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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: 1068646-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns/Scott Brandt Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) left the facility without supervision in the middle of the night, unclothed, and was unable to be located for several hours. Date of Incident(s): September 11, 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)17, paragraph (a)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 October 20, 2023; from documentation at the facility and from medical records; and through five interviews conducted with three facility staff persons (P1, P2, and the SP) and two of the VA’s family members who were also the VA’s guardians (FM1 and FM2). The VA was non-verbal and because of his/her limited communication abilities, the VA was not able to provide information for this investigation. Although the VA’s case manager (CM) was contacted, the CM did not respond to requests for an interview. A review of the VA’s file including his/her support plan showed that the VA was diagnosed with autism, bipolar disorder manic phase, and a severe intellectual disability. The VA enjoyed playing with small basketballs, tearing up paper, watching sports, watching movies, and singing songs. Staff persons were to accompany the VA into the community because the VA “may not always act appropriately towards other members of the community.” The VA had a history of “disrobing” and leaving without supervision, so “there are chimes placed on the exits of the residence to alert staff [persons] to [the VA] attempting to [leave without supervision].” The VA typically left without supervision “more often in the evening and overnight hours.” Historically, when the VA left without supervision, s/he typically went to gas stations and especially liked Speedway gas stations. Staff persons were to “check on [the VA] every hour when [s/he] remains in [his/her] room for long periods of time.” The facility was a two-story house with a basement where four clients lived and received services. When entering through the front door on the first floor, there was a living room, and beyond that, a dining room area. Beyond the dining room area was a kitchen. Through the kitchen was a stairwell leading to the basement, two bedrooms (including the VA’s), and an entryway leading to the back door. The VA’s bedroom was the closest bedroom to the back door and off the dining room was another hallway which consisted of a bedroom, a bathroom and a door leading upstairs. The upstairs consisted of at least one bedroom that was in use by a client, a bathroom, and a few other rooms. There was an alarm on the VA’s bedroom window and door, and a door alarm on each of the exterior doors. The alarms would sound in the back entryway and in the living room area when the doors were opened. There was also a plug-in component to the alarm system located in the living room that extended the range of the chime, making it audible in more areas of the facility. P2 said that at the time of the incident, the alarm on the back door was working, but that the volume could have been lowered by a staff person or another client who did not like loud noises by unplugging the plug-in component or using a keypad to turn down the volume. However, even if either of those were done, the alarm would still make a “faint” noise when doors were opened. P2 also said that s/he was not certain whether the alarm on the VA’s bedroom was working at the time of the incident. Staff persons were to refer to the VA’s Elopement Protocol if the VA left without supervision, which stated the following: · If one staff person was working when the VA left without supervision, the staff person was to immediately call 9-1-1 and explain that the VA was non-verbal, describe his/her appearance, and let them know that the VA lived in a facility setting. Chain of command of the facility was then to be called and the program manager would assist in locating the VA and transporting the VA back to the facility. · If two staff persons were working when the VA left without supervision, one staff person would remain at the facility, while the second staff person would follow the VA. If the second staff person lost sight of the VA, they were to immediately call 9-1-1. Once the VA was found, s/he was to be assisted back to the facility. P1 provided the following additional information: · On September 11, 2023, P1 arrived for his/her shift a little after 6:00 a.m. and knocked on the front door of the facility as it was locked. The SP opened the front door and went back to helping a client with showering. P1 heard one of the showers running but did not hear the living room alarm sound when the front door opened and saw that it was not plugged in. P1 observed shredded paper on the living room and kitchen floors and walked toward the kitchen to set down his/her belongings. P1 then noticed that the VA’s bedroom door was open and that s/he did not hear the VA, so s/he yelled twice, “Where is [the VA],” to get the SP’s attention. P1 then walked through the kitchen and toward the VA’s bedroom. P1 stopped when s/he observed the back door was open and realized that the VA was gone. The SP then entered the kitchen and P1 told the SP that the VA was gone. The SP replied, “[The VA’s] gone?” and P1 again stated that the VA was gone. The SP was “frantic” and did not know that the VA was gone. The SP told P1 that the last s/he knew, the VA was asleep in his/her room and the SP was helping another client get ready for the day. P1 did not know what time that was. · The SP then went to look outside and P1 dialed 9-1-1 to report the VA missing and to ask for assistance from law enforcement. The SP checked the backyard and P1 drove around the area, looking for the VA. P1 drove toward Speedway, but Speedway was closed. P1 stated that in general, if Speedway was closed, the VA would attempt to open car doors or try to find another Speedway. P1 asked a few people if they had seen the VA, and no one had, so P1 went back to the first Speedway, which was open by this time. The Speedway employees were familiar with the VA, so P1 told the employee to call him/her if the VA showed up and if possible, to try to keep him/her in the store. P1 let the employee know that the VA was not dangerous. At some point, the facility chain of command was called, but P1 did not state which staff person made the call. · P1 went back to the facility and observed the VA’s clothing on the floor. P1 knew that the VA slept with clothing on and P1 thought that it was possible that the VA may have been unclothed or only wearing “underwear.” · P1 continued to drive around, searching for the VA and waiting to hear back from law enforcement. P1 and another unnamed staff person called around to area hospitals. P1 called a hospital which was the closest hospital and at approximately 9:30 a.m., it was determined that the VA was at the hospital as an unidentified person. P1 and P2, a supervisory staff person, each stated that they found out that the VA was found several miles away near two businesses’ parking lots by an ambulance crew and that the VA was unclothed. The VA was then transported to the hospital by ambulance. P1 drove to the hospital to meet P2 and to assist in bringing the VA back to the facility. Hospital staff persons were unfamiliar with the VA and the VA’s diagnoses. They were unaware that the VA was a vulnerable adult and thought that the VA was under the influence of something. As a result, the VA was “strapped down” by hospital staff persons and given a blood test. P1 stated that the VA was “frantic” and “calmed” once P1 and P2 arrived, but ended up running down the hospital halls for about ten minutes before they caught up to him/her. The VA had no injuries and was discharged to P1 and P2 that day and they returned to the facility. The parking lots where the VA was found were approximately 2.6 to 2.9 miles from the facility, when walking, and depending upon the route taken, according to www.google.com maps website. The VA’s medical records showed that the VA was found by an ambulance crew, unclothed, and was “hyper alert and perseverating.” The VA also appeared to be anxious. Ambulance staff persons restrained the VA and transported the VA to the hospital. At 5:35 a.m., the VA arrived at the hospital and was transferred to a hospital bed. The VA was “hanging off [the] end of [the] bed in restraints.” The restraints were released and readjusted for the VA’s safety. The VA also had blood tests completed due to concerns that the VA had a medical problem causing “altered mental status.” All of the test results were “normal” and were negative for illness. The VA was given droperidol (a medication used to treat nausea) and Versed (a medication used to help people calm) to help “calm” the VA. The VA was discharged on the same day that s/he was admitted. The SP provided the following information: · The SP typically worked overnight shifts. On September 10, 2023, the SP started his/her shift at 10:30 p.m. and was scheduled until 9 a.m. on September 11, 2023. The clients were asleep when the SP arrived for his/her shift and this was “always” the case. The SP generally woke the VA when s/he started his/her shift and several times throughout the night to avoid the VA having bathroom accidents in bed. Sometimes, the VA woke him/herself up, turned on the bedroom light, went to the bathroom, turned off the bedroom light, and then went back to bed. The SP knew when the VA was up because the SP typically sat in the dining room with the lights off and could see when the VA turned on his/her bedroom light. The SP would then go to assist the VA. · The night of the incident, the SP had a “normal” evening and shift. The VA used the bathroom at the start of the SP’s shift and the VA again used the bathroom at around 3:00 a.m. The VA did not get up after that for the bathroom, as far as the SP knew. The SP stated that it was standard practice to check on the VA approximately every two hours each night at 10:30 p.m., 1:00 a.m., 3:00 a.m., and at either 5:30 a.m. or 6:00 a.m. This was what the SP did on the night of the incident and had last checked the VA at 3:00 a.m. When the SP did overnight checks on clients, the SP opened bedroom doors, turned on the lights, made sure clients were clothed, checked for bathroom accidents, and assisted the clients to use the bathroom, if needed. When the SP did the 3:00 a.m. check, the VA was clothed. When asked why the SP did not do the 5:30/6:00 a.m. check, the SP stated that s/he was waking up another client at 5:30 a.m. and there was a second client to wake up and get ready for work and school. · A little after 6:00 a.m., P1 knocked on the front door while the SP was with the client upstairs. The SP opened the front door for P1 and then went back upstairs. P1 next told the SP that the VA was not in his/her room and that the VA was gone after seeing the back door open. · The SP did not see the VA’s light turn on that night. The VA slept with the bedroom door closed and the SP was usually able to hear when the bedroom door opened and bedroom door alarm alerted, but it was later determined that the bedroom door alarm was non-operable during this shift. The SP was unaware of this at the time and stated that s/he did not hear any door alarms. The SP stated that s/he may also have been in the bathroom when the VA left the facility. · The living room alarm was plugged in when the SP arrived for his/her shift and the SP checked this every time s/he worked. The SP stated that s/he did not hear the door alarm at any point during the overnight shift and explained there were “issues” with a “loose” living room outlet. · Some overnight duties for the SP were cleaning the floors of the VA’s shredded papers, using a wet mop on the floors, doing dishes, doing laundry (located in the basement) and, cleaning both bathrooms. At about 4:00 a.m., the SP would have been done with these tasks and would have been sitting down “waiting” after checking on everyone at 3:00 a.m. · The SP stated that s/he did not have another job and did not sleep while working at the facility the night of the incident or any other shifts. In the approximately seven months that the SP worked at the facility, the VA had never left without supervision. The SP had heard that the VA had tried to leave the facility before, but that s/he had never succeeded in leaving. · The SP was trained to call the police and management if the VA left without supervision and not to leave the facility if working alone. When it was discovered that the VA left without supervision, P1 was present so P1 and the SP worked together to search for the VA and call 9-1-1. P2 provided the following additional information: · The SP did not tell P2 when s/he last saw the VA, but the SP told P2 that at about 5:50 a.m., the SP went to wake another client up on the second floor of the facility. · This was the first time that the VA had left without supervision this early in the morning and the first time s/he left without clothing. The VA had a history of tearing up his/her clothing, so his/her extra clothing was kept in the lower level of the facility. Staff persons located the VA’s clothing under his/her bed. P2 added that the VA did not like wearing shoes. The facility’s Internal Investigation of a Vulnerable Adult or Maltreatment of Minors Report provided the following information: · When P1 was interviewed, s/he stated that when s/he arrived at the facility on the morning of the incident, the living room plug-in piece of the alarm was “unplugged” and “laying on the floor.” P1 stated that “one of the individuals at the house unplugs it.” P1 also stated that with the alarm unplugged, “You would not hear the back door from the hallway shower or bedroom area especially with the shower on, and you would not hear it from the upstairs either.” · The SP stated that s/he did his/her “normal checks” at 11 p.m. and 3 a.m. The SP went upstairs at about 5:50 a.m. to wake up one of the clients. The SP stated that s/he did not hear any of the alarms sound during his/her shift. The facility had documentation which showed when various doors were opened and closed. Documentation showed that the back door (the door the VA presumably left from) was opened at 4:12 a.m. on September 11, 2023. The front door was not opened that morning, except for when P1 came to work around 6 a.m. The facility had an Excel spreadsheet where staff persons were to document, hourly, the status of the VA. From midnight until 6 a.m. on September 11, 2023, it was documented that the VA was sleeping, but the document did not identify the name(s) of the staff persons making those entries. Additionally, no entries were made from 9:00 p.m. to midnight on September 10, 2023. FM1 and FM2 stated that the VA had previously left without supervision but had not left before without clothing. FM1 and FM2 were told that the VA was located within 20-30 minutes of leaving the facility and did not appear to be injured when examined by ambulance and hospital staff persons. FM1 and FM2 said that medical staff persons thought that the VA might have been on a controlled substance due to being found without clothing (they did not specify if this was ambulance or hospital staff persons). According to https://weatherspark.com/ the temperature on September 11, 2023, at around 5 a.m. was about 55 degrees Fahrenheit. Around 6 a.m., the temperature dropped to about 53 degrees Fahrenheit before warming up to approximately 63 degrees Fahrenheit by about 10 a.m. P1, P2, and the SP provided the following additional information: · P1 and the SP each stated that the VA was to be checked on every two hours during the overnight shift and P2 stated that it was a general guideline, but not a policy, to check on clients each hour during the overnight shift. Day staff persons’ shifts overlapped with the overnight staff persons’ shifts (in this case the SP and P1) for several hours each morning and the two staff persons would work together to get the clients ready for the day. By the time the day staff person would get there, at around 6:00 a.m., two of the clients would have already been showered by the overnight staff person. Those two clients had day programs or schooling to attend and needed to be ready first. · P1 and P2 stated that while alarms were on the exterior doors of the facility, another client sometimes unplugged the alarm, and it was determined that the plug-in component of the alarm was not plugged in when P1 arrived for his/her shift the morning of the incident. P2 stated that when plugged in, the door alarms would beep for about one second. The door sensors on the VA’s bedroom door were not operational on September 11, 2023. The SP stated that s/he worked overnights when the clients were asleep, and was unaware of clients unplugging the alarms, however stated that the living room outlet was “loose,” and the alarm frequently fell out. The SP also stated that the alarm made a ding like the sound of a “Ring” doorbell and was “medium volume.” · P1 stated that there were instances in the past in which the VA left without supervision, and that when the VA left through the back door, staff persons could usually catch the VA near the front before s/he left the facility property. During the years that P1 worked at the facility, the VA had never left the facility property before staff persons would get to the VA and assist the VA back to the facility. A screen door was added to the rear door frame several years prior to give more time to staff persons to get to the back door when alerted it was opened before the VA went through both doors. · P1 stated that there was no policy on keeping the alarms plugged in, but it was a tool that staff persons used to alert them to when the VA was attempting to leave the facility. The SP said it was a “rule” to keep the alarms plugged in so that staff persons would know if a client was attempting to leave, and the SP said s/he checked the doors and alarms at the start of each shift. Both P1 and the SP stated that there were areas of the house where staff persons could not hear the alarm, such as some of the client’s bedrooms, the basement, the bathrooms, especially if the showers were running, anywhere upstairs, and when music was on. One client needed “loud music” each morning to wake up, so at times, loud music was playing in the morning. During the site visit, a staff person showed this investigator where the living room outlet was located and this investigator observed a plug-in component with a musical note logo on the front, similar to the size of a smart plug device. The alarm made a “ding” sound and was not loud. The SP’s Job Description stated that one of his/her responsibilities included, “Implement all personal outcome plans and other site programming procedures as written.” All staff persons interviewed in this report had been trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s specific care plans, except for P2 who did not provide direct care services at the facility. Relevant Rule and/or Statute Minnesota Statutes, section 245D.07, subdivision 1a, stated that the license holder must provide services in response to the person’s identified needs, interests, preferences, and desired outcomes as specified in the coordinated service and support plan and the coordinates service and support plan addendum. Conclusion: A. Maltreatment: The SP stated that on September 11, 2023, s/he last saw the VA at 3:00 a.m. when the SP checked on the VA in the VA’s bedroom. Facility documentation showed that the back door, the door that the VA likely left through, was opened at 4:12 a.m. At about 6:00 a.m., P1 came to work and noticed shortly thereafter that the VA was not at the facility. P1 called 9-1-1 to report the VA missing and the SP looked for the VA outside. P1 drove to local areas that the VA might be but did not find the VA. P1 went back to the facility and around 9:30 a.m., P1 called the hospital and found out the VA was there. While in the hospital, the VA was treated with medications to help him/her calm and tests showed that the VA was not injured. P1 and P2 went to the hospital and then the VA was released the same day. The VA’s Elopement Protocol stated that the VA had a history of leaving without supervision during “evening and overnight” hours and the VA’s support plan stated that the VA had a history of leaving without supervision and that staff persons were to check on the VA hourly when the VA was in his/her bedroom for “long periods of time.” The VA did not have any unsupervised time in the community. The SP stated it was his/her practice to check on the VA every two or more hours, at 11 p.m., 1 a.m., 3 a.m., and 5:30/6 a.m. which was not according to the VA's plan and a violation of Minnesota Statutes, section 245D.07, subdivision 1a. The VA could have left the facility without supervision between hourly checks even if the SP had completed the checks as required. However, the SP did not check on the VA hourly so when the VA likely left through the backdoor at 4:12 a.m., the SP did not know the VA was gone until 6 a.m. when P1 arrived and notified the SP. Given this and the longer amount of time and distance the VA was able to travel from the facility and remain in the community longer unclothed and without supervision and that the VA was at the hospital, unidentified, posing a greater risk of harm to the VA, there was a preponderance of the evidence that there was a failure to provide the VA with reasonable and necessary care and supervision to maintain the VA’s health and safety. 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 was trained on the VA’s plans and on the Reporting of Maltreatment of Vulnerable Adults Act. Although some of the door alarms may not have been working or the SP could have been doing other tasks when the VA left, the SP did not check on the VA hourly as required by the VA’s plans. Therefore, 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 did not meet statutory criteria to be determined as recurring maltreatment because it was a single incident or as serious maltreatment because the VA did not sustain an injury. Action Taken by Facility: The facility completed an Internal Investigation of a Vulnerable Adult or Maltreatment of Minors Report, which stated that although policies and procedures were adequate, the SP did not follow the VA’s “supervision requirements.” The report also showed that the VA had a history of leaving without supervision “during the evenings and overnights.” The SP was no longer at the facility. In addition, the facility provided additional training to staff persons, made a “requirement” that alarms “are always plugged in,” and added more staff person coverage during the overnight hours. 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. The facility was not issued a Correction Order for the violation outlined in this report because they took immediate corrective action.
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