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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: 1094765-H_CRS (Home and Community-Based Services-Community Residential Setting) 1090632-HCBS (Home and Community-Based Services) Investigator(s): Gessner Rivas / Carla Harvieux 651-431-3970 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) left without supervision from the facility on numerous occasions and “ran around’ outside the facility, sometimes naked. The VA would enter neighbors’ garages and vehicles and would not leave when requested requiring law enforcement intervention. On February 3, 2023, law enforcement found the VA hiding in a neighbor’s car when the outside temperature was five degrees Fahrenheit below zero. Date of Incident(s): Various dates 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 April 4, 2023; from documentation at the facility, law enforcement records, and through four interviews conducted with facility staff persons (P1-P3) and the VA’s guardian. Investigators attempted to interview the VA but were unable to due to the VA experiencing mental health symptoms. The VA was diagnosed with epilepsy, anxiety, and compulsive behavior. The VA enjoyed going for walks and attended school four days a week. The VA’s Individual Abuse Prevention Plan (IAPP) noted that the VA had no understanding of sexuality and was likely to undress in inappropriate places. The IAPP also noted that the VA had a tendency to ignore her/his personal safety and was likely to not dress appropriately for the weather, particularly in winter. The VA’s Self-Management Assessment stated that the VA had a history of leaving without supervision and when the VA left without staff person supervision and was out of sight, staff persons were to contact law enforcement for help. Concerns were reported to the Department of Humans Services by a community person that the VA would wander outside without appropriate clothing in winter. At times, the VA entered the garages of other houses in the community. Sometimes, law enforcement officers would escort the VA back to the facility. P1 provided the following information: · P1 stated that staff persons were not allowed to physical restrain the VA when s/he tried to leave without supervision from the facility. Staff persons were only allowed to verbally redirect the VA who regularly left without supervision; once every two to three days. The facility raised the idea of implementing a rights restriction procedure with a member of the VA’s team, but that option was declined. · P1 stated that the VA did not recognize weather conditions and thus would not dress appropriately, and the VA did not recognize the risk to her/his safety when the VA left without supervision. P1 stated that s/he was not aware of the VA being injured as a result of going outside without proper clothing. · A team was working on creating a safety plan for the VA, the group consisted of the VA’s case manager, the VA’s guardian, a Law Enforcement (LE) liaison, a representative from the VA’s school, and representatives from the facility. P1 also stated that the VA had a Positive Support Professional that worked with her/him and had coached facility staff persons on techniques to get the VA to return to the facility without incident. · As a result of the number of calls to LE when the VA left without supervision from the facility, the facility was given an abatement notice by LE, where the facility would be charged $250 per call. Per LE’s recommendation, the facility then started to use COPE; a mobile crisis response team of Hennepin County. However, by the time COPE responded the VA would often have returned to the facility. The facility, therefore, returned to calling LE when needed. · The VA was given a 60-day notice of service termination on or about March 21, 2023. P2 provided the following information: · P2 stated that the facility was not a locked facility and typically had a ratio of four residents to one staff person. When the VA left without supervision, the staff person would stay with the other residents and call LE. Sometimes, when there were two staff persons working, one staff person stayed with the other residents and the other staff person would go with the VA until the VA returned to the facility. · P2 stated that during her/his shifts at the facility, s/he at times called LE multiple times a day when the VA left without supervision. The VA would enter other people’s properties. At times the VA would leave while her/his family member was visiting. P2 explained to that family member that P2 could not go after the VA because s/he had to stay with the other residents at the facility. · The VA’s family member would drive the VA to and from school, but the VA would refuse to get out of the car. The facility tried many things to address the VA’s pattern of leaving without supervision including having a behavior specialist come in to provide positive support for the VA. · P2 stated that it was not uncommon for the VA to leave the facility without appropriate clothing, or at times no clothing. P2 could not recall if the VA was ever hurt when s/he left without supervision. P3 provided the following information: · P3 stated that in the last two to three months the VA began to leave without supervision from the facility. Staff persons tried to keep the VA focused on activities to prevent the VA from leaving but it did not work. The VA was supervised constantly but other residents also needed supervision. When the VA left the facility, staff persons would keep an eye on the VA from within the facility if the VA remained in view. P3 noted that when there were two staff persons at the facility, the VA did not leave as much. · P3 stated that the VA liked the sight of the police and at times the VA would call 9-1-1 from the facility’s landline. The VA would “take advantage” when there was only one staff person at the facility. · P3 stated that the facility would call the COPE helpline, but by the time COPE responded, the VA had returned to the facility. P3 could not recall if the VA ever sustained any injury as a result of leaving the facility in the winter when the VA was not dressed appropriately. If possible, staff persons would follow the VA outside and place a coat on the VA. · P3 stated that the VA had issues getting along with other residents, the VA would go into other residents’ bedrooms, and teased other residents. The VA needed constant reminders to use the bathroom, the VA defecated in front of another resident’s bedroom door. Law Enforcement records provided the following information: · A report dated November 8, 2022, noted that the VA entered a staff person’s car and refused to leave until s/he spoke to her/his family member. The report noted that LE had many previous contacts with the VA, where the VA was “wandering around outside naked and trying to get into neighbors’ houses.” · A report dated November 24, 2022, noted that the VA was knocking on windows of houses in the area, staff persons from the facility tried to get the VA into a van to take the VA back to the facility. The VA refused and the police and staff persons just waited for the VA to change her/his mind. Officers left and parked around the corner, but the VA began to knock on windows again, and neighbors called 9-1-1. Officers returned, pulled the VA away from the house and sat her/him down. Other staff persons arrived and were finally able to get the VA into the van after an hour and a half. · There were multiple LE reports noting that the VA was not dressed for the weather. A report dated February 3, 2023, noted that the outside temperature was negative five degrees Fahrenheit, and the VA was not dressed for the weather. A report dated February 5, 2023, also noted that the VA was not dressed for the weather and officers had to walk her/him back to the facility. A report dated February 10, 2023, noted that the VA had refused to return to the facility, fell on the ice, refused to get up, her/his “shorts had frozen a bit,” and was assisted getting up and returned to the facility. A report dated February 12, 2023, noted that the weather outside was below freezing and the VA was only wearing a t-shirt and sweatpants. Officers attempted to escort the VA back to the facility, but the VA went “dead weight and sat on the ground.” The report further noted that the VA’s family member came out of the facility and was able to convince the VA to return to the facility. Another report dated February 20, 2023, noted that the VA was only wearing a t-shirt, shorts, and Crocs. The VA’s feet were red and the VA expressed that s/he was cold. The report went on to note that officers had been to calls regarding the VA “and this situation approximately 57 time this year.” Facility documentation showed that P1, P2, and P3 were each trained on the Reporting of Vulnerable Adults Act and the VA’s care plans. Conclusion: From November of 2022 through February of 2023, the VA had a history of leaving without supervision from the facility. At times the VA left without appropriate clothing; sometimes when the temperature outside was below freezing. The facility was unlocked, and staff persons could not physically restrain the VA from leaving the facility. The staffing ratio at times prevented staff persons from following the VA outside. Given that P1, P2, and P3 provided consistent information that the VA could not be physically stopped from leaving without supervision from the facility, that when staff persons could not follow the VA they called 9-1-1 for assistance, and that there was no information that the AV sustained any injuries or required medical care when s/he left, there was not a preponderance of the evidence that there was a failure to provide the VA with reasonable and necessary care and services. It was not 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). Action Taken by Facility: The facility conducted an Internal Review of the incidents and determined that their policies and procedures were adequate and followed. Facility staff persons took appropriate actions upon the VA leaving without supervision from the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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