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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: 1114368-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scout Peterson/Scott Broady 651-431-6578 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA), who required two to one staffing, left the home without staff supervision and was unaccompanied in the community for approximately six hours. Date of Incident(s): October 24, 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 November 29, 2023; from documentation at the facility, law enforcement records, and medical records; and through four interviews conducted with two staff persons (SP1 and SP2), a supervisory staff person (P), and the VA’s guardian (G). Investigators met the VA, but s/he was unable to provide information pertinent to the investigation. According to facility documentation, the VA had a primary diagnosis of autism spectrum disorder. The VA lived at the facility since June 2022 and had a history of leaving the facility without staff supervision. The VA enjoyed doing puzzles, listening to hip-hop music, and dancing. The facility was a ranch style single-family home. The VA lived in the basement, and another client lived upstairs. The basement had two entrances located across from one another in a combined kitchen/dining room. Each door was equipped with a door alarm that made a sound when the door was open. One entrance was at the base of a stairway leading to the upper level and the other entrance was an exterior door that led to a fenced-in backyard. A living room was located through two doorways in the kitchen/dining room. The exterior door could not be seen from the living room due to a wall. The VA’s bedroom was located through a door in the kitchen next to the stairway leading upstairs and down a short hallway across from the bedroom was a bathroom. The VA’s CSSP Addendum including Self-Management Assessment Information (CSSP-SMA) stated that the VA was not able to self-manage in the area of “community survival skills” and listed the following regarding supports: · Caregivers and staff will notify 911 and the VA’s legal guardian if the VA leaves without staff knowledge or supervision. · Caregivers and staff should attempt to follow the VA should s/he leave the facility without staff supervision. · Staff will contact the site Designated Coordinator and District Direct during incidents. The VA’s CSSP-SMA listed the following regarding the VA’s “unauthorized or unexplained absence from a program”: · If the VA leaves the house without staff, the staff will follow the VA and keep him/her within visual range. · If staff lose sight of the VA, they will call 911 for immediate assistance and contact the Designated Coordinator. · Staff had a “grab and go bag” which contained a blanket and set of clothing to take when the VA leaves without supervision. · Staff should contact the VA’s guardian after the incident is resolved. The VA’s CSSP-SMA also stated that the VA required two staff to be with him/her during awake hours, both at home and in the community. There were door alarms “on the outside doors and windows” to alert staff if the VA attempted to leave the house alone. The VA could be alone in the bathroom and his/her bedroom. According to law enforcement records: · On October 24, 2023, at 6:18 P.M. SP1 called 9-1-1 to report that the VA left the facility without staff supervision and was wearing a pink or white shirt, shorts and slippers. A law enforcement officer then called SP1 who stated that the VA left approximately 15-20 minutes prior. SP1 did not want to report the VA missing because s/he had to talk to his/her supervisor, and it was facility protocol to notify the police when the VA leaves. · At 6:52 P.M., another law enforcement officer called SP1 for additional information. SP1 said that “one of their residents” ran run away but SP1 did not want to report the VA as a missing person at that time and “did not indicate that [the VA] had any type of disabilities that would be a concern.” · At 9:35 P.M. the G called 9-1-1 and told the police that s/he was the VA’s legal guardian and was just contacted by “the director from the group home” who told the G that the VA ran away. The G said the VA was autistic and had very limited verbal skills so “being [the VA’s] legal guardian [s/he] would like to officially report [the VA] as a missing person.” · “While officers were in the beginning stages of the search effort,” the VA was located “walking back to [his/her] group home.” Law enforcement officers accompanied the VA back to the facility, and the VA was transported to a hospital via ambulance to be evaluated. [Note: No information was provided regarding what time the VA was located.] The G provided the following information: · On the night of the incident at 9:30 p.m., s/he received a call from the S who informed him/her that the VA left the facility at 6:30 p.m. without staff supervision. The G then went to the facility and when s/he arrived, there were two staff persons working. One staff person was mopping the floor and the other staff person walked into the room from the bathroom when the G arrived. The G could not recall the names of the staff persons, however, they informed the G of what occurred with the VA. · The VA had left the facility without staff supervision prior and there were protocols in place for what staff persons were when this happened. The facility was supposed to have a “go bag” that had a copy of the VA’s identification card, medical information, support plans, and high-visibility vests for the staff persons to wear. The G said that the door and window alarms were not working when the G went to the facility the night of the incident, s/he did not see the “go bag” and stated, “No one knows where it went.” · The G stated that s/he called law enforcement who told him/her that when the staff persons called law enforcement, they did not know how to spell the VA’s name, could not provide them with the VA’s date of birth, and did not inform them that the VA was a vulnerable adult, limited verbally or “at high risk for exploitation.” The G was concerned because when the VA was located six hours later, his/her clothes were completely dry, but it was raining. According to weatherunderground.com, on October 24, 2023, in Brooklyn Park, MN, the average temperature from 6:30 p.m. to midnight was 55°F and precipitation totaled 0.63 inches. SP1 provided the following information: · On the evening of October 24, 2023, SP1 was sitting on a chair next to the stove near the exterior door, SP2 was sitting in the living room, and the VA was sitting at the dining room table. SP1 had eyes on the VA, but SP1 could not see SP2, because there was a wall in between them. SP1 thought that SP2 could see the VA from where s/he was sitting in the living room. · The VA got up and walked past SP1 and went to the bathroom. SP1 then heard something fall to the floor. SP1 went to the bathroom and found that a light fixture had fallen. SP1 then started to pick up the broken light fixture, during which time the VA left the bathroom. · While SP1 was in the bathroom picking up the broken light fixture, s/he heard the exterior door open but did not hear the door alarm. SP1 called out to SP2 but “didn’t get a response.” SP1 then left the bathroom, checked the VA’s bedroom for the VA, and the VA was not there so SP1 left the facility out the exterior door to see if s/he could see the VA. When SP1 did not see the VA outside, s/he went back inside and SP2 was exiting the living room. SP1 told SP2 that the VA “got out.”
· SP1 and SP2 immediately looked around the basement for the VA and then went outside to look further. SP1 and SP2 each searched separate areas of the yard but did not find the VA. SP1 and SP2 then got in a car and began driving around looking for the VA in the community including parks and local gas stations the VA was known to frequent. · As SP2 drove, SP1 called law enforcement and gave them the VA’s name and age, and a description of the VA’s clothing. SP1 then spoke to a law enforcement officer and informed them that the VA lived at the facility and was a vulnerable adult. SP1 stated the only information that s/he was unable to provide was the VA’s date of birth. SP1 also told law enforcement that s/he needed to contact the S prior to filing a missing person’s report. · After talking to law enforcement, SP1 called the P and informed him/her that the VA left and that law enforcement was notified. SP1 spoke to the P three additional times and was directed by the P to continue to search for the VA which SP1 did. SP1 stated that s/he made three additional 911 calls and spoke to the dispatcher who stated that the information provided had been passed onto the police. · SP1 stated that they continued to search for the VA in the community until they were told by the P to go to the facility to meet the G when s/he arrived. They did so and the G arrived “about an hour” later. SP1 stated that s/he and SP2 then left the facility and continued to search for the VA until the end of their shift at 10 p.m., when they returned to the facility to “document the events of the day.” SP2 provided the following information: · On the evening of October 24, 2024, SP2 and the VA were sitting in the living room listening to music and SP1 was sitting on a chair in the dining room by the exterior door. The VA got up and went to the bathroom. SP2 did not follow because SP1 was closer to the bathroom and wanted to give the VA privacy while s/he used the bathroom. SP2 thought that the VA was using the bathroom but then heard SP1 say, “Where is [the VA]?” and they both began looking for the VA · SP1 and SP2 then left the facility through the exterior door and searched the yard for the VA. When they did not find the VA, they got into SP2’s car and started searching for the VA at gas stations and parks. As SP2 drove, SP1 called 9-1-1 and the S. SP2 stated that s/he “definitely” heard SP1 tell the 911 dispatcher that the VA was a vulnerable adult. SP1 called 911 “a couple of times” and “the dispatcher just kept saying they were on their way.” · SP2 stated that they continued to search for the VA until the P called and told them to meet the G at the facility and they did so.” After talking with the G, SP2 and SP1 resumed searching for the VA. SP2 stated that s/he and SP1 searched for the VA until the end of their shift at 10 p.m. at which time they went back to the facility, completed shift notes, and left for the night. The P provided the following information during his/her interview, in notes, and a phone call log record: · On the day of the incident between 6:32 and 6:33 p.m., SP1 and SP2 each called the P but the P did not answer. At 6:36 p.m., the P called SP2 and was notified that the VA left and between then and 7 p.m. the P was “talking with staff and assessing.” · At 7:23 p.m. SP2 called the P and asked if they should file a missing person report (MPR) with law enforcement. The P was not sure, so s/he then called another supervisory staff person who was “helping [the P] follow protocol.” That supervisory staff person told the P that a MPR should be filed and that the G should be contacted if the VA was not found “soon.” At 7:34 p.m. the P called SP2 and told him/her to file an MPR. The P stated that s/he also told SP2 to tell law enforcement to call the P if they needed additional information. At 8:43 p.m. the P called the G and informed him/her of the incident. · At 10:02 p.m. the G called the P and told him/her that SP1 and SP2 had not given law enforcement the VA’s date of birth or vulnerable adult status. The P noted, this was “the first time I became aware that [law enforcement] had not been given all the necessary info on [the VA].” The P stated that up until this point s/he believed that a missing persons report had been filed and that law enforcement had all the information needed because s/he had not heard otherwise. · At 11:48 p.m., a night staff person called the P and told him/her that the VA had been found. The P documented “that [s/he] had come around the corner on the sidewalk and was seen walking toward [facility staff] and EMS [emergency medical services] team.” · The P stated that s/he was told that the VA’s often left the facility without supervision and that the G told a “former staff” that s/he “preferred to not be called” about the VA leaving without supervision until the VA was found. [Note: The VA’s plans stated, “Once the incident is resolved staff should call [the VA’s] guardian.”] · The P stated, “Throughout every phone call [SP1 and SP2] were very actively engaged and attentive and concerned,” and “I felt like they were doing the right thing, taking my instructions and putting [them] in practice,” and “doing everything I asked them to.” The VA’s medical records from the hospital stated that the VA arrived at the hospital on October 25, 2023 at 12:46 a.m. and was discharged at 2:00 p.m. back to the facility. The VA’s physical exams were “normal” and s/he had no injuries. Regarding the window and door alarms at the time of the incident: · SP1 and SP2 each stated the door alarms were not working at the time of the incident. SP2 thought the alarms needed new batteries and had told the P that the alarms were not working “multiple times” before the incident. · The P stated that the alarms were working properly the night of the incident, they were audible, “but it was faint. The P also stated that s/he was aware the batteries needed to be replaced and had purchased new batteries “a couple days before,” but they were the wrong size. The P informed maintenance that the alarms needed new batteries the weekend before the incident. Regarding the VA’s “to-go” bag: · SP1 and SP2 stated they were unaware of the VA having a “to-go” bag to be taken with if s/he left the facility without staff supervision. SP1 stated that s/he received training on what to do if the VA left without staff supervision, however, was not trained or know about a bag. SP2 stated that s/he did not receive training on what to do if the VA left the facility without supervision until after the incident. · The P did not know the VA required a “to-go” bag at the time of the incident but was informed during the incident by the other supervisory staff person. That person stated that the VA used to have a bag, but it was unknown where it was currently. · Following the incident, the P purchased a “to-go” bag and set it up in accordance with the VA’s plan. The P trained house staff persons on the use and location of the “to-go” bag. Facility documentation showed that P1, P2 and the P received training on the Reporting of Maltreatment of Vulnerable Adults Act. SP1 and SP2 were trained on the VA’s support plans. Related Rules and/or Statutes: Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a), states that the license holder must provide services in response to the person’s identified needs, interests, preferences, and desired outcomes as specified in the support plan and the support plan addendum and in compliance with the requirements of this chapter. Conclusion: Information from all sources was consistent that on October 24, 2023, shortly after 6 p.m. the VA left the facility without staff person’s supervision and was gone for approximately five and a half hours. When the VA returned to the facility, the VA was taken to the hospital where the VA’s physical exams were “normal” and s/he had no injuries The VA’s plans stated that there were door alarms to notify staff persons when the VA left the facility and that there was a “grab and go bag” for staff persons to take with them. However, information from all sources was consistent that the door alarms were not working or needed batteries and staff persons were not aware of the bag and there was no bag available for staff to take, which were violations of Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a). Prior to the VA leaving, SP1 was sitting in a chair by the stove and exterior door and SP2 was in the living room when the VA got up to use the bathroom. When SP1 heard something fall in the bathroom, s/he immediately went into the bathroom and found a broken light fixture. As SP1 was cleaning it up, the VA left the bathroom and although the door alarms were not working properly, shortly after the VA left the bathroom, SP1 heard the door open and close. SP1 immediately left the bathroom, notified SP2, and they began searching for the VA and continued to do so until the end of their shift. SP1 and SP2 also notified 9-1-1 and supervisory staff persons. Although SP1 and SP2 were responsible for the care and supervision of the VA at the time the VA left the facility, given that SP1 heard the door open, immediately left the bathroom and notified SP2, and they began looking for the VA, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services including supervision that was reasonable and necessary to maintain his/her 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 policies and procedures were adequate but not followed. There was a need for additional staff training and corrective action to protect the heath and safety of the VA. The facility’s corrective action plan stated the door alarm was fixed, a “to-go bag” was put together, the VA’s information was placed in the company vehicle for staff to access in case of future elopements, the VA’s support plans, individual prevention plans, and elopement protocol were updated. Staff were retrained on the VA’s program protocols, procedures related to the VA leaving without supervision, and prevention strategies to keep the VA from leaving without supervision. The facility replaced the batteries in the door alarms. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate corrective action a Correction Order was not issued for the violations outlined in this report.
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