Vista Prairie at Copperleaf Ll.

Finding: Substantiated, facility responsibility Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The alleged perpetrator neglected the resident when the alleged perpetrator failed to follow the residents care plan and gave the resident coffee in a ceramic coffee cup. The resident suffered burns to his fingers and ended up with a right ring finger amputation due to the burn. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. When the resident sustained burns to his left hand from a hot coffee cup, the facility did not put interventions in place to prevent the risk of recurrence. Three weeks later the resident’s right hand sustained burns from a hot coffee cup, which eventually led to an amputation of one of the resident’s fingers on his right hand. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family member and An equal opportunity employer. the resident’s provider. The investigation included review of the resident’s facility record and facility’s internal investigation. Also, the investigator observed staff to resident interactions. The resident resided in an assisted living facility. The resident’s diagnoses included dementia, type 2 diabetes, and neuropathy (damage to the nerves that cause weakness, tingling, and numbness). The resident’s service plan included meal services but did not identify if the resident needed specific assistance. The resident’s assessment indicated he ate independently following set-up which may include cutting up foods at times. The assessment indicated the resident had mild memory and thinking problems and a history of disorientation. The assessment further indicated the resident had numbness or tingling in extremities and neuropathy in hands and feet. The facility internal investigation, completed approximately seven weeks following the initial incident, indicated the resident was served hot coffee in a blue ceramic coffee mug during lunch. The resident was holding the coffee mug which injured his hand, although which hand was not specified. The document indicated the wound was a “reinjury” but did not specify what previous injury it was referring to. The document indicated the coffee mug was replaced with a silver insulated coffee mug, but it did not specify when the replacement took place. Injury #1 The progress notes indicated the resident was handed a ceramic coffee cup and sustained burns on three of his fingers on the left hand. The same note indicated the resident’s medical provider would be updated at her next visit on “Friday” [the documents indicated the burn occurred on a Wednesday]. The note indicated the staff were told to use an insulated cup. The facility’s electronic medical record showed this was a late entry on the same day the facility’s internal investigation was dated (approximately seven weeks later). Two days after the resident sustained the burns on his left hand the medical provider notes indicated she saw the resident who had second degree burns with blisters on three fingers on his left hand. The medical provider wrote orders for wound care. Injury #2 Approximately three weeks after injury #1 the progress notes indicated the resident was handed a ceramic cup and sustained blisters to his right hand. The facility’s electronic medical record showed this was a late entry on the same day the facility’s internal investigation was dated (approximately four weeks after injury #2). Two days later the medical provider notes indicated the resident had second degree burns on the fingers of his right hand. The same note indicated the medical provider discussed with staff to consider an insulated coffee mug to prevent burns. The medical provider also documented the resident had neuropathy in both hands and did not feel when his fingers were burning on a hot coffee mug. The same note indicated the burns on the residents left hand were still present. The note was dated more than three weeks after the initial injury to the resident’s left hand. Subsequent notes from the medical provider indicated she ordered a referral for a wound clinic as healing was complicated by the resident’s impaired thinking and memory and he had a tendency to pick at his wounds. Infection and Amputation Approximately three weeks after the residents second injury, the resident’s right hand developed an infection and the resident received antibiotics. During this same week, the wound clinic determined the wound had worsened and, after a hand surgeon was consulted, an amputation of one of the resident’s right fingers was planned related to a “full thickness” burn. The resident admitted to the hospital for the amputation and returned to the facility following a hospital stay. A review of the resident’s medical record did not identify the facility updated the resident’s care plan to include the use of an insulated coffee mug after injury #1 occurred to the resident’s left hand and prior to recurrence of a similar injury to the resident’s right hand. During an interview, an activities assistant stated it was part of his job to assist with serving drinks and meals to the resident at mealtimes. The activities assistant stated on the day of the incident (injury #1) he served the resident coffee prior to the meal. The activities assistant stated the resident used a special coffee mug, which was at the table when he served the coffee. The activities assistant stated the resident had a couple of different coffee mugs but the one he used the day of the incident was brown with no handle and had a lid. During an interview, the nurse stated following training, activities assistants were able to serve beverages at meals times. The nurse stated staff, including activities assistants, were able to see if a resident used adaptive equipment by viewing their care plan. The nurse stated the resident used an insulated mug with a handle, but she did not think it always had to be used. The nurse stated she was unsure whether the insulated mug was on the resident’s care plan at the time of the incident (injury #1) but was sure one of the other nurses put it on the resident’s care plan following the incident. The nurse stated she did not discuss the incident with the activity assistant but reported it to their direct supervisor and a member of management who would have been responsible to follow up with them. The nurse further stated nursing staff were re-educated at a staff meeting three to four weeks following the incident; however, there was information posted electronically prior to the meeting. The nurse thought the resident burned his right hand during this incident and could not recall if there was a second burn incident which caused burns to the other hand. During an interview, a member of management stated the resident had a special coffee cup that went everywhere with him. The cup was big so the resident could hold it better, but the member of management could not recall what it looked like. The member of management stated she was not in the facility when the incident (injury #1) occurred but understood the incident was witnessed by staff, staff intervened, the nurse practitioner got involved for treatment right away, and the burn was to the resident’s right hand. The member of management stated the resident started using an insulated coffee mug following the incident but was unsure whether the information was added to his care plan. When discussing the resident’s documentation, the member of management stated the nurse practitioner put in the incorrect information at first because it was the resident’s right hand that got burned. With further discussion regarding documentation in the resident’s record, the member of management denied a second burn incident and stated, “I only recall a right-hand burn.” During an interview, the resident’s medical provider stated the resident obtained burn injuries to fingers on both hands in two separate incidents. In the first incident, the resident burned three fingers on his left hand. In the second incident, the resident burned fingers on his right hand and reinjured the burns to his left hand, making them worse. In conclusion, the Minnesota Department of Health determined neglect was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19.