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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: 1114728-H_CRS (Home and Community-Based Services-Community Residential Setting) 1068742-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a staff person (SP) was involved in a vehicle accident while transporting a vulnerable adult (VA). The SP and VA returned to the facility, but left the facility in the SP’s vehicle and the SP was arrested by law enforcement (LE) due to potentially driving under the influence. Date of Incident(s): July 13, 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 July 25, 2023; from documentation at the facility and law enforcement records; and through five interviews conducted with the VA, two facility supervisors (P1 and P2), and the VA’s guardians (G1 and G2). This investigator attempted to contact the SP via phone call, and sent a certified letter requesting an interview, however the SP did not respond. During the site visit the VA showed this investigator his/her garage and had a planned community gathering for local emergency personnel. The VA said s/he liked living in the neighborhood and interacting with people in the community. The VA enjoyed being active, and liked working. The VA was described as funny and communicative. Facility documentation showed the VA was diagnosed with developmental disabilities, anxiety, and attention deficit hyperactivity disorder. The VA’s Individual Abuse Prevention Plan showed the VA was susceptible to all forms of abuse within the assessment. The facility provided the VA with 1:1 staffing. The VA said s/he was present for both incidents on July 13, 2023, however, was not able to provide any specific and/or consistent details related to the incident. The VA said s/he was scared, and the SP was arrested. On July 13, 2023, the SP worked with the VA during the evening shift and there were no other staff persons working. On July 13, 2023, at 6:08 p.m., the SP and VA were involved in a car accident. LE completed a Crash Report with the following information: · The SP was a driver of a vehicle that was involved in the crash and his/her physical condition was “apparently normal (including no drugs/alcohol)”. · LE noted the roadways were “dry,” the weather was “clear and warm,” and the traffic at the location of the accident was “heavy.” Both a community person’s vehicle and the SP’s vehicle (facility vehicle) were in the left-hand turn lanes (there were two lanes for left hand turns), the SP in the left of the two lanes and the community person in the right of the two lanes. The SP proceeded straight, and the community person turned left. The front, passenger-side quarter panel of the vehicle the SP was driving came into contact with the front, driver's-side wheel of the community person’s vehicle. · The vehicle the SP was driving required towing due to disabling damage. · There were no apparent injuries to the SP and the VA, and all persons involved were wearing seatbelts. · The SP “failed to keep in the proper lane,” and was issued a citation for “Failure to Use Designated Lane.” The facility completed an Incident Report regarding a car accident that occurred on July 13, 2023, at 6:08 p.m., while the SP was driving, and the VA was in the vehicle. The SP made an “incorrect turn” and collided with another vehicle. The was no information which showed the SP and/or the VA suffered any injuries during the accident. A community person contacted law enforcement (LE), who arrived and completed an assessment of the scene. The VA was not injured during the accident; however, the facility vehicle was not drivable. The SP contacted P1, who went to the scene of the accident. P1 drove the VA and SP back to the facility. P1 provided the following information: · P1 said s/he was not present for the car accident but went to the accident after s/he was contacted. Upon P1’s arrival LE was present and eventually allowed the SP, and the VA to leave the scene of the accident.
· P1 said while driving the SP and VA back to the facility the SP was “all over the place” and seemed “just off.” P1 believed the SP’s abnormal behavior was related to being in an accident and did not notice any other concerning symptoms of drug or substance use during their interaction. P1 was not concerned with the SP’s behavior or ability to care for the VA and did not believe the SP would leave the facility in his/her personal car. On July 13, 2023, at approximately 8:19 p.m., LE pulled over the SP in Byron, Minnesota. LE interacted with the SP and LE records provided the following information: · LE was dispatched after a community person observed a car driving through a yard with their flashers on. On July 13, 2023, at 8:19 p.m., LE stopped the vehicle and the SP was identified as the driver, and the VA was also in the vehicle. · LE believed the SP was under the influence of a substance and had the SP complete sobriety tests. LE observed the SP have slow motor movement and slow/slurred speech, as well as an appearance of being “very sleepy” and “lethargic.” While interacting with LE the SP’s eyes “almost went completely shut,” and appeared to stare “right through” LE. LE described multiple other concerning behaviors the SP exhibited during the traffic stop and sobriety test. · The SP admitted to smoking marijuana around 6 p.m. but did not use any other substances. The SP said s/he had taken a Xanax one or two days ago. The SP said s/he was driving around doing Door Dash (meal delivery service) with the VA present. · LE arrested the SP due to suspicion of driving while intoxicated. The VA was transported to the facility by LE upon the SP’s arrest. A blood draw was completed on the SP, and LE was awaiting results. The facility completed an Incident Report regarding the second incident that occurred on July 13, 2023. After returning to the facility from the car accident, as described above, the SP left the facility in his/her personal vehicle with the VA. The SP attempted to deliver food to a friend, however the SP was pulled over by LE. LE had the SP complete sobriety tests, and the SP was arrested due to suspected driving under the influence. The VA was transported to the facility by LE. The facility had a Safe Transportation Policy which stated that no driver shall operate a vehicle when his/her ability to do so safely had been impaired, affected, or influenced by alcohol, drugs, medication, illness, fatigue, injury, or distress. P2 provided the following information: · P2 was not present for either of the two incidents, but said s/he spoke with the SP after the car accident. The SP behavior seemed “heightened” after the accident and the SP said the vehicle was drivable, however later P2 found out the information was inaccurate. · P2 provided consistent information from that within the Incident Reports and from LE Records. G1 and G2 said the VA complained of some back/neck pain, but was not otherwise physically injured during incidents, and there was not concern the VA had been provided or used any substances. The SP provided the following information when interviewed for the facility’s internal review: · The SP said s/he was prescribed medications for anxiety and depression, and had taken a medication shortly before 6 p.m. · The SP said that the accident was around 6 p.m., and occurred when a community person attempted to turn and hit the facility vehicle. The SP said s/he was in a left-hand turning lane, and the community person was either in a straight or right-hand turning lane prior to the accident. · The SP said after returning to the facility the VA was “bummed out” and the SP took the VA for a ride in his/her personal vehicle to “kill” some time. The SP said the VA would get more agitated and irritated the longer they stayed at the facility. · The SP said s/he dropped off food at a friend's house, and was in the driveway when LE pulled him/her over. The SP said s/he was trying to get his/her driving directions to work on his/her phone. The SP informed LE that s/he had a previous arrest (two years ago) for driving under the influence. The SP said s/he was arrested at approximately 10:30 p.m. · The SP said s/he completed field sobriety test, and the SP believed s/he had passed the test because LE let him/her go at the end of the day, however later stated LE believed the SP was intoxicated and the SP competed a blood draw. The SP, P1 and P2, were trained on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policy and procedures, and the VA’s client specific programming. Conclusion: A. Maltreatment: It was reported the SP was involved in a vehicle accident at 6 p.m. while transporting the VA. The SP and VA were not injured and returned to the facility, but thereafter left the facility in the SP’s personal vehicle. The SP was pulled over and arrested by LE due to driving under the influence. The VA was aware of the accident, and LE involvement, but was unable to share specific details beyond that s/he was scared, and the SP was arrested. The SP was contacted by this investigator, but did not respond to an interview request. The facility completed an investigation and interviewed the SP. The SP said s/he had taken a prescribed medication just prior to the accident at 6 p.m. After returning to the facility, the SP and the VA left the facility with the VA in his/her personal vehicle to “kill” some time. The SP provided information related to the SP’s arrest, however the information the SP provided the facility was inconsistent with that of the LE Records. LE Records showed police was dispatched as a vehicle was driving through a community persons yard. LE had the SP complete sobriety tests, which showed multiple indicators the SP was impaired. The LE records stated that the SP admitted to using marijuana. The SP was arrested, a blood draw was completed, and results were pending. Given that the SP was arrested for being under the influence while transporting the VA which posed a significant risk of harm to the VA and admitted to being under the influence of marijuana while providing care and services to the VA, there was a preponderance of evidence that the SP failed to supply the VA with reasonable and necessary care and services. It was 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP received training on the VA’s programming, supervision requirements, and the facility’s policy and procedures. The SP was responsible for the VA’s care and supervision at the time of the incident. The SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the SP was responsible was not recurring maltreatment because it was a single incident and was not serious maltreatment because the VA was not injured. Action Taken by Facility: The facility completed an internal review and determined the facility’s policies and procedures were adequate, but not followed. The facility did not complete any additional training as the SP were no longer employed by the facility. The report was not similar to past events, and no corrective action was completed to protect the persons that received services. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.
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