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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: 1070490-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was not adequately supervised, left the facility without supervision, and hit a community person (CP1). The VA had a history of leaving the facility without supervision and there were concerns that the facility could not adequately supervise the VA. Date of Incident(s): Prior to April 26, 2023, and ongoing 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 19, 2023; from documentation at the facility and law enforcement records; and through interviews conducted with facility staff persons (P1, P2, and P3), and the VA’s guardian (G). This investigator met the VA, who communicated with a few words and gestures, but s/he did not provide information regarding the allegations in this report. The facility was in a rural setting but faced a busy two-lane road that had significant traffic. Community persons resided near the facility, and their properties could be accessed through wooded areas to the sides of the facility or from the road the facility faced. Facility documentation showed that the VA was diagnosed with a developmental disability and a seizure disorder. The VA had no unsupervised time in the community, might consume inedible items, was vulnerable to all forms of maltreatment, and had poor boundaries. When the VA was upset, s/he might have aggressive behaviors and s/he had a history of leaving the facility unsupervised and walking toward the road in front of the facility. If staff persons observed the VA leave the facility when two staff persons were on shift, one staff person was to stay with the other individuals while the second staff person followed the VA. If staff persons did not see the VA leave and later discovered that s/he was not at the facility, the second staff person was to search the facility grounds and the surrounding neighborhood for the VA. If the VA was not located and the direction in which the VA went was unknown, staff persons were to immediately contact a supervisory staff person, who would decide whether a law enforcement agency should be contacted. Staff persons might also contact other nearby facilities operated by the same program to help them locate the VA. If the facility was single staffed when the VA left or was discovered missing from the facility, the staff person was to verbally redirect the VA to return to the facility if s/he was located, call a supervisory staff person for instructions, and call a law enforcement agency for assistance when necessary. Staff persons were not to leave the other individuals unsupervised to follow the VA or look for him/her. No information showed how the VA was to be supervised inside the facility, but there were alarms on the exit doors of the facility to let staff persons know when the facility’s exterior doors were opened. Occurrence/Injury Reports showed that on April 4, 2023, the VA was upset, called others names, raised his/her voice, and tried to hit staff persons. On the morning of April 7, 2023, staff persons observed the VA leaving the facility with no shoes and no jacket. The VA was encouraged to return to the facility, and s/he did, but s/he “yelled” at staff persons. On April 13, 2023, law enforcement officers (LEOs) were called to the facility. The VA kicked and spat at the LEOs multiple times, and an ambulance was called to transport the VA to a hospital for mental health concerns. When s/he was not upset, the VA was kind and caring and liked going shopping. Facility documentation, records from the law enforcement agency, the facility’s Internal Review, and interviews with this investigator provided the following: Records from the law enforcement agency showed that an unspecified time on April 26, 2023, a law enforcement officer (LEO1) responded to a phone call from the facility saying that the VA left the facility without supervision. Later, CP1 also contacted the law enforcement agency and stated that when the VA left the facility, the VA came to CP1’s residence, hit CP1’s face with his/her closed fist, and spat on CP1 while s/he guided the VA back to the facility. CP1 had swelling and bruising from the VA hitting him/her, and when s/he arrived at the facility with the VA, s/he learned that P1 had been working single staffed at the facility when the VA left without supervision. P1 had been unable to follow the VA. According to the records, the VA continued to be upset at the facility and raised his/her fist several times to hit LEO1, who “sternly” advised the VA to lower his/her fist. The VA did not hit LEO1 but was given a citation for his/her actions toward CP1 and was left under the supervision of staff persons. CP1 declined to pursue criminal charges against the VA. LEOs also came to the facility on January 2, 13, and 20, February 19, March 1, and April 5, 2023, because the VA left the facility without supervision. When LEOs arrived during one of the incidents, staff persons were assisting the VA from the road in front of the facility. According to the records, the VA had a history of hitting staff persons, individuals at the facility, and LEOs. P1 said that at about 8:30 a.m., on April 26, 2023, the VA declined to take his/her prescribed medication and left the facility just before 9 a.m. while P1 supervised him/her. P1 was working single staffed at the facility but followed the VA into the yard, encouraging the VA to come inside the facility. However, the VA declined, raised his/her voice to P1, and sat at a picnic table outside. P1 went into the facility to check on the other individuals who had no unsupervised time, and when s/he returned to check on the VA, the VA was walking away from the facility toward the road that passed in front of the facility. P1 called out to the VA to return to the facility, but s/he did not respond to P1 and continued to talk toward the road. P1 called LEOs to help with the VA, but the VA returned to the facility about 10 minutes later, before the LEOs arrived. P2 soon arrived for his/her 9 a.m. shift and the Ps talked with the LEOs, who told them that the VA had hit CP1. LEO1 talked with the VA, and s/he calmed. The rest of the day went well with no further incidents. Two other community persons (CP2 and CP3) were also aware of the VA’s history of leaving the facility without supervision and voiced their concerns to DHS. When the VA left the facility on April 5, 2023, s/he entered CP2’s residence and initially declined to leave but was later redirected back to the facility. P3, a supervisory and administrative staff person, confirmed that when two staff persons were on shift, one staff person could leave to follow the VA if s/he exited the facility without supervision. However, there were not always two staff persons available for each shift and some shifts were single staffed. P1 followed the facility’s policies and procedures during the incident and no information showed that the VA sustained an injury from the incidents. Personnel files, including training information was reviewed. The facility trained its staff persons on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, and the VA’s plans of care prior to the April 26, 2023, incident. Conclusion: The facility was in a rural area near a busy two-lane road that passed in front of the facility and information was consistent that the VA had a history of leaving the facility without supervision, then walking toward the road. The VA might enter community persons’ residences and decline to leave or behave aggressively. When two staff persons were on shift, one was to follow the VA while the second staff person remained at the facility to supervise other individuals. The VA left the facility without supervision a few times between January and April of 2023, but on April 26, 2023, when the VA left the facility without supervision, the VA hit CP1. P1 was on shift when the VA left but could not follow him/her because s/he was the only staff person on shift at the time and was also responsible for supervising other individuals who had no unsupervised time in the community and were present at the facility when the VA left. According to P3, P1 followed the facility’s policies and procedures. Although the VA left the facility without supervision on April 26, 2023, given that P1 was the only staff person on shift when the VA left, that P1 attempted to supervise the VA and the individuals, redirected the VA to return, followed facility policies and procedures, and that the VA did not sustain an injury during the incident, there was not a preponderance of evidence whether there was a failure to provide the VA with care and supervision 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 facility began requiring that there were two staff persons on each shift so that one staff person could follow the VA and installed a privacy fence at the facility to slow the VA’s progress when s/he left the facility without supervision. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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