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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: 1114742-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman Suspected Maltreatment Reported: It was reported that a staff person (SP) was scheduled to work one-on-one with a vulnerable adult (VA). Another staff person (P1) found the VA unsupervised in the community dressed inappropriately for the outdoor temperature. The SP was not aware that the VA left the facility. Date of Incident(s): January 30, 2023 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 February 28, 2023; from documentation at the facility; and through eight interviews conducted with the VA, a guardian (G), and six facility staff persons (the SP and P1-P5). The VA’s Community Support Plan showed that s/he enjoyed shopping, fishing, playing games like Rummy or Bingo, and looking at cars, especially classic cars. The VA’s diagnoses included mild intellectual disability, episodic mood disorder, anxiety disorder, attention deficit hyperactivity disorder, disruptive behavior disorder, and speech apraxia. People who are not familiar with the VA may have difficulty understanding him/her and the VA liked it when people repeated back to him/her what s/he said to ensure s/he was understood. The VA was dependent on others to ensure his/her safety and required a 24-hour plan of care. The VA was assigned a 1:1 staff person to keep him/herself and others as safe as possible. The VA has a history of being assaultive, usually when feeling embarrassed about something. The VA did not like loud noises or crowds as overstimulation increased his/her anxiety. The VA’s plans showed the following information: · The Individual Abuse Prevention Plan (IAPP) stated that the VA had “zero [unsupervised] time at home and in the community. Staff [persons] will remain within visual and/or auditory range of [the VA].” · An Individual Absolutes/Specific Instructions stated that the VA had zero hours of unsupervised time at the facility and zero hours of unsupervised time in the community. The instructions further stated that the VA was at risk for “elopement” and required visual and audio supervision. · An Intensive Services Assessment (ISA) stated that “audio sounding alarms have been added to the exterior doors” of the facility to aide staff persons in recognizing if the VA left without supervision. The Program Abuse Prevention Plan (PAPP) stated that the facility was located in a residential area, in a cul-de-sac. Staff persons were supposed to “stay within audio and/or visual range of people served at the program site” and were also “trained on the alarm system” in the facility. The facility was a split-entry with an attached garage. An entryway included access via a front door or a garage service door. The PAPP said there were “chimes on the exit doors to notify staff [persons] of movement.” (Note: At the time of the investigator’s site visit, it was observed that each exit door had a wireless, battery powered alarm mounted at the top. Each alarm had the option of two settings and each setting was magnetically tripped when the door opened. The first setting made a one to two second, high-pitched chime/ding-ding sound and then stopped. The second setting was a blaring alarm. On the day of the site visit, both alarms were set to the shorter, chime setting and the investigator was told that was the setting consistently used.) An Incident/Emergency Report stated that at approximately 12:40 p.m., P1, who was not scheduled to work, contacted a supervisory person (P2) and stated the VA was “about to cross a road near Happy Dan’s gas station, without staff [persons], and inappropriately dressed for the weather (-11 wind chill.)” P1 was able to get the VA into P1’s car and transported the VA back to the facility. While this was occurring, P2 contacted the SP who was at the facility and was “unaware [the VA] had left the home and had no knowledge of [his/her] whereabouts at the time of that contact.” After returning to the facility, the VA was assessed by a facility health care professional, and it was determined there were “no injuries as a result of this incident.” The VA provided the following information when interviewed by this investigator: · Before any questions were asked, the VA stated that the SP did not work at the facility any longer because s/he “could not drive.” Throughout the remainder of the interview, the VA frequently stated that s/he did not like the SP because s/he “could not drive.” · The VA said that the day s/he left the facility, the SP was “in the bathroom I guess” and the door chime “did not” sound. The VA said that s/he first walked “through the snow to the school” to the “Mankato school” and pointed out the window in the direction of Mankato East High School. (P1 was present during the interview and confirmed that the VA said s/he went to Mankato East High School and not Kennedy Elementary School.) The VA said while at the Mankato school, s/he talked to a “cop” and asked the “cop” his/her age but “[s/he] didn’t want to tell me.” The VA then walked to the “Kwik Trip” and saw another “cop.” (P1 said that the VA frequently called Happy Dan’s gas station Kwik Trip and during the remainder of the interview the VA fluctuated between saying s/he was at Kwik Trip or Happy Dan’s gas station.) The VA had $5 and bought a pop/soda, went to the bathroom, and “then [P1] picked me up.” · The VA said when s/he left the facility s/he was wearing a t-shirt, pants, shoes, and a cap that s/he lost and believed s/he may have left in the bathroom at the gas station. The VA did not wear anything on his/her hands. The VA showed this investigator a zippered fleece sweatshirt that s/he was wearing over his/her t-shirt. P1 provided the following information when interviewed by this investigator: · P1 was not scheduled to work at the time of the incident on January 30, 2023. Although P1 was unsure of an exact time, s/he estimated that between 11:30 a.m. and noon, s/he saw the VA unsupervised in the community near Happy Dan’s gas station, approximately a 15 minute walk from the facility. It was sunny outside and P1 believed the temperature was in the single digits. P1 made contact with the VA and asked the VA if s/he could bring him/her back to the facility. The VA “was not fully knowing what was going on.” The VA was “cold,” his/her “nose was dripping” and s/he had a pop. The VA was wearing shoes and socks, pants, a t-shirt, and a fleece sweatshirt. · Once in P1’s vehicle, the VA kept repeating, “[The SP] can’t drive, [the SP] can’t drive.” Although P1 did not know if the VA asked the SP to drive the VA to the gas station, P1 said the VA was aware the SP did not drive and believed the VA took it upon him/herself to walk to the gas station. (P1 said that a “couple times” prior to the incident, the VA told P1 that s/he did not like the SP because s/he did not drive.) · P1 telephoned P2 and P3 (they were together) and told them that the VA was found outside unsupervised in the community. P1 then transported the VA back to the facility. Upon arrival, the VA and P1 walked into the facility simultaneously and P1 heard the alarm sound on the front door. Upon their arrival, P1 thought the SP was in the garage on the telephone with P2. The SP was “fully awake” and looked “frantic.” The SP said, “Thank God you are back.” · P1 assisted the VA into a shower. The SP was asked to leave the facility and left as soon as his/her ride arrived. After the VA showered, P1 wanted to take pictures of the VA’s hands; however, the VA did not want P1 to touch his/her hands and said they “hurt.” Shortly after, the VA was back to being “normal [VA’s name].” · P1 was aware that the SP wore hearing aids and believed the SP was “fully trained,” however, s/he did not know who trained the SP and guessed it was P3. After the incident, P1 said that the VA’s supervision required staff persons to have “eyes on” the VA with the exception of when the VA was sleeping in his/her room. P2, a supervisory person, provided the following information: · On January 30, 2023, P2 and P3 were together at the facility between 10:15 and 10:45 a.m. P2 heard the door alarm upon entering and observed the VA was downstairs playing video games and the SP was upstairs completing kitchen tasks. While at the facility, P2 and P3 briefly spoke with the VA and the SP. · After leaving the facility, P2 and P3 were together when P1 telephoned P3 at approximately 12:40 p.m. and sent a picture of the VA stating the VA was unsupervised in the community. While P3 was on the phone with P1, P2 called the SP’s cell phone; however, the SP did not answer. P2 then called the facility phone and asked the SP if s/he could talk to the VA. P2 heard the SP looking for the VA and after 20 to 40 seconds, the SP said the VA must be sleeping and P2 heard the SP knocking on a door. P2 heard the SP walking around calling the VA by name. P2 then told the SP that the VA was with P1; however, the SP “was not understanding” and told P2 that s/he would need to leave a message for the VA. · P2 said that the VA did not have street safety skills and would likely walk in front of a car if s/he saw something of interest. Although P2 heard that the VA left without supervision at his/her prior placements, the VA had not left without supervision since moving into the facility (June 2022). · P2 was not certain who provided the SP’s onsite orientation/training; however, believed it was either P1 or another staff person (P4). · P2 said that s/he was initially not aware that the SP relied on hearing aids in one or both ears until approximately two weeks before the incident the SP said that one hearing aid was not working and s/he was “on track to get it fixed” and made it sound like it was “no big deal.” P3, a supervisory person, provided the following information: · The VA required audio and/or visual supervision and it was acceptable to be able to hear the VA if s/he was downstairs. Staff persons did not need to remain in the same room as the VA because s/he “has a right to privacy.” · P3 provided similar information as P2 regarding the time P2 and P3 were at the facility on the morning of January 30, 2023, that the door chime was working that day, and the whereabouts of the VA and SP at that time. · On January 30, 2023, P3 first received a phone call from P1 just prior to 12:30 p.m. telling P3 that the VA was at Happy Dan’s unsupervised. P1 then transported the VA back to the facility and sent a text to P3 at 12:44 p.m. letting P3 know they arrived at the facility. · All staff persons were trained to have the door alarms on and be able to visually see both doors. P3 believed that either P1 or P4 provided site specific training to the SP regarding the VA. · On January 31, 2023, P3 sent a text to all facility staff persons informing them that the VA left the facility the day prior and “we need to have eyes in [sic] [the VA] or the doors at all times if [s/he] is downstairs and wants to be left alone the. [sic] We need to make sure we can see the doors at all times.” · P3 was aware that the SP used hearing aids; however, did not know if the SP was able to hear the chime/alarm on the doors because the SP did not say either way. P4 said that the last time s/he worked at the facility was the “summer” of 2022. (Information showed the SP was hired mid July 2022.) P4 said that staff persons needed to have “eyes on” the VA at all times unless s/he was in the bathroom. P4 said that the SP “read” the information in the VA’s book. When asked by this investigator about training specific to the physical plant and/or alarms, P4 said that s/he “did not have to do any” of that training with the SP. P4 was aware that the SP wore hearing aids and said that staff persons “had to repeat ourselves like five times” in order for the SP to hear when speaking to him/her. P5 said that P3 trained him/her and said that the VA had to be “within sight” of staff persons. P5 was aware of security devices on the facility doors; however, P5 described a system that identified “door number one-open.” (That was not the type of alarm installed at the VA’s facility.” P5 said that s/he worked with the SP at another facility and was aware that s/he was “definitely hard of hearing’ and “has hearing aids.” SP provided the following information: · The SP said that s/he worked with the VA one day per week for approximately the last month and January 30, 2023, “started like any other day.” After breakfast the VA went downstairs and played games on the TV. That morning, the VA had “two visitors” (likely P2 and P3) and after that another unidentified staff person stopped by and dropped off keys for the vehicle in the garage. (Attempts made to identify this staff person and the time this person was at the facility were not successful.) · On January 30, 2023, the VA “did not speak” to the SP and the SP had the “feeling [the VA] did not want me to be there” so the SP “stayed out of [the VA’s] way and gave [him/her] privacy.” The SP remained upstairs on the couch while the VA was downstairs playing games. The only time the downstairs area was not visible to the SP was when s/he used the downstairs bathroom. (The bathroom was at the bottom of the stairs and the area where the VA watched TV/played games was around the corner and not visible from the bathroom door.) · After using the bathroom, the SP said that the TV in the basement was still “on,” but s/he did not look to see if the VA was still sitting across from the TV or on a couch in the same area where the VA sometimes took a nap. The SP went back upstairs and while waiting for the VA to come back upstairs, the SP got a telephone call asking him/her to give the phone to the VA. The SP looked for the VA and “discovered [the VA] was not here.” The SP did not know who was calling for the VA because they were “hard to hear.” The SP explained that s/he had two hearing aids and the facility phone was “not compatible” with his/her hearing aids. While the SP was looking for the VA, the caller hung up and a “few minutes later” the VA returned to the facility with P1. · When asked about the VA’s supervision needs, the SP said the VA “did not want me in sight and when I was [the VA] was more irritable and irritated” so when the VA went down to the basement, the SP “gave [the VA] privacy and respect” and remained upstairs sitting on the couch (both doors were visible from the couch). · The SP said on other occasions the VA walked out the front door to the mailbox that was in sight. When asked about any alarms on the doors, the SP said “No, they don’t have an alarm.” When asked what noise the door made when opened, the SP said, “It does not squeak or anything.” When this investigator described the chime on each door, the SP was only aware of a doorbell on the outside of the front door and said s/he did not hear any chime when the doors opened or closed. · When asked who trained the SP regarding the VA and the facility, the SP said, “One of the coworkers showed me around” and told the SP about the VA’s meds and what the VA liked to do. The SP “read [the VA’s] book that was on the table.” The SP said that s/he was “never able to gain rapport with [the VA] working only one day a week.” The G provided the following information: · On January 30, 2023, s/he received a text from P2 informing the G that the VA left the facility unsupervised and was back safely at the facility. The G said that the temperature that day was -11 degrees Fahrenheit, and the VA was not wearing a coat. · The G stated that the SP was working at the time of the incident and suspected the SP was sleeping because there was “no way” a staff person “cannot hear door alarms.” The SP used “two hearing aids” and “shuts them off” and on two occasions when the G was at the facility, the SP was sleeping when the SP was supposed to be awake. The G did not provide dates or times; however, said that s/he told P2 about the SP and another staff person (P5) sleeping when they were supposed to be awake. P2 told the G that s/he needed to “take a picture and catch them sleeping.” The G said that the VA also told him/her that unidentified staff persons were either “asleep by 8 a.m. or watching their programs” and therefore not supervising the VA. · On January 31, 2023, P1 and the VA told the G that the VA also walked to a school, talked to a police officer, and went to buy a pop. Following that conversation, the VA “showed” the G that s/he went to “Kennedy school, door #13” and talked to two school officers, they would not tell the VA how old they were, and the VA got “irritated and walked back.” The G said that sidewalks were not cleared so the VA “would have had to walk on the road.” The VA told the G that s/he must have dropped his/her mittens. An online search via Weather Underground showed that the temperature on the day of the incident between 11 a.m. and noon was between one and two degrees Fahrenheit, and the wind speed was 12 miles per hour. A wind chill calculator (estimates the temperature felt by the body as a result of wind speed and actual temperature) showed that at that time the combined temperature and wind chill would feel like minus 16 degrees Fahrenheit and frostbite to exposed skin would take greater than 30 minutes. Photographs of the neighborhood as well as an online map showed that the route the VA described taking included him/her walking down his/her residential street and turning onto a dead-end road (Marwood Drive). At the dead-end road there was an opening in a fence intended to allow access to the rear property of Mankato East High School. From the high school, the VA likely continued on Hoffman Road/County Road 54 to Happy Dan’s convenience store. The online map showed a total distance from the facility to the high school and then to Happy Dan’s was exactly 1 mile with an estimated walking time of 19 minutes. Information showed that staff persons interviewed were trained regarding the Reporting of Maltreatment of Vulnerable Adults Act. In addition, the SP’s New Employee Orientation showed that s/he was also trained regarding principles of person-centered planning, resident rights, and the facilities policies and procedures. A New Site Orientation checklist signed and dated by the SP in September 2022, showed that the SP had one hour of training specific to the VA that included a review of the VA’s support plan, IAPP, and ISA. There was no instructor’s signature and a notation stated, “If a staff person reviews the plans and procedures themselves, by signing this form, they verify that they are capable of training themselves to competency, and that they will call the appropriate person or position if they have questions during their training or at any time.” Conclusion: On January 30, 2023, the SP was working alone with the VA. Information showed that there was a discrepancy between what staff persons believed and what was written regarding whether or not the VA required staff persons to have their “eyes on” the VA or if it was acceptable to have the VA within sound. Two supervisors, P2 and P3, were at the facility together that morning and estimated they left around 10:45 a.m. At that time, the VA was downstairs in the TV area and the SP was upstairs. The SP said that the VA did not speak to him/her that morning and the SP had the “feeling [the VA] did not want me to be there” so the SP “stayed out of [his/her] way and gave [him/her] privacy.” The SP remained upstairs on the couch where s/he could see the two exit doors. However, at an unknown time, s/he went downstairs to use the bathroom. After using the bathroom, the SP said the TV was “on” and s/he believed the VA was in the TV area; however, s/he did not look around the corner to verify the VA’s whereabouts. The SP went back upstairs and sat on the couch where s/he was able to observe the exit doors again. At approximately 12:40 p.m., P2 and P3 received a telephone call and text message from P1 informing them that the VA was in the community unsupervised. The VA said that s/he left the facility, walked to a nearby school, and then went to Happy Dan’s for a total distance of one mile that likely took him/her 19 minutes to walk. After P1 returned the VA to the facility, an assessment showed no harm came to the VA as a result of being outside for an unknown period of time in temperature the VA was not properly dressed for. The exact time the VA left was not determined. Given that the SP was able to see the exit doors, it was likely the VA left the facility when the SP was in the downstairs bathroom. Although it would have been reasonable for the SP to visually see the VA after s/he used the bathroom, the SP was aware that the TV was “on” and likely believed the VA remained in the TV area. Information from P1-P5 showed that all staff persons were aware that the SP wore hearing aids and P2 was aware that one of the SP’s hearing aids was not working approximately two weeks prior to the incident. The SP said s/he was not aware of any alarms or chimes on the doors despite signing a form that talked about “audio sounding alarms” on the exterior doors. The VA had a history of leaving without supervision from facilities s/he lived at in the past; however, the VA had no prior incidents of leaving without supervision since moving into the facility in June 2022. Although SP may not have been able to hear the alarms on the exit doors, given that s/he kept the exit doors in sight with the exception of when s/he went to the bathroom and that the VA was not harmed as a result of the incident, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services that were 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 policies and procedures were adequate but were not followed by the SP. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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