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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: 1092294-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Alice Percy Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) left the facility without the supervision of a staff person (SP) and met a community person (CP) in the driveway who provided the VA with a syringe and methamphetamine. The VA injected him/herself with the drug, which resulted in the VA exhibiting symptoms of psychosis. Date of Incident(s): July 27 - 28, 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 August 31, 2022; from documentation at the facility; and through three interviews conducted with a facility administrative staff person (P1), the SP, and the VA’s case manager (CM). The VA declined to speak to this investigator. The VA’s diagnoses included schizoaffective disorder, bipolar type, post-traumatic stress disorder (PTSD), borderline personality disorder, depression, and severe chemical dependency. The VA enjoyed bicycle riding, listening to music, participating in sports, and spending time with his/her family members and friends. The VA had a community job and was not subject to guardianship. According to the VA’s Coordinated Services and Supports Plan (CSSP) and Coordinated Service and Support Plan Addendum, the VA required 24-hour 1:1 staffing. The VA had a history of substance abuse and had a goal of abstaining from drugs and alcohol and maintaining his/her sobriety. The staff persons were to report any observed or suspected substance abuse to the VA’s interdisciplinary team. The facility was located in a split-level house in a rural community. A few other private residences were located on the same road as the facility. The VA lived on the upper level of the facility and another resident (R) lived on the lower level. One staff person typically supervised the VA on the upper level and two staff persons typically supervised the R on the lower level. The VA and the R typically remained on their separate levels. Consistent information was provided that at the time of the incident, the SP was responsible for the supervision of the VA, while two staff persons (P2 and P3) were responsible for the supervision of the R. The VA’s bedroom opened onto a hallway next to the stairs leading to the main entrance of the facility. The kitchen was located across from the top of the stairs. A wall partially blocked the view of the stairs from the kitchen. P1, the SP, and the facility’s documentation provided the following information: · On July 27, 2022, at 11 p.m., the SP began his/her overnight work shift at the facility. When the SP arrived at the facility for his/her work shift, the VA was in his/her bedroom. The SP counted the medications and then did chores in the facility’s kitchen. The SP stated that s/he did not hear any vehicle pull into the facility’s driveway or see any headlights from the kitchen window of a vehicle approaching the facility. At some point during the night, the VA briefly left his/her bedroom, but the SP did not recall what the VA did when s/he left his/her bedroom. The SP stated that if the VA went outside the facility during the night, “it was quick” and the SP was not aware that the VA left the facility. The SP stated that every hour during the night, s/he listened at the VA’s bedroom door to ensure that the VA was present. · In the following days, when the SP worked at the facility, the SP seemed to need to clear his/her throat and went into the bathroom more frequently than usual. The SP stated that s/he told the other staff persons that the VA acted “a little off.” The SP did not observe any needle marks on the VA’s arms or any drug paraphernalia in the facility. P1 stated that the staff persons working at the facility told him/her that the VA behaved “erratically,” complained of headaches, was “boisterous,” isolated him/herself, talked to him/herself, and mumbled. When questioned, the VA told P1 that on July 27, 2022, the VA texted a community person (CP), who drove to the facility’s driveway. The VA ran outside and purchased two syringes and methamphetamines from the CP and then went back to his/her bedroom. The VA showed the text messages to P1. The text messages showed that at 11:30 p.m., the VA texted the CP and shortly after 12 a.m. (midnight), the CP texted the VA that s/he was driving into the driveway and had “two points and a bag” for the VA. · P1 stated that the VA provided inconsistent information about what occurred on the night of the incident. The VA told P1 that s/he went outside without saying anything to the SP. The VA also told P1 that s/he told the SP that s/he forgot something in the facility van and went outside to get it. The VA then told P1 that the SP was lying down when the VA went outside. The SP told P1 that s/he did not hear a car drive into the facility’s driveway and did not hear the VA go outside the facility. The two staff persons working on the lower level of the facility also told P1 that they did not hear the VA leave the facility. After the incident, the VA did not require medical care. · The SP stated that the VA required 1:1 supervision except when s/he was in his/her bedroom or the bathroom. P1 stated that it was rare for the VA to be out of his/her bedroom during the nighttime hours, but that if s/he left his/her bedroom, the staff persons were to provide supervision. While the VA had a history of drug and alcohol abuse, the staff persons encouraged the VA to maintain his/her sobriety. There were no alarms on the doors of the facility. The CM stated that the VA required 1:1 staff supervision and that the VA had a history of chemical dependency. The CM was unaware of any similar incidents occurring with the VA at the facility. Facility documentation showed that the SP and the P each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Conclusion: On July 27, 2022, at 11 p.m., the SP began his/her overnight work shift at the facility. The VA was in his/her bedroom when the SP arrived at the facility, which was where the VA typically remained during the night time hours. At 11:30 p.m., the VA sent a text message to the CP, asking to purchase methamphetamines. At approximately 12 a.m. (midnight), the CP sent a text message to the VA, saying that s/he was in the driveway. The VA later told P1 that s/he ran outside, purchased two syringes and a bag of methamphetamines from the CP, and returned to his/her bedroom. The VA provided inconsistent information to P1 about the SP’s whereabouts when the VA went outside. The VA told P1 that s/he went outside without saying anything to the SP, then told P1 that s/he told the SP that s/he needed to get something from the facility van prior to walking outside, and also that the SP was “lying down” when the VA went outside. The SP stated that s/he counted medications and worked in the kitchen on chores after s/he arrived at the facility. The SP did not hear a car drive up to the facility, did not observe any headlights, and did not see or hear the VA leave the facility. During the night, the SP listened at the VA’s bedroom door each hour to ensure that the VA was in his/her bedroom. Although the VA left the facility briefly to purchase syringes and methamphetamines from the CP in the facility’s driveway, given that at the time of the incident, the SP was engaged in assigned tasks within the facility, that there were no alarms on the facility doors to alert the SP that the VA left the facility, that the VA typically remained in his/her bedroom during the night time hours, and that the SP stated that s/he did hourly checks to ensure that the VA was in his/her bedroom, there was not a preponderance of the evidence whether the SP failed to provide supervision which was reasonable and necessary to maintain the VA’s physical or mental 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 the facility’s policies were adequate, but were not followed by the SP. The SP was retrained on the facility’s reporting policy. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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