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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: 1069242-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Henne 651-431-3444 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA), who requires continuous supervision, was left unsupervised in a closed, not running vehicle for at least 15 minutes. The VA was found by law enforcement and was noticeably sweating inside the hot van. The temperature outside was 86 degrees. Date of Incident(s): September 20, 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 October 4, 2023; from documentation at the facility and law enforcement records; and through eight interviews conducted with two supervisory staff persons (P1 and P2), a staff person (P3), an administrative staff person (P4), two family members of the VA (FM1, who was also the VA’s guardian, and FM2), the VA, and the SP. The VA valued his/her friends and family and liked spending time with them. The VA also enjoyed playing games such as Bingo and participating in group activities and community outings. The VA’s diagnoses included borderline intellectual functioning, moderate intellectual disabilities, cerebral palsy, and spastic delay quadriplegia. The VA “very limited communication.” According to the VA’s Individual Abuse Prevention Plan, staff persons were to be aware of the VA’s needs and activities and would be within sight and/or audible range. The VA was mostly nonverbal and used a wheelchair. The VA did not have any unsupervised time at home or in the community. According to the VA’s Intensive Service Assessment, the VA was dependent on staff persons to complete daily tasks and maintain his/her health safety. The VA lived in a facility where s/he received 24-hour supervision seven days per week with sleep staff. This investigator met the VA who had limited communication and was difficult to understand. The VA responded with “yep” or “yeah” when asked questions including to being left alone in a van. When this investigator asked the VA how long s/he was alone inside the van, the VA held up five fingers. This investigator then asked if the VA meant five minutes and the VA said, “Yeah.” The VA said s/he was “hot” and that the windows were up. Law enforcement records provided the following information: · On September 20, 2023, around 4:10 p.m., law enforcement was called by a community person to the SP’s residence/apartment building regarding a disturbance. Upon arrival, approximately 4:12 p.m., a law enforcement officer (LEO) saw a person sitting inside a van but was unaware of the situation until leaving the residence 15 minutes later. Upon leaving the residence, the person (determined to be the VA) was still in the van so the LEO went to the vehicle. At this time, the temperature outside was 86 degrees Fahrenheit and sunny. All of the vehicle windows were rolled up, the doors were closed, and the ignition was off. The LEO opened a door, and the inside of the van was “very hot,” and the VA was sitting in a wheelchair “sweating.” The VA was mostly non-verbal but was able to confirm s/he was waiting for the SP. The LEO then went back inside the residence and asked the SP if s/he was responsible for the VA, and the SP confirmed s/he was. The LEO informed the SP that it was very hot inside the vehicle and that s/he needed to tend to the VA right away. Within one minute the SP went to the van with the VA and drove away. · After the incident, the LEO went to the facility to check on the VA, who appeared to be medically fine and was no longer sweating and seated in an air-conditioned kitchen. The VA was unable to tell the LEO how s/he was doing due to her diagnoses. The facility’s Internal Review (IR) provided the following information: · On September 20, 2023, the facility was notified about the incident by the LEO. The facility requested a wellness check by LEO, which was completed around 5:15 p.m. and the LEO stated the VA “appeared to be fine and found no signs of distress.” · The SP stated that s/he went to his/her residence because s/he received a call that his/her dog had been barking, causing a disturbance. The SP said s/he was aware of the VA’s level of supervision and reported that the VA was in the van by him/herself for less than five minutes and that the VA did not experience any heat exhaustion and was “fine.” · On the date of the incident, the staff person who worked with the VA after the incident occurred stated that the VA was fine and there were no signs of distress. That staff person worked from 6:12 p.m. until the following morning at 7:43 a.m. P1-P4, FM1 and FM2 provided the following information: · P4 said that on the day of the incident, around 4:40 p.m., the LEO called him/her and told him/her about the VA being alone in the closed van. P4 and P2 then worked to get a staff person to replace the SP for the remainder of the SP’s shift. · P1 said that on the day of the incident, prior to the incident, the SP asked P1 if s/he could go to his/her home, which was nearby, to drop off his/her dog and P1 gave the SP permission to do so. The dog was at the facility because the VA “really love[d]” the dog. However, P1 was “under the assumption” that the SP’s significant other would “come down” and get the dog because the SP’s unit had “a million stairs” and no elevator so P1 knew that the VA was not able to go inside the apartment. P1 worked the following day, September 21, 2023, and said that the VA was “fine.” · FM1 said s/he was notified by the facility about the incident a week after it occurred and FM2 said that P4 contact him/her and FM1 on September 28, 2023, around 6 p.m. FM2 said the VA could accurately respond to “yes” or “no” questions. FM2 also stated that the VA and the SP had a “good relationship” and said that the SP was a “good” staff person for the VA. · P1-P3 said the VA had no unsupervised time and had no previous concerns about the SP. The SP said that on the date of the incident, sometime around 3 p.m., s/he left the facility with the VA to get some dinner. At some point, the SP got a call from one of his/her family member’s that his/her dog was barking and “acting up” and the SP said that s/he would come get the dog. The SP drove to his/her residence with the VA and left the VA in the vehicle while s/he “ran up” to get the dog and was gone “about two minutes.” The front windows were rolled down halfway, and the vehicle was not running. When the SP returned to the vehicle with his/her dog, s/he realized s/he left his/her purse inside his/her residence, so s/he put the dog in the vehicle and went back up. While the SP was in his/her residence, LEO showed up at the SP’s door. LEO was talking to the SP regarding a different matter for about five minutes before returning to the vehicle. When the SP returned to the vehicle, the VA was in the back middle of the vehicle in a wheelchair drinking a “cold pop.” The VA did not appear uncomfortable or to be sweating and was excited to see the dog. The SP did not think the VA had any unsupervised time. However, the SP said that P1 told him/her it was okay to stop by his/her residence. According to autosinnovate.org, hyperthermia can occur when persons are left unattended in vehicle and heatstroke can happen any time of year. Once a vehicle is parked, and its windows are closed or even left cracked open, temperatures can “skyrocket” quickly. In “mere minutes,” the car’s interior temperature can exceed that of the outside ambient air significantly. Additionally, leaving windows open does not prevent overheating. According to goodcalculators.com/inside-car-temperature-calculator, a vehicle that is parked in direct sunlight with an outside temperature of 86 degrees Fahrenheit after 15 minutes reaches an internal temperature of 110 degrees Fahrenheit. Scholars at the Stanford University School of Medicine performed a study in which they investigated the rate at which the interior temperature of a parked vehicle increased during sunny days of temperatures between 72 and 96 degrees Fahrenheit. The findings showed that the temperature inside a vehicle increased by 40 degrees Fahrenheit on average over the course of 60 minutes, irrespective of the ambient temperature. Also, 80 percent of the observed increase in temperature occurred during the first 30 minutes. All staff persons interviewed were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adult’s Act. Conclusion: A. Maltreatment: On September 20, 2023, the VA was left unsupervised in a vehicle with an outside temperature of 86 degrees Fahrenheit. The SP said the VA was unsupervised for less than five minutes, but the LEO was at the SP’s apartment for 15 minutes during which time the VA was in the van. The SP also stated that the windows were partway down but the LEO said they were rolled up. Given that the LEO had no reason to provide inaccurate information and that the SP had reason to minimize his/her actions for fear of repercussions, it was more likely that the VA was in the van with the windows rolled up for at least 15 minutes. The VA’s Individual Abuse Prevention Plan stated that staff persons were to be within sight and/or audible range of the VA and the VA had no unsupervised time. Although the VA did not sustain any injuries as a result of being left unsupervised, given the SP left the VA unsupervised, in a vehicle that was not running, had the windows closed, while it was 86 degrees Fahrenheit outside, there was a preponderance of the evidence that the SP’s actions were not accidental or therapeutic conduct and were a failure to provide the VA with necessary care to maintain the VA’s physical or mental health or safety. It was determined 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 the Reporting of Maltreatment of Vulnerable Adult’s Act. 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 or serious. It was a single incident for which the VA did not sustain any injuries that required the care of a physician. Action Taken by Facility: The facility completed an Internal Review and stated that their policies and procedures were adequate, but not followed. P2 did not follow the Incident Emergency Responding Reporting and Review Policy and was retrained on the policy on September 29, 2023. The SP no longer worked at the facility. 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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