Maltreatment reduction

Individuals can receive injuries related to the use of wheelchairs, van/bus lifts and safety restraints during transportation. Providers are required to have a transportation safety policy and procedures as identified under the Home and Community-Based Services Standards. In addition, the following may reduce the likelihood of injuries involving transportation:

• Establish clear procedures for staff people to follow when individuals utilize wheelchairs. (Failure to correctly secure wheelchairs in vehicles and/or to correctly secure individuals in the chair has resulted in serious injury to individuals and a finding of maltreatment.)
• Train and familiarize staff people with the provider's procedures for wheelchair tie downs and the use of a lift on a regular and continuous basis.
• Establish a system to follow and retain the manufacturer's directions for use and maintenance of the equipment.

An individual's coordinated service and support plan addendum (CSSPA) includes assessments used to identify an individual's needs, vulnerabilities, and risks in multiple areas. Inadequately written and improperly implemented CSSPA's could result in harm to individuals receiving services. The following may reduce the likelihood of harm and incidents related to an individual's needs, vulnerabilities, and risks identified in the CSSPA:

• Ensure that CSSPAs are written objectively with detailed and clear information.
• Include detailed instructions for staff people on how to minimize risk when an identified need and/or vulnerability is present.
• Update the plan as soon as possible when an individual’s needs, vulnerabilities and/or risks change.
• Train staff people on the individual's CSSPA each time a change is made.

Individuals may sustain injuries while using a wheelchair. It is the provider's responsibility to assess the individual's risk when using a wheelchair. This assessment includes:

• The individual's ability to propel their wheelchair independently and to navigate uneven terrain
• The individual's risk around open stairwells
• The individual's risk when using lifts to get in or out of vehicles
• The individual's need for additional adaptive equipment such as a mechanical lift, shower chair, etc.
• The individual's need for assistance with transferring in and out of their wheelchair.

Incidents where individuals fall or slip out of mechanical lift slings or wheelchairs occur because safety belts or straps are not utilized, either while in a mechanical lift or a wheelchair, prior to having either the mechanical lift or wheelchair in the proper position to transfer the individual safely. To reduce the likelihood of incidents, providers should:

• Ensure that all adaptive equipment (brakes, seatbelts, straps, slings, etc.) is maintained in working order.
• Develop and implement specific procedures in the individual's coordinated service and support plan addendum that assess how staff people can address the individual's risk in the above areas.
• Train staff people on the individual's identified needs.

An individual's money, medications or property may be mismanaged or stolen by a staff person.

Money and property

In several reports received by DHS licensing, a supervisory staff person was responsible for the mismanagement and was the sole person responsible to audit the individual's finances - allowing the exploitation to continue over a number of months or years. To reduce the likelihood of such incidents, providers should:

• Develop an audit system which includes regular oversight of each individual's money and property (including cash, gift cards, ATM/debit cards, checkbooks and bank statements) by more than one staff person.
• Keep an up-to-date inventory of the individual's belongings to assist with tracking and safekeeping of the belongings.
• Be aware of warning signs of financial exploitation, such as when a staff person evades or delays scheduled audits of individual's finances. Providers should also prevent the purchase of unnecessary items or items used by all individuals receiving services at the facility, particularly during "spend downs."

Medications

Many individuals are prescribed psychotropic and Schedule II medications. The Licensing Division receives reports when these medications are missing or thought to be stolen. Providers should:

• Establish written policies and procedures regarding the safe keeping of medications, which in some cases must include ensuring that the medications are kept locked and scheduled counts of the medications are completed by more than one staff person.
• Ensure that as needed medications are not regularly being refilled and/or automatically administered instead of administered based on symptoms.
• Dispose of discontinued or expired medications per the Food and Drug Administration Guidelines

In addition, you can seek information from your pharmacist or call your city or county government to find out if a drug take-back program is available in your community.

License holders serving adults with children are required under Minnesota Statutes, section 245G.19, subdivision 3, to have a policy and schedule explaining the times and circumstances when the license holder is responsible for supervision of a child in the program and when the child's parents are responsible for supervision of a child. The policy must explain how the program will communicate its policy about the responsibility of the supervision of a child to the parents. 

License holders must also have written procedures addressing the actions a staff member must take if a child is neglected or abused, including under the supervision of the child’s parent.

Safe sleeping and bathing practices as described on this page are also important. Such practices may reduce the likelihood of infant deaths and should be used in program policy and procedure development and in required staff person training.

• When placing an infant to sleep, place the infant on the infant's back, unless the provider has documentation from the infant's physician directing an alternative sleeping position for the infant. It is recommended that the physician directive be on a form approved by the commissioner and remain on file at the licensed location. An infant who independently rolls onto his/her stomach after being placed to sleep on his/her back may be allowed to remain sleeping on his/her stomach if the infant is at least six months of age or the provider has a signed statement from the parent indicating that the infant regularly rolls over at home.
• Place the infant in a crib directly on a firm mattress with a fitted sheet that is appropriate to the mattress size, that fits tightly on the mattress, and that overlaps the underside of the mattress so it cannot be dislodged by pulling on the corner of the sheet with reasonable effort. Do not place anything in the crib with the infant except for the infant's pacifier.
• If an infant falls asleep before being placed in a crib, move the infant to a crib as soon as practicable, and keep the infant within sight until the infant is placed in a crib. When an infant falls asleep while being held, the sleeping infant must not be in a position where the airway may be blocked or with anything covering the infant's face.
• Placing a swaddled infant down to sleep in a licensed setting is not recommended for an infant of any age and is prohibited for any infant who has begun to roll over independently. However, a parent or guardian may place an infant who has not yet begun to roll over on his/her own down to sleep in a one-piece sleeper equipped with an attached system that fastens securely only across the upper torso, with no constriction of the hips or legs, to create a swaddle.

• Never leave a child/infant unsupervised around water, not even for a moment.
• Do not put an infant into a tub when the water is still running. The water temperature could change or the water could get too deep.
• Fill the tub with only 2 to 4 inches of water for infants or use an infant tub.
• Water temperature should not be above 120 degrees Fahrenheit.

The needs of individuals receiving services may exceed the licensed facility's capacity to provide services. These situations can and often do result in harm to the individual receiving services. When an individual's physical and/or mental health changes, providers should re-evaluate the facility's ability to provide services to the individual.

Mandated reporters at licensed facilities have failed to report alleged or suspected maltreatment of a vulnerable adult. Frequently, facility staff people stated that they did not report the alleged or suspected maltreatment because they did not know whether the alleged incidents of maltreatment occurred.

Minnesota Statues, section 626.557, subdivision 3, states that a mandated reporter who has reason to believe that a vulnerable adult has been abused, neglected or financially exploited shall immediately report the information to the common entry point. Reason to believe includes being told by another person that an incident occurred. Facility staff people must ensure the safety of the vulnerable adult upon learning of the alleged maltreatment, but no further investigation is necessary prior to reporting the suspected maltreatment to the common entry point.

Minnesota Statutes, section 245A.65, subdivision 1, states that providers must establish and maintain policies and procedures to ensure that an internal review is completed within 30 calendar days and that corrective action is taken as necessary to protect the health and safety of vulnerable adults when the facility has reason to know that an internal or external report of alleged or suspected maltreatment has been made. 

This review must include an evaluation of whether related policies and procedures (relating to the incident, not the reporting policy) were followed before, during and after the incident; whether the policies and procedures were adequate; whether there is a need for additional staff training; whether the reported event is similar to past events with the vulnerable adult(s) or services involved; and whether there is a need for corrective action by the license holder to protect the health and safety of vulnerable adults.

Children have received food to which they are allergic. The following may reduce the likelihood of children's exposure to such food:

• Create a protocol to ensure that children are not exposed to allergens and ensure that all staff people are trained on the protocol. Some providers have included the use of a different colored cup, plate, or placemat to aid in recognizing food allergens.
• Ensure that allergies are posted as required.
• Ensure that the facility is provided with current prescribed medications, such as Benadryl or an EpiPen^®; if the child has been prescribed epinephrine for allergies. In addition, provide training to staff people on how to recognize symptoms and respond to a child having an allergic reaction, which may include information on how and when to use an EpiPen^®.

Children have suffered elbow injuries at child care centers. The most common injury is referred to as "nursemaid's elbow," partial dislocation, or radial head subluxation. The most common cause of such an injury is staff persons lifting or pulling children by the wrist or hand. Examples of incidents involving children suffering "nursemaid's elbow" include the following:

• A staff person "yanked" a child by the hand when the child refused to walk with the staff person.
• A staff person pulled a child by the hand(s) when the child extended their hand(s) for assistance getting up from the floor or over a partition.
• A child dropped to the floor while a staff person held onto the child's hand.

In addition to increased awareness of this safety concern, the following might help prevent these injuries:

• Lift children by grasping them under their arms or around their bodies.
• Discontinue leading a struggling child by the hand.
• Never grab, drag, pull, yank, swing, lift, or restrict movement of children of any age by their arms or wrists; allow the child to hold onto the staff person's hand instead of the staff person holding onto the child's hand.

Children's fingers can be pinched in doors at child care centers. Children are at risk of their finger(s) being caught in a closing door; resulting injuries have included severing of a fingertip and permanent loss of a fingernail. There have also been incidents where children's fingers were pinched in cabinet doors. The following may reduce the likelihood of this type of incident from occurring:

• Delineate a visual "safety zone" around the door, showing an area where children should not stand or sit.
• Increase awareness and supervision by staff persons around doors.
• Use door protectors (light weight plastic that adheres to the door and frame and discourages a child from placing his/her fingers in the hinge side of the doorframe). These are not guaranteed to prevent an injury, but may reduce the severity of the injury.
• Secure doors in an open position, if appropriate.
• Remove any unnecessary doors.

Sexual contact can occur between children at child care centers and at children's residential facilities. The following may reduce the likelihood of such incidents:

• Increase awareness and supervision by staff people in child care centers, including awareness of children who are playing in obstructed view areas such as climbers, play houses and tents as well as discussions about appropriate boundaries with children.
• Increase awareness and supervision by staff people in children's residential facilities, including increased awareness of where children are at all times, especially in areas that are difficult to supervise, such as bedrooms, hallways and bathrooms. Develop plans to address supervision for children with histories of engaging in inappropriate sexual behavior and discuss appropriate boundaries with all children receiving services.

Rough handling of children in child care centers by staff people also has been reported. The following may reduce the likelihood of such incidents:

• Provide training to the staff persons on acceptable methods of behavior guidance as required by Minnesota Rules part 9503.0055.
• Discuss with parents or guardians methods of behavior guidance they have used successfully with their child.
• Develop a behavior plan when a child engages in persistent unacceptable behavior and provide training to staff persons on the implementation of the behavior plan as required by Minnesota Rules part 9503.0055, subpart 2.

Thorough development, training and implementation of a child care center risk reduction plan required by Minnesota Statutes, section 245A.66, subdivision 2, may help reduce the likelihood of incidents of known risk to children including:

• Closing children's fingers in doors
• Leaving children in the community without supervision
• Children leaving the facility without supervision
• Dislocation of children's elbows
• Burns
• Injuries from equipment
• Food allergies
• Children falling from changing tables.

Children have been injured on playground equipment. The following may reduce the likelihood of playground injuries:  

• Ensure surfaces around playground equipment are covered with material such as wood chips, mulch, sand, pea gravel or safety-tested rubber-like material. 
• Ensure that protective surfacing extends at least six feet in all directions from play equipment. 
• Ensure play structures are spaced an adequate distance apart. 
• Check for dangerous hardware or sharp edges on equipment. 
• Check equipment and playgrounds regularly to ensure they are safe and in good condition. Dirt or grass surfaces below playground equipment do not adequately protect children if they fall.

Ensure that the playground equipment is age-appropriate for the children using the equipment. Children who are allowed to play on playground equipment designed for older children are at greater risk of injuries from falls.  

Further information from the U.S. Consumer Product Safety Commission regarding playground equipment is available in the Public Playground Safety Handbook (PDF). The U.S. Consumer Product Safety Commission also warns that children’s climbing equipment should not be used indoors on wood or cement floors (PDF) even if covered by carpet. Carpet does not provide adequate protection to prevent injuries.

Minnesota Statutes, section 245A.66, states that providers must establish and maintain policies and procedures to ensure that an internal review is completed (except for family child care settings and foster care for children in the license holder's residence) within 30 calendar days and that corrective action is taken if necessary to protect the health and safety of children in care when the facility has reason to know that an internal or external report of alleged or suspected maltreatment has been made. 

The review must include an evaluation of whether related policies and procedures were followed before, during and after the incident; whether the policies and procedures were adequate; whether there is a need for additional staff training; whether the report is similar to past events with the children or the services involved; and whether there is a need for corrective action by the license holder to protect the health and safety of the children in care.

Due to the severity and preventability of incidents regarding hot water, sun and heat application burns, providers are reminded of this danger. In addition, information is provided regarding burns from hot food and drink. The following information may reduce the likelihood of such incidents:

To prevent burns from hot water:

• Routinely check the temperature of water coming out of faucets in various locations at varying times of the day, including any time a water heater is installed or repaired
• Install temperature control devices on the hot water heater or faucets
• Train staff people to measure and control water temperature for individuals who are unable to do so themselves (not to exceed 120 degrees Fahrenheit).

To prevent burns from the sun:

• Develop and implement written procedures, in consultation with a health professional, to reduce the risk of injury from sun exposure
• Increase staff people's awareness of medications that may increase photosensitivity
• Train staff people on preventative measures such as avoiding mid-day sun exposure, applying sunscreen prior to sun exposure and at frequent intervals during sun exposure especially when engaging in water activities, covering exposed skin with hats or clothing, and checking the expiration dates on sunscreen products.

To prevent burns from food and drinks:

• Train staff people to ensure that all food and drink served to individuals are at a safe temperature
• Develop and implement a plan to reduce the risk that hot food and drink pose to an individual with limited dexterity, such as an individual with limited hand dexterity drinking hot coffee
• Increase staff people's awareness of the danger posed by their own food and drinks when in an area with individuals receiving services.

To prevent burns from bottle warmers:

• Secure bottle warmers to the back of a countertop
• Ensure that electrical cords are out of the reach of children
• Post signs warning that the bottle warmer may be hot and that staff people should not allow, or carry, children in the area of the bottle warmer.

Heat applications can be dangerous, especially to individuals who have decreased mobility and other health issues. Prolonged use on one area of the body can cause severe burn, even when the heal application is at a low temperature setting. To prevent burns from heat applications (electric heating pads or items warmed in a microwave, such as rice bags):

• Only use heat applications with a physician's order.
• Follow and retain on file the manufacturer's directions.
• Inspect the application prior to use.
• Keep a removable cover on the application during use.
• Provide close supervision during use. These items can be dangerous, especially to individuals who have decreased mobility and other health issues. Prolonged use on one area of the body can cause severe burn, even when the heating pad is at a low temperature setting.

The Licensing Division receives reports each year where an individual was not provided with necessary and timely first aid and/or cardiopulmonary resuscitation after an incident or injury occurred. Individuals have developed serious medical conditions and/or died prior to receiving emergency medical treatment.

Delayed first aid treatment

Not providing first aid to an individual or moving an individual has resulted in more serious injuries than the initial injury presented. To prevent an individual's injury from worsening, the provider should develop and implement written policies and procedures, in conjunction with a health care professional, that:

• Provide clear guidelines for staff persons on how to assess a situation and how to provide, or obtain, first aid for the individual.
• Address how to continually monitor the injury or illness for worsened or changed symptoms.

Delayed emergency medical care

In many cases, a staff person attending to the individual did not telephone 911 because they minimized the individual's condition, assumed the individual's symptoms were behavioral, or believed that they needed permission from a parent, guardian or a supervisory staff person prior to telephoning 911. Providers should develop and implement written policies and procedures, in conjunction with a health care professional that:

• Provide clear guidelines for staff people on how to assess and identify an emergency situation.
• Authorize and encourage staff people to call 911 without approval from a supervisory staff person, when a serious situation arises.

Sexual contact and nontherapeutic personal contact can occur between facility staff people  and individuals receiving services in our licensed programs. To reduce the risk of such occurrences, providers should review with staff people the importance of maintaining professional boundaries with the individuals who receive services at their facility.

Failing to maintain healthy boundaries is not therapeutic and might be maltreatment or a licensing violation. The following list is not all encompassing but provides areas for consideration in staff training and policy and procedure development.

Staff people should know how to:

• Maintain an appropriate level of emotional involvement with individuals.
• Identify appropriate physical contact: for example, a pat on the back may be appropriate but a kiss on the lips is not.
• Avoid relying on individuals receiving services for personal support.
• Maintain reasonable privacy regarding your personal life and finances.
• Avoid favoring one individual over others as indicated by time alone with the individual, attention, and/or favoring their choices for meals or activities.
• Identify whether staff people can visit with individuals on non-work hours, whether at the facility or elsewhere.
• Avoid engaging in sexual or intimate relationships with individuals receiving services.
• Avoid using discipline or rewards to manipulate individuals.
• Communicate with individuals using their formal name (or accepted nickname such as Bobby, Sue, Becky, etc.) in an age appropriate and professional manner.
• Avoid exchanging personal belongings with individuals including unreasonable gift giving or purchasing or selling any items by staff persons and by individuals receiving services.
• Keep clear separation and documentation of an individual's and the facility's funds and or property.
• Avoid allowing individuals to perform tasks or favors for someone else's personal gain.
• Avoid the use of mood altering substances including drugs and alcohol with individuals receiving services.

While the Licensing Division recognizes that staff people function in many roles for individuals receiving services and that providing a supportive nurturing environment is an important component of quality care, staff people need to be mindful that they are compensated to provide professional services for the individuals they support and to be responsive to their own limitations; working with the individual's interdisciplinary teams and involving additional professional services as needed.

The Licensing Division receives reports involving children leaving child care centers without staff persons' knowledge, children left without supervision on playgrounds or in classrooms, children left behind in community settings and children leaving the group during outings or field trips. In addition to the provision of required supervision (Minnesota Statutes, section 245A.02, subdivision 18 and Minnesota Rules, part 9503.0045, subpart 1, item A), the following suggestions are made to reduce the likelihood of such incidents:

• Increase awareness by staff persons of the elevated risk during transitions and at busy times of the day when entrance doors are frequently used by parents and other visitors.
• Maintain an accurate attendance list of children. Take attendance at regular intervals during the day by matching names on the list with the children present.
• Ensure that children are within sight and hearing at all times. Train all staff people on appropriate supervision requirements and document that staff persons demonstrate competence in implementation.

Vulnerable adults have been left without supervision at residential, work and community settings. In addition, reports are received that involve individuals leaving facilities without supervision. The following suggestions are made to reduce the likelihood of such incidents:

• Increase communication between residential and day service providers to ensure that staff people are available to maintain supervision of individuals during transitions such as pick-ups and drop-offs.
• Ensure that individuals with histories of leaving without supervision have plans in place that address enhanced supervision requirements and all staff people are trained on those plans. Ensure plans include steps for staff persons to take in case an individual leaves the facility without supervision.
• Ensure warning systems for staff people, such as door and window alarms, are checked on a regular basis to ensure that they are in working order and can be heard throughout the location. Ensure that alarms are not able to be tampered with or disabled by the individuals receiving services.
• Train staff people how to operate alarm and warning systems. Ensure staff people can recognize if the system is malfunctioning, can operate, test function and reset the system as needed.