigned responsibility for meeting the person’s health service needs according to section 245D.05. Conclusion: On August 30, 2025, the VA was brought to the emergency room for an “altered mental state” because s/he was “crying out.” The VA’s primary diagnoses was complicated urinary tract infection, kidney stones, and left hydronephrosis (swollen kidney). The VA was also diagnosed with a pressure ulceration on the VA’s right lower back and right ankle without cellulitis (visible signs of infection), abscess, or crepitus (popping or crackling sound). The discharge notes stated that pain in the ulcer areas might have contributed to “behavioral changes.” Information showed that the VA’s ulcer was first noticed on his/her back approximately one week prior to August 30, 2025, and that P2 told P3 to apply cream and bandages over it and reposition the VA “more often” when in bed and that P3 then told P4 the same information. However, there was no documentation of the ulcer in the VA’s file which was a violation of Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b), clause (3); and no documentation of the treatment provided to the VA which was a violation Minnesota Statutes, section 245D.05, subdivision 2, paragraph (c), clause (6). In addition, the G and the CM were not notified as required, which was a violation Minnesota Statutes, section 245D.05, subdivision 1, paragraph (a). Although the VA had no history of pressure ulcers and developed one on his/her lower back and ankle, given that P3-P8 each stated they repositioned the VA every two hours while in bed and more often after the discovery of the back ulcer; and that when the first pressure ulcer was observed staff persons provided care, continued to monitor it, and took the VA to the doctor when the VA began to demonstrate that s/he might be in pain, there was not a preponderance of the evidence whether there was a failure or omission to supply 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 did not follow the VA’s plans regarding changing his/her adult undergarment and monitoring for skin breakdown while in bed. Staff persons received additional training on the VA’s plans. Staff persons also received additional training in incident reporting and notifications. The facility purchased a new mattress for the VA’s bed. Action Taken by Department of Human Services, Office of Inspector General: On January 9, 2026, the license holder was issued a correction order for the violations outlined in this report.
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