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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: 1068647-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns Suspected Maltreatment Reported:
It was reported that a staff person (SP) was working at the facility smelling of alcohol, then drove a vulnerable adult (VA) to an outing. Date of Incident(s): January 18, 2024 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 March 6, 2024; from documentation at the facility; and through six interviews conducted with two supervisory staff persons (P1 and P2), one facility staff person (P3), the VA’s guardian (G) who was also a family member, the VA, and the SP. The VA’s diagnoses included autism spectrum disorder (ASD) and “mild” cerebral palsy. The VA liked disassembling and building computers, video game design, reading technology news, socializing with friends on the internet around the world, conversing with others, mall walking, and going to the bookstore. The VA lived at the facility with one other client. The facility was a sectioned-off unit of a larger home which included a living room, a dining room, a cordoned off space in the living room with temporary walls, two bedrooms, a kitchen, and a bathroom. There was a stairwell leading to the basement which had an office, unfinished storage rooms, and a laundry area. P1 provided the following information: · On the day of the incident, P1 and P3 were working at the facility. P1 did not recall what day the incident occurred but that it was a "Thursday" a month prior to this interview. P1 was talking to P3 and the SP arrived at the facility at around 10 to 10:30 a.m. for his/her shift. P1 noticed that the SP looked a little “off” with “glossy eyes,” “really red skin,” and “wasn’t walking normal[ly].” While P1 was talking to the SP near a medication closet on the main level, P1 smelled an odor that smelled “like a bar.” P1 went downstairs and called P2 and let him/her know that there was a “strong smell of alcohol on [the SP].” P1 asked P2 what s/he should do and P2 agreed to come to the facility. When P1 got off the phone, the SP and the VA had left the facility in a facility van. There were no scheduled outings but P3 told P1 that the SP took the VA to a bookstore at a nearby mall. P1 called P2 back and explained that the SP and the VA left the facility for the bookstore. · P2 arrived at the facility several minutes later. P2 told P3 to come with P1 and P2 to drive to the mall so that P3 could stay with the VA and the VA did not need to end his/her outing early. P1, P2, and P3 drove to the mall together. P1 stayed in the vehicle while P2 and P3 went inside the bookstore. P3 got the key to the facility van from the SP and P2 talked to the SP. P1 did not know what was said to the SP while at the bookstore. P1, P2, and the SP went back to the facility, leaving P3 and the VA at the bookstore with the facility van. During the drive back to the facility, P2 and the SP were sitting in front talking about “nothing in particular” and P1 was in the backseat. P2 did not ask the SP if s/he had been drinking alcohol and the SP did not say that s/he had been drinking alcohol. P1 could smell the odor of alcohol and it was “bad” once in the “enclosed” car. When P1, P2, and the SP got back to the facility, the SP went inside, grabbed his/her things, said that s/he “hoped whatever [was] going on could be worked out,” and left in his/her vehicle. Law enforcement was not called. · Outings were generally scheduled on a calendar so that outings did not interfere with the other client’s work schedule. Staff persons did not usually just decide to leave for an outing, but instead typically set a timeframe and date and planned for the outing. · The SP worked two shifts prior to the shift at this facility the day of the incident. The SP was “pleasant” and asked questions about the clients. On one previous shift when the SP was working with P1, s/he noticed that the SP “kinda smelled like alcohol,” but P1 thought the smell was “aftershave.” To P1, the alcohol smell on the SP the day of the incident smelled “strong” compared to the day P1 thought s/he smelled aftershave. P1 stated that the SP smelled like someone had just “opened a bottle [of alcohol].” · The VA stuck to the “facts” but was a little “animated” when relaying information. P1 believed what the VA said when s/he spoke. P2 provided the following information: · The day of the incident, P1 called P2 and told P2 that the SP smelled of alcohol. While P1 and P2 were on the phone, the SP and the VA left for the VA’s outing. P2 then called his/her supervisor and they decided to “pull” the SP from shifts on the facility schedule. When P2 found out that the SP left the facility with the VA, the SP was called and asked if s/he was still at the bookstore with the VA. Then P2 brought P1 and P3, who were also working that day at the facility with him/her to the bookstore so that P3 could stay with the VA to finish the outing. · In the bookstore, there was also a coffee shop so it smelled like coffee to P2, and s/he was initially unsure if s/he smelled alcohol on the SP. Then, P1, P2, and the SP got into the car to bring the SP back to the facility and P2 could smell the odor of alcohol “on the [SP].” P2 could not tell if the alcohol smell was on the SP’s breath or “on” the SP. P2 did not ask the SP if s/he had “been drinking.” The SP did not make any “admissions” of drinking. · On the drive back to the facility, P2 told the SP that they needed to “pull” him/her from the schedule and that the Human Resources department would follow up with any questions. P2 had only met the SP one other time and it was a “brief” interaction, so s/he was not able to tell if the SP was acting differently or not. P1 told P2 that his/her only indication that the SP might have been drinking alcohol, was the “odor [of alcohol].” · The VA had no injuries. This was the third or fourth shift the SP worked at this facility location. · The VA was able to answer questions if asked. P3 provided the following information: · About a month and a half prior to this interview, P3 was working an 8 a.m. to 5 p.m. shift and the SP arrived for a 12 p.m. to 10 p.m. shift. The SP began “pacing” through the facility, “muttering and talking to [him/herself].” P3 had not met the SP prior to this shift as the SP was new to the facility location. Sometime within the first 30-45 minutes of the SP’s shift, the VA asked the SP if s/he would take him/her to the bookstore and then they left. This particular bookstore was the VA’s favorite because s/he could get coffee, socialize, and chat with internet friends. Within five minutes of them leaving, P1 went downstairs to the office and then came back up and told P3 that s/he thought P1 smelled “alcohol” on the SP’s breath and asked where the SP was. P3 told P1 that the VA and the SP went to the bookstore. P3 had been standing approximately three to four feet from the SP and did not smell anything but said that s/he had a “bad nose.” · P3 thought that then P1 called P2 to inform P2 that the SP and the VA left. Soon after, P2 arrived and picked up P1 and P3 to go to the bookstore. P3 then “switched off” with the SP and stayed with the VA at the bookstore. The SP left with P1 and P2 to go back to the facility. The VA did not know what was going on and P3 was unsure what P2 told the VA, so P3 stayed with the VA at the bookstore until the VA was ready to leave, which was around 2 to 2:30 p.m. When the VA and P3 arrived back at the facility, the SP was gone. P3 told P1 and P2 that s/he did not smell anything on the SP or on the SP’s breath. · The VA did not ask P3 questions but was “angry” that this was “intruding on [his/her] outing.” · P3 was trained at several facilities and heard “rumors” that the SP had a “drinking problem” or “substance abuse problem.” P3 “assumed” alcohol and substance use was “not tolerated” while working at the facility. · The VA was “very chatty” and P3 had known the VA over ten years from a previous facility the VA resided at. The VA was “reliable” if you kept him/her “on track” but “sprinkle[d] in a little truth with a little something else.” The VA provided the following information: · Sometime in December 2023 or January 2024, the SP drove the VA to the bookstore. The VA and the SP arrived, and the SP was not “showing any signs of being inebriated.” P2 then called and the SP was “nixed” and P3 took over for the SP. The VA thought to him/herself, “What the F just happened?” and was “weirded out” and “shocked.” P3 drove the VA back to the facility after the outing. The VA said that it came out later that the SP “might have been drunk on the job” and the VA was “sorry” to hear that and hoped that the SP “works [him/herself] out.” It took the VA a few days to “get back to normal.” · The VA used to “go to bars” and “knew some people that needed a bit of help.” The VA knew what alcohol smelled like and if s/he thought the SP smelled like alcohol, s/he would have been telling “everyone that, hey, there was a problem during my outing.” The SP did not “display any of those things,” and the VA “personally did not observe anything.” The SP “drove normally,” was not “swerving,” and there was “no road rage.” The SP “did not act any funnier than normal.” The SP talked to the VA like s/he “was a person.” The VA was still “really upset” about the SP no longer working at the facility and really “liked” the SP. · The SP worked at the facility for a few days prior to the date of the incident. The VA said s/he told a supervisory staff person, “You let this [person, the SP] go because you assumed [s/he] was drunk.” · The VA was not “covering” for any staff persons and if s/he caught a staff person doing “anything funny” s/he would “report” the staff person. The G provided the following information: · The G was notified of an incident involving an “intoxicated” staff person but when the G spoke with the VA about it, the VA said that the SP “did not smell like [alcohol].” The VA “liked” the SP and was “disappointed” that the SP would no longer be working at the facility. The VA was “rather unperturbed” that the SP possibly was drinking alcohol but was “perturbed” that the SP lost his/her job. The incident occurred possibly a “couple of weeks” before this interview and the VA said that the SP and the VA were at a mall. · The VA’s ability to provide information was kind of “variable” in that the VA was “well-communicative” but the G did not know if a person could always “trust [the VA’s] narrative.” The SP provided the following information: · The SP was transferred to the facility sometime in January 2024 and worked for several weeks with his/her last day being January 18 or 19, 2024. On the last day, the SP arrived “on time” for his/her shift. The SP could not recall what time his/her shift began that day because his/her shifts varied. The SP estimated that s/he started his/her shift between 2 and 5 p.m., but later determined the start time had to be earlier, rather than later, due to driving home with some daylight present in the month of January. Shortly after the SP arrived, the VA asked if the SP would take the VA to the bookstore. The SP asked where the bookstore was, and the VA told the SP. The SP estimated that it was about 12 miles away. Being new to the facility, the SP asked P1 if s/he could take the VA on the outing and P1 said that s/he could. · The SP then drove the VA to the bookstore in the facility van, they got settled in, and less than thirty minutes later, P1 called the SP and asked if they were at the bookstore. The SP said that they were, and P1 said, “Okay, sit tight.” About 25 minutes later, P1 and P2, who the SP was not “familiar with,” arrived and said that P1 and P2 would transport the SP back to his/her vehicle at the facility and P3 would drive the VA back in the facility vehicle. At first, the SP thought that P2 was there to see the VA, but P2 said, “No, I’m here for you.” The SP was “curious” and said, “Okay, what can I do for you? What is going on?” P2 replied, “I can’t tell you,” and said that the SP would need to wait for a phone call. P1 drove the SP and P2 back to the facility where the SP gathered his/her belongings and left the facility in his/her personal vehicle. There was no additional conversation about why the SP was relieved from his/her shift or questions from P1 or P2 about alcohol consumption. · The SP “vehemently den[ied]” that s/he smelled like alcohol and stated that if that were the case, why would P1 have let him/her go out with the VA, but it “wasn’t the case,” that s/he smelled like alcohol. Before coming to the facility that day, the SP stated that s/he “most likely just hung out at home.” The SP did not have any other jobs at that time and stated that s/he “absolutely” did not consume alcohol before or during his/her shift the day of the incident. The SP could not have any reason as to why s/he may have smelled like alcohol. The SP was “sure” that the facility had provided the substance use policy to him/her “upon hire.” · The SP previously had an incident in November 2023 at another facility location where s/he had “a couple of pints” before going into to work at the facility. The SP did not drive any clients that day, but after about three hours of working, was asked to “go home.” During that investigation, the SP was “honest” because the SP was “an honest person” and did not “try to lie” or “make excuses.” The SP was suspended for an indefinite period of time and then reassigned to this facility location. The results of the SP’s investigation were not mentioned to the SP “in spite of [his/her] requests.” · The facility did not call law enforcement about concerns regarding the SP leaving the facility in his/her own vehicle after allegedly smelling like alcohol. · Both clients at the facility could cook and were independent, so the SP’s main tasks beyond driving them places was to provide company and do housekeeping. The VA was “very social.” · The SP was never told why s/he no longer worked at the facility, never received a phone call from the facility, and as a result, got a job elsewhere. The website www.maps.google.com showed that the bookstore was a little over 14 miles from the facility, depending upon which route was taken. All facility staff persons interviewed for this investigation were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information showed that on January 18, 2024, the SP arrived at the facility for his/her shift and P1 thought that the SP smelled like alcohol. P1 went downstairs to consult with P2 via telephone, then came back upstairs to find that the SP had left in the facility vehicle with the VA to bring the VA to the bookstore. The SP drove the VA to the bookstore and while they were sitting down there, P1 called the SP and asked him/her if they were still at the bookstore. The SP stated that they were, and P1 told them to stay where they were. P2 drove to and arrived at the facility and then brought P1 and P3 with him/her to the bookstore. P1 stayed in the car, and P2 and P3 went into the bookstore to tell the SP that P3 would take over for the SP on the outing. P3 got the keys for the facility van from the SP, then stayed with the VA at the bookstore and P1, P2, and the SP returned to the facility. At first, the SP thought that P2 was there to see the VA, but s/he said, “No, I’m here for you.” The SP was “curious” and said, “Okay, what can I do for you? What is going on?” P2 replied, “I can’t tell you,” and said that the SP would need to wait for a phone call. The SP went inside the facility to get his/her belongings, before leaving the facility in his/her own vehicle. Law enforcement was not called. P1 smelled alcohol on the SP at the facility and noticed that the SP was little “off” with “glossy eyes,” “really red skin,” and “wasn’t walking normal[ly].” P1 and P2 each stated that once the SP got into the vehicle, they could smell alcohol on the SP. The VA and P3 did not smell alcohol on the SP. P3 stated that s/he was three to four feet from the SP at the facility. P3 stated that when the SP arrived at the facility, s/he began “pacing” through the facility, “muttering and talking to [him/herself].” The VA used to “go to bars” and knew what alcohol smelled like and if s/he thought the SP smelled like alcohol, s/he would have been telling “everyone that, hey, there was a problem during my outing.” The SP did not “display any of those things,” and the VA “personally did not observe anything.” The VA stated that the SP did not “show signs of being inebriated.” The SP “drove normally,” was not “swerving,” and there was “no road rage.” The SP “did not act any funnier than normal.” The SP “vehemently” denied consuming alcohol before or during his/her shift. Although P1 and P2 stated that they smelled alcohol on the SP, given that P3 and the VA did not smell alcohol on the SP, that the VA stated that the SP “drove normally,” and did not show signs of being “inebriated,” and that the SP denied consuming alcohol before or during his/her shift the day of the incident, there was not a preponderance of the evidence whether there was a failure to provide care or services to the VA which were reasonable and necessary to maintain the VA’s 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’s Internal Review showed that although the facility’s policies and procedures were accurate, they were not followed. There was not a need for additional training or the need for corrective action to be taken to protect the health and safety of vulnerable adults. The reported event was similar to a past allegation regarding the SP smelling of alcohol on a shift at a different program. The SP no longer worked for the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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