|
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: 1072267-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that a staff person (SP) left a vulnerable adult (VA) on a toilet for over 12 hours overnight because when the SP attempted to assist the VA off the toilet, the VA refused so the SP left the VA and went to sleep. The VA had a large circle brown and red bruise from sitting on the toilet. Date of Incident(s): November 27, 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 December 11, 2025; from documentation at the facility; and through five interviews conducted with a facility management person (P1) and four facility staff persons (P2-P5). Although this investigator contacted the SP via phone and set up a phone interview at a time that was agreeable to the SP, the SP did not answer the call and did not return messages to the investigator. Also, the SP did not respond to written requests to be interviewed. The VA’s guardian (G) was contacted, but did not respond to requests to be interviewed. This investigator met the VA, but the VA was unable to provide information in an interview due to his/her abilities. The VA’s support plan showed that s/he enjoying listening to music and watching “family type shows.” The VA’s diagnoses included a “severe” developmental disability, glaucoma, and hypothyroidism. The VA was non-verbal. The VA’s behavioral concerns, such as self-injurious behavior (SIB), physical aggression and property destruction “have decreased, but remain a major concern” and that staff “give [the VA} Acetaminophen/Ibuprofen when [s/he] is verbally and physical aggressive. [S/he] appears to calm 30 minutes after taking the Acetaminophen/Ibuprofen.” When the VA engaged in verbal aggression, staff were trained to talk to the VA in a “calm” manner and encourage him/her to relax in a quiet area. When the VA engaged in physical aggression toward others, staff were trained to “walk away” and reapproach the VA in “a few minutes to attempt positive interactions.” The VA’s Individual Abuse Prevention Plan showed that the VA had an as needed (PRN) medication for “severe agitation.” The plan showed that listening to music seemed to help the VA with calming. The VA was incontinent and used adult undergarments. Staff assisted the VA with completion of activities of daily living, such as bathing, using the bathroom, and teeth brushing. The VA had a history of holding urine. Staff persons assisted the VA into the bathroom every three to four hours or more frequently as needed. The VA’s Intensive Support Services Assessment showed that the VA ambulated independently but had a “slight gait” and a “limp in [his/her] step.” The VA “independently gets around [his/her] environment.” A review of the VA’s plans did not document the level of assistance the VA needed onto and off the toilet. Also, there was no documentation in terms of how often staff were to check on the VA during the overnight. The facility’s Timecard Report showed that the SP began working at 6 p.m. on November 27, 2025, and worked the overnight until 8:03 a.m. on November 28, 2025. Although a part of the SP’s overnight shift would normally be a sleep position, the SP did not record any sleep hours that night. The report showed that P2 began working at 8 a.m. on November 28, 2025. P1 provided the following information: · Shortly after 8 a.m. on November 28, 2025, P2 called P1 and told P1 that when P2 arrived at the facility that morning, around 8 a.m., the VA was on the toilet and that the SP told P2 that when the SP assisted the VA with using the bathroom at about 6: 30 p.m. the night before, the VA engaged in physical aggression and the SP was unable to assist the VA off the toilet. P2 also told P1 that when P2 talked to the SP that morning, the SP said that s/he slept during the night. The SP told P2 that s/he was “scared” of the VA and “didn’t know what to do.” The VA had a red mark on his/her buttocks that lasted several hours, but medical care was not needed. · When staff needed assistance of any kind, they were trained to call a supervisor or manager. The SP did not call anyone for assistance that night and did not return calls to management to discuss the incident. · Normally when staff verbally asked the VA to get up after using the toilet, the VA needed some physical assistance with getting up and with pulling up his/her adult undergarment and pants. When the VA did not want to get up initially, staff were trained to reapproach the VA a few minutes later and that was usually successful. The VA had not had behavioral concerns when using the toilet for “many years.” P2 also stated that if the VA attempted to get up from the toilet without staff assistance, there was a risk that the VA may fall. There was no documentation in the VA’s medication administration record that the SP administered PRN medications or Acetaminophen or Ibuprofen to the VA during his/her shift on November 27-28, 2025. P2 provided the following information: · P2 did not remember when s/he worked on November 27, 2025, but remembered that s/he assisted the VA with changing his/her undergarments and clothing that morning and did not notice any marks on the VA at that time. · When P2 began working around 8 a.m. on November 28, 2025, the SP told P2 that the VA became verbally and physically aggressive toward the SP when the SP attempted to assist the VA with getting ready for bed at about 6:30 p.m. on November 27, 2025, and that the VA remained on the toilet all night. The SP was “very physically upset, crying” and was “very emotional.” · Shortly after the SP left, P2 went into the bathroom and noted that the VA was still sitting on the toilet and was “leaning” on his/her left side. P2 assisted the VA off the toilet and noticed that the VA had a red mark on the left side of his/her buttocks. P2 was not certain but thought that the red mark was gone within a day or two. When P2 assisted the VA from the bathroom to his/her bedroom, the VA was “tired” and his/her legs began to give out, but the VA did not fall. · P2 did not witness the VA having physical aggression or verbal aggressive toward others when the VA used the toilet and “very rarely” would get up from the toilet without assistance. P3-P5, who were not working at the time, heard information from P2 regarding the incident and so providing information in interviews that was consistent to information provided by P2. An entry by P2 in the VA’s Individual Log, dated November 28, 2025, stated that upon P2’s arrival at the facility that morning, the VA was on the toilet and that the SP said that the VA “had behaviors and would not come off the toilet throughout the night.” The VA’s health care notes, dated November 29, 2025, stated that the VA had a two inch by three-inch red area on the back of his/her right thigh. Staff noticed the area on November 18, 2025, but was not sure if area redness would continue to be red after sitting on the toilet and that the VA “did not seem bothered by the area.” The facility’s Incident Report and Internal Review showed that the red area was two inches by three inches and was still evident on the morning of November 29, 2025, and that the VA “did not seem bothered by the area.” The facility’s training records showed that P1-P5 and the SP were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to November 27, 2025. Conclusion: A. Maltreatment: Information was consistent that on November 28, 2025, when P2 arrived around 8 a.m., the SP told P2 that s/he assisted the VA onto the toilet around 6:30 p.m. the day before and the VA was still on the toilet. The SP told P2 that the VA was physically and verbally aggressive when the SP tried to assist the VA off the toilet and that the VA “would not come off the toilet throughout the night.” The VA had a large circle red and brown bruise from sitting on the toilet. The SP did not respond to interview requests and did not provide information. The SP did not record asleep time the night of the incident, but it was reported that after attempts to assist the VA off the toilet, the SP left the VA and went to sleep. P1-P5 provided information that it was quite unusual for the VA to engage in physical or verbal aggression when the VA used the toilet. Also, there was no information that the SP called management, or anyone, for assistance when the SP was unable to assist the VA from the toilet and there was no information that the SP administered PRN medications or Acetaminophen/Ibuprofen, which were used to assist the VA with calming down, to the VA. The VA might be able to get off the toilet independently s/he typically needed assistance and could not. Although it was not determined if the SP was sleeping and the SP told P2 that s/he attempted to assist the VA off the toilet but the VA was aggressive and did not want to, given that the VA was on the toilet for approximately 14 hours overnight, that the SP did not call for assistance, and that the VA had a bruise from sitting on the toilet for so long, there was a preponderance of the evidence that the SP failed to provide the VA with reasonable and necessary care and services. 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. Given that the SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to November 27, 2025, 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 because this was a single incident and not serious because the VA did not require the care of a physician. Action Taken by Facility: The facility’s Incident Report and Internal Review showed that policies and procedures were adequate but were not followed. The SP was no longer employed by 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.
|
