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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: 1070503-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux Suspected Maltreatment Reported: It was reported that two community persons (CP1 and CP2) saw two staff persons (SP1 and SP2) having alcoholic drinks at a bar with two vulnerable adults (VA1 and VA2). After having drinks, the SPs then drove the VAs back to the facility in a facility vehicle, but it was unknown whether SP1 or SP2 drove. Date of Incident(s): July 9, 2022 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 July 28, 2022; from documentation at the facility; and through interviews conducted with facility staff persons (SP1, SP2, P1, and P2), VA1 and VA2, and CP1 and CP2. Facility documentation showed that VA1 and VA2 each received services at the facility. Their diagnoses included a developmental disability, but no information showed that VA1 and VA2 had a history of alcohol/substance misuse. VA1 loved listening to music and liked to travel. VA2 enjoyed taking walks, which helped him/her stay fit and manage his/her stress level. Facility documentation, information provided by CP1, CP2, SP1, SP2, VA1, VA2, P1, and P2, and information from the facility’s Internal Review, provided the following: · CP1 and CP2 provided consistent information that on July 9, 2022, they saw SP1 and SP2 with the VAs having drinks at a bar in the community, after the SPs and VAs attended an event which CP1 and CP2 also attended. The CPs recognized the SPs and the VAs and thought that staff persons should not drink alcohol while providing care to vulnerable adults. CP1 said that the SPs and the VAs sat at the same table as s/he and CP2 did at the bar, but sat at the “opposite end” of the table. CP1 knew that the drinks the SPs had were alcoholic drinks because s/he heard SP1 order a “bloody mary” for him/herself and “beer” for the VAs and SP2. CP1 thought that SP1 and SP2 had one or two drinks each, but could not be sure. · CP2 agreed that the SPs and VAs shared a table with the CPs and added that the table was on the patio at the bar. CP2 was five to ten feet from SP1 when SP1 ordered alcoholic drinks inside the bar, but CP2 heard the drink order and said that the SPs had “hard liquor” while one of the VAs had beer. CP2 saw the bartender making the drinks, but could not recall which drinks the SPs had. CP2 thought that the SPS had two drinks each, but was unsure. · CP1 and CP2 each stated that they were unaware which staff person drove when the SPs and VAs left the bar and there was no indication that the SPs were impaired. In hindsight, the CPs felt that they should have intervened to prevent the SPs from transporting the VAs after drinking, but did not think of it at the time of the incident. · VA1 said that at the bar, s/he had a cherry seven up, VA2 had a root beer or a bottle of beer, and the SPs had cocktails. VA1 was unsure whether the SPs drinks contained alcohol, but said that s/he thought that SP1 did not drink anything with alcohol in it. VA2 said that at the bar, the VAs and the SPs played pull tabs and had non-alcoholic drinks. VA2 knew the drinks were not alcoholic because s/he was “sitting right next to” the SPs, but s/he could not recall more information regarding the time at the bar. The VAs said that SP1 drove the VAs back to the facility and there were no concerns that the SPs consumed alcohol and drove the facility vehicle. · SP1 and SP2 provided consistent information that they were at the bar with the VAs on the date of the incident, but SP2 was not “on the clock.” SP1 drove the VAs and SP2 to the community event, to the bar, and back to the facility. At the bar, the SPs and VAs played pull tabs, SP1 had two “virgin bloody mary,” drinks, VA1 had a “kiddie” cocktail, VA2 had a beer, and added that SP2 was not on shift at the time, so “who cares” what s/he drank. SP2 said that s/he also had a virgin bloody mary, and did not finish it. SP1 did not consume alcohol when s/he was on shift and did not drink and drive. According to SP1, if anyone thought s/he was planning to drink and then drive the VAs back to the facility, they should have called the police and “embarrassed themselves” when it was discovered that s/he had not consumed alcohol, or intervened immediately to protect the VAs. SP1 denied that s/he consumed alcohol and transported the VAs. · P1 and P2, who were supervisory/administrative staff persons, had no concerns regarding the SPs’ work, and said that no information indicated previous similar behavior from the SPs. The facility’s Internal Review showed that the information the SPs and VAs provided was consistent with statements they made in interviews with this investigator. The facility’s Drug, Chemical, & Alcohol Testing Policy showed that individuals were to be served free of substance abuse. Staff persons were prohibited from coming to work while under the influence of illegal/controlled substances, chemicals, alcohol, or excessive prescription medication. The facility’s personnel and training records showed that staff persons interviewed for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: Facility documentation showed that the VAs’ diagnoses included a developmental disability, but the VAs did not have a documented history of alcohol/substance misuse. On July 9, 2022, VA1, VA2, SP1, and SP2 attended a community event which CP1 and CP2 also attended. The CPs provided mostly consistent information that they observed the SPs drinking alcoholic beverages at a bar after the event, and then transporting the VAs back to the residence. CP1 heard SP1 order a “bloody mary” for him/herself and a beer for SP2. CP2 said that SP1 ordered the drinks for the SPs and the VAs, and was five to ten feet from the CPs at that time. No information showed that the SPs were impaired when they left the bar. The VAs provided varying information regarding whether the SPs’ drinks were alcoholic or nonalcoholic but each stated that there were no concerns that SP1 was impaired when s/he drove them back to the facility. The SPs were at the bar with the VAs, and SP1 said that s/he drove the VAs to and from the bar. SP1 had two “virgin bloody mary” drinks but did not say what SP2 drank because SP2 was not on “the clock;” therefore it did not matter whether s/he drank alcohol. Although the CPs said that the SPs drank alcohol before transporting the VAs, given that SP1 said that s/he transported the VAs that day, that VA1 said that the SPs’ drinks were nonalcoholic, that VA2 was unsure whether the drinks contained alcohol, that SP1 provided consistent information that his/her drinks were nonalcoholic, and that no information showed that SP1 was impaired at the time of the incident, there was not a preponderance of the evidence whether there was a failure to provide the VAs with care or services that were reasonable and necessary to obtain or maintain the VAs’ 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 which determined that its policies and procedures were adequate and were followed. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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