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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: 801558-RMI (Residential Treatment and Services for Adults with Mental Illness) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that on April 3, 2023, a vulnerable adult (VA) was transported from a hospital to the facility by two facility staff persons. When enroute, the VA forcibly removed a back window of a facility van and threw his/her body onto the highway. The VA sustained injuries and was transported via air ambulance for treatment. Date of Incident(s): April 3, 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 April 18, 2023; from documentation at the facility, law enforcement records and hospital medical records; and through four interviews conducted with three facility staff persons (P1-P3), and a law enforcement officer (LEO2). This investigator did not meet the VA as s/he was hospitalized at the time of the site visit; however, this investigator briefly met the VA on a prior occasion while at the facility. The VA was admitted to the facility on February 28, 2022. The VA’s diagnoses included borderline personality disorder, oppositional defiant disorder, major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder. The VA enjoyed writing, playing cards, coloring, doing crafts, and listening to music. Facility documentation showed that the VA had a long-standing history of “disruptive and self-injurious behaviors.” Prior to his/her admission to the facility, the VA resided at Anoka Metro Regional Treatment Center (AMRTC) due to “unmanageable self-harm” primarily by means of swallowing inedible items, requiring medical intervention on multiple occasions. While at AMRTC, the VA had a 4:1 staff ratio at all times and was able to acquire items to ingest while staff persons were present at his/her side. It was determined that staffing ratio or proximity to the VA at all times was not determined to impact his/her ability to swallow inedible items. On the contrary, staff person proximity to the VA added exposure to items s/he could swallow (face masks, name badges, keys, eyeglasses, etc.). Information also showed that the VA’s history included a plethora of psychotropic medications and electro convulsive therapy, all of which were thought be ineffective in managing his/her self-harm behaviors. The VA’s Individual Abuse Prevention Plan (IAPP) stated that s/he had a significant history of self-injurious behaviors and suicidal ideation with past attempts. The VA engaged in self-harm including headbanging, swallowing inedible objects (such as pieces of eyeglasses, paper clips, clothing, towels, shoes, playing cards, and vehicle vent pieces,) tying items around his/her neck, and cutting him/herself. Several of these instances resulted in the VA being transported for medical procedures. After each incident of foreign body ingestion, facility medical providers evaluated the need to transport the VA to a hospital via ambulance to limit the VA’s access to items s/he had historically swallowed. However, “Due to limited resources, [the VA] is transported back to [the facility] in a caged van with two staff [persons], unless the hospital deems it medically necessary to transport [the VA] back in an ambulance. When in the caged van, one staff [person] should maintain visual contact of [the VA] at all times to ensure safety.” The facility’s “caged van” was a Dodge Grand Caravan equipped with a partition/wall directly behind the two front seats. The partition/wall was solid from the floor to just below the front seat headrests. Behind each headrest was a plexiglass window and between the two plexiglass windows was a screened area that allowed visibility and conversation between the front and back of the van. There was a single seat at the very back the van with a seatbelt. There were windows on each side of the back seat that opened with a latch that locked the window when shut or allowed it to open outward approximately four inches when unlatched. The facility’s Use of Restraints for Transport Outside the Secure Perimeter policy stated that the treatment team determined if restraints outside the secure perimeter were necessary. Restraints included handcuffs that were to be applied to the patient with hands in front of their body, a transport belt (also known as a D-belt) for vehicle transports, and/or metal or Velcro leg restraints used to limit the range of motion of the legs during transport. (P3, a supervisory person, demonstrated for this investigator the procedure for applying these devices that included feeding the handcuffs through the D ring that was attached to one end of the belt. Handcuffs were then applied with the hands in front of the person. The belt was applied around the waist and secured with Velcro. The belt also had segmented holes throughout that allowed for an additional set of handcuffs to further secure the belt if necessary; however, P3 stated that a second set of handcuffs were not typically used by the facility.) The policy further stated that staff persons were to arrange seating so that the driver’s protection was maximized, and good observation of the patient was maintained. (Information from a law enforcement report and interviews showed that at the time of the incident, the VA was secured as s/he was supposed to be.) A law enforcement officer (LEO1) documented that on April 3, 2023, at approximately 5:39 a.m., the LEO was dispatched to a “disturbance” near the intersection of US Highway 14 and State Highway 60 in rural Eagle Lake, MN. (This was a divided highway with two lanes in each direction.) The facility vehicle was traveling westbound on US Highway 14. Statements were taken from two facility staff persons (P1 and P2): · P1 was the driver of the vehicle and P2 was the passenger in the front seat of the van. P1 stated that they drove to Rochester Mayo to pick up the VA from the hospital and were transporting him/her back to the facility. The VA was seated in the far back seat on the driver’s side. P1 said the VA began to strike the window next to his/her seat when they were near Rochester. They stopped the vehicle and were able to get the VA to stop hitting the window. Later during the drive the VA said, “The window is broken,” and the VA immediately jumped headfirst out the window onto the highway. P1 was not sure how the window broke. · P2 provided information that was consistent to P1 regarding the VA striking the side rear window near Rochester and then pulling over the van to talk to the VA. P2 did not hear the VA say anything prior to the VA jumping headfirst out of the backseat side window. · LEO1 observed small shards of glass on the highway and approximately 10 yards later, there was blood on the road surface about two feet from the center line. Blood on the surface of the road continued until it stopped at the shoulder of the road where LEO1 believed that emergency medical staff (EMS) dragged the VA from the middle of the lane and provided aid from the shoulder of the road. LEO2 arrived shortly after LEO1. P1 and P2 said that during the transport, the VA was wearing “ankle shackles and a restraint belt with front facing handcuffs.” LEO2’s documentation showed that s/he arrived on the scene, took photographs, and interviewed P1 and P2. P1 provided the following information to LEO2: · P1’s shift began on April 2, 2023, at 10 p.m. During that shift, P1 was informed that s/he was on “mandatory overtime” and would be going to Rochester Mayo to supervise the VA. Approximately 10 minutes prior to arriving in Rochester, P1 and P2 were informed the VA was being discharged and they were supposed to transport the VA back to the facility. P1 and P2 arrived at the hospital and met two other staff persons (P4 and P5) who were supervising the VA. The VA was compliant when restraints were applied to his/her wrists and ankles. P1 said this was the second time s/he was involved in transporting the VA. · Near the towns of Byron or Kasson (about 15 to 20 minutes after leaving Rochester Mayo), P1 and P2 heard three loud “bang thuds” coming from the rear of the van where the VA was seated. When the VA was asked about the noise, the VA said s/he woke up from a bad dream. P1 pulled the van over to the side of the road and P2 exited the vehicle, opened the right-side sliding door of the vehicle and had a conversation with the VA. There was no damage to the vehicle observed and the VA was told if s/he did not stop his/her behavior, P2 would ride in the back of the van with the VA. The VA seemed “fine,” and they got back onto the highway. Approximately 50 minutes later, P1 heard the VA say something like, “this is broken.” At that time, the cruise control of the vehicle was set at 65 miles per hour. As P2 asked what was broken, P1 saw the VA in the left side view mirror, leaning out the rear driver’s side window of the van, and P1 slammed on the brakes. P1 believed the vehicle slowed to about 40-45 miles per hour; however, at that same time the VA “dove/climbed” out of the vehicle head-first. P1 stopped the vehicle and P2 ran back to check on the VA, called 9-1-1, and tended to the VA who cried, said that his/her shoulder hurt, and that s/he wanted to die. P2 provided the following information to LEO2: · P1 and P2 had not met nor worked together before the morning of the incident.
· Prior to leaving the Rochester Mayo hospital, hospital staff persons administered a medication to “calm” the VA. · When P1 and P2 heard “banging” on the interior of the van and asked the VA what was wrong, the VA said s/he was just trying to fall asleep. P2 got out of the van, opened the right-side sliding door and talked with the VA. The VA did not seem angry or upset. P2 did not observe any damage to the vehicle. · Later during the transport, at approximately 5:30 a.m., P2 again heard “banging” coming from the rear of the van. When P2 looked to see what was going on, s/he observed the rear left side window of the van was “out” and P2 told P1 to stop the van. As P1 was slowing down the van, the VA “dove out” of the vehicle. · P2 exited the van and flagged vehicles over so that the VA was not struck by passing vehicles. P2 called 9-1-1 and tended to the VA until EMS arrived. LEO2 documented that at some point after the incident, the VA’s handcuffs and restraints were removed and kept for “evidence.” Hospital information showed that during the transport from the hospital to the facility, the VA was in “four-point restraints” (both arms and both legs) when s/he used his/her feet to break open the window of the transport vehicle and then “jumped out of the moving vehicle.” The VA was returned to the hospital and several abrasions to the left side of his/her body were observed. The VA was diagnosed with “left scalp laceration with imbedded foreign bodies” and “nondisplaced left scapular fracture.” The VA was discharged from the hospital back to the facility that same day in the evening. When interviewed by this investigator, P1, P2, and P3 provided the following information: · P1 said that as of April 3, 2023, s/he worked with the VA “five or fewer times” and that day was the first time s/he transported the VA in a vehicle. P1 affirmed s/he was trained regarding the use of restraints during transports and said that a “D-Belt” was used to secure the VA’s hands near his/her waist and leg shackles were placed on the VA’s ankles. P1 said that there was only one set of handcuffs available when s/he thought there were supposed to be two; one for the VA’s hands and one to secure the strip of Velcro on the D-belt. Because a second set of handcuffs was not available, an unidentified hospital staff person supplied P1 and P2 with “two zip ties” to secure the Velcro on the D-belt. · After the VA was in the van, P1 saw P2 enter the van and ensured the VA’s seatbelt was secured. The VA said s/he was tired and wanted to sleep, asked for music on the radio and wanted the temperature inside the van warmer. · When P1 heard “three thuds,” P1 pulled over the vehicle and P2 went to the rear of the van to “investigate.” P2 returned to the front of the van and they continued driving until the VA said something like “this is broken.” Immediately after that, P1 saw the VA in the side mirror exiting the vehicle and attempted to stop and pull over the vehicle. At the time of the incident, it was still dark outside and P2 ran back to ensure no vehicles hit the VA who was on the highway. P1 and P2 moved the VA onto the shoulder of the road. Emergency responders arrived and the VA was airlifted to a hospital. · P1 believed s/he provided supervision to the VA as trained. · P2 said that on April 3, 2023, P1 and P2 were sent to the hospital to supervise the VA. P2 worked with the VA “once maybe” prior to that date. P1 and P2 were taking over supervision of the VA from P4 and P5. However, upon arrival, it was decided that the VA was being discharged so the vehicle driven by P2 was returned to the facility by P4 and P5, while P1 and P2 transported the VA in the facility van. The VA was secured with a D-belt, handcuffs, and leg shackles and placed in the facility van. A hospital security guard suggested using a zip-tie to secure the D-belt. · Once inside the van, P2 secured the VA’s seatbelt. P2 sat in the front of the van while P1 drove. P2 “kept looking back” about “every 30 seconds” at the VA. Although it was “tough to see” into the back of the van since it was dark outside, P2 tried to see the VA from the lights of other vehicles “every time a car went by.” · When they were about 35 minutes away from the facility, the VA asked how much longer they would be driving so P2 told the VA. The VA thanked P2 for the information and asked for the radio station to be switched. Within five minutes, “We heard a loud bang,” and when P2 looked back the VA was “halfway out” of the window. · P2 believed s/he provided supervision to the VA as trained. · P3, a supervisory person, was not aware until the interview with this investigator that P1 and P2 used zip ties to replace a second set of handcuffs they believed were supposed to be used on the D-belt. P3 stated that a second set of handcuffs to secure the D-belt was not mandatory and not traditionally used because the second set of handcuffs secured the D-belt would be located behind the individual’s back and would rub and be uncomfortable. P3 said that using zip ties to secure the D-belt was not a trained technique used by the facility. Despite the use of the zip-ties, proper restraints (one set of handcuffs, one set of leg shackles, and one D-belt) were available and used at the time of the incident. · When P3 was asked about transporting the VA during times of the day when it was dark outside, P3 said that the non-driving staff person was supposed to have eyes on the VA “to the best of their ability” while wearing their seatbelt as required by law. No dome lights were turned on inside the vehicle; however, observation was possible via the lights from the dashboard as well as from the headlights of any oncoming vehicles. · After the incident on April 3, 2023, P3 was present when the VA was discharged later that day and transported back to the facility. At that time the VA told P3 that prior to the incident, s/he unclipped his/her seatbelt, leaned over, and kicked the bottom frame of the window. When s/he realized it opened up, s/he “went for it” and threw him/herself out of the window. · P3 said that staff persons did not sit in the back of the van with the VA because there was only one seat in the back and the VA could be “very dangerous” because “nothing is off limits” as s/he was known to “bite, scratch, claw, and kick” and was difficult to control in a struggle. The facility’s internal review stated that “due to limited resources,” the VA was transported back to the facility in a caged van with two staff persons “unless the hospital deems it medically necessary to transport [the VA] back in an ambulance.” It was initially planned that at the time of the incident on April 3, 2023, the VA would be transported by back to the facility via ambulance, however, the ambulance was unwilling to transport, therefore the transportation back to the facility was completed by facility staff persons in the caged van. Information showed that one staff person should maintain visual contact of the VA at all times to ensure safety. Facility staff persons were trained regarding policies and procedures including emergency medical response, outside medical coverage, patient transport, the use of restraints for transport outside the secure perimeter, the VA’s individual plans, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information showed that on April 3, 2023, at approximately 5:30 a.m., the VA was being transported in a facility van from the hospital to the facility. P1 was driving the van, P2 was seated in the front passenger seat, and the VA was wearing handcuffs and ankle shackles as well as a seatbelt while sitting in the back seat of the van. Early on during the transport, when noises/banging at the back of the van was heard, P1 pulled over the van and P2 talked to the VA and P1 and P2 each stated that they did not observe any damage to the vehicle. Although P2 said that it was “tough to see” into the back of the van since it was dark outside, during transport P2 stated that s/he looked back at the VA about every “30 seconds” and tried to see the VA from the lights of other vehicles “every time a car went by.” When they were approximately 35 minutes away from the facility, P1 heard the VA say something and before P1 could pull over, the VA had the rear window open and pushed him/herself out, landing on the highway. Although the VA was able to get out of the van via the back window, restraints were used as required and earlier in the transport, after banging was heard, P1 and P2 checked on the VA and did not observe damage to the van. In addition, although the IAPP stated that one staff person should maintain visual contact of the VA at all times to ensure safety, given that it was dark out and P2 looked back at the VA approximately every 30 seconds, and that staff persons took immediate action to care for the VA, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. 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 not adequate, were not followed, and there was a need for additional staff person training. Specifically, the secure van was determined to be unsuccessful transportation for the VA and the facility submitted paperwork for a Transportation Level of Need Assessment, seeking approval for ambulance-gurney transport that allowed ambulance services to be reimbursed for transporting the VA back to the facility as it was determined to be medically necessary. Prior authorization was issued until October 2023. The facility was also exploring additional alternative modes of transportation, including the facility potentially acquiring a more secure vehicle. The facility also identified a stronger transport process to enhance communication at the time of discharge from an emergency department. Training regarding documentation expectations when a patient received care in an emergency room or hospital was also shared with all staff persons. Action Taken by Department of Human Services, Office of Inspector General: On October 6, 2023, the facility was issued a correction order for not following the facility’s policies and procedures regarding the use of zip ties.
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