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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: 1123293-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman Deb.Neubauer-Hoffman@state.mn.us Suspected Maltreatment Reported: It was reported that when a vulnerable adult (VA) was admitted to a hospital, s/he was soaked in urine and had multiple sores on his/her coccyx, right hip, and right shoulder. Date of Incident(s): January 16, 2020 and prior 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 January 28, 2026; from documentation at the facility and hospital medical records; and through seven interviews conducted with the VA, a facility health care professional (HCP), four facility staff persons (the DM and P1-P3), and a case manager (CM). The VA’s family was important to him/her. Smoking and watching TV calmed the VA. The VA’s diagnoses included type 2 diabetes, cardiomyopathy, lung cancer metastatic to bone, and stage 3B chronic kidney disease (moderate to severe kidney loss). The VA had right-sided weakness and used a wheelchair. The VA was not subject to guardianship. The VA’s Individual Abuse Prevention Plan stated that s/he had a history of refusing to go to the hospital or a doctor when s/he had potentially emergent health situations and “may become agitated or verbally aggressive when staff prompt [him/her] to get checked out.” If the VA refused medical care, staff persons called 9-1-1 to come check the VA and if s/he refused treatment, the paramedics may have him/her sign a refusal document. The VA was “very independent” and was able to complete a majority of his/her activities of daily living care on his/her own; however, s/he often refused to shower. If staff persons observed skin breakdown or other concerns, they contacted the VA’s primary care physician and scheduled an appointment. The VA needed assistance with cooking, cleaning, organizing, and home maintenance. The VA had 24-hour staffing to ensure his/her needs were met and that s/he was safe. The VA’s Self-Management Assessment stated that s/he became verbally and emotionally aggressive when s/he was frustrated or in pain. The VA did not like being reminded that s/he needed to smoke outside. On January 16, 2026, a report written by an emergency medical technician (EMT) showed that an ambulance crew arrived at 5:29 a.m. The VA was found in his/her bed, awake, but slow to respond. The VA complained of weakness and fatigue and “intermittent mild confusion” was observed. The VA “smells strongly of pungent urine” and his/her “brief is soaked through, with [VA] lying in urine-soaked bedding.” The staff person present (determined to be P1) said the VA was feeling “unwell since yesterday” and that a nurse (determined to be the HCP), was concerned about wounds on the VA’s “buttocks.” The VA was “normally able to utilize a urinal on [his/her] own but has not been able to sit up to do so the past day or so.” The VA’s hospital records showed that on January 16, 2025, s/he was transported via ambulance to a local hospital emergency room and subsequently admitted. Multiple labs and tests were completed and the VA’s diagnoses included “numerous decubitus ulcers,” failure to thrive, malnutrition, bilateral lower lobe pneumonia, and (at the facility) the VA was “declining medical interventions”. The decubitus ulcers were observed on the VA’s lower back/coccyx, right upper back, left shoulder, right hip and were “possibly infected.” On January 17, 2026, the VA had surgery for debridement of the ulcer on his/her right hip. The VA’s care was deferred to a wound care team; however, the VA “declined wound care, position changes, and nursing care.” The VA was supposed to use an oxygen mask but kept taking it off and requested it remained off. While hospitalized, the VA completed a seven-day course of antibiotics for bilateral lower lobe pneumonia. The VA “improved slightly” but continued to decline most cares and asked to be left alone. The VA and his/her family agreed with a plan for discharge to include receiving hospice services. The VA was discharged on January 26, 2026, and returned to the facility. (Information showed that the VA was hospitalized a second time within hours of that discharge.) This investigator interviewed the VA during his/her second hospitalization, and the VA provided the following information: · The VA believed s/he had sores on his buttocks and other parts of his body for a “few weeks” before s/he was initially hospitalized (January 16, 2026.) The VA did not tell staff persons that s/he had any sores. · The VA needed assistance to get in and out of his/her wheelchair but was then able to manage his/her own hygiene and did not need assistance with showering, therefore, staff persons would not have had the opportunity to see the sores on his/her body. The VA said s/he should have been hospitalized sooner, but s/he “refused” and preferred to “stay at home.” The DM provided the following information: · On January 15, 2026, (documentation showed it was likely January 14, 2026), P2 and P3 assisted the VA and observed some sores on the VA’s body and they notified the HCP. · When the HCP came to the facility on January 15, 2026, s/he “cleaned and packed” the sore and called 9-1-1. The VA made his/her own medical decisions and when the paramedics arrived at the facility, the VA refused to be transported to the hospital. That night, P1 worked overnight and checked on the VA throughout the night and early morning. At approximately 4 a.m. the VA was “unresponsive.” P1 called 9-1-1 and the VA was transported to the hospital. When asked about the VA being “urine soaked” upon arrival at the hospital, P1 believed the VA “refused” to be changed prior to leaving with the paramedics. · Prior to the incident, the VA was able to position him/herself in bed, wore disposable briefs, used a urinal in bed, and was able to be transferred with a “standby assist” after which the VA completed all activities of daily living on his/her own. · The VA resided at the facility for approximately a year and a half and the VA “never experienced” pressure sores while residing at the facility. · Approximately a week before the VA was hospitalized, staff persons noticed changes in the VA that included staying in bed more and “lethargy.” Prior to that time, the VA was “very independent” and “proud and private” and did not want staff persons touching him/her. The VA told staff persons when s/he needed his/her brief changed. If staff persons observed that the VA’s brief needed to be changed and the VA did not request assistance, staff persons provided verbal prompts. The VA “hated prompting” and sometimes continued to refuse assistance. The HCP provided the following information during an interview with this investigator and/or documented in the VA’s Resident Notes: · The VA needed “minimal to moderate” standby assistance getting in and out of his/her wheelchair. · On January 13, 2026, the HCP met with the VA who was in bed. The VA was in a “foul mood,” and his/her oxygen was “low 80’s” but increased to 92% with deep breaths. The VA asked for a cigarette several times and the HCP offered the VA assistance to get out of bed to go outside to smoke; however, the VA replied, “Never mind just give it here it’s cold outside.” The HCP reminded the VA there was no smoking within the facility. The HCP reviewed the VA’s “current condition” with the VA and asked the VA if s/he would go to the hospital with the HCP. The VA refused to go to any hospital. · On January 15, 2026, the HCP returned to the facility. The HCP brought the VA a burger, fries, and soda that the VA requested two days prior. However, the VA said s/he was not hungry and did not have an appetite. Assistance was provided to remove the VA’s clothing and wash him/her after being incontinent. The HCP observed a “deep tissue injury” (ulcer) on the VA’s right hip. As the ulcer was cleaned, the VA “moaned due to discomfort” and asked staff persons to stop. Another sore was observed near the base of the VA’s spine. The HCP explained the VA’s skin appearance to the VA and told the VA that s/he needed to be seen at the hospital for “immediate attention.” Paramedics arrived to assess and transport the VA; however, the VA said s/he was “going nowhere.” After the VA refused to be transported, the HCP called the VA’s primary physician to request treatment orders, and an appointment was scheduled for January 20, 2026. P1 worked the overnight shift January 15 until the morning of January 16, 2026. P1 checked on the VA throughout the night, gave the VA his/her medication at 2 a.m., and believed s/he changed the VA’s wet clothing one time. Around 4 a.m., the VA “was not responding appropriately” and P1 called 9-1-1. When the paramedics arrived, “they took [the VA] as [s/he] was.” P3 believed s/he first saw the VA’s pressure sore on January 14, 2026. While trying to “clean” the VA, P3 observed one sore on the VA’s “thigh” about the size of a quarter and a second sore looked like a “bruise” on the VA’s back. Because P2 worked a few days before January 14, 2026, P3 asked P2 if s/he saw any injuries on the VA prior, but P2 said that s/he had not. P3 contacted the HCP who said s/he would come the next day. P3 said that staff persons attempted to change the VA’s clothing daily; however, the VA sometimes refused. P2 said that on either January 14 or 15, 2026, P2 and P3 assisted the VA with changing his/her clothing when they first observed a “sore” on the VA’s “side” and “back” and “butt.” The HCP was immediately notified. A review of the VA’s Resident Notes from January 1-16, 2026, showed the following information: · Throughout the first 16 days of January 2026, there were numerous refusals by the VA to check his/her blood glucose, wear leg braces, and eat meals. On January 12, 2026, the HCP was notified regarding the VA’s “health issues” and when the HCP attempted to talk to the VA over the phone, the VA said, “Leave me alone,” and hung up on the HCP. · On January 13, 2026, the HCP came to the facility and talked with the VA while the VA was in bed. · On January 14, 2026, P3 assisted the VA with changing his/her clothing and observed “injuries” on the VA’s back and buttocks. The HCP was immediately notified. · On January 15, 2026, the HCP came to the facility to assess the VA while P3 cleaned the VA’s body and changed the VA’s clothing. The VA refused to go to the hospital. · On January 16, 2026, P1 documented that the VA was not feeling well and was in pain throughout the night. P1 called 9-1-1 and the VA was transported to the hospital. The HCP spoke to nurse at the hospital about the VA’s recent refusal of care, food, liquids, and activities of daily living as well as the “progression of new changes of skin integrity including tissue injury within the last 12-24 hours.” The CM only worked with the VA since mid-December 2025 and “didn’t have a lot of communication” with the facility and there were no concerns mentioned about the VA’s health during an exchange of information at the end of December 2025. However, the CM said that s/he was informed of the VA’s bedsores and hospitalization in January 2026. According to the National Library of Medicine, the Mayo Clinic and/or the Merk Manual, uninterrupted pressure can cause significant tissue damage within two to six hours. Rather than a progression from stage 1, a pressure ulcer can progress to stage 4 (involving deep tissue, muscle, and bone damage) in as little as a few days to a week. Common sites of pressure sores included the tailbone or buttocks, shoulder blades, spine, hips, lower back, heels, and ankles. Risk factors included diabetes, smoking history, dry skin, low body mass index, impaired mobility/infrequent repositioning, urinary and fecal incontinence, and malnutrition. Sometimes the first sign of a pressure ulcer was a deep, necrotic stage 3 or 4 injury. Facility information showed that staff persons were trained in client mobility, lifting and safe transfers, resident rights, first aid, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information from the VA, DM, and HCP showed that prior to January 2026, the VA needed assistance to get in and of bed and his/her wheelchair but was able to reposition him/herself. The VA said because s/he completed activities of daily living by him/herself, staff persons were not aware of any sores on the VA’s body, and the VA did not tell anyone about the sores. On January 14, 2026, P2 and P3 observed sores on VA’s body and they notified the HCP. On January 15, 2026, the HCP and paramedics attempted to convince the VA to go to the hospital, but the VA refused. In the early morning of January 16, 2026, paramedics were again called to the facility because the VA was not responding as usual. When the paramedics arrived, they found the VA soaked in urine with multiple sores on his/her body. P1 said that s/he changed the VA’s clothing one time during the overnight shift, prior to the paramedics arriving at the facility, and then the paramedics “took [the VA] as [s/he] was” and the VA was transported and admitted to the hospital. The hospital diagnosed the VA with multiple decubitus ulcers on areas of the VA’s body that were not easily visible due to being covered with clothing. While hospitalized, the VA continued to refuse recommended treatments. Given that the VA did not tell anyone about the sores on his/her body, that the VA was not subject to guardianship and was able to direct his/her own care and refused earlier attempts to go to the hospital, there was not a preponderance of the evidence whether there was a failure to provide the VA with services that were reasonable and necessary to maintain his/her physical health. 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 were followed. It was also determined that this incident was similar to past events due to the VA’s history of refusing emergency medical care. The VA no longer resided at the facility after it was determined his/her care needs exceeded what the facility was able to provide. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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