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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: 1115695-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady/Kyle Youker Suspected Maltreatment Reported: It was reported that there were multiple concerns regarding lack of staff person supervision of a vulnerable adult (VA) that allowed the VA to engage in property destruction, attempt to start fires, leave the facility, access his/her medications, and be in the presence of minors when s/he was not allowed to do so. Date of Incident(s): Ongoing prior to October 19, 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 October 19, 2022: from documentation at the facility, law enforcement records, and medical records; and through seven interviews conducted with three facility staff persons (P1-P3), a supervisor staff person (P4), an administrative staff person (P5), the VA’s guardian (G), and the VA’s case manager (CM). The VA was not interviewed because on the day prior to the site visit, the VA left the facility without staff person supervision and his/her location was unknown. The VA’s support plans included the following information. The VA was diagnosed with adjustment disorder with depressive mood and was susceptible to emotional abuse. The VA had a history of violent and risky behavior including a fascination of starting fires. The VA needed assistance with laundry, cooking, taking medication, and going to medical appointments. The VA enjoyed music and video games. The VA thought of him/herself as smart and resourceful. The goals of the VA were to find a job. The facility was a single story home with a basement in a residential neighborhood. Upon entering the front door, there was a living room to the left, and a kitchen and dining room to the right (the kitchen was not visible from the living room). The kitchen had a locked medication cabinet and a locked drawer for storing sharp items. Off the dining room was a hallway that led to the VA’s bedroom, two bathrooms, and a staff office. One bathroom (ensuite) could be accessed from the hallway and the VA’s bedroom. The ensuite bathroom had a crank-out window that was 15 inches wide by 38 inches tall. In the hallway, there was also a doorway leading to the basement. Also off the dining room was a door to an attached garage and a sliding glass door that opened to a deck and an unfenced backyard. From the dining room, only a portion of the backyard was visible. The backyard contained a fire pit as well as a charcoal grill on the deck. The majority of the deck was visible from the dining room. The air conditioning unit was located on the back of the facility, outside of sight of the dining room. Regarding the VA’s supervision Requirements The VA’s support plans stated that due to the VA being susceptible to physical, sexual, emotional, and self-injurious behavior, the VA was to be in auditory and visual range of staff at all times, remaining aware of the VA’s activities at all times. The VA’s plans did not specifically address the VA’s supervision in the bathroom or bedroom. All medications were to be locked in the medication cabinet and all sharp items were to be locked up as well. The G and P1-P4, and facility documentation provided the following information: · The G stated that the VA was to have 24 hour staffing at a 1:1 ratio. The G was unaware if staff persons were to have constant auditory and/or visual supervision of the VA at all times. The G stated that staff persons were allowed to sleep at night while working. · The VA was dating an individual and this individual was frequently at the facility. When the VA and the individual were in the VA’s bedroom, the door could be closed. The individual frequently spent the night with the VA. When the VA was in his/her bedroom the VA was allowed his/her privacy so staff persons were not allowed to be in there. Staff persons were trained to knock on the VA’s door to check on the VA. · Family members of the VA frequently visited the facility, often on the weekend. During these visits, the VA and his/her family utilized the grill on the back deck. P1-P4 each stated that when family visited staff persons tried to provide some privacy to the family and the VA, though they still conducted “periodic” checks. (Note: There was no additional information regarding specifics of periodic.) · P4 stated that the keys to various locks in the facility were located on a single lanyard that was to be on staff person at all times. The lanyard included keys to the medication cabinet and the drawer with the knives and sharp items. Staff persons provided inconsistent information as to whether the lanyard of keys were always kept on staff persons. P2 and P4 kept the lanyard of keys on their persons at all times, P1 kept the lanyard of keys on the kitchen counter, and P3 kept the lanyard of keys on their persons but would place them onto the kitchen counter when s/he used the bathroom. Regarding the VA’s property destruction Interviews with P1 – P4, and facility documentation and a fire department report, provided the following information: · On an unknown date prior to October 2, 2022, P1 was working. At some point while the VA was showering in the ensuite bathroom, the toilet began overflowing and water began flooding into the hallway. P1 asked the VA to get out of the shower and once the VA was out, P1 began cleaning up the water. P1 told P4 and the VA and staff persons were instructed to use the other bathroom. Shortly after, the toilet over flowed in the other bathroom. P1 again cleaned up the water and notified P4. A plumber was called to the facility. The plumber told P4 that both toilets had aluminum foil stuffed into the bowl to cause the toilet to overflow and that rubber gloves were wedged into the tank to cause the toilet to run continuously. It was believed that the VA obstructed the toilets and caused the flooding. · On October 2, 2022, the fire department was called to the facility because a staff person smelled smoke. Upon arrival, the fire department located the source of smoke and found paper in the ensuite bathroom in the heating vent. Paper was also found in an electric heat register in the basement, but the heat register was cold and was not suspected of being the source of smoke. It was believed that the VA put the paper in the heating vents. During the fire inspection of the facility, it was discovered that a water pipe had burst and soaked electrical wires. It was unknown how the water pipe burst. Because of the soaked wire, the fire department disconnected the electricity from the facility and declared it uninhabitable so the VA along with staff persons were temporarily relocated to a hotel.
· The fire department found two jugs of lighter fluid in a spare bedroom where it was stored. There were concerns about lighter fluid being accessible to the VA. P2 stated that the facility had its own bottle of lighter fluid in addition to one bottle of lighter fluid left by the VA’s family. P2 stated that all lighter fluid was kept in the closet of the staff office, away from the VA. P4 stated that the lighter fluid that was kept locked in the staff office, and when it was to be used staff persons would, “sprinkle on there and get it lit and put it back.” There was no information that the VA obtained access to the lighter fluid. · The fire department also observed evidence of a previous fire in the kitchen. An unknown staff person told the fire department it occurred on an unknown date about one week prior. P1 stated that s/he was working the date that the fire started in the kitchen. P1 was sitting in the living room while the VA was cooking. At some point, P1 heard a commotion in the kitchen and went to check on the VA. P1 saw flames coming from a pan on the stove. P1 removed the pan from the stove and put a cover on it to put out the flames. P1 stated that the VA was cooking chicken, which upon inspection appeared to be still frozen, in a pan with hot oil so P1 believed that was how the fire started. · At one point on an unknown date in 2022, the central air conditioning did not work. A maintenance technician came out and determined that an electrical part in the air conditioning unit outside was tampered with causing it not to work. It was believed that the VA tampered with the air conditioning unit. The air conditioning unit was repaired. The air conditioning unit was not visible from the dining room if staff persons were looking out the sliding glass doors. · On an unknown date, when P3 was working, the tires on the van were punctured. At the beginning of P3’s shift, P3 saw that the van tires were inflated and in working order. At some point over the course of the night, P3 went into the garage and saw that the front and rear tires on the passenger side of the van were punctured. P3 did not know who punctured the tires on the van but stated the VA, “could be quiet and sneak past me if I was sleeping.” P2 asked the VA about the van tires being punctured and the VA “had no answer for me.” It was believed that the VA punctured the van tires. On a later date, a knife belonging to the facility was discovered in the neighbor’s yard. · There was no information that any incident resulted in harm to the VA. Regarding the VA leaving without supervision Interviews with P1-P5 and facility documentation provided the following information: · P5 stated after the fire department declared the facility uninhabitable the VA spent the nights of October 2 and 3, 2022, at the hotel. · P1 and P3 each stated that after the fire department declared the facility was uninhabitable, the VA temporarily moved to a hotel and P1 and P3 both spent the night with the VA in the same room. P3 slept, while P1 stayed awake. P3 said that in the morning (October 4, 2022) after P1 left, P3 used the restroom. While in the restroom, P3 heard the VA leave the room. As soon as s/he was able, P3 then left the hotel room, looked in the hotel lobby, a gas station next to the hotel, drove around the immediate area, called P4 and called law enforcement. · The VA was gone from the facility from October 4 to 13, 2022. P1 stated that s/he was working the day the VA was returned to the facility (October 13, 2022). That same day, the VA went to take a shower in the ensuite bathroom. After a period of 10 to 12 minutes where the water was running continuously, P1 knocked on the bathroom door to check on the VA. When the VA did not answer immediately, P1 entered the bathroom and saw the window open. The VA was not in the bathroom and had left the facility. P1 checked around the facility, and contacted law enforcement. Regarding the VA accessing his/her medications Interviews with P1-P4 and facility documentation, including an internal review, provided the following information: · The VA’s medications were kept in a locked cabinet in the kitchen. This included medications in a medication minder, and bottles and/or a bubble packs of medications. The VA’s Medication Administration Record (MAR) stated that the VA was prescribed guanfacine (used to treat high blood pressure) one time daily. The MAR showed that the VA was not administered his/her medication from September 22 through 25, 2022. · P1 stated that on September 22, 2022, s/he forgot to give the VA his/her medication. The following morning, P1 contacted a facility health care professional (HCP) to see if s/he should give the VA his/her medication and the HCP told P1 not to give it and resume giving it to the VA at his/her next scheduled dose that evening. P1 stated that the medications were in the cabinet at that time. After notifying the nurse, P1 was at the facility for one additional hour and believes s/he kept the keys on his/her person. · P2 stated that on September 23, 2022, (unknown time) s/he discovered that all of the VA’s medication was missing from the medication cabinet and notified P4. On the morning of September 26, 2022, P4 notified the HCP that the VA’s medications were missing. The HCP contacted the pharmacy was able to obtain the VA’s medication. The HCP asked the VA if s/he took the medications and the VA said, “No.” It was believed that the VA took the medications. · P3 worked after P1 and before P2 on September 23, 2022. P3 said that s/he did not have the lanyard of keys on his/her person at all times, taking them off when utilizing the bathroom. · P1, P3, and P4 stated that at times the lanyard of keys, which included the key to the medication cabinet, would be left on the kitchen counter. P2 stated that the keys were always on his/her person. P1 and P3 each stated they were not told to keep the lanyard of keys on their person at all times. P1 “assumed” that staff should keep the lanyard of keys on their person at all times. P4 stated that staff persons were told to keep the lanyard of keys on their person. P1-P4 each stated that they did not take the VA’s medications. · P4 stated that there was no harm to the VA as a result of not taking his/her medications. Regarding the VA’s contact with minors Interviews with P1-P4, the G and the CM, and the VA’s Probation Agreement for the VA provided the following information: · The VA was on probation, and as part of the conditions of the probation, the VA was not to have any contact with minors. · The G stated that the VA was not allowed to have contact with minors, but was able to have contact with his/her sibling, who was a minor. There may have been an instance in which the sibling also brought a friend, who was a minor, to the facility. The G stated that there was a concern that staff members were unaware of the no-contact clause in the VA’s probation. · The CM stated that the VA was to have no contact with minors as a part of his/her probation. The CM stated that the no-contact included the VA’s sibling. The CM stated that the VA’s probation officer was not taking action with the VA regarding the VA’s contact with his/her sibling and his/her sibling’s friend. · P1-P4 each stated that the VA’s sibling came to the facility with a parent and/or grandparent during family visits with the VA. The VA’s minor sibling was never alone with the VA. · P1 recalled one instance in which a minor friend of the sibling attended a family visit with the VA. P1 was not aware of the minor friend being alone with the VA during this visit. Facility documentation showed that P1-P4 each received training specific to the VA and the reporting of maltreatment of Vulnerable Adults Act. Relevant Statutes: Minnesota Statutes, section 245D.05, subdivision 2, paragraphs (a) and (b) which states in part what "medication administration" means and responsibilities for the license holder when medication administration is assigned to the license holder. Conclusion: The VA’s plans stated that the VA was to be in auditory and visual range of staff at all times, remaining aware of the VA’s activities at all times. P1-P4 provided consistent information that the VA was able to have privacy in his/her bedroom with the individual the VA was dating and some privacy when his/her family members visited. However, the plans did not specifically address the VA’s supervision in the bathroom or bedroom or when the VA had visitors. The G stated that the VA had 1:1 staffing 24 hours a day but that staff persons could sleep during the overnight. The VA’s plans stated that all medications were to be locked in the medication cabinet and all sharp items were to be locked up as well. P4 stated that the lanyard with keys was to remain on the staff person at all times. However, P1 stated s/he kept the keys on the counter, and P3 stated that s/he kept the keys on his/her person unless s/he used the bathroom. Regarding the VA’s property destruction On multiple dates, there were incidents at the facility that caused damage to the facility including two overflowing toilets; the smell of smoke, which was subsequently determined to be papers stuffed into a heating vent; a fire in the kitchen; damage to the air conditioner; and puncturing the van tires. It was believed that the VA was responsible for each incident of damage. Although it was possible that the damage was caused by the VA without staff persons knowledge, given that the VA was alone in the bathrooms and his/her bedroom, it was possible for the VA to engage in behaviors that staff persons were not aware of such as stuffing toilets and vents. In addition, the kitchen fire started by the VA could have been accidental and staff persons were able to extinguish it before there was any harm to the VA. Additionally, the VA spent time in the backyard during family visits when staff persons supervised the VA from the dining room window to allow the VA some privacy with his/her family; the air conditioning unit was not visible from the dining room window. Therefore, it is possible the VA was able to tamper with the air conditioning unit during family visits without staff supervision. Given that the VA plans did not specifically address the VA’s supervision in the bathroom or bedroom or when the VA had visitors and that the VA was not harmed as a result of the incidents, there was not a preponderance of the evidence whether there was the failure to provide the VA with reasonable and necessary care. Regarding the VA leaving without supervision On October 4, 2022, the VA left the hotel without staff person supervision while P3 used the bathroom. P3 was the only staff person working at the time and it was reasonable for staff persons to utilize a bathroom during their work shift. In addition, P3 took immediate action to locate the VA. On October 13, 2022, the VA told P1 that s/he was going to shower and then left out a bathroom window that was 15 inches wide by 38 inches tall. P1 stated that after 10 to 12 minutes of the VA using the shower s/he knocked on the door and when the VA did not answer, P1 immediately opened the door. It was reasonable for P1 to not check on the VA until after the water was running for what P1 thought was a long continues period of time and P1 took immediate actions when s/he learned the VA left. Given that it was reasonable for staff to use the bathroom during their shift and that P3 and P1 each took immediate action to try to locate the VA, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care. Regarding the VA accessing his/her medications and knife drawer On September 22, 2022, P1 forgot to give the VA his/her evening medication. That morning, when P1 called the HCP, the medications were there. On the evening of September 23, 2022, P2 discovered that all of the VA’s medications were missing from the medication cabinet (which was supposed to be locked). Due to miscommunication between staff persons, the HCP was not notified of the missing medications until September 26, 2022, at which time s/he obtained the medications from the pharmacy. P4 stated there was no harm to the VA not receiving his/her medications. However, the facility’s failure to ensure the VA took his/her medication was a violation of Minnesota Statutes, section 245D.05, subdivision 2, paragraphs (a) and (b). P1-P4 and the VA each denied taking the VA’s medications. In addition, a kitchen knife was found in a neighbor’s yard shortly after the facility van had its tires punctured while parked in the garage. Although staff persons thought the VA punctured the tire, it was not determined whether the VA had access to or obtained the knife or whether the VA in fact was the person who punctured the van tires. Although P4 said that staff persons were to keep the keys on them at all times, information from P1-P4 was consistent that no all staff persons kept the keys on their person. Instead, they were kept on the counter allowing the VA to have access to the keys and therefore, his/her medications. Because it was not determined how the kitchen knife ended up in the neighbor’s yard or how the tires were punctured, as well as what happened to the VA’s medications, and there was no information that the VA was harmed as a result of either incident, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care. Regarding the VA’s contact with minors Information showed that the VA had regular visits from family members, including a sibling who was a minor, when they spent time outside in the yard. There was also at least one occasion when the minor sibling brought a friend who was also a minor. Staff persons stated that they were aware that the VA was out in the yard with his/her family, but to give them privacy did not always have eyes on the VA. Because it was the VA’s family members who brought minors to the facility and there was no information staff persons allowed the VA to be alone a minor, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care. 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 conducted an internal review and determined that the facility policies were adequate, but not followed related to the VA being able to access medications. The facility provided retraining to staff persons regarding medications and required that all medications and sharps be kept in a locked safe in the staff office. The HCP stated that s/he also provided training to P1, P2, and P3 regarding medication errors and medication discrepancies. Action Taken by Department of Human Services, Office of Inspector General: The facility was issued a correction order for the violation outlined in this report.
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