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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: 1104980-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns Suspected Maltreatment Reported: It was reported that on March 6, 2026, a vulnerable adult (VA) fell while in his/her sit to stand device, cut his/her left arm, was transported to the emergency room (ER), and the cut was treated with a bandage. The VA’s bandage was not changed by facility staff persons until his/her follow-up visit on March 10, 2026. Date of Incident(s): March 6 - 10, 2026 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 March 31, 2026; from documentation at the facility and medical records; and through nine interviews conducted with four facility staff persons (P1, P3, P5, and P6), two supervisory staff persons (P2 and P4), a facility nurse (N), the VA’s guardian (G) who was also a family member, and a community medical professional (CMP). The VA was diagnosed with moderate intellectual disabilities, anxiety disorder, and was in remission from hairy cell leukemia. The VA liked the Minnesota Vikings, eating M&M’s, watching TV, and going to Burger King. The VA’s plans stated that s/he had reduced mobility and ambulated throughout the facility using a wheelchair and “refused” to use his/her walker. The VA needed staff person assistance for transfers to and from his/her wheelchair and was unable to do so on his/her own. Staff persons used an “Invacare Get-U-Up” sit to stand chair with handles and a belted sling to assist the VA with transfers to and from his/her bed. The VA’s staffing ratio was one staff person to four individuals. When available, two staff persons assisted the VA with using the sit to stand chair, however the VA’s plans did not require two staff person transfers. The VA’s plans stated that s/he had a “high pain tolerance” and would not tell staff persons if s/he was hurt anywhere. The VA did not like attending doctor’s offices and had the option of taking an as-needed medication prior to attending medical appointments or procedures. The VA’s standing orders, signed December 22, 2025, for “Minor Scratches, Cuts, and Abrasions,” stated, “Clean area well with soap and water. Apply Bacitracin or triple antibiotic ointment topically, 1-3 daily PRN [as needed]. May cover area with a band-aid. Observe for signs and symptoms of infection. Do Not use on deep or punctured wounds or burns. Consult nurse/[medical doctor].” The CMP stated that on March 10, 2026, the VA was seen at a medical clinic that was part of the hospital’s network for a follow-up visit for an injury to his/her hand that occurred during a fall at the facility on March 6, 2026. When the VA arrived at the appointment, the CMP stated that the VA’s bandages had not been changed by the facility since March 6, 2026, when the VA was treated at the ER, and that the bandages were dirty, “rock hard,” and “caked with dried blood.” The CMP stated that the bandages had to be soaked to be removed. According to the CMP and medical records, the medical clinic had “standing orders,” for wound care, signed December 22, 2025, which were good for one year with the facility in the VA’s file. The March 6, 2026, after visit summary was sent to the facility upon the VA’s release from the ER provided instructions regarding how to care for a “skin tear.” The CMP stated that the instructions stated to keep the area clean and covered with a bandage, and that it was to be cleaned with “plain” water, twice per day, and to let it air dry. The CMP stated that the care for this would have fallen under the standing orders for wound care. On March 10, 2026, at the follow up appointment, the medical clinic provided the facility wound care orders which “matched” the VA’s standing orders on file. On March 10, 2026, the CMP spoke with P4 who told the CMP that the facility did not have orders to care for the wound, so they “couldn’t do anything” for it. The VA’s medical records from March 6, 2026, stated that the VA’s injured areas included a forehead contusion and a skin tear on the VA’s left forearm. Some staff persons described the skin tear as on the VA’s hand and some described it as on the VA’s arm, but there was only one visible injury in that area. According to the VA’s after visit summary dated March 6, 2026, there were attached instructions for “Skin Tears.” The Overview section provided background information on skin tears, how to control bleeding, a brief overview on cleaning, preventing infection, and recovery time of approximately one month’s time. The next section provided more specific information regarding the wound. In summary, the “How Can You Care For Yourself at Home” section stated that pain could be treated by taking over the counter medications, then listed instructions for cleaning which stated: · If you have a bandage, follow your doctor’s instructions for changing it. · Follow your doctor’s instructions about bathing. · Gently wash the skin tear with plain water 2 times a day. Do not rub the area. · Let the area air dry. Or you can pat it carefully with a soft towel. · The skin care instructions also listed when to contact the doctor if there were additional issues related to the skin tear. The VA’s medical records from March 10, 2026, stated that there was “old appearing Coban dressing” on the VA’s left forearm and hand. Under that was “dried/blood caked telfa pads.” The VA’s after visit summary and wound care orders from March 10, 2026, the instructions stated, in summary, to “gently clean” the area with washcloth and warm soapy water, then apply a thin layer of Vaseline or petroleum jelly to the surface after soaking and drying, followed up with covering the wound with a “Tefla” pad or large Band-aid. The bandage was to be held in place using a wrap such as an “Ace” bandage or “Coban” tape to avoid the material sticking to the VA’s skin. These cares were to be discontinued once the wound was “dry and/or healing.” Interviews with P1, P2, P3, and the N provided the following information: · According to P1, on Friday, March 6, 2026, right before 2 p.m., P1 was working alone at the facility. P1 was in the process of changing the VA’s absorbent undergarment and the VA was in the sit to stand chair. The use of the chair required the VA to participate by standing upright during the transfer process and holding onto the handles. The VA began leaning sideways and the stand began to “flip,” so P1 grabbed the VA, but the combined weight of the stand and the VA made it so that P1 could not keep it upright. P1 stated that s/he did what s/he could to “easily” lower the VA to the ground, but in the process, the VA hit his/her forehead on the stand and had a “scratch” on his/her left arm. · According to P1, s/he called P2, to notify him/her that P1 could not get the VA up alone. P2 said that s/he would be right there. P1 also called P3 to ask if s/he could come in early. P3 arrived at the facility and called P5, who was on a scheduled week off from the facility and s/he instructed them not to move the VA, and to call 9-1-1. P2 arrived at the facility shortly thereafter. Emergency Medical Services (EMS) arrived, bandaged the VA’s arm, and transferred the VA to the ER. P1’s shift ended after s/he completed a shift note summary and paperwork, and s/he went home. P1 did not return to the facility again until Monday, March 9, 2026. P1 stated that s/he informed P4 that s/he could no longer work with the VA without a second staff person present. · According to P2, on March 6, 2026, s/he arrived at the facility about five to ten minutes after talking to P1 and P3 arrived around the same time. P2 called 9-1-1 and was instructed to leave the VA on the floor until EMS arrived. The VA was on the floor for approximately ten minutes and P2 thought s/he observed a cut and bruised arm and possibly a cut on the VA’s head. The cut on the VA’s arm was between a “scratch” and a “deeper cut” that was bleeding and was approximately three or four inches long. · P3 stated that s/he rushed to the facility when s/he saw a missed call from P1. When P3 arrived, s/he saw the VA on the floor. P1 told P3 what happened, then P2 arrived and called 9-1-1. P3 drove to the ER bringing the VA’s facility documents for ER staff. The VA was in the examination room when P3 arrived at the ER. The VA’s vitals were taken, and the doctor ordered a computerized tomography (CT) scan to check for a head injury, but the VA was “agitated,” which was the VA’s “baseline.” The VA would not be still, so they were unable to complete the CT scan. Medical records showed that the VA also received X-rays on his/her left elbow and wrist. P3 said s/he received instructions from the doctor that if there was any concern regarding the VA’s head, to bring the VA back. P3 did not observe any scratches or bumps on the VA’s head. · According to P3, medical professionals at the ER did not “say anything” about caring for the VA’s hand injury during discharge and did not give P3 any medical supplies. P3 did not see any wound care instructions on any paperwork and handed P2 all the paperwork upon returning to the facility sometime after 8 p.m. P3 stated that the VA’s left hand, which was scratched, bruised, and bleeding, formed a scab and was wrapped with bandages at the ER. The injury was about three centimeters long. P3 gave P2 the paperwork that P3 brought to the ER, and possibly aftercare summary paperwork. P3 stated that s/he started a “seven-day watch” for a head injury on the VA immediately, and there were no additional issues with the VA. · P2 did not think s/he got a copy of any wound care instructions from P3 and stated that s/he did not get the aftercare visit summary from the VA’s visit on March 6, 2026. Due to this, when P2 saw that the VA arrived at the facility from the ER with a bandage on his/her arm, s/he contacted the N on March 7, 2026, to get more clarification to find out if the bandage should be changed by facility staff persons. · P2 stated that on March 7, 2026, the N told P2 to follow up with the hospital nurse phone line to clarify the instructions on replacing the VA’s bandages. P2 stated that s/he called the nurse line that day, left a message, and did not get a return call from the nurse line for a day or two. P2 could not recall if s/he followed up with the N. · On March 7, 2026, P3 said s/he worked and the VA had the same bandage that was placed at the ER. No staff persons had changed the VA’s bandage since the appointment. P3 stated that there were no instructions provided by the ER or facility on changing the VA’s bandage until three or four days later, after the VA’s follow-up visit. Once the facility had doctor’s orders to change the bandage on March 10, 2026, the N changed the bandage “right away” and P2 told staff persons, including P3, to continue to change the bandages per the orders. · According to P1, staff persons were not given any instructions or medical supplies to change the VA’s bandage at the VA’s ER visit on March 6, 2026. According to P2, there were no “clear instructions” provided from the ER and P2 was confused by that. · P4 was notified about the VA’s fall the day it happened and returned to work on March 8, 2026. P4 stated that the VA had a wound on his/her ankle, before later saying that there was not an ankle injury, and that it was on the VA’s hand, then later corrected to “arm.” The VA had bandages on his/her arm that were put on at the ER on March 6, 2026. The VA did not leave the ER with any extra, unused bandages and P4 said that staff persons at the facility could not change the VA’s bandage until they were instructed to change it or had “doctor’s orders.” P4 said that these general instructions, to not touch or change client bandages, came from the facility nurses. · P4 stated that the VA’s bandage was not changed until March 10, 2026. P4 told this investigator that the VA’s bandage was not changed by staff persons at the facility prior to the March 10, 2026, appointment, but the internal review showed that P4 stated that s/he changed the VA’s bandage, prior to the March 10, 2026, appointment. The VA was seen for the follow-up appointment by the medical clinic on March 10, 2026, but was not sent back with any medical supplies for wound care on that date. After getting doctor’s orders on March 10, 2026, the N went to the facility and showed staff persons how to clean the wound. By this point, it was entered into the VA’s ECP and the bandages were changed twice daily. · P5 stated that s/he was at the facility on March 7, 8, and 11, 2026, and saw the VA with a bandage on his/her arm. During those shifts, s/he did not do any wound care or bandage changes for the VA. P5 was not provided any instructions from supervisory staff persons for wound care for March 7 or 8, 2026, and was unsure if any staff persons did wound care for the VA on March 11, 2026. P5 provided information in the internal review which stated that s/he observed P4 change the VA’s bandage prior to the March 10, 2026, appointment. · P1 stated that on March 9, 2026, before the VA was seen for his/her follow up the following day, P1 asked P4, who was back from being off the schedule if staff persons were supposed to change the VA’s bandage and they discussed how no orders or supplies were sent back with the VA from the ER visit on March 6, 2026. · P1 stated that s/he took the VA to the follow up appointment on March 10, 2026, where the VA’s bandage was changed, and supplies were sent back to the facility to change the VA’s bandage as it healed. P1 had taken clients to “many” medical appointments and always returned the paperwork to a facility supervisor, typically P4, but sometimes P2. Once staff persons were told to change the bandage, the VA’s bandaged got changed, as directed. · P6 stated that the first date s/he was scheduled after the VA’s fall was on March 10, 2026. P6 was told by someone at the facility that the VA had an appointment for his/her arm, but P6 could not recall who took the VA to the appointment. The N provided the following information: · On March 7, 2026, the N first heard about the VA’s skin tear via text message from P2, which was the day after the injury occurred. P2 told the N that there were no “orders” regarding caring for the skin tear, so the N told P2 to follow up with the hospital. The N stated and text messages showed that the N did not hear back from P2 via text message that day. · The N typically heard about incidents prior to a client being discharged from the ER. Facility documentation and information from the N showed that on Monday, March 9, 2026, the N followed up with P2, P4, and the N’s supervisor via e-mail because s/he had not heard an update about getting orders for the VA’s wound care. The e-mail stated that P2 described the “skin tear” as larger than a Band-aid and on the VA’s forearm. P4 replied to the email and stated that the VA had a follow-up appointment scheduled for the next day, March 10, 2026, and that wound care was to be discussed at the appointment. On March 10, 2026, P2 replied to the e-mail and stated that orders were sent home with the VA from his/her appointment that day. · The next morning, March 11, 2026, the N got the orders for the dressing change, purchased medical supplies, and changed the VA’s bandages. The N showed staff persons, including P4, how to change the VA’s bandages. The N took a photograph of the VA’s injury during the bandage change and sent it to P2. The N “highly encouraged” the VA to be seen by “wound care,” a place that specialized in the healing of wounds. The N was concerned that facility staff persons were not trained in “sterile techniques.” Wound care appointments were set up for the VA. After several weeks of seeing wound care, the VA’s wound was healing. The VA had several more weeks of appointments for follow-up. · The N stated that although the VA had signed standing orders from a doctor for cuts and scrapes, the facility “could” have utilized those for the wound care instructions, but since the standing orders did not list “skin tear,” the standing orders would have applied more to “general first aid” and the N, had s/he known, would have wanted clear instructions. · Due to the condition of the VA’s skin, the N thought that the VA possibly “picked” at his/her skin and caused the wound. The N was not informed that the origin of the injury was related to any sort of fall until several days later. The N stated that typically communication from the facility was from P4, but because s/he was not working, communication was from P2. Typically, P2 or P4 would be responsible for entering after visit summary instructions, such as medication changes or wound care into a client’s Electronic Care Program (ECP) following an appointment, but the N could also do it if s/he was notified. The N entered the instructions for twice-daily wound care and bandage changes in the ECP on March 11, 2026, so that staff persons would know to change the bandage, and made sure that there were supplies at the facility to do so as soon as s/he could. The VA’s ECP showed that the orders for bandage changes started on March 11, 2026, and were completed twice daily until March 18, 2026, when the VA had a follow-up appointment with wound care. P2 stated that typically, the standing orders for cuts and scrapes would apply to minor cuts, and that if changing the bandages for the VA due to the arm injury was not in the VA’s ECP or staff persons were specifically told to do so prior to the task being placed onto the VA’s ECP, staff persons would not have been expected to change the VA’s bandage. P3 stated that facility staff persons were “not allowed” to do “wound care” for clients. It was the responsibility of P2 or P4 to review the after-visit summaries, then inform staff persons of any follow up treatment was to happen. When P5 brought the VA to appointments, s/he returned with paperwork and would place it on P4’s desk. P5 would not perform wound care or bandage changes on a client without being “told to and trained to.” If the bandage change populated in the VA’s ECP, then P5 would ask a supervisory staff person prior to changing a bandage. P6 stated that on March 12, 2026, s/he completed a bandage change on the VA’s arm after his/her shower, per instructions given by P4. The wound was approximately the size of a quarter. P6 stated that for staff persons to do bandages changes, it would need to be listed in the VA’s ECP, or be told directly, and that it was not yet on the VA’s ECP on March 10, 2026. P4 typically entered changes into the ECP. The G stated that s/he was informed of an accidental fall that the VA had while staff person(s) were assisting the VA to or from bed using the sit to stand chair. The VA’s arm was injured, but the G had recently gotten a phone call that the VA’s arm had been “treated successfully.” The G felt that the facility had been providing very good care for the VA. All staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans. Conclusion: Information from P1, P2, and P3, showed that on March 6, 2026, P1 was working alone and assisting the VA with a transfer from his/her wheelchair to his/her bed, using a sit to stand chair and that both the chair and the VA began to “flip.” P2 and P3 arrived shortly thereafter and P2 called 9-1-1. Per instructions from 9-1-1, they did not move the VA and the VA was transferred to the ER by ambulance. The VA was examined at the ER and a bandage was applied to the VA’s arm. P3, who was at the ER with the VA, stated that s/he brought paperwork back to the facility and gave it to P2 but P3 could not recall if after visit summary paperwork was included in what s/he gave to P2. P2 stated s/he did not think s/he got the after-visit summary paperwork and also stated that there were not “clear” instructions for caring for the VA’s arm wound. P2 contacted the N regarding the VA’s wound on March 7, 2026, and asked about caring for and changing the VA’s bandage. The N instructed P2 to call the nurse line for more information. P2 said s/he called the nurse line, left a message, and did not hear back for several days. On March 9, 2026, the N asked P4 about the VA’s orders and P4 said that the VA had a follow-up appointment scheduled for the following day, March 10, 2026. P2 and the N stated that the “standing orders” that were on file at the ER and clinic for the VA would not have applied to the VA’s “skin tear” but would have applied to more basic cuts and scrapes. P1, P3, P5, and P6 stated that they did not change the VA’s bandage because there were no instructions in the ECP until there were doctor’s orders for changing the bandage after the VA’s follow up visit on March 10, 2026. P4 stated that s/he did not change the VA’s bandage because it was not in the orders from March 6, 2026, but told the facility during the internal review, that s/he changed the VA’s bandage on the morning of March 10, 2026, prior to the VA going to his/her appointment. The internal review showed that P5 said s/he watched P4 change the bandage. The CMP stated that the VA arrived to the follow up visit on March 10, 2026, with the same bandage that had been put on at the ER and that it was “rock hard.” The VA’s medical records from March 10, 2026, stated that there was “old appearing Coban dressing” on the VA’s left forearm and hand. Under that was “dried/blood caked telfa pads.” The CMP stated that the bandages had to be soaked in order to be removed. The VA was sent home with wound care and bandage changing orders. On March 11, 2026, the N got supplies for the VA, went to the facility, showed staff persons how to change the VA’s bandage, and entered the task on the VA’s ECP. The VA’s bandages were changed twice daily starting March 11, 2026, and until March 18, 2026, when s/he had a follow up with the wound care clinic. Although it would have been reasonable for staff persons to ensure clear care instructions were obtained when the VA went to the ER on March 6, 2026, so they could change the VA’s bandage, given that there were no specific doctor’s orders from the ER appointment directing staff persons to change the VA’s bandage, that staff persons, including the N made attempts to follow up to obtain care instructions, and that at the March 10, 2026, follow up appointment, the care the VA received was changing the bandage and there was no information that not changing the bandage prior to that affected the VA’s condition, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. 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 were retrained and some of the policies were changed to prevent future falls using the sit to stand chair. P2 no longer worked for the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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