Department of Human Services, Division of Licensing
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.”
Program License Number: 801558
Rule and/or Statute under which Facility is Licensed: Residential Treatment and Services for Adults with Mental Illness
Division of Licensing
Minnesota Department of Human Services
PO Box 64242
Saint Paul, Minnesota 55164-0242
Suspected Maltreatment Reported:
It was reported that a vulnerable adult (VA) went on “pass” from the facility with a family member (FM), and subsequently assaulted the FM.
Note: The focus of this investigation is on the events leading up to the VA leaving on pass and the VA’s treatment at the time of the incident. The VA’s act of assaulting his/her family member is being investigated by law enforcement.
Date of Incident(s): May 8, 2012
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.
Site visit: May 18 and June 19, 2012
Interviews (conducted between May 18 and June 29, 2012):
• A facility health care professional (HCP)
• A facility psychologist (mental health professional – MHP)
• Three facility staff persons (P1, P2, and P3)
• A law enforcement officer (LEO)
The VA was not interviewed due to the on-going law enforcement investigation. The VA’s family member (FM) was not interviewed due to his/her health condition at the time of the investigation.
Documents reviewed included:
• The facility’s program file for the VA including: a Face Sheet, an Intake Evaluation dated February 4, 2011; two History and Physical Assessment Reports dated February 4, 2011, and February 2, 2012; a Psychological Assessment dated February 28, 2011; a Psychiatric Assessment dated February 4, 2011; a Monthly or Quarterly Psychiatric Review dated April 25, 2012; a Social Services Update dated April 25, 2012; an Initial Assessment – Therapeutic Recreation dated February 15, 2011; an Addendum to the Initial Chemical Dependency Assessment dated February 15, 2011; an Individual Treatment Plan dated February 14, 2012; a Forensic Transition Services Quarterly Self-Assessment dated February 14, 2012; a Quarterly Report dated February 14, 2012; a Vulnerability Assessment and Risk Reduction Plan dated August 12, 2011; a Relapse Prevention Plan dated October 7, 2011; a Risk Appraisal Addendum dated August 15, 2010; and a Transaction History from the VA’s on-campus bank for January 2012 to May 2012
• Information regarding the VA’s security levels and pass plan including: a Special Review Board Recommendation dated October 25, 2012; a Special Review Board Evaluation Report dated July 29, 2012; a Request for SRT Review to Remove Electronic Monitoring dated June 4, 2011; a Grounds Privilege Checklist for Treatment Team Assessment dated as last updated on August 12, 2011; a Security Review Team Monitoring recommendations Report dated October 25, 2011; a Pass Plan Level 1 form dated November 14, 2011; an Elopement Risk Checklist dated February 14, 2012; a Pass Planning Checklist for Treatment Team Assessment dated as last updated on May 8, 2012; Pass Plan Flow Sheets dated between February 6 and May 6, 2012; Liberty & Request Flow Sheets dated between December 14, 2011, and May 7, 2012; and a Risk Appraisal Addendum dated September 22, 2011
• Progress Notes, Treatment Plan Progress Notes, Treatment Progress Notes, RN Treatment Progress Notes, and Social Services Treatment Progress Notes dated Between December 2011 and May 2012
• The facility’s Grounds Privileges policy; Forensic Services Therapeutic Passes for Persons Committed as Mentally Ill and Dangerous policy; Therapeutic Pass Planning policy; and Patient Liberty Program Parameters policy
• The facility’s Internal Review of Maltreatment Report dated May 23, 2012
Pertinent Information/Summary of Findings:
A History and Physical Assessment Report dated February 4, 2011, stated that the VA was diagnosed with schizoaffective disorder, bipolar type; history of narcissistic personality disorder; history of bipolar affective disorder; and polysubstance dependency.
At the time of the incident, the VA resided in transition services at the facility which, although under the same license as the Minnesota Security Hospital, was located in a separate building and run as a separate program. P1 stated that Transition Services were a “conduit” for patients who were ready to be discharged into the community. Patients at this level had been through the Minnesota Security Hospital program and approved by a Special Review Board to be transferred to Transition Services. Transition Services were a “non-secure” environment and the purpose of the program was to teach patients community living skills as many of them had been “institutionalized” for many years.
A History and Physical Assessment Report dated February 4, 2011; Psychological Assessment dated February 28, 2011; and a Psychiatric Assessment dated February 4, 2011, provided the following information:
• The VA was initially admitted to the facility on June 30, 1998, after killing his/her sibling on May 7, 1998. The VA stated that s/he went to the FM’s house with the intention of “killing” the FM, but his/her sibling was “in the wrong place at the wrong time.” The VA believed that the FM was “evil” and that the world would be better without the FM. The VA was committed as mentally ill and dangerous on December 12, 1998.
• On January 7, 2008, (10 years after being admitted to the facility), the VA was transferred to Transition Services. The VA was provisionally discharged from Transition Services to a licensed care center on December 3, 2010. At this time, the VA was “meeting all treatment plan expectations.” While at the licensed care center, the VA demonstrated “clinical instability” including difficulty sleeping, manic behavior, and paranoia about peers. This mental “decompensation” was suspected to be related to the VA’s increased tobacco smoking which influenced the efficacy of his/her psychotropic medication. The VA returned to Transition Services on December 17, 2010, on a voluntary basis. Upon return to Transition Services, the VA verbalized his/her intent to stop smoking and recognized that it was a “risk factor” in his/her mental health recovery. At the time of the provisional discharge, the VA was counseled on the “ramifications” of increased smoking on the effect of his/her medication. After returning to the facility, the VA continued to work with staff persons on smoking cessation.
• The VA was provisionally discharged from Transition Services a second time to the same licensed care center on January 13, 2011. On February 4, 2011, the VA’s provisional discharge was revoked as the VA exhibited relapse symptoms including: psychotic thinking related to number manipulation, recurrent sleep difficulties, paranoia, severe back pain, increased smoking, irritability/anger, and intimidating behavior of posturing and yelling at staff persons. It was determined that the VA’s health could no longer be “adequately managed” in a community setting. Upon re-admittance to Transition Services, the VA denied any suicidal or homicidal feelings, but admitted to feelings of “elopement.” The VA was fitted with an electronic ankle monitor.
• The VA experienced “significant stress” due to his/her provisional discharge revocation, but appeared to have coping strategies in place. The VA had “several” strengths which included the ability to maintain behavioral control, the willingness to meet with treatment providers, and remaining in compliance with the unit rules. The VA was to work on gaining a better understanding of the reasons for the revocation of his/her provisional discharge and the expectations for a provisional discharge in the future.
According to the facility’s Internal Review of Maltreatment Report, on May 8, 2012, the VA had a quarterly meeting at the facility and went on “pass” with the FM at 3:15 p.m. following the meeting. The FM expressed no concerns prior to leaving and stated that they planned on having a picnic at a nearby park. At 7 p.m. law enforcement notified facility staff persons that the VA was arrested at the park after “assaulting” and “stabbing the FM.
This investigator was unable to obtain law enforcement records due to the on-going law enforcement investigation. However, a law enforcement officer (LEO) provided the following information:
• The LEO stated that the VA had a large backpack with him/her when s/he went on pass with the FM and that the VA had never taken a backpack with him/her on pass prior to this. The backpack contained multiple items including: changes of clothing, an electric razor, a winter coat, and a scissors. In addition, the VA had withdrawn all of his/her money from the on-campus bank and had three envelopes containing personal documentation.
• When the LEO spoke to the VA, the VA stated that the FM was the “anti-Christ” and that s/he had thoughts of killing the FM for several weeks. The VA stated that s/he told “staff” about these thoughts but did not provide specific information about who s/he told. The LEO stated that the VA was “blatantly honest” about his/her actions so s/he did not think the VA would “lie” about telling staff persons about his/her feelings.
• The LEO stated that the VA stabbed the FM with steak knives which the FM brought with him/her to the park. After the incident, the VA was arrested and the FM was transported to the hospital in critical condition.
A Pass Plan Level 1 form stated that this pass plan was approved for the VA on November 14, 2011. This pass plan stated that the VA could utilize unaccompanied day passes into the community for up to 10 hours each. A History and Physical Assessment Report dated February 2, 2012, stated that the VA utilized these passes to walk to and from the community library three times each week. The library was located 1.6 miles from the VA’s residence on campus.
The facility’s Forensic Services Therapeutic Passes policy and Therapeutic Pass Planning policy stated the following:
• Therapeutic passes were authorized unaccompanied absences from the facility grounds, which could include day passes or overnight passes. Therapeutic passes provided patients an opportunity for gradual and structured re-entry into the community and the opportunity to demonstrate appropriate social skills, abilities, and functioning in the community.
• Assessing a patient’s readiness for a therapeutic pass included the evaluation of several factors including: whether the patient demonstrated successful use of on ground activities or supervised off grounds activities; the patient’s progress in accomplishing treatment goals; and the patient’s readiness for community activities. In addition the patient’s team was to develop a relapse prevention plan and the Forensic Evaluator was to complete an assessment of the patient’s readiness for therapeutic passes.
• Therapeutic pass plan levels included:
o Level One: Day passes for up to 10 hours each pass. The Medical Director could extend a day pass for up to 2 additional hours for the purpose of travel if the pass was related to work.
o Level Two: Overnight passes for a maximum of 2 nights and 3 days per pass and up to 10 overnights per calendar month.
o Level Three: Increased duration of overnight passes, up to 3 nights and 4 days per pass, up to 10 overnights per calendar month.
• When a patient requested a day pass, the patient completed the pass request form which was then reviewed by the patient’s treatment team. If the pass was approved, the treatment team documented and clearly defined any expectations/limits with the pass. If the pass was approved for a local area, a treatment team member completed a visual check while the patient was on pass to verify the patient’s behavior and location on a randomly scheduled basis.
The HCP, P1, and P2 provided the following consistent information about the therapeutic passes when interviewed separately:
• Once a patient was approved for therapeutic passes the frequency of the passes gradually increased until they reached an “unlimited” number of passes that were approved each week. When a patient wanted to utilize a pass, they were to fill out a pass request form and identify where they wanted to go. When a patient was first approved for passes, staff person checked on them in the community every time they went out on pass. These checks were gradually stepped down to a more intermittent basis. If staff persons questioned a patient’s use of the pass, the patient might be required to go with a “buddy” the next time or have their pass privileges temporarily revoked. If a patient was going on pass with a family member, staff persons did not complete a visual check of that patient while on pass. The family member spoke to staff persons before and after the pass to give a progress update.
• There were no restrictions as to what patients could bring with them on pass since it was an “open environment.” Patients were allowed to, and often did, bring backpacks with them on pass. The only “contraband” items were “basic” things such as weapons, drugs, alcohol, and cigarettes. When patients returned from pass their belongings were searched for contraband items.
P2 provided the following additional information during an interview:
• The main thing that patients in Transition Services worked on was gaining the skills necessary to transition to living in the community. This included building job skills, working on a budget, and community integration. Prior to being approved for a pass plan, patients participated in a three level community integration therapy group which worked on readying the patients for unsupervised time in the community by providing “extensive instruction” to the patients.
• P2 worked on “a lot” of community integration activities with the VA which helped the VA become comfortable being in the community. P2 went out to meals and shopping with the VA to have the VA practice his/her social skills.
• When the VA returned to the facility after his/her second provisional discharge, the “main focus” was medication management. The VA was reluctant to quit smoking cigarettes, so s/he underwent several medication changes to find a medication that was not effected by nicotine. The VA had been “stabilized for quite a while” on the new medication. When the VA was “stable” s/he was very high functioning and did not display mental health symptoms such as pressured speech, hallucinations, and paranoia.
• On the day of the incident, the VA had a quarterly meeting. The FM attended the meeting and discussed with the group that s/he wanted to take the VA on pass that afternoon and discussed if s/he could extend the 10 hour pass to take the VA to a card tournament in Minneapolis. This request was denied, because passes were not allowed to be extended beyond 10 hours per policy. Both the VA and the FM were “extremely disappointed.” The VA had participated in “at least” 10 similar passes with the FM and each pass went well. The VA was looking forward to going on more passes with the FM.
• P2 never heard the VA discuss wanting to harm the FM. At every meeting, including the quarterly meeting on the day of the incident, staff persons reviewed the VA’s Individual Abuse Prevention Plan. Part of this review included asking the VA if s/he had any thoughts of harming anyone. On the day of the incident, the VA responded, “No,” and every indication was that the VA was happy. P1 knew that this incident happened on the anniversary date of the VA’s sibling’s death, but did not know if the two were connected. The VA typically went out with the FM on this day since it coincided with his/her quarterly meeting and previous passes on or around this date were successful.
• The VA was a “star patient” and served as a “peer mentor” to other patients. The VA was on the patient panel which consisted of patients who attended new employee orientation to talk to new staff persons about what it was like to be a patient at the facility. P2 stated that there was “no” indication that the VA was planning on harming the FM. The VA was good about reporting relapse symptoms in the past and had not mentioned any concerns recently.
• When P2 was notified of the incident, P2 was also informed of the contents of the VA’s backpack. P2 stated that patients leave to go on pass with their backpacks every day because they go shopping on pass and need something to carry their purchased items in.
P3 provided the following information during an interview:
• P3 stated that the VA was “asymptomatic most of the time.” If the VA felt “different,” s/he reported his/her symptoms to staff persons. The last time that the VA reported feeling symptomatic was soon after s/he returned to the facility from his/her provisional discharge. The “primary” things the VA spoke about were his/her back pain and difficulty sleeping. These things were not relapse symptoms but were “risk factors” for relapse with the VA. P3 worked with the VA on willingness to take a PRN sleep medication.
• The VA was approved for a pass plan which allowed him/her to go into town unsupervised. The VA did not have any problems during any of these passes and wrote in his/her journal upon returning. When P3 reviewed the VA’s journal, s/he did not note anything of concern. It was “normal” for patients to bring backpacks with them when leaving the facility on pass. The VA typically rode his/her bicycle to town and liked to carry a backpack to carry things s/he purchased in town.
• The FM came to all of the VA’s treatment planning meetings and was the VA’s only support person. The FM told P3 that s/he was the “best barometer” of how the VA was doing. The FM felt “perfectly comfortable” taking the VA on pass. The FM checked in with a health care professional before and after each pass and did not note any concerns.
• Patients used an on-campus bank for direct deposit of their paychecks. The bank was open three days a week for patients to make withdrawals. Patients were able to withdraw $92 per week. When P3 reviewed the VA’s bank statements, there was not a change from the VA’s general pattern of withdrawals; the VA typically withdrew the majority of his/her paycheck each two week cycle.
• P3 stated that the VA was a “model patient” and was “very forthcoming” with his/her “story.” The VA showed emotion appropriately and was able to recognize and talk about early warning signs of relapse. P3 stated that the VA’s relapse prevention plan was reviewed with the VA on a quarterly basis. This was reviewed on the day of the incident with the VA and the VA was asked if s/he noticed any signs or symptoms of relapse, and the VA stated that s/he did not. P3 stated that the VA never spoke about the
anniversary date of his/her sibling’s death. Since the VA did not bring up the date, P3 did not “tune into” the date as an issue to address with the VA.
The MHP provided the following information during an interview:
• The MHP met with the VA monthly as well as “occasionally” for group therapy sessions. The MHP spoke with the VA about his/her relationship with his/her family members. The VA described his/her relationship with the FM as “very supportive” and the VA was “grateful” that the FM wanted to spend time with the VA. The VA typically went on pass with the FM after his/her quarterly meetings. One of the quarterly meetings coincided with the anniversary date of his/her sibling’s death. The MHP talked to the VA about this anniversary date and the VA stated s/he was “sad” but it did not appear to “impact [him/her] much.”
• The VA never mentioned having thoughts of hurting the FM. The FM was “really comfortable” spending time with the VA and believed that s/he had “good radar” and could tell when something was going on with the VA. At the quarterly meeting on the day of the incident, the FM was “comfortable” with the VA and asked to extend the time limit on their pass for that afternoon.
• The MHP stated that the VA’s relapse symptoms including not tracking conversations, forgetting things, and having hallucinations or delusions. In the weeks and months leading up to the incident, the VA’s thinking was “really clear and logical” and the VA’s concentration was “really good.” The “only thing” the MHP identified as a risk factor with the VA recently was his/her trouble sleeping. The VA related this to smoking cigarettes while s/he was on pass, so the MHP had the VA track his/her sleep and smoking patterns to identify if they were related. At the quarterly meeting on the day of the incident the VA stated that s/he had “mood changes” recently. The MHP had never heard the VA say this so s/he asked the VA what s/he meant, and the VA stated that s/he was “excited” for a possible provisional discharge and had been thinking about it a lot.”
• The MHP was “shocked” by the incident and it was “hard” for the MHP to believe that the VA was having symptoms prior to the incident. The MHP stated that staff persons did everything they could to properly assess the VA and his/her progress in treatment. The VA appeared to have remorse for killing his/her sibling and stated that s/he had to be “vigilant” about tracking his/her symptoms and talking to staff persons. When the VA experienced relapse symptoms in 2008 and 2009 the VA identified these symptoms and spoke to staff persons about them.
P1 stated that when a provisional discharge was revoked the individual returned to Transition Services and was able to stay there for up to 60 days without a subsequent Special Review Board Hearing. If a patient needed greater attention or a security level than Transition Services could provide, the patient was transferred back to the program at the Minnesota Security Hospital. P1 stated that the VA was not exhibiting any signs or symptoms of relapse or active symptoms that would have made staff persons question him/her. The VA was a “leader” to other patients on the unit.
An Initial Chemical Dependency Assessment signed on February 15, 2011, stated that upon the VA’s return to the facility after his/her second provisional discharge, it was “increasingly clear” that the VA was not ready to live in the community at this state of his/her recovery process. Prior to this discharge, the VA “excelled” with his/her treatment at the facility, which was most likely because the process moved slow and remained “fairly rigid.”
A Psychiatric Progress Note dated February 2, 2012, stated that the VA reported some sleeping difficulties and when asked about these, the VA believed that “lingering” effects of his/her as needed (PRN) sleep medication were making him/her tired throughout the day. The VA became defensive when a staff person pressed the VA further about his/her sleep patterns expressing that s/he did not want to be “set back” in his/her path to provisional discharge. When a health care professional spoke to the VA, the VA expressed that s/he was having difficulty sleeping after returning from pass where s/he consumed cigarettes and caffeine. The VA denied any suicidal or homicidal thinking and any problems with concentration or paranoid thoughts.
A Forensic Transition Services Quarterly Self-Assessment was filled out by the VA on February 14, 2011. In this assessment, the VA documented that s/he was “aiming for a discharge to the community as soon as poss [sic], by learning from my mistakes, making healthier choices, participating in treatment, and showing responsibility.” The VA stated that s/he used “town passes” with no issues and enjoyed “10 hour passes” with the FM.
A Social Services Update dated April 25, 2012, stated that the VA resided in the “open unit” of Transition Services for the past year and had not experienced any “significant signs of relapse.” The VA was compliant with all unit and treatment expectations. There were times when the VA had trouble sleeping or experienced back pain, but not to the extent that it impacted his/her mental health. The VA underwent a “couple” medication changes but had been on his/her current medications since December 2011. The VA had insight into his/her mental illness and his/her risk factors for relapse. The VA was “remorseful” for his/her crime. The VA’s vulnerabilities included that the VA had a history of “relapsing rapidly” if s/he experienced symptoms that were not addressed in a timely manner.
According to the facility’s Internal Review of Maltreatment Report, after returning to the facility on February 4, 2011, from his/her second provisional discharge, the VA was approved for therapeutic passes on November 14, 2011. Between November 16, 2011, and May 7, 2012, the VA utilized 91 successful passes, including 4 passes with the FM. May 8, 2012, was the VA’s 5th pass with the FM. Including the VA’s previous admissions to Transition Services, the VA utilized a total of 295 passes and 8 passes with the FM.
The VA’s Relapse Prevention Plan last reviewed on May 3, 2012, stated that the VA’s “first sign[s]” of relapse included sleeping difficulties, back pain, paranoia and delusional thinking, and problems with concentration. Things that helped to reduce the chance of relapse included taking his/her prescribed medication daily, attending support groups, actively working on anger issues, and staying busy with positive activities.
A Transaction History for the VA’s on-campus bank stated that between January and May 2012, the VA received paychecks which were direct deposited into his/her account every two weeks and averaged between $100 and $200. The VA routinely withdrew the entire amount of his/her paycheck over the two week period leaving less than a dollar in his/her account each time.
On May 8, 2012, at 3:15 p.m. the VA left the facility with the FM. The VA and the FM went to a nearby park to have a picnic. At 7 p.m. facility staff persons were notified that the VA was arrested for assaulting and stabbing the FM. The FM was transported to the hospital in critical condition.
The LEO stated that when s/he spoke to the VA, the VA stated that s/he believed the FM was the “anti-Christ” and that the VA had thoughts of killing the FM for several weeks. The VA told the LEO that s/he told staff persons that s/he had these thoughts, but did not name any specific staff persons that s/he spoke to. The LEO believed the VA was planning the attack as s/he had a large backpack with him/her filled with clothing, an electric razor, a winter coat, and a scissors. In addition, the LEO stated that the VA had personal documents and had withdrawn all of the money from his/her bank account.
The VA was approved for a Pass Plan Level 1 on November 14, 2011. This pass plan stated that the VA could utilize unaccompanied passes into the community for up to 10 hours each. According to the facility’s Internal Review of Maltreatment Report, between November 16, 2011, and May 7, 2012, the VA utilized 91 successful passes, including 4 passes with the FM. The MHP stated that the VA described his/her relationship with the FM as “very supportive” and that s/he was “grateful” that the FM wanted to spend time with the VA. P3 and the MHP each stated that the FM expressed s/he was comfortable with the VA and spending time with the VA. P2 and P3 each stated that it was “normal” for the VA to bring his/her backpack with him/her on pass because the VA often purchased items in town on pass and needed a way to carry them back to the facility. The HCP, P1, and P2 each stated that patients’ items were not searched prior to leaving on pass since it was an “open” environment. Patients’ belongings were searched when they returned from pass for contraband items of weapons, drugs, alcohol, and tobacco.
P2 stated that the VA was “stable” at the time of the incident and did not mention anything about wanting to harm the FM. P2 stated that the VA was a “star patient” and that there was no indication that s/he was thinking about harming someone. The MHP stated that in the days and weeks leading up to the incident, the VA’s thinking was “really clear and logical” and the VA’s concentration was “really good.” A Social Services Update dated April 25, 2012, stated that the VA had not experienced any “significant signs of relapse” and was complaint with all unit and treatment expectations. In addition, the VA had a quarterly meeting at the facility prior to leaving on pass with the FM. P2, P3, and the MHP each stated that the VA was asked at this meeting, as part of the required assessments, whether s/he was having relapse symptoms or thinking about harming him/herself or someone else. The VA denied each.
P3 stated, and a summary of the VA’s bank transactions showed, that the VA’s paycheck was direct deposited into his/her account every two weeks and over the two week period the VA typically withdrew the entire amount of the withdrawal leaving less than $1 in his/her account. This pattern did not change prior to the incident.
Although the VA assaulted the FM while on pass, given the above information, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care or 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 identified that all of their policies and procedures were followed and adequate.
Action Taken by Department of Human Services, Licensing Division:
The facility was issued a correction order on January 7, 2013, and ordered to address discrepancies and inconsistencies in their security level and grounds privileges policies and procedures.
PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer