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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: 1115051-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jason Pehler/Beth Virden 651-431-4830 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) left the facility without the knowledge or supervision of a staff person. The staff called 9-1-1, and the VA was later found walking on a highway, unharmed. Date of Incident(s): April 1, 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 May 10, 2023; from documentation at the facility and law enforcement records; and through interviews conducted with the VA’s case manager (CM), facility staff persons (P1-P3), and a supervisory staff person (P4). At the time of the site visit, the investigator met the VA, but did not complete an interview due to the VA’s limited communication skills. The VA’s guardian (G) was also contacted for this investigation but did not provide additional information. The VA’s support plan and support plan addendum provided the following information: · In 2018, the VA moved into the facility seeking supports and services relating to his/her diagnoses, which included autism spectrum disorder and severe developmental disability. · “[The VA] has minimal community orientation skills. [The VA] is unable to communicate [his/her] name, address, or phone number. [The VA] has very limited verbal communication skills and will often repeat what [s/he] has heard rather than answer the question.” · “[The VA] has 2:1 staffing when in the community … Staff will accompany [the VA] at all times when out in the community … [The VA] will be no farther than an arm’s length away from staff when walking near an intersection or in a community setting. If [the VA] were to run or head toward a vehicle staff will verbally cue [him/her] to ‘stop’ and physically intervene if [s/he] is at risk of harm.” · “[The VA] has 1:1 awake staffing when at home … Staff will remain near [the VA] at all times when [s/he] is at home … There are usually three staff on at home during most awake hours for [the VA and the VA’s housemate]. There is one asleep and one awake staff at night.” · “[The VA] has the ability to unlock doors and windows. [S/he] may try to leave the home during the day or overnight … If [the VA] experiences an unexplained absence from the home, staff will search the perimeter of the home and if [the VA] is not on the property or within staffs’ line of sight, staff will immediately call 9-1-1 for assistance.” The facility was a single-family home where the VA lived with a housemate (H). The facility provided at least two staff persons 24 hours a day. The main floor included the VA’s and the H’s bedrooms, which were across a hallway from one another. There was also a kitchen and two living rooms. Information was provided that the VA typically used one of the living rooms and the H typically used the other. There was an exterior door in the VA’s living room leading directly outside. The door had an alarm that made a sound when opened. The facility, itself, was in a large residential neighborhood and within one mile of Highway 77 and Interstate 35W. An Eagan Police Department Report stated the following: · On April 1, 2023, exact time not identified, 9-1-1 dispatch received a call for assistance for a missing person, later identified as the VA. The staff did not know when the VA left and had been searching for him/her for about 15 minutes at the time of the call to 9-1-1. The VA was wearing camouflage shorts, a blue jacket, a grey t-shirt, and a backpack. · At 2:20 p.m., 9-1-1 dispatch received a call from a community person. The community person saw the VA standing on the side of Highway 77, “looking like [s/he] was going to cross the highway.” · “[Law enforcement] then responded to the area and did find [the VA] standing on the median shoulder at the start of the exit ramp to Highway 13 from northbound Cedar Avenue. This is the apex in the middle of the road between the lanes of traffic for the exit ramp and the four lanes that continue northbound Cedar Avenue. The freeway was very busy. Once [the VA] saw [law enforcement], [s/he] initially started to go into another lane of traffic and then just started walking northbound … Officers were able to cut [the VA] off at Highway 13 and force [him/her] onto the exit ramp. [Facility staff] then arrived on scene and were able to stop [the VA] from walking without incident. [The VA] then got into the van with the help of staff and was transported back home.” The CM said that the VA was supposed to receive “1:1” staffing at home, which meant that at least one staff person should always know the VA’s whereabouts within the house. The VA had a history of leaving without telling anyone. Most recently, prior to this incident, the VA ran out of the house with staff running after him/her. P1-P3 provided the following information: · On April 1, 2023, P1-P3 were working at the facility with the VA and the H. P1-P3 each provided information that there was not one staff person assigned to one resident. Rather, P2 said that the facility typically had three staff during daytime hours. One of the staff typically sat on the H’s side of the house, and the other two typically remained on the VA’s side of the house. P1 said that at least one staff “sticks with” the VA when at home. However, the VA could be in the living room and the staff could be in the kitchen; they did not have to be always in the same room. · That day, the VA appeared “agitated”; P1 associated this with the VA missing his/her family. P2 said that the VA appeared “fine,” and P3 did not notice anything noteworthy about the VA’s demeanor. · Around 1:30 p.m., P1 left the facility to drop the H off at a different location. At that time, P1-P3 each said that the VA was lying down on his/her bean bag chair in the living room, covered by a blanket, and watching television. P2 and P3 added that a short time later, the VA paused the television and completely covered his/her body, including head, with the blanket. “We thought [s/he] was sleeping.” · P2 and P3 each said that staff were supposed to clean when they had an opportunity, and most staff took advantage of the times when the VA was resting to do this. P3 said that whenever the VA was lying in his/her bean bag chair, s/he did not typically get up. “[S/he’s] comfortable there.” · Upon seeing the VA lying down, P2 began cleaning the H’s bedroom and P3 went downstairs to start a medication count. P2 said that s/he checked on the VA “a couple of times” and each time the VA remained in his/her bean bag chair with the blanket covering his/her head. · Around 2 p.m., P1 returned to the facility after having been gone for about 30 minutes. P1 immediately noticed the facility’s exterior door was “cracked open.” Upon approaching, P1 saw the door alarm was disabled with its “controls exposed”; it had been tampered with. P1 walked inside and could not immediately see or locate the VA. · P1 shouted, “[The VA’s] gone.” P1-P3 “rushed out,” searched, and called a supervisor. · P2 said that, at that point in time, the VA had been gone for about five minutes. P2 knew this because s/he had checked on the VA about five minutes prior and saw the VA sitting on his/her bean bag chair. P2 did not hear the exterior door open, or the door alarm being disabled. “There wasn’t any sound” to indicate the VA was leaving the house. · P1-P3 searched the house for about ten minutes and without finding the VA, P1 called 9-1-1. Dispatch instructed the staff to continue searching for the VA, including walking around the neighborhood and nearby gas station. P1-P3 were in vehicles and on-foot searching for the VA. · About 15 minutes later, a law enforcement officer called P1 that they found the VA in the northbound lanes on Highway 77 near an off-ramp. P3 described this area as being “a fairly busy highway.” · P1-P3 each said that the VA knew how to disable the door alarms and appeared to have done so in this instance. P4 provided the following information: · P4 said that the VA did not require a staff person to be always physically next to him/her. The VA had a history of going into his/her bedroom and closing the door without a staff person following. “[The VA] was independent. [S/he] can go to [the G’s house]. We don’t have to follow [him/her]. [S/he] can go to the bathroom and you don’t have to follow, but it’s always staff making sure to know where [the VA] is.” Staff should be checking on the VA by opening the bedroom or bathroom door and verifying s/he was still present in the room. P4 did not have concerns with staff being in other areas of the house while the VA was lying on his/her bean bag chair at the time of the incident. · P4 did not have, and was not aware of others having, previous or related concerns with P1-P3’s conduct. P4 did not have concerns with P1-P3’s response to the incident. “They did it perfectly.” They searched for the VA, notified a supervisor, and called 9-1-1. This was consistent with the facility’s elopement response procedure. The facility’s policies and procedures stated that in the event a person eloped from the facility, staff were supposed to implement the person’s elopement protocol, if relevant. Next, staff searched the immediate and surrounding area; and if after no more than 15 minutes, the search was unsuccessful, staff contacted law enforcement authorities, and then the on-duty supervisor. Facility documentation stated that P1-P4 received training on the VA’s support plan and support plan addendum, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a), states the license holder must provide services in response to the person's identified needs, interests, preferences, and desired outcomes as specified in the coordinated service and support plan and the coordinated service and support plan addendum, and in compliance with the requirements of this chapter. License holders providing intensive support services must also provide outcome-based services according to the requirements in section 245D.071. Conclusion: On April 1, 2023, the VA left the facility without the knowledge or supervision of a staff person. The VA’s support plan/addendum stated, “Staff will accompany [the VA] at all times when out in the community … [The VA] will be no farther than an arm’s length away from staff when walking near an intersection or in a community setting.” The failure to provide the VA with community supervision was inconsistent with his/her support plan/addendum and in violation of Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a). However, prior to leaving, the VA was lying down in the living room, gave no indication of his/her intention to leave, and P2 was checking on him/her. The VA’s support plan/addendum stated, “[The VA] has 1:1 awake staffing when at home … Staff will remain near [the VA] at all times when [s/he] is at home.” P1-P4 each stated that they did not have to always remain within the same room as the VA. The CM said, “1:1” staffing at home meant that at least one staff person should always know the VA’s whereabouts within the house. Although it was not known exactly how long after the VA left that s/he was unsupervised in the community, the supervision provided to the VA before leaving was consistent with the VA’s support plan/addendum and the staffs’ and the CM’s understandings of the VA’s supervision requirements. In addition, upon discovering the VA gone, P1-P3 searched the area, called a supervisor, and called 9-1-1 within ten minutes, which was consistent with the facility’s policies and procedures. Given this, it was not determined what other actions could have been taken by staff to prevent the VA from leaving or to locate the VA sooner; and because of this, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services, which were reasonable and necessary for the VA’s health and 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 and followed. Following this incident, the facility replaced the door alarms with ones that could not be disabled by the VA. Action Taken by Department of Human Services, Office of Inspector General: On July 19, 2023, the facility was issued a Correction Order for the violation outlined in this report.
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