|
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: 1070216-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux Minnesota Department of Human Services 651-431-6616 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) developed pressure sores on his/her buttocks that worsened over a month. Date of Incident(s): Prior to July 22, 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 August 13, 2026; from documentation at the facility and the VA’s medical records; and through interviews conducted with a facility staff person (the P), the VA’s guardian (G), and two staff persons at the day program (DPS1 and DPS2) where the VA received services. This investigator met the VA, but the VA did not provide information regarding the concerns in this report, and responded to questions by answering, “Yeah” or “Okay.” At the day program, the VA might engage in skill development, learn through experiences, and enjoy community inclusion. Through the program, individuals might develop social relationships, foster and develop independence, build and expand skills, and express themselves artistically. The VA used a wheelchair for mobility and remained seated in the wheelchair at the day program. When the pressure sores on the VA’s buttocks were initially observed, the VA was attending the program several days a week for a few hours each day. The VA was subject to guardianship and received community residential services from a facility in which s/he resided to help him/her build confidence and develop skills, including traveling safely, that were based on his/her needs. The residential facility worked to form partnerships with local employers and day program providers, to meet each person’s goals. The residential facility’s documentation showed that the VA’s diagnoses included a traumatic brain injury, spastic triplegia, and dysphagia. Spastic triplegia was a form of spastic cerebral palsy where three of a person’s limbs were affected by high muscle tone and stiffness. The VA needed assistance to stand, and a mechanical lift was used to move the VA between his/her wheelchair, bed, other furniture, or bath chair when s/he needed to transfer between them. The VA told staff persons when s/he was ill or injured but tended to provide inaccurate information regarding his/her health and might make comments about his/her health when there were no symptoms to support his/her statements. Staff persons were to observe the VA’s health and document any changes, then assist the VA to communicate medical concerns to health care professionals. The VA sat in his/her wheelchair most of the time and had a history of developing pressure sores. The “My Plan” documentation for the VA from the residential facility showed that staff persons at the facility preferred the VA to use a manual wheelchair which ensured that staff persons had full control of the wheelchair. The VA had a motorized wheelchair that s/he might use independently, but it was frequently damaged when the VA collided with stationary objects (furniture, buildings, a vehicle in a parking lot) in the chair, and it often had to be repaired. The VA might become incontinent of bladder or bowel if s/he was not prompted to go to the bathroom every two to three hours, but s/he required assistance to clean him/herself after using the bathroom and did not wear adult protective undergarments. The VA was kind and generous and preferred to choose the clothing s/he wore buts/he sometimes chose clothing that was not appropriate for the weather. The residential facility’s Internal Review, the VA’s medical records, and interviews with this investigator provided the following: · DPS1 and DPS2 provided consistent information that there was a scabbed over pressure sore on the VA’s right buttock and a developing pressure sore on the VA’s left buttock. At the day program, staff persons used a mechanical lift to transfer the VA from his/her wheelchair to use the bathroom, and the VA was usually continent when s/he was regularly assisted to use the bathroom. On July 10, 2026, the VA’s team met, and the sores on the VA’s buttocks were discussed, but no actions were planned and some of the team members dismissed concerns related to the sores. In addition, there were also concerns that the VA’s hair was not properly cared for, that s/he was not dressed warmly when s/he came to the program in the colder months, and that the VA’s quality of life was diminished because his/her motorized wheelchair was being repaired and the VA had to use the manual wheelchair, which s/he could not operate independently. · DPS1 and DPS2 monitored the sores and thought that the sores were worsening. On July 22, 2026, it was requested that the VA’s sores be evaluated by a physician before s/he returned to the day program. The VA had an annual physical scheduled in August 2026, but the residential facility agreed to immediately take the VA to a medical clinic for evaluation of the sores. · The VA’s medical records showed that on July 23, 2026, the VA was evaluated at an urgent care clinic which was part of his/her primary health care network for the sores on his/her buttocks. The VA’s vital signs were within normal limits, and s/he did not have an elevated temperature. The VA had “minimal breakdown” of the skin on the left buttock, his/her skin was dry, there was not “discrete ulceration,” no surrounding redness or swelling, and no purulent discharge. There was no large ulceration or wound that required a referral for wound care, no signs of secondary bacterial infection to warrant oral antibiotics, no abscesses, and no signs of systemic infection. The area was cleansed and bandaged. Staff persons were instructed to gently cleanse the area daily, apply “Aquaphor or Vaseline” to hydrate the skin, and apply a topical antibiotic to prevent infection. The VA was to use a donut pillow when sitting for extended periods and seek further care if the sores did not improve, if there was increased discomfort, fever, redness or swelling, or other issues. · On August 6, 2026, the VA had an annual examination with his/her primary care physician which showed that the VA had a “chronic” stage one pressure sore on the left buttock that was not currently open. The VA sometimes declined to lie in bed because s/he was uncomfortable in bed and preferred to sit in his/her wheelchair. A new wheelchair “on order” for the VA, and s/he recently lost weight likely due to a medication change. It was recommended that home care, physical therapy, and occupational therapy assess the VA for wound care and strategies to lessen pressure on the VA’s buttocks, including seating and equipment assessment. Staff persons were to reposition the VA every two hours. · The P, a residential supervisory staff person, said that the VA had a history of getting sores on his/her buttocks, and in July 2026, the VA had a sore that had healed on his/her right buttock and a sore that was in the process of healing on the left buttock. When the VA was evaluated for the sores at the urgent care clinic, staff persons were instructed to continue caring for the sores at the residential facility and were given a recommendation to purchase a donut pillow for the VA to sit on in his/her wheelchair. The P bought two donut pillows to alleviate pressure on the VA’s buttocks when s/he was in the wheelchair and sent one to the day program for the VA to use there. The VA sat in his/her wheelchair from 6 a.m. until s/he went to bed at night, but staff persons repositioned the VA in the wheelchair at the residential facility every two hours and as needed and used ointments and protective skin barrier creams to prevent and or treat pressure sores. The P said that the VA was not neglected. · The G said that sores on the buttocks were becoming a chronic problem for the VA because s/he used a wheelchair for mobility. The G felt that residential staff persons were doing the “best they could” for the VA, and the G had no concerns. Facility documentations showed that the P was trained on the Reporting of Maltreatment of Vulnerable Adults Act and on the VA’s plans. Conclusion: Information was consistent that in July 2026, the VA had two pressure sores on his/her buttocks. The sore on the VA’s right buttock was healing/scabbed over, and the sore on the VA’s left buttock was in the process of healing. The VA used a wheelchair for mobility from 6 a.m. until s/he went to bed daily and had a history of developing pressure sores on his/her buttocks. The VA needed assistance to move from the wheelchair, and s/he had some high muscle tone/stiffness in his/her limbs. The VA’s team met in early July 2026, and the sores on the VA’s buttocks were discussed, but no action was taken. DPS1 and DPS2 continued monitoring the sores and thought the sores were worsening. On July 22, 2026, the day program asked the residential facility to have the VA’s sores medically evaluated before the VA returned to the day program. Medical records showed that on July 23, 2026, the VA was evaluated at an urgent care clinic for the sores on his/her buttocks. The VA’s vital signs were normal, s/he did not have a fever, and his/her skin was dry, but there was “minimal breakdown” of the skin on the left buttock without redness, swelling, or discharge. A referral for wound care was not required, and oral antibiotics were not needed. Staff persons were instructed to gently cleanse the sores daily, apply a cream or lotion for hydration and a topical antibiotic to prevent infection. The P said that when the VA’s sores were evaluated, staff persons were instructed to continue caring for the sores as they had been, and it was recommended that the VA use donut pillows when sitting in the wheelchair for extended periods. The P bought two donut pillows, and took one to the day program for the VA. At the residential facility, staff persons repositioned the VA in the wheelchair every two hours/as needed and applied ointments and creams to the sores. The G was aware of the VA’s sores and said they were becoming a chronic problem, but s/he felt that the residential staff persons were doing the best they could and the G had no concerns regarding the VA’s care. Although the VA had a healing pressure sore and a stage one sore on his/her buttocks, given that the P said that staff persons were caring for the sores, that the team was aware of the VA’s sores and his/her history of pressure sores, that the medical records described the skin breakdown on the left buttock as minimal with no signs of infection, and that the residential facility followed the instructions provided by the physician, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services that were reasonable and necessary to obtain the VA’s physical 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 were followed. The VA had a history of developing pressure sores on his/her buttocks because s/he sat for long periods of time in his/her wheelchair. The facility took the VA to an appointment with his/her physician and purchased donut pillows for the VA as recommended. In addition, the facility scheduled a follow up appointment for the VA at a hospital to help improve the VA’s seating/wheelchair and other mobility equipment. A health care professional at the facility developed a pressure sore injury prevention protocol for the VA. Staff persons were trained on the protocol and instructed to perform and document daily body checks on the VA to take action on new pressure sores that might develop in the future. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
