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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: 1068587-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was reported that a staff person (SP) failed to supervise a vulnerable adult (VA) in the community as required and the VA was arrested for theft. Date of Incident(s): March 10, 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 March 30, 2023; from documentation at the facility and law enforcement records; and through six interviews conducted with supervisory staff persons (P1, P2, and P3), the SP, the VA, and the VA’s guardian (G). Facility documentation showed that the VA was a great dancer and author. The VA was not a morning person and enjoyed playing video games through the night. The VA’s main goal was to get a job and hoped that interviews would be scheduled for him/her. The VA’s Support Plan Addendum stated that the VA had a history of stealing and was required to be within eyesight of staff persons at all times while out in the community. The VA was diagnosed with schizophrenia, bipolar disorder, and major depression. The facility’s internal investigation stated that on March 10, 2023, the SP took the VA and another resident (R) to a local store to check on the status of the VA’s employment application. Prior to the VA going into the store, the SP had a conversation with the VA about not taking items that did not belong to him/her and the SP gave the VA a “shot” to prove s/he could be trusted. The SP and the R waited in a facility van while the VA went into the store. Approximately 15 minutes later, the VA exited the store and was apprehended by law enforcement. The VA stole several items from the store. The SP spoke with law enforcement officers and was told that they were keeping a knife the VA had in his/her possession. When P1 asked the SP about the incident, the SP stated s/he “made a poor choice.” The VA enjoyed living at the facility. On the day of the incident, the SP took him/her and the R to a local store and the VA went into the store while the SP and the R stayed in a van. The VA did not want to talk about what happened at the store. When the VA moved into the facility, s/he brought a knife but did not tell anyone that s/he had the knife. The VA purchased the knife online before moving into the facility. The VA said that s/he was not supposed to be in the community without staff persons supervision. The G stated that March 12, 2023, P2 emailed the G and explained that a staff person knowingly let the VA walk into a store without supervision. The VA required one to one supervision anytime s/he left the facility and there had been specific training on the VA’s plans with each staff person at the facility. P1, P2 and P3 provided the following consistent information: · The VA did not have independent time in the community and staff persons were to always be within eyesight of the VA and to be aware of what s/he was doing. The R did not require supervision and had unlimited unsupervised time while in the community. · On March 10, 2023, at approximately 3:30 p.m., the SP allowed the VA to go into the store unsupervised while the SP and the R stayed in the parked van. No matter where the SP parked in the parking lot, s/he could not have been able to see the VA in the store. While in the store, the VA stole items and was awaiting charges. · The SP was trained on the VA’s supervision requirement and should have gone into the store with the VA. · After the incident, P1 spoke to the SP who provided information to P1 that was consistent with the information the SP provided below. P1 told the SP it was not his/her choice to make changes to the VA’s programming and that it was the VA’s support team who did so. P3 stated, “[The SP] does what [s/he] wants to do, not what [s/he’s] supposed to do.” The SP and the VA’s progress note dated March 10, 2023, and written by the SP, provided the following consistent information: · On March 10, 2023, the SP took the VA and the R out of the facility. Their first stop was the local store so the VA could check the status of his/her job application. · While in the van, in the parking lot of the store, the SP asked the VA if s/he could “trust” him/her to go in and check on his/her application. The SP asked the VA, “This is your opportunity to do something on your own, can you handle it?” The VA promised that s/he would not have “sticky fingers,” and would “run in and run out.” · The VA entered the local store alone while the SP and the R remained in the van. After approximately ten to fifteen minutes, the SP saw three police cars pull up to the front of the store. As the VA exited the store, the law enforcement officers approached the VA and had him/her empty his/her pockets. The officers took the VA back into the store and the SP got out of the van and talked with officers and explained that s/he was the VA’s caretaker. After approximately 20 minutes, the VA was released to the SP. The VA, the SP, and the R then went back to the facility and the VA went to his/her bedroom. The VA came out of his/her room to eat dinner and later that evening watched television with the R. · The SP allowed the VA to go into the store alone because the SP considered it a “growing” moment. · The SP read the VA’s plans and knew the VA was not allowed to go into the store alone because the VA had a history of theft. The law enforcement report provided the following information: · Law enforcement officers responded to a “shoplifting in progress” call at a local store because a store representative saw the VA open packages and put items in his/her pants. · As the VA exited the store, officers stopped and searched the VA and found three BB guns, two knives, a shoulder holster, a pair of boots, a coffee drink, and a bag of jellybeans. The total value of the items was $314.79. · It was determined the VA stole one knife from the store and had brought one knife into the store with him/her. Because the knife was used to open packages, it was a burglary tool during a theft which was a felony charge. · The VA was awaiting charges for this incident. Facility documentation showed that P1-P3 and the SP were trained on the Reporting of Maltreatment of Vulnerable Adults Act and trained on the VA’s plans. Conclusion: A. Maltreatment: Information from all sources, including the VA’s plans, was consistent that because the VA had a history of shoplifting, when in the community, the VA did not have any unsupervised time and always required staff persons visual supervision. On March 10, 2023, at approximately 3:45 p.m., the SP allowed the VA to go into the store unsupervised while the SP and the R waited in the facility van in the parking lot. While the VA was unsupervised, s/he stole items valued at $314.79 and charges were pending. Given that the VA required supervision in the community to prevent the VA from engaging in illegal activity, that R did not require a staff person’s supervision in the community, and that the SP allowed the VA to enter the store without supervision resulting in the VA shoplifting and had charges pending, there was a preponderance of evidence that the SP’s actions were not accidental or therapeutic and that there was a failure to supply the VA with reasonable and necessary care and services. It was determined that 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.) B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans including supervision requirements. The SP was responsible for the supervision of the VA at time of the incident and stated that s/he knew the VA was not allowed to go into the store alone because the VA had a history of theft. The SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the SP was responsible in this report did not meet statutory criteria to be determined as recurring or serious because it was a single incident for which the VA did not sustain an injury that reasonably required the care of a physician. However, information obtained by the Department of Human Services, in combination with this report, resulted in the SP being disqualified for recurring maltreatment. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined the facility’s policies were adequate, but not followed. The facility conducted a staff meeting and retrained the staff on the VA’s supervision requirements. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.
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