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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: 1098135-H_CRS (Home and Community-Based Services-Community Residential Setting) 1088139-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler/Beth Virden 651-431-4830 Suspected Maltreatment Reported: It was reported a vulnerable adult (VA) was unsupervised in the community, attempted to break and enter a neighbor’s house, and was arrested by law enforcement. Date of Incident(s): April 12, 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 19, 2023; from documentation at the facility; and through interviews conducted with the VA, the VA’s guardian (G), the VA’s case manager (CM), a neighbor (N), a facility staff person (SP), and a supervisory staff person (P). The VA’s support plan and support plan addendum provided the following information: · The VA’s diagnoses included moderate intellectual disabilities, major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder. · “[The facility] was developed specifically for [the VA] and [s/he] does not have housemates. [The facility] provides [the VA] 1:1 staffing and at times 2:1 staffing.” · “[The VA] has difficulty regulating [his/her] emotions. It appears that difficult situations cause [him/her] heightened anxiety and a need to either fight or run in the moment of conflict. [The VA] has aggressed towards [him/herself] and others, made threats of aggression, ran away, and made allegations against [staff] to get them out of [his/her] life.” · “[The VA] is at high risk for harm both due to [his/her] vulnerabilities and aggressive behaviors towards others.” · “[The VA] may not always recognize when someone is manipulating or harming [him/her] and also has a history of making false allegations towards others in [his/her] life just to get away from them or to be brought to the hospital. [The VA] eloped from [his/her] home on several occasions, most often going to one of the neighbor's homes.” The facility was a single-family home in rural Minnesota. The nearest neighbor (N) was approximately 0.2 miles away; down the facility’s driveway, across a road, and then into the N’s yard. The surrounding area included forests, farming fields, and a train track. The nearest town was approximately ten miles away. The facility’s Incident Report Form, dated April 12, 2023, included the following: [The VA] had gone to bed for the night early at about 5:30pm ([S/he] usually goes to bed at 6pm and wakes very early in the morning). [The VA] later slipped past [the SP] out [his/her] window, got over to [the N’s] house, and the police were called. [The VA] was eventually brought to jail. [The P] responded and [s/he] was present when the police arrived, but the police were adamant that [the P] not talk to [the VA] and that they bring [the VA] to jail without negotiation. In talking with [the SP], [the VA] had been winding down for the night, had [his/her] meds and had gone to [his/her] room. Somewhere thereafter [the VA] slipped out [his/her] window and went over to [the N’s]. [The VA] had no concerning symptoms or behavior that day. The N said that at the time of the incident, the SP must have been “sleeping” because s/he seemed to have “no idea” the VA was out of the house for about 20 minutes. The N had an active a restraining order against the VA. The VA had previously threatened the N’s family. The N had a motion-activated camera on the outside of his/her house, which captured the following on the day of the incident, April 12, 2023: · At 5:02 p.m., the VA approached the N’s house and walked to the front door. It was not clear if the VA entered the house. There were no other people visible on the camera. · At 5:03 p.m., the VA sat on the N’s exterior front steps. The VA stood and again walked to the front door. It was not clear if the VA entered the house. There were no other people visible on the camera. · At 5:23 p.m., the VA sat on the N’s exterior front steps appearing to speak to the SP, who was standing a few feet away. An unidentified person could be heard in the distance, off camera, “Go fucking home, [the VA’s first name]. Go home.” · At 5:24 p.m., the VA sat on the N’s exterior front steps appearing to speak to the SP. An unidentified vehicle backed out of the N’s driveway and another unidentified vehicle entered the driveway. The CM said that the VA had a history of eloping and going to the N’s house. “[The VA] has a long issue with [the N],” and the N had “an active restraining order” against the VA. The CM and the G did not have concerns with the facility’s overall care and supervision. The VA provided the following information: · At the time of the incident, the SP was the sole staff person working. The VA was in his/her bedroom, and according to the VA, the SP was either sleeping on the living room couch or playing a game on his/her cellphone. “[The SP] was not paying attention.” · There was nothing going on at the facility at the time. The VA explained, “I just decided to leave. I don’t know why I left … [I’m] kind of determined to leave at that point. [I] didn’t want to be here.” The VA slid his/her bedroom window open and jumped out. [Note: There was an outdoor staircase about two to three feet below the VA’s window, which then led to the ground level outside.] · The VA walked to the N’s house, which was the closest house to the facility. The VA was at the N’s house “for a while.” The N and the VA did not have a good relationship. According to the VA, the N had “elbowed” him/her during some of their previous interactions, including times when the VA entered the N’s house. · On this day, the VA tried to go inside the N’s house but was stopped by the N’s family member, who said they were calling 9-1-1. The VA sat on the N’s exterior front steps and waited for law enforcement. · The SP was “pretty quick” to follow the VA to the N’s house. The VA believed s/he was unsupervised at the N’s house for ten minutes before the SP arrived. · When law enforcement arrived, the VA was arrested, placed in jail for two days, and then released back to the facility with pending criminal charges. · The VA did not want to live at the facility anymore and wanted to live independently. The SP provided the following information: · The VA had a history of eloping from the facility and had successfully done so about twice within the past year. However, numerous other times, the SP caught the VA mid-elopement, or in the process of eloping, and was able to “talk [him/her] out of it.” “Literally, just walking into [his/her] room and actually seeing [him/her] halfway out the window.” · The VA might also elope through the front door. The facility was single-staffed, and so staff might be using the restroom and the VA could walk out the door. “[S/he’ll] just walk out even though [s/he] is perfectly fine and showing no signs of [planning to elope]. You could be making dinner and [the VA] could just walk out of the house … [S/he’ll] start walking around and then all of a sudden, [s/he’ll] just start running down the driveway.” · The VA “always” went to the N’s house whenever s/he eloped. The VA wanted to go to a jail or a hospital. “[S/he] wants to leave. [S/he] tells me multiple times a day. [S/he] wants to leave every single day.” According to the SP, the VA knew that if s/he went to the N’s house, they would call 9-1-1, which was what the VA wanted and because the N did this once, the VA repeatedly returned so that s/he would call 9-1-1 again. In addition, each time the VA was successful in going to the jail or the hospital, s/he would then struggle for a period upon returning home. · When the VA was in his/her bedroom, staff were not required to be with him/her. The VA could be unsupervised in his/her bedroom, especially when sleeping. The facility was not able to lock the VA’s bedroom window for fire code reasons. The facility had tried using a “beeper” or “alarm” on the window, but the VA repeatedly removed the batteries or destroyed it. At the time of this incident, the facility was no longer putting a beeper or alarm on the VA’s window. Whenever the VA was in his/her bedroom, the SP checked on him/her by opening his/her bedroom door once every ten minutes. If staff remained in the VA’s bedroom for longer or checked on the VA too frequently, s/he got “really upset” and then remained awake the rest of the night.
· On the day of the incident, the VA was having “a pretty good day.” Typically, or “90% of the time,” the VA showed “signs of anxiety” prior to elopement. On this day, s/he did not show any such signs. The SP believed the VA was having “a normal day.” · They ate dinner around 4 p.m. The SP then administered the VA’s medications, including melatonin (sleep aid). The VA preferred to go to bed at 6 p.m. Typically, after the VA fell asleep, there were no issues the remainder of the night. On the day of the incident, the VA went to his/her bedroom after dinner. The SP checked on him/her by opening his/her bedroom door every ten minutes. The VA was “fine,” and did not show signs of an impending elopement (e.g., “signs of anxiety”). · The SP was sitting on the living room couch, either watching television or playing on his/her computer. The SP did not see or hear the VA elope through his/her bedroom window. “[The VA] likes to do that very quietly.” [Note: The facility’s floorplan showed the living room down a hallway from the VA’s bedroom.] · When the SP next went to check on the VA, s/he was not there. · The SP immediately went to the N’s house; and heard yelling from the VA, the N, and the N’s family member. The VA was sitting on the N’s exterior front steps. “I kept trying to talk [the N and the N’s family member] down. And at the same time I was trying to talk [the VA] down. Every time I would make any type of progress with [the VA], [the N and the N’s family member] would start saying stuff to [the VA] and getting [the VA] all amped up all over again … I was just trying to say anything I could really to get [the VA] out of that situation.” · The N had called 9-1-1, and when law enforcement arrived, they acted “rude” to the SP, and would not allow the SP to speak to the VA or negotiate the VA not going to jail. · The SP believed the VA was unsupervised in the community for about 20 minutes. The VA was unharmed but faced criminal charges relating to the incident. The P provided the following information: · When the VA was in his/her bedroom, staff were supposed to give him/her space. “You don’t want to be too overbearing.” However, staff were supposed to check on him/her every five to ten minutes. “It's usually when [s/he] goes to bed. Usually, you'd make sure like peeking on [him/her] make sure [s/he's] sleeping before you kind of let your guard down.” · The P believed that the VA had eloped three times in 2022. “It’s not super common.” However, “100% of the time” the VA went to the N’s house after eloping. The VA’s goal was to go to the jail or the hospital. · The SP was an “experienced” staff and “alert.” The P had no concerns with the SP’s conduct. “[S/he is] an excellent worker.”
Note: At the outset of this investigation, information was provided to the investigator that an unidentified community person was living on the facility’s property in a trailer. The P denied this, and the investigator did not see evidence to indicate this was true. Given the lack of any additional information or witnesses, a licensing violation was not determined. Facility documentation stated that the SP and the P each 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. Conclusion: It was reported that the VA eloped through his/her bedroom window without the SP’s knowledge or supervision. The VA went to the N’s house. The N called 9-1-1. The VA was arrested and faced criminal charges. The N had an active restraining order against the VA. Prior to the incident, the VA was showing no “signs of anxiety” or an impending elopement. The SP administered the VA’s melatonin (sleep aid) and the VA went to his/her bedroom as s/he typically did each night. The SP sat on the living room couch and checked on the VA every ten minutes, which was consistent with what staff were supposed to do according to the SP and the P. Although the N and the VA each said the SP was sleeping on the couch, there was no information to support this account. The SP responded to the N’s house immediately upon discovering the VA had eloped. The SP unsuccessfully tried to negotiate the VA returning home and not going to jail. Given the aforementioned, and that the SP followed the VA’s supervision requirements and responded immediately, and that there was no information of previous concerns with the SP’s conduct, there was not a preponderance of the evidence whether the SP failed to supply the VA with care or services, which were reasonable and necessary to maintain the VA's physical or mental 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 and determined the following: · Policies and procedures were adequate and followed as it pertained to the incident. · “[The VA] is very clever at sneaking out of the house and has bothered [the N] on other occasions. [The VA] is fixated on going to the hospital and has learned that bothering [the N] almost always leads to law enforcement being called and a trip to the ER. [The G, the CM, and the facility] is weighing options for additional supervision in the evenings and when [the VA] is asleep to reduce the possibility of [him/her] eloping, even though [the VA] has historically done better with asleep staff.” · “It is recommended that some form of active supervision be employed at night, whether electronic or awake staff, to monitor the facility security cameras. The implementation of such will have to be carefully considered, since [the VA] has a history of worsening behavior when awake night staff are present. A second support staff person should also be considered during the evening hours when [the VA] could easily slip out of the house when the staff is in the bathroom or attending to household tasks.” Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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