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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: 1070024-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Beth Virden Suspected Maltreatment Reported: It was reported that a staff person (SP) left a vulnerable adult (VA) sitting in a recliner for around 12 hours, at which point, the VA’s brief and the recliner were “soaked” with the VA’s urine and feces. Date of Incident(s): October 5, 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 October 21, 2025; from documentation at the facility and medical records; and through interviews conducted with the VA’s guardian (G) who was also the VA’s family member, facility staff persons (the SP and P1), and supervisory staff persons (P2 and P3). The DHS investigator also interviewed the VA; however, the VA said that s/he did not remember the SP or the incident and did not provide additional information. The VA’s support plans, including Intensive Support Self-Management Assessment, stated the following: · The VA lived at the facility for help relating to his/her diagnoses, which included cerebral palsy and neurological impairment. The facility was a single-family home that provided the VA with at least one staff person 24 hours a day. The VA was “fun to be around” and had a “good sense of humor.” · The VA used a wheelchair and a mechanical lift and relied on staff to transfer him/her and help with mobility. The VA was unable to reposition him/herself. Staff used wedges to prop the VA from side to side and repositioned him/her “every few hours” to minimize pressure sores. It was important the VA got out of his/her wheelchair for “an hour a day.” The VA did not like lying in bed except when sleeping. · The VA required assistance from staff with all activities of daily living. The VA enjoyed having clean clothes and bedding and relied on staff to ensure his/her clothes and bedding were clean. The VA wore a disposable undergarment and had a history of incontinence. The VA sometimes told staff when s/he needed a new disposable undergarment and relied on staff to change it when it was soiled. · It was important for the VA to make his/her own decisions. The VA was “partially verbal” and verbally stated his/her wants and needs; however, might not always state if s/he was in pain or upset. Staff watched the VA’s body language and facial expressions to determine how s/he was feeling. · The VA was susceptible to abuse from others and might not identify abusive situations, defend him/herself or seek help, or report abuse to an appropriate person. Staff always stayed with the VA and removed him/her from potentially dangerous situations and reported abuse on the VA’s behalf. The facility’s documentation included the following information: · Staff meeting minutes dated March 25, 2025, stated that there was discussion about a sore (wound) on the VA’s buttocks and that staff should transfer the VA out of his/her wheelchair every three hours. P1-P3 and the SP attended this meeting. · An incident report dated July 18, 2025, stated that staff noticed the VA’s wound looked “worse” and had a “bad smell” and brought him/her to an emergency room. A doctor determined the VA’s wound was in the early stages of tunneling. (A tunneling wound was a wound that forms a narrow channel or tract extending from the surface into deeper tissue layers, often complicating healing and increasing infection risk.) The VA was admitted to a hospital and after a few days, transitioned to a rehabilitation (rehab) clinic for intensive wound care. The plan was for the VA to stay at rehab for two to four weeks. · Staff communication logs and meeting minutes dated September 23, 2025, stated that the VA would be discharging from rehab and returning to the facility on September 26, 2025. The G visited the facility to show staff how to change the VA’s wound dressings and clean the wound. “[The VA] will need to be rotated [every] 2-3 (hours).” “Repositioning (wedges/air mattress) chair to eat meals only. Recliner and bed only. Recliner-day bed-night.” P1-P3 and the SP attended this meeting. · Staff communication logs dated September 26, 2025, stated the VA moved back into the facility and noted the following, which was also posted on the VA’s bedroom wall: Reposition every 2 hours. [The VA] does like left side better. USE WEDGES! ALWAYS! 1/2 hour at a time in wheelchair for meals only. Then back to bed or recliner. · An incident report dated October 5, 2025, stated the following: When [P1] came into work (at 8 a.m.), they noticed that [the VA] was in [his/her] recliner in the living room. [The SP] then informed [P1] that [the VA] had slept in the living room for the night in [his/her] recliner. [The SP] said that [the VA] had fallen asleep around 10 p.m. and woke up at around 3 a.m. Then [the VA] fell back asleep around 5 a.m. until around 7 a.m. [The SP] had also mentioned that they had checked [the VA] at 6:30 a.m. and [the VA] was completely dry in [his/her disposable undergarment]. After [the SP] had left, [P1] had checked [the VA’s disposable undergarment] and [s/he] was completely soaked and smelled like urine. Staff got [the VA] to [his/her] room and into [his/her] bed to change [him/her] and to allow [his/her] body to rest and stretch out as [s/he] is not supposed to be left in [his/her] recliner all night. Upon moving [him/her] to [his/her] bed from [his/her] recliner staff could smell the odor even more intense. [The VA] had completely soaked through [his/her disposable undergarment], [his/her] sling and down to [his/her] recliner. The shirt [s/he] was also wearing was soaked. When staff removed [the VA’s disposable undergarment], staff seen that [the VA] had also had a [bowel movement]. Staff got [the VA] all cleaned up and changed. Staff as well noticed during changing that [the VA’s] wound bandage for [his/her] bed sore was soaked as well. Staff took the proper steps and cleaned the wound and put on a new bandage. After [the VA] was given a dose of acetaminophen to help with any stiffness due to sleeping in [his/her] recliner. [The VA] also had no wedge under [him/her] in [his/her] recliner to help release any of the pressure when [P1] came in this morning to relieve [the SP]. [P3] and [P2] interviewed … [the SP]. [The SP] admitted that [s/he] did not move [the VA] out of [his/her] recliner for 12 hours. · An incident report and the VA’s medical records dated October 14, 2025, each stated that staff saw blood in the VA’s urine and brought him/her to an emergency room where s/he was diagnosed with a urinary tract infection (UTI). There was no mention of what caused the UTI or of the condition of the VA’s wound. The G said that as of March 2025, the VA had a persistent wound on his/her buttocks. One of the VA’s doctors said that the VA could sit in a chair (on his/her buttocks) for up to one and a half hours at a time; however, another doctor said that the VA should not sit for more than 15 to 20 minutes at a time. On October 5, 2025, staff left the VA in his/her recliner overnight. The G had no prior concerns with the facility but also wondered if there had been any other instances when the VA was left in a chair for a prolonged time. On October 14, 2025, the VA was diagnosed with a UTI and the G wondered if the UTI was caused by the incident on October 5, 2025. According to goodrx.com, once bacteria enter a person’s urethra, they start multiplying until the first symptoms of a UTI start, which is usually in about 48 hours. According to another internet source, UTI symptoms typically appear within three to seven days after the infection begins, but this can vary. P1-P3 provided the following information: · P2 said that on October 4, 2025, at 8 p.m., s/he was relieved at work by the SP. At that time, the VA was sitting in his/her recliner and P2 told the SP that the VA should be transferred into bed at 10 p.m. · P1 said that on October 5, 2025, at 8 a.m., s/he relieved the SP at work. At that time, the VA was sitting in his/her recliner. The SP told P1 that s/he checked the VA’s disposable undergarment about 30 to 45 minutes prior to 8 a.m., and it was “dry.” Around 8:10 a.m., P1 checked the VA and discovered urine and feces “soaked” through the VA’s brief, wound bandages, t-shirt, and the two chuck pads underneath the VA, which then soaked into the recliner. P1 could see “lines” on the VA’s skin from where the VA was sitting but otherwise, “not much” was concerning about the VA’s skin. P1 asked the VA if s/he was “sore” or uncomfortable and the VA said, “No.” As the day progressed, P1 did not notice any increased discomfort from the VA. P1 said that the VA might experience large bowel movements or urine loads, but not to the point of soaking through his/her chuck pads within 30 to 45 minutes. P1 cleaned the VA up and then called P2. · P2 and P3 each said that they called the SP, who told them that s/he “rotated” the VA once on October 5, but did not transfer the VA out of his/her recliner at any point. The SP said that s/he last checked the VA’s disposable undergarment around 6:30 or 7 a.m., and it was “dry.” The SP was not aware the VA’s disposable undergarment and chuck pads were soiled when s/he left at 8 a.m. P3 told the DHS investigator, “You don’t get soaked that much” between 6:30 or 7 a.m. and 8:10 a.m. P3 believed the SP’s account of when s/he last checked the VA was “a lie.” · P1 said that “most of the time” following an incontinence episode, the VA became vocal, which prompted staff to check and change the VA’s disposable undergarment. The VA typically did not let staff know ahead of time or in time to use the toilet. The VA had a history of “holding” (declining to release) his/her urine and bowel movements because s/he did not like using the toilet or getting his/her disposable undergarment changed. · P1-P3 each said that staff were to reposition the VA every two hours. P2 and P3 each said that the amount of time the VA sat in his/her recliner was not important if staff were repositioning him/her every two hours and changing his/her disposable undergarment as needed. · P3 said that s/he was not aware of prior concerns with the SP’s conduct. The VA did not have a history of UTIs. P1 was not aware if the VA’s UTI was caused by the incident on October 5. The SP said that on October 4, 2025, at 10 p.m., the SP arrived at work, and the VA was sitting in his/her recliner in the living room. The VA fell asleep in his/her recliner and did not want to be transferred into his/her bed. The SP “rotated” the VA at 12, 2, 4, and 6 a.m. on October 5, and each time the VA’s disposable undergarment was dry. The VA typically let the SP know if s/he had a soiled disposable undergarment and the VA did not do so on October 4 or 5, 2025. The VA had a habit of “holding” his/her waste “until [s/he] dumps everything” or “floods completely.” Facility documentation stated that the SP and P1-P3 received training on the VA’s support plans, including Intensive Support Self-Management Assessment, and on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: On October 5, 2025, at 8 a.m., P1 arrived at work in relief of the SP and discovered the VA in his/her recliner and soaked in urine and feces. The VA had been in his/her recliner for 12 hours. The VA’s skin had lines from where s/he was sitting; however, the VA denied being sore and did not appear uncomfortable. The SP told the DHS investigator that s/he rotated the VA every two hours between October 4, 2025, at 10 p.m., and October 5, 2025, at 8 a.m., and each time, the VA’s disposable undergarment was dry. The SP told P2 and P3 that s/he rotated the VA once and last checked the VA’s disposable undergarment around 6:30 or 7 a.m., and it was dry. Given that the VA had a history of holding his/her urine and bowel movements and then releasing everything at once, it was possible the VA’s disposable undergarment was dry and then soaked within the timeframe the SP said s/he last checked it. There was no information that the VA’s skin was raw or bleeding or that the VA’s wound was changed or needed additional care, and although the VA was diagnosed with a UTI on October 14, 2025, there was no determination made by a doctor whether the two were related. In addition, the SP stated that the VA did not want to move out of the recliner and fell asleep. Therefore, there was not a preponderance of the evidence whether the SP’s conduct included repositioning the VA every two hours and changing his/her disposable undergarment as needed or whether the SP’s conduct included a failure to supply the VA with care or services, which were reasonable and necessary to maintain the VA's physical or mental health or 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. The SP and/or the VA had no history of similar incidents. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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