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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: 1099532-Intensive Residential Treatment Services/Residential Crisis Stabilization Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that on April 6, 2022, a vulnerable adult (VA) died by suicide at the facility. The Department of Human Services (DHS) was notified timely of the VA’s death in April of 2022, but a maltreatment investigation was not assigned. On October 19, 2022, DHS received information alleging that the facility did not provide the VA with additional supervision which s/he requested the day before s/he passed away. An investigation into the VA’s death was then assigned for investigation. Date of Incident(s): April 6, 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 December 7, 2022; from documentation at the facility, law enforcement records, records from a medical examiner’s office, and the VA’s hospital records; and through six interviews conducted with facility staff persons (P1, P2, P3, and P4, who was a supervisory staff person) and the VA’s family members (FM1 and FM2). The VA was not subject to guardianship when s/he passed away. The facility was a residential treatment facility for adults who were overcoming mental health and chemical dependency issues. Services at the facility included counseling and personalized substance use disorder recovery services to guide individuals from addiction to recovery in a supportive environment. According to the facility’s Patient Rights Policy, facility residents were permitted to retain their personal items as space permitted if they did not present a risk to medical safety, a risk to personal safety, or a “programmatic concern.” There was a video recording system at the facility that recorded its common areas, including the hallway where the VA’s bedroom was located. Facility documentation showed that on March 23, 2022, the VA was admitted to the facility under a commitment order, after s/he was discharged from a Community Behavioral Health Hospital (CBHH) which provided short term inpatient psychiatric care to individuals before discharging them to appropriate settings in the community. Records from the CBHH showed that the VA’s diagnoses included “psychosis and paranoid ideation.” The VA might have disorganized, agitated, and threatening behaviors, and was sometimes withdrawn and guarded, which made it difficult to obtain information from him/her. Stressors/triggers identified by the VA that might prevent him/her from staying healthy included “traffic” inside his/her head, listening to certain music, and watching certain things on television. When the VA felt unwell, s/he might sleep too much or have “paranoia.” Avoiding stressful situations helped the VA cope. At the facility, the VA’s diagnoses included schizoaffective disorder depressed type, but the VA disagreed with the diagnoses and told facility staff persons that s/he did not know whether s/he saw or heard things as others said s/he did. When the VA initially arrived at the facility, staff persons checked on him/her every 15 minutes when s/he was in his/her bedroom, which was a standard practice for newly admitted individuals. When the VA was participating in groups or in common areas, staff persons were not required to complete or document checks on him/her. All staff persons were responsible for completing checks on individuals and the frequency (every 15, 30, 45, or 60 minutes) of the individuals’ checks was noted by the individual’s name on a white board near the staff persons’ desk. The white board was only visible to staff persons because it was in an enclosed area with windows of darkened glass and was erased at the end of each shift. The frequency of checks was also documented in the individuals’ plans. However, no information documented the time that the VA (or other facility residents) entered their bedrooms, thereby triggering staff persons to begin bedroom checks on them. According to the facility’s Individual Abuse Prevention Plan (IAPP) and the Mental Status Exam and Safety and Risk Assessment for the VA, s/he had a history of suicidal ideation and substance use but in the Assessment of Immediate Needs which was completed upon admission, the VA denied any active suicidal ideation, desire, planning, or intent. Staff persons were to monitor the VA and assess him/her for substance use then increase the VA’s supervision or modify his/her free time as necessary. Suicide assessments were to be conducted if staff persons noticed warning signs or triggers. Dialectical behavior therapy-based skills, peer support groups, creative coping, at home skills groups, and health/wellness groups were offered to the VA daily, and once a week and s/he was offered one to one therapy with a licensed independent clinical social worker. When the VA was admitted, there was no evidence that s/he had psychotic symptoms, perceptual disturbances, or delusional thoughts. The VA was not a high risk of suicide or other self-harm but had highs and lows and wanted to be well so that s/he could participate in outdoor activities with FM1. The VA’s IAPP showed that the VA’s moods were up and down at the facility, and s/he “struggled” with participation in groups at times. The frequency of the VA’s checks varied while s/he resided at the facility based on information s/he provided in his/her interactions with staff persons and facility mental health care professionals (MHCPs). However, it was documented that the VA continued to deny that s/he had active suicidal or homicidal ideations, and on the day s/he passed away, staff persons were to check on the VA randomly once every 30 minutes. FM1 and FM2 provided consistent information that they thought the VA requested additional supervision the day before s/he passed away but did not receive the increased supervision. This investigator obtained the VA’s hospital records from November 28, 2021, from a behavioral health center in another state, where the VA resided prior to residing at the CBHH and later the facility in which s/he passed away. In late 2021, the VA was determined to be a danger to him/herself or others because s/he had a knife in his/her pocket, and it was thought that the VA reached for the knife at the emergency department of a hospital. The VA said that s/he was depressed and in a bad mood at the time. The VA was at the behavioral center until s/he began residing at the CBHH and his/her diagnoses included psychosis, schizophrenia, post-traumatic stress disorder, suicidal ideation, and noncompliance with medication regimen. The VA had nightmares but denied that s/he had auditory or visual hallucinations and denied any suicidal or homicidal thoughts. It was recommended that s/he be discharged to a facility that provided intensive residential treatment and services to transition to independent community living. The FMs were concerned that some of the records they had regarding the VA’s care at the facility in which s/he passed away, had been changed or altered, to make it appear that the VA’s plans of care were followed, when they were not. Facility documentation, records from the law enforcement agency, the VA’s hospital records, records from the Medical Examiner’s Office, and information provided in interviews with this investigator provided the following: P1 said that shortly after 11 p.m., on April 6, 2022, s/he opened the VA’s bedroom door and looked inside to complete a check on the VA. It was dark inside the bedroom and P1 thought that s/he heard the VA breathing but was not sure, so s/he asked P2 to check on the VA. P2 entered the VA’s bedroom and called the VA’s name a few times, but the VA did not respond. P1 and P2 turned on the bedroom light and observed the VA sitting cross-legged on his/her bed, turned slightly away from the door, with a plastic bag over his/her head. P1 and P2 provided consistent information that the VA’s hands were tied with shoelaces hooked to his/her shoes so that the VA could not remove the bag if s/he was in distress. P1 immediately began removing the bag from the VA’s head but the bag was small and difficult to remove. P1 tore away a portion of the bag on the VA’s face to permit the VA to breathe, removed the rest of the bag, laid the VA flat on his/her bed, began cardiopulmonary resuscitation (CPR), and called for P3, instructing him/her to call 9-1-1 and facility security officers. P1 and P2 alternated performing CPR on the VA and removed the shoelaces from the VA. Emergency medical technicians (EMTs), law enforcement officers (LEOs), firefighters, and security officers arrived within a few minutes and the EMTs began giving the VA CPR. Records from the law enforcement agency showed that the agency investigated the VA’s passing. At 11:12 p.m., on April 6, 2022, the agency received a 9-1-1 call regarding the VA, and LEOs went to the facility where they assisted EMTs and staff persons to care for the VA. At 11:47 p.m., EMTs determined that the VA could not be revived. LEOs reviewed video recordings that showed the hall on which the VA’s bedroom was located and determined that prior to passing away, the VA was often in and out of his/her bedroom that evening. The VA was last observed alive outside his/her bedroom at 10:10 p.m., when s/he entered the bedroom with dark colored string/s draped over his/her neck. The strings were hanging loose, and they did not appear to be tied. P1 told the LEOs that at about 10:20 p.m., s/he saw the VA sitting cross-legged on his/her bed in his/her bedroom. The VA said that s/he wanted “privacy” which was not uncommon for the VA to say. P1 told LEOs that s/he checked on the VA again at 11:05 p.m. and saw the VA lying on his/her bed, but the VA’s position looked odd. P1 walked away briefly, and then returned to the bedroom a few minutes later, opened the door a second time, looked inside, briefly entered the bedroom, and then called for assistance. P2 and P3 quickly responded and P3 called 9-1-1. The agency determined that the SP checked on the VA shortly after 11 p.m., but staff persons did not check on the VA for about 47 minutes prior to P1 observing the VA unresponsive in his/her bedroom during that check. However, the VA’s injuries were consistent with self-harm and after obtaining records from the Medical Examiner’s Office, the law enforcement agency closed its investigation and took no further action. Records from the Medical Examiner’s Office showed that the VA had faint furrows across each wrist and the right foot that were consistent with descriptions of how the VA was found in his/her bedroom. A basic blood screening showed that the VA’s blood was negative for ethanol and “common drugs of abuse.” It was determined that the VA died by suicide and his/her cause of death was asphyxia by a plastic bag. P1, P2, and P4 (who was a supervisory staff person), provided consistent information that the VA often declined to participate in groups, but residents could choose to opt out of them. P4 said that “bedtime” at the facility was at 11 p.m., and the VA’s supervision needs were noted on his/her IAPP, but there was no documentation that specified when staff persons should begin bed checks. The VA was generally quiet, not very social, and preferred to spend time in his/her bedroom. P1 said that when the VA was upset, the VA might say a quick expletive and then leave the room. On the day the VA passed away, “nothing was any different from other days” according to P1, and if the VA was upset that day, s/he did not tell anyone and kept it to him/herself. Staff persons were to check on the VA every 30 minutes and P1 thought that s/he completed checks on the VA as required in the hours before the VA passed. P1 described completing a check as discreetly opening the bedroom door but trying not to bother or wake the individual inside, then looking for obvious distresses that might cause concern. During the law enforcement investigation, P1 learned that there was a period of 47 minutes when the VA was inside his/her bedroom without being checked on by a staff person, but P1 thought that the checks were supposed to be random so that individuals at the facility would not expect them and might sometimes be slightly delayed when staff persons were assisting others. Because of the length of time between the VA’s death and P1’s interview, P1 was unable to recall details about checking on the VA in the hours prior to his/her death and was unsure whether s/he had been slow to check on the VA because P1 was assisting another individual at the facility. P1 said that plastic bags were accessible to the VA and other individuals at the facility since they assisted to clean the facility and could change plastic bags in the garbage bins. Documentation showed that when staff persons completed bed checks on the VA between March 23 and April 6, 2022, the checks were done at the frequency specified by his/her plans. Provider Notes from the facility showed that on March 29, 2022, when the VA was talking by phone with his/her former significant other, s/he heard a voice saying that if the VA went to visit FM1, someone would die. The VA called FM1, began shouting, and had difficulty calming. Facility security officers and P4 came to assist the VA to calm. On April 2, 2022, at 2 a.m., the VA had difficulty sleeping because s/he had a nightmare which upset him/her. However, the VA declined to discuss his/her feelings, took a prescribed as needed medication, and went to his/her bedroom. Staff persons checked on the VA at 5 a.m., and s/he was lying awake in his/her bed. The VA got up at 5:30 a.m. and ate breakfast. On April 5, 2022, at 1 a.m., P3 documented that the VA made a phone call to an unspecified person but was redirected that s/he should not make during “quiet hours.” The VA ended the phone call and told P3 that s/he was having nightmares which prevented him/her from sleeping. The VA was given melatonin and returned to his/her bedroom at about 1:10 a.m. On April 6, 2022, a health care professional (HCP) tried to talk with the VA about his/her prescribed medications and needs at the facility, but the VA said that s/he was in a “bad mood” and asked if they could talk the next day. The HCP agreed and asked if s/he could do anything to help the VA, but the VA declined. On April 6, 2022, Observation Notes documented that the VA limited his/her participation in groups but was often in and out of his/her bedroom and ate breakfast and lunch. At 5:45 p.m., the VA met with a MHCP who assisted the VA to call FM1 so that FM1 could participate in his/her meeting with the VA. Initially, the MHCP and VA could not reach FM1, but when they tried again, they spoke with FM1, who took part in the meeting. The VA said that s/he was truly struggling and doing the “worse” that s/he ever had. The VA had delusions that unidentified people were coming to the facility to hurt him/her and had constant fears that someone would hurt FM1. The MHCP wrote that s/he offered “support and safety” to the VA, but the VA replied that “if they wanted to get to me, you couldn’t keep me safe.” FM1 and the MHCP made supportive statements to the VA, but the VA wanted to leave the facility to visit FM1 and FM2. The MHCP reminded the VA that passes to leave the facility had to be requested and said that s/he could not abruptly leave. The VA became upset and quickly ended his/her conversation with the MHCP. Later that evening at 8:14 p.m., the VA was being checked on every 30 minutes and declined to have a second phone call with FM1. According to facility documentation, on April 6, 2022, staff persons checked on the VA at 12, 12:30, 1:02, 1:32, 2:02, 2:30, 3:01, 3:31, 4:01., 4:31, 5, 6, 6:30, and 7:01 a.m., and 11:08 p.m. When the VA was in groups or in common areas of the facility, checks were not documented because the VA was with staff persons and other individuals at the facility. No information showed how staff persons were to know when to begin checking on individuals when they entered their respective bedrooms. An April 7, 2022, Critical Incident Reporting Form showed that on April 6, 2022, at 11:08 p.m., P1 checked on the VA in his/her bedroom and found the VA unresponsive. P1 called for assistance from P2 and began CPR on the VA. Facility security persons and 9-1-1 were called, and LEOs, firefighters, and EMTs arrived within seven minutes. EMTs continued CPR on the VA but s/he was unresponsive and was determined to be deceased at 11:47 p.m. The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans prior to the incident. Conclusion: Information was consistent that the VA’s diagnoses included mental health concerns and s/he had a history of hospitalizations in facilities that provided care and treatment to persons with mental illnesses. The VA was admitted to the facility on March 23, 2022, after s/he was discharged from the CBHH. The facility provided services to adults who were overcoming mental health and chemical dependency issues and guided them from addiction to recovery in a supportive environment. Facility residents could retain their personal items as space permitted if the items were not a safety risk. The VA had access to his/her personal items at the facility and no information showed that the VA had suicidal ideation at the time s/he passed away. On April 6, 2022, the VA died by suicide at facility. The FMs thought that the day before the VA passed away, s/he requested more frequent supervision, but did not receive it. The frequency of checks for the VA at the facility varied during his/her stay, but at the time s/he passed away, staff persons were to check on the VA every 30 minutes when s/he was in his/her bedroom. The frequency of checks was noted in an area of the facility that was accessible only to staff persons and was in documentation. Checks were to be random within the 30-minute time frame and might be impacted when staff persons assisted others at the facility. Information was consistent from facility documentation, P1 and P2, the law enforcement agency, and the recordings made by the facility’s video recording system, that the VA entered his/her bedroom at 10:10 p.m., on April 6, 2022. P1 stated that at 10:20 p.m., s/he saw the VA sitting on his/her bed and the VA said that s/he wanted privacy, which was not usual. Shortly after 11 p.m., (a time confirmed by the video recording made by the facility’s video recording system), P1 checked on the VA in his/her darkened bedroom. P1 was unsure whether s/he heard the VA breathing, so s/he asked P2 to check on the VA. P2 entered the VA’s bedroom and called his/her name, but the VA did not answer. When the lights were turned on, P1 and P2 saw the VA sitting cross-legged on his/her bed with a plastic bag over his/her head and his/her hands tied. P1 and P2 removed the bag and began CPR on the VA, and P3 called 9-1-1. First responders arrived and attempted to revive the VA, but s/he did not respond to their efforts and was declared deceased at 11:47 p.m. Law enforcement officers determined that the VA was not checked on for approximately 47 minutes before s/he was found deceased shortly after 11 p.m., and s/he had access to shoelaces and a plastic bag which s/he used when s/he died by suicide. However, given that the VA could be unsupervised in his/her bedroom for 30 minutes, that no information showed that the VA voiced his/her intentions to staff persons, that the VA was not prohibited from having shoelaces or a plastic bag, that it was unknown whether timelier or more frequent checks on the VA would have prevented the VA’s death, and that there was no information that staff persons were engaged in anything other than therapeutic activities that delayed the timeliness of checks, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services that was reasonable and necessary to obtain or maintain the VA’s 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. The VA did not communicate an intent to harm him/herself or others, requested additional supervision and received it, and was “forward thinking” and discussing future plans on the evening of his/her passing. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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