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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: 1106314-SUD (Substance Use Disorder) Investigator(s): Kyle Youker/Lindsay Arth 651-431-4056 Suspected Maltreatment Reported: It was alleged that a staff person (the SP) gave Tetrahydrocannabinol (THC) gummies to a vulnerable adult (the VA). Date of Incident(s): November 23, 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 19, 2022; from documentation at the facility; and through six interviews conducted with the VA, a facility client (the C), a staff person (P1), a supervisory staff person (P2), another staff person (P3), and the SP. The facility had two floors. The main floor contained staff offices and meeting rooms. Client bedrooms were on the second floor, and clients typically shared a bedroom with other clients. Facility documentation showed that on November 2, 2022, the VA was admitted to the facility and received substance abuse disorder treatment until November 24, 2022. The VA was diagnosed with stimulant addiction disorder and cannabis addiction disorder. The VA enjoyed playing basketball, listening to music, and photography. The VA was not subject to guardianship. The VA provided the following information: · The VA saw and heard about the SP demonstrating “weird” behavior around clients of the opposite gender. The VA was told by an unknown client that the SP gave him/her personal care items and books for free. The SP asked the VA and other clients of the opposite gender if s/he could “pray” for them and attempted to hold the VA’s hand. The SP never tried to kiss or have sexual contact with the VA. · The SP gave the VA his/her phone number on November 22, 2022, because the SP told the VA s/he wanted to “hang out” on Thanksgiving together. The VA did not give the SP his/her phone number. The SP and VA did not text or call each other initially. · On the evening of November 23, 2022, the VA got upset at another staff person for making an “inappropriate” comment about which hand the VA used to write and was planning to leave the facility. S/he then texted the SP, for the first time, that s/he needed a ride to leave the facility. The SP told him/her to stay at the facility for the night. The SP then told the VA s/he found him/her a ride from the facility the following day, but s/he would have to stay with the SP for a day at his/her residence until the ride showed up. · The SP then texted that s/he would arrive at the facility for work around 9:30 p.m. that evening, and that the VA should come find him/her around 11 p.m. At around 11 p.m., the VA approached the SP and the SP gave the VA some food, a lamp for his/her room, and a plastic bag that contained 12 THC gummies. The SP told the VA the gummies were THC. The VA texted the SP that s/he would eat all the THC gummies and then s/he took them all at the same time. · Later that night the VA started getting “really paranoid” and had what s/he described as a “drug induced psychosis” because all the THC gummies were consumed at the same time. The VA never “tripped like that” off THC gummies before. The VA also became paranoid because the SP had asked him/her to spend the night at his/her residence. · The VA stayed at the facility and went to sleep. The VA slept until around 6 p.m. on November 24, 2022, when P1 checked on the VA in his/her bedroom. The VA told P1 that s/he was “fucked up” and needed to go to detox. The VA had difficulty walking and did not have any “strength or energy” due to taking the THC gummies. The VA stated the C saw him/her during this time because the VA and the C shared a room together at the facility. · The VA was transported to the emergency room by P1 and spent one or two hours there receiving tests. The VA only remembered having his/her blood drawn while at the hospital. The hospital staff told the VA s/he had an “overactive thyroid” but did not mention anything about THC or other drugs being present in his/her blood. The VA did not think the hospital tested him/her for drugs. · After being discharged from the emergency room, P1 drove the VA to a detox facility where s/he stayed for approximately two weeks. The VA stated s/he was “fucked up” for three days after taking the THC gummies. The C provided the following information: · The C was roommates with the VA at the time of the incident. · On November 23, 2022, the VA told the C that s/he was trying to leave the facility the next day. The VA told the C that s/he had a ride arranged through his/her sibling. · On November 24, 2022, the VA told the C that s/he ate THC gummies and said the VA could barely sit up. The C immediately told P1 about the VA’s condition after s/he was told about the THC gummies. · The VA initially told the C that his/her former significant other provided food for him/her the evening of the incident and placed the THC gummies into the bag with the food. After leaving the detox facility the VA told the C, that it was the SP that purchased the food and provided the THC gummies. · The SP never tried to give the C items, and s/he did not think the SP gave any other clients THC gummies. The C did not think the VA had the SP’s phone number.. · The C thought the SP was “weird” and “creepy” because s/he would tell clients of the opposite gender that s/he would get them anything they wanted. Other staff persons would not bring food or other items to clients, and s/he believed there was a rule about that. P1 provided the following information: · P1 was working at the facility on November 24, 2022, the VA was “not feeling well,” and would not get out of bed for the majority of the day. P1 “periodically” checked on the VA in his/her room throughout the day. During one of the checks, P1 told the VA that s/he had been selected for a random urinalysis.
· At around 5:30 p.m., the C told P1 that the VA needed to speak to him/her. P1 went to the VA’s room and was told by the VA that his/her urinalysis would be “dirty” because s/he had eaten “a bunch of gummies” the previous night. · P1 immediately called P2 and was told to bring the VA to a detox facility. The VA was having difficulties standing up when s/he was trying to pack his/her bag for the detox facility. After the VA had packed his/her bags and was walking out of the facility, P1 stated the VA became “pasty” and had no color in his/her lips. The VA then asked P1 to bring him/her to an emergency room. · P1 immediately drove the VA to an emergency room and stated within five minutes of being admitted the VA began vomiting. The VA had his/her phone at the emergency room and appeared to be texting an unknown person. P3 called P1 and stated the VA’s parent called the facility and told him/her the SP provided the VA with the THC gummies. · While in the emergency room the VA also told P1 the SP gave him/her the THC gummies. The VA was discharged from the emergency room on the same date and P1 then transported him/her to the detox facility. After P1 dropped off the VA at the detox facility, s/he immediately called P2 and told him/her about the SP giving the VA the THC gummies. · When P1 was back at the facility, P2 called him/her after speaking with the VA at the detox facility. P2 told P1 that the SP had given the VA his/her address. P1 searched the VA’s desk in his/her bedroom and found a piece of paper with the SP’s address on it. P2 provided the following information: · Immediately after P1 told him/her about the SP giving the VA the THC gummies, P2 called the SP and told him/her not to come into work that date due to the allegations. · P2 went to the detox facility at an unknown time on November 24 or November 25, 2022, to speak with the VA. The VA said s/he took a “handful” of THC gummies that the SP gave him/her. The VA told P2 s/he had also exchanged text messages with SP. · The VA allowed P2 to look at the text messages with the SP on his/her cell phone. P2 saw text messages about the SP providing the VA with THC gummies and trying to find the VA a ride from the facility. P2 stated the text messages made him/her “sick.” · On November 28, 2022, P2 spoke to the SP in person, and s/he asked to tell his/her “side of the story,” but P2 did not want the SP to tell him/her because s/he was “too angry.” P2 stated the SP told him/her that s/he did not have an “excuse” and there was no “justification,” but did not provide P2 with any further details. P3 stated s/he saw the VA and the SP have conversations together on multiple unknown dates at the facility but did not have any concerns about the interactions between the SP and the VA, prior to the incident. P3 stated the SP, on unknown dates, gave another client clothing and personal care items. P3 stated that while P1 and the VA were at the emergency room, the VA’s parent called the facility and told him/her that the VA texted that a staff person gave him/her the THC gummies. The facility provided copies of the text messages between the SP and the VA. The VA first texted the SP at 6:25 p.m. on November 23, 2022. The text messages showed that the SP gave the VA THC gummies and told the VA the gummies contained THC. The messages also showed that the VA told the SP that s/he was going to eat all the THC gummies at once. The VA’s medical records from the emergency room on November 24, 2022, showed the VA received testing by emergency room staff and was medically cleared for his/her transfer to the detox facility by P1. The VA did not submit a urinalysis drug screening while at the emergency room. The medical records stated the VA’s symptoms were likely due to consuming the THC gummies. The SP provided the following information: · On multiple unknown dates prior to November 23, 2022, the VA repeatedly asked for his/her phone number and was trying to reach the SP on Facebook. S/he initially did not want to give the VA his/her phone number and did not know why the VA wanted his/her phone number. On November 23, 2022, the SP “used bad judgment” and gave his/her phone number to the VA. · On November 23, 2022, the VA sent a text message that s/he was going to leave the facility. The SP initially told the VA not to leave the facility but then offered to give the VA a ride. The SP stated it was inappropriate to assist the VA when s/he was trying to leave the facility. The SP denied ever having the VA in his/her vehicle. · The SP again “used bad judgment” and gave the VA the nine THC gummies on November 23, 2022. When asked why s/he gave the VA “marijuana gummies” the SP stated s/he thought “what harm could it do” because the VA was already going to leave the facility. The SP purchased the THC gummies from an “smoke shop.” The SP stated the THC gummies should be taken one at a time and if someone took all the gummies at once they would get “really sick.” The SP also gave the VA food but denied giving him/her anything else. · The SP sent the VA a text message sometime after November 24, 2022, to say s/he was sorry for giving him/her the THC gummies. On a later date the VA texted the SP asking for gas money, but the SP denied giving him/her any money. The SP also gave the VA his/her home address, but stated the VA never came to his/her home. The SP denied having a relationship or sexual contact with the VA. · The SP knew staff persons were not supposed to give clients drugs of any kind. The SP never gave drugs to other clients prior to the incident. The SP denied giving his/her phone number to clients other than the VA. The SP stated staff persons were not supposed to give clients their personal phone numbers. The facility had a Patient Relationships and Boundaries policy. The policy stated staff persons may not give clients their personal phone numbers or provide clients with gifts. The facility had an Employee Conduct policy that prohibited staff persons from possessing and distributing drugs. Facility documentation showed that staff persons were trained on the Patient Relationships and Boundaries policy, the Employee Conduct policy, and received training on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Information was consistent that on November 23, 2022, the VA took between 9 and 12 THC gummies that were given to him/her by the SP. The VA became sick and was brought to an emergency room due to the VA’s symptoms. The SP providing THC gummies to the VA was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. In addition, the VA was at the facility to receive treatment for his/her diagnosis of stimulant addiction disorder and cannabis addiction disorder. Therefore, there was a preponderance of the evidence that there was a failure to provide the VA with care and services which were reasonable and necessary to maintain the VA’s physical and mental health and safety. 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. Facility documentation showed the SP was trained on the facility’s Patient Relationships and Boundaries policy, and on the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for the 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 did not meet statutory criteria to be determined as recurring or serious. The SP gave the VA THC gummies on one occasion and though the VA went to an emergency room, s/he was discharged after receiving diagnostic testing, assessment, and observation only. Action Taken by Facility: The facility completed an internal review. The facility determined the policies and procedures were adequate, but not followed by the SP. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.
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