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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: 1070421-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady 651-431-6557 Suspected Maltreatment Reported: It was reported that on multiple occasions, a vulnerable adult (VA) was able to leave the facility and on occasions enter neighbors’ homes and vehicles. On one occasion, the VA was naked and covered in feces. Date of Incident(s): Multiple between September 8 and November 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 13, 2023; from documentation at the facility and law enforcement records; and through interviews conducted with seven facility staff persons (SP1-SP6 and the P) and a family member/guardian (FM) of the VA. The VA was not able to provide information pertinent to the investigation. The VA’s support plans stated: · The VA’s diagnoses included a moderate intellectual disability, obsessive compulsive disorder, and attention deficit and hyperactive disorder. · The VA cooperated with taking his/her medications. The VA was always to be within sight of staff persons in the community. The VA was to have a one-to-one staff person 14 hours each day (the times were not specified). Otherwise, the facility had one staff person for four consumers. · The VA had a history of leaving the facility and going into neighbors’ vehicles and houses. The VA was “strong and fast.” If the VA left the facility, staff persons were to follow him/her. Staff persons were to calmly ask the VA to return to the facility and remind the VA that they would do an activity with him/her once s/he returned. If staff persons lost sight of the VA they were to call 9-1-1. If only one staff person was working when the VA left the facility, that staff person could not leave the facility and was to call 9-1-1. If the VA became aggressive to others, staff persons were to call 9-1-1. · The VA had difficulty regulating his/her emotions and was quick to get angry. If the VA was upset, the VA would aggress against other persons. Staff person were to redirect the VA by suggesting an activity to get him/her to focus on something else. · The VA was always listening and observing others. The VA was smarter and more manipulative than others perceived him/her because of the VA not having good verbal skills. The VA had a history of undressing and walking naked around the facility as well as outside of the facility. · The VA enjoyed sporting events on television and in person and spending time with family. The P, a supervisory staff person, provided the following information: · The facility typically had three staff persons working during awake hours and one staff person working on overnights. During awake hours, the VA and one other consumer each had a one-to-one staff person. At the time of the investigation, the facility was in the process of attempting to add a one-to-one staff person for the VA during the overnight shift. · The VA had a history of being loud, leaving the facility, and getting into personal spaces in the community. Staff persons were to redirect the VA such as offering to go for a ride depending on the time of the day, playing a game, watching television, and/or listening to music. The VA participated in activities during the day, but had trouble in the evenings managing his/her behaviors (other staff persons also stated that the VA’s challenging behaviors generally occurred in the evening). If redirection did not work with the VA, staff persons could administer the VA an as needed medication (PRN) to help calm the VA down. · There were two doors leading out of the facility that the VA used to exit. There were alarms on both doors. There was a hook lock on one door, which the VA could open, but it slowed the VA down when s/he left. Otherwise, staff persons stood in front of the doors to try to block the VA from leaving. The VA was strong and was able to push the staff persons out of the way to go outside. · If the VA got past staff persons and went outside, staff persons were to go outside with the VA and attempt to redirect the VA back into the facility. If the VA left the yard, the staff person assigned to work one-to-one with the VA was supposed to follow the VA while other staff persons were to call 9-1-1. The FM stated that at the time of the investigation, the facility was working on making improvements to address the VA’s needs, but had issues with staff persons being properly trained to work with the VA. Facility documentation showed that SP1-SP6 and the P each received training on the Reporting of Maltreatment of Vulnerable Adults Act and training specific to the VA. The facility’s policies stated that emergency use of manual restraints were not allowed. If strategies as outlined in consumer support plans were not effective and anyone’s safety was at risk, 9-1-1 was to be called. Staff persons were able to block or redirect a consumer’s limbs or body without holding or limiting the consumer’s movement as long as there was less than 60 seconds of contact by staff persons. Regarding September 8, 2023 A facility incident report and a facility Behavior Intervention Reporting Form (BIRF) stated that on September 8, 2023, at about 9:40 p.m., the VA started to take off his/her clothes. Staff persons tried to keep the VA inside the facility, but s/he ran out through one door as staff persons blocked the other door. The VA started walking around the neighborhood knocking on neighbor’s doors. Staff persons were with the VA trying to get him/her to come back inside. The VA then got into one of the neighbor’s vehicles. One of the neighbors called 9-1-1 and when the police arrived, they were able to get the VA out of the vehicle. A police report stated: · At about 10 p.m., the police responded to a call about the VA. At that time, SP1, SP2, and SP3 were at the facility. The VA was able to get out of the facility and tried to enter a neighboring home and then locked him/herself in a vehicle. When the police arrived, the VA was naked sitting in a vehicle with several persons standing around the vehicle. The police were able to hold the VA’s hand and walk the VA back into the facility. After bringing the VA inside, while the police were outside of the facility, the VA walked out again and staff persons made little attempt to stop him/her. The police then transported the VA to the hospital. SP1, SP2, and SP3 told the police that they were not able to keep the VA from leaving the facility and were not able to redirect the VA out of the vehicle. · The VA was prescribed Olanzapine (antipsychotic) that could be given to the VA PRN to limit the VA’s outbursts. The police and paramedics, who also were at the facility, were told that the VA received the medication at 7 p.m. Due to the VA’s behaviors when they arrived, the police did not believe that the VA received the medication. Staff persons showed the police the documentation that showed that the VA did get the medication. The police were told that SP4 administered the VA’s medication earlier and the paramedics called SP4 who confirmed that s/he gave the medication. It was also noted that the VA did not have more of the medication at the facility. SP1, SP2, and SP3 provided the following information: · The VA was out with SP4, who was the VA’s one-to-one staff person, until sometime after 8:30 p.m. At some point after the VA returned, SP4 left because his/her shift was over. At that point, SP1, SP2, and SP3 were working at the facility. · At 10 p.m. the VA took off his/her clothes and wanted to go into another consumer’s bedroom, but staff persons blocked the VA. Staff persons tried to redirect the VA by offering him/her pizza and by playing music that the VA liked. The VA then left the facility out one door as staff persons were blocking the other door. SP2 and SP3 followed the VA outside while SP1 stayed in the facility with the other consumers. The VA got into the neighbor’s vehicle. · The police arrived and were able to get the VA out of the neighbor’s vehicle. The police brought the VA back to the facility and then brought the VA to the hospital. The police were concerned whether the VA received his/her PRN medication. The police were told that SP4 gave the VA’s medications before s/he left so the police called SP4 and SP4 told police that s/he gave the VA his/her medications. · SP1 stated that it was the first day that s/he worked at the facility. SP2 stated that s/he was in training on the day of the incident. SP3 stated that s/he was not trained to work with the VA as s/he was trained to work with another consumer at the facility, but was aware of what the VA needed assistance with because s/he worked at the facility. Additional information regarding the VA’s medications: · SP1 and SP3 each stated that they always administered medications as directed. SP2 did not know anything about the VA’s medications, but when SP2 did pass medications to consumers, SP2 administered medications as directed. · SP4 stated that s/he regularly administered the VA’s medications and always administered the VA’s medications as ordered. If the VA became upset, staff person were able to give the VA a PRN but the PRN did not always work. · SP6 said that initially when s/he worked at the facility, s/he did not administer medications to the VA, but then later s/he took on the role of being responsible for administering the VA’s his/her medications. SP6 gave the VA medications as ordered. SP5 stated that sometimes SP6 set up the VA medications and SP5 then administered the medications to the VA. · The P stated that s/he did not have concerns about the VA not getting his/her prescribed medications. Staff persons signed off on medication sheets and also signed off on bubble packs that the medications came in, a bubble pack contained a month’s worth the VA’s medication. Once in a while the P would find that a staff person documented on the bubble packs that a medication was given, but forgot to document on the medications sheets. A facility BIRF stated that it was recommended that staff persons continue to follow the VA’s support plans and to engage the VA in activities so that by the end of the day the VA would be tired and ready to go to bed. Because staff persons attempted to redirect the VA and block the VA from the leaving before the VA was able to leave and that staff persons were with the VA when police arrived, staff persons’ actions were reasonable. In addition, although the police were concerned about the VA receiving his/her PRN medication, SP4 stated and documented that s/he gave the VA his/her medication. Regarding September 16, 2023 A facility incident report, completed by SP5, and a facility BIRF stated that on September 16, 2023, at about 8 p.m., the VA left the facility, entered a neighbor’s vehicle, and then entered the neighbor’s house and hit a child on the head. Staff persons were then able to redirect the VA back to the facility. A police report stated that at about 6:30 p.m., staff persons were not able to prevent the VA from going into the neighbor’s vehicle or the neighbor’s house. The VA did not cause harm to the child when s/he hit him/her, but caused the child to cry. The neighbor stated that the VA also entered the house on September 10, 2023, but nothing else occurred. In both incidents the neighbor was able to get the VA to leave the house without further incident and with both incidents, staff persons were outside of the house and were not able to redirect the VA. SP3, SP5, and SP6, who were the staff persons working at the time of the incident, provided the following information: · Prior to the VA leaving the facility, staff persons stood by the doors to try to block the VA from leaving the facility. After the VA left, SP3 and SP5 followed the VA. The VA got into a neighbor’s vehicle. SP3 and SP5 offered the VA pizza and soda to return but that did not work as the VA then went into the neighbor’s house. · The neighbor was able to get the VA back out of the house and SP3 and SP5 were able to get the VA back to the facility by offering him/her pizza. Neither SP3 nor SP5 saw the VA hit the child. After the VA returned to the facility, the police arrived.
SP5 stated that s/he received training specific to the VA. SP6 stated that s/he was trained to work with the other two consumers but not the VA. On the day of the site visit, it was the first time that SP6 was responsible to work with the VA. The facility BIRF stated that it was recommended that supervisory staff persons work with the VA to ensure that they were following the VA’s program plans. An emergency meeting with the VA’s team was planned to discuss the VA. Given that staff persons made attempts to prevent the VA from leaving the facility, followed the VA when the VA left the facility, and eventually were able to get the VA to return to the facility, staff persons’ actions were reasonable. Regarding September 25, 2023 A facility incident report and a facility BIRF stated that on September 25, 2023, at about 7 p.m., the VA was agitated and attempted to leave the facility. Staff persons were attempting to redirect the VA by offering alternative activities. At some point, the VA punched SP4. The VA continued to try to leave the facility and staff person continued to try to redirect the VA, but staff persons ended up calling the police. The police arrived and the VA was aggressive toward the police, so the police had to restrain the VA and take him/her to the hospital. A police report stated: · When the police arrived, they heard the VA yelling inside the facility. The police entered and saw SP4 with blood on his/her face. There was also blood all over the kitchen floor. The VA was down the hallway yelling. The police transported to the VA to the hospital for a behavioral health hold. · SP3 and SP6 stated that they were trying to deescalate the VA for two hours. Staff persons stood at each door so the VA would not leave while another staff person talked to the VA asking him/her what s/he wanted or needed to relax. Eventually the VA hit SP4 in the face multiple times as SP4 blocked the door. · It was noted that the keys for the medication cabinet were in the medication door allowing anyone to have access to the medications. SP4 provided the following information: · SP4 arrived at 2 p.m. and at that time the VA was fine. SP3 and SP6 worked with SP4 that day. On any given day, most the VA’s behaviors started after 7 p.m. · The VA attempted to leave the facility for two hours and SP4 was trying to prevent the VA was leaving the facility when the VA punched SP4 in the face. SP4 demonstrated that s/he stood in from the door with his/her arms outstretched blocking the VA. Prior to being hit, SP4 attempted to redirect the VA by offering the VA something to drink, to watch television, but nothing worked. · Staff persons were only able to attempt to block the doors when the VA wanted to leave the facility. If the VA left, the VA went to neighbors’ homes and if staff persons were not able to talk the VA into returning to the facility, staff persons had to call the police. SP3 stated that prior to the VA hitting SP4, s/he was sitting by the front door and SP4 was by the other door blocking the VA from the leaving. Staff persons kept telling the VA to relax. The VA was naked. SP4 blocked the VA from for about 90 minutes. During that time, the VA threw items and staff persons had to move out of the way. The VA then punched SP4 so SP3 called the police and the police arrived and intervened. SP4 was taken to the hospital. SP6 stated that prior to the VA hitting SP4 and 9-1-1 being called, SP4 was trying to calm the VA down and asking the VA to sit. SP6 did not recall anything else about that day. The BIRF stated that it was recommended that the VA obtain a medical evaluation and continue to work with staff persons to ensure that they were following the VA’s program plans. Given that staff persons were attempting to redirect the VA inside the facility and were able to block the VA from leaving the facility despite the VA punching and injuring SP4, staff persons actions during the incident were reasonable. After the site visit on October 13, 2023, there were three additional incidents (October 15, and November 19 and 20, 2023) reported to the Department of Human Services. Regarding October 15, 2023 A police report stated that at about 9 p.m., the police were called and arrived to find SP3, SP5, SP6, and another consumer outside a neighbor’s house which the VA attempted to enter. The VA had multiple scratches to his/her arm that were bleeding. The VA was cooperative with the police, but the police had to be “stern” with the VA. The police were told that the VA went into the other consumer’s room naked after using the bathroom and would not leave. Staff persons were not able to use any force to get the VA to leave so the consumer got the VA out of his/her bedroom and then the VA left the facility. Staff persons followed the VA but were only allowed to use blocking maneuvers with the VA. During that time, the VA was aggressive and pushed staff persons around. A facility incident report, completed by SP6, and a facility BIRF stated that the VA became agitated which led to him/her leaving the facility and going to a neighbor’s property. The VA stood by the road surrounded by staff persons for about 10 – 15 minutes until the police arrived and took him/her to the hospital. SP5 stated that the VA was attempting the leave the facility and staff persons were blocking the doors, so the VA went back to his/her bedroom. The VA came out of his/her room naked and was able to get by staff persons and leave the facility as they were trying to block the doors. When the VA left s/he went to the neighbor’s yard and staff persons were trying to get the VA to come back, staff persons called the FM and the police. While at the neighbor’s home the VA was rubbing his/her back against the neighbor’s door which might have caused an injury to the VA. After 20 minutes the police came and at that time the VA was standing in the road. The police were able to get the VA into the facility, got the VA dressed, and brought the VA to the hospital. The BIRF stated that to avoid future uses of behavioral interventions, the VA was on a waiting list for a behavioral analyst evaluation and the facility was working with the VA’s psychiatrist to find ways to assist the VA cope with his/her behaviors and keep other around him/her safe. Given that staff persons were trying to redirect the VA prior to the VA leaving the facility, the VA did not gain entrance to the neighbor’s house, and the VA was surrounded by staff persons when the police arrived, staff persons actions during the incident were reasonable. Regarding November 19, 2023 A police report stated that on November 19, 2023, at about 8:45 a.m., the police responded to a call that the VA, who was naked, entered a neighbor’s home and then went outside to the driveway. When the police arrived, the VA was sitting in a neighbor’s vehicle, covered in feces, and honking the horn. The VA agreed to walk back to the facility with the police. The VA returned to the facility and got dressed. In the VA’s bedroom there was feces on the floor, dresser, and television. The VA was transferred to the hospital as the staff person was not able to care for him/her. The staff person working (SP7) said that the VA needed a one-to-one staff person and that staff person needed special training to handle the VA’s health problems, but the facility had not yet provided that training to SP7. A facility incident report, completed by SP7, and a facility BIRF stated that when SP7 arrived, the VA was knocking on other consumers’ bedroom doors, tried to fight another consumer, smeared feces on the living room television, then ran out of the facility while SP7 was cleaning up after the VA. SP7 was working alone so SP7 called the police when the VA left the facility. The BIRF stated that to avoid future uses of behavioral interventions, the VA was on a waiting list for a behavioral analyst evaluation and the facility was working with the VA’s support team to find an appropriate source of care. Given that only one staff person was working and engaged in work related activities when the VA left, the staff persons actions of calling the police, as they could not follow the VA, were reasonable. Regarding November 20, 2023 A police report stated that at about 8:45 p.m. the police responded to a call that the VA entered a neighbor’s home. The VA was naked at the time. The neighbor got the VA back into the garage and locked the VA in the garage. The police arrived and transported the VA back to the facility. At the facility, the VA remained in the police car and the police went in to get the VA’s clothes. At that time, it was observed that there was dried feces on the VA’s dresser. SP6 told the police that s/he was the only staff person working. The VA was transported by the police to the hospital. A facility incident report, completed by SP6, and a facility BIRF, stated that the VA was calm throughout the day, took his/her 5 p.m. medications, and at 7:45 p.m. as SP6 was preparing medications for other consumers, SP6 heard the front door open and close. SP6 went and looked outside and saw the VA naked in a neighbor’s yard. SP6 called the police as SP6 was the only staff person working and could not leave the facility. The BIRF stated that to avoid future uses of behavioral interventions, the VA was on a waiting list for a behavioral analyst evaluation and the facility was working with the VA’s support team to find an appropriate source of care. Given that only one staff person was working and engaged in work related activities when the VA left, the staff persons actions of calling the police, as they could not follow the VA, were reasonable. Conclusion: Between September 8 and November 20, 2023, the VA left the facility on multiple occasions. The VA got into neighbor’s home and vehicles and on one occasion, hit a neighbor’s child. One incident the VA had some injuries, that staff persons attributed to his/her behaviors. Regarding staff persons In all the instances of the VA leaving staff persons either attempted to redirect the VA, blocked the VA from leaving, and/or were working alone engaged in work related activities. Staff persons went outside with the VA in all instances where there was more than one staff person working. Staff persons’ actions were consistent with facility policies that allowed brief physical contact for redirection and blocking, but prohibited the use of manual restraint. In all six incidents mentioned in the report, the police were contacted and assisted the VA to return to the facility and/or transported the VA to the hospital. Given the above regarding the staff persons actions and given the VA’s behaviors that staff persons were attempting to address, there was not a preponderance of the evidence whether staff persons failed to provide the VA supervision which was reasonable and necessary to obtain or maintain his/her physical or mental health or safety. Regarding the facility The P stated that during awake hours the VA was to have a one-to-one staff person and during overnight hours, there was only one staff person scheduled to work at the facility. The VA’s support plans stated that the VA was to have a one-to-one staff person 14 hours each day (the times were not specified). Otherwise, the facility had one staff person for four consumers. Information showed that the facility did not always schedule a one-to-one staff person to work with the VA during awake hours (as stated by P1) as on November 19 and November 20, 2023, the VA left at 8:45 a.m. and 8:45 p.m. while only one staff person was working. However, the VA’s support plans did not specify the exact times that the VA was supposed to have a one-to-one staff person and given that the VA had ten hours a day where one was not required, it was likely that some of those hours fell outside on either side of overnight hours. It should be noted that most of the incidents occurred with multiple staff person working. Given the above, it was not determined whether additional staff persons would have prevented any of the incidents from occurring. On September 8, 2023, SP1 and SP2 were new to working with the VA and SP3 was not trained to work with the VA. However, information showed that not all staff persons were trained to work with the VA, as some were trained to just work with the other consumers, but were available to support the staff person assigned to work with the VA. There was no information that showed that staff persons, during any of the incidents, failed to take any action before and/or after the VA left the facility. The incidents occurred over a span of approximately six weeks. During that time, the facility BIRFs stated that the facility continued to work with staff persons on how to redirect the VA, made the VA’s team aware of the incidents, consulted with the VA’s psychiatrist, and placed the VA on a waiting list for consultation with a behavior analyst. However, given the nature of the VA’s behaviors occurring within the parameters of a facility where manual restraints were not allowed, there was not a preponderance of the evidence whether the facility took adequate action to address the VA’s ongoing behavior of leaving the facility. Therefore, there was not a preponderance of evidence whether there was a failure to provide the VA with reasonable and necessary supervision to maintain the VA physical health and 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 that their policies and procedures were adequate and followed. On October 3, 2023, the VA’s psychiatrist ordered a medication change for the VA. At the time of the investigation, the VA was on waiting list for behavioral consultation from an outside agency. Staff persons were to receive ongoing training regarding interventions for the VA including training developed by any outside agency. At the time of the issuance of this report, the VA no longer lived at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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