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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: 1112472-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux carla.harvieux@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) transported a vulnerable adult (VA) in a facility vehicle when the SP was under the influence of alcohol and methamphetamines. Date of Incident(s): March 2, 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 April 30, 2024; from documentation at the facility and law enforcement records; and through interviews conducted with facility staff persons (P1 and P2) and the VA, and information provided by P3 and the SP in the facility’s Internal Review and in records from a law enforcement agency. Two letters, one certified, were sent to the SP requesting an interview with this investigator, but the SP did not respond to the letters or additional attempts to contact him/her. Facility documentation showed that the VA was diagnosed with down syndrome and had a mild developmental disability. Staff persons encouraged the VA to complete all activities that s/he could without assistance and urged the VA to be as independent as possible. The VA could voice any concerns that s/he had, but s/he had recent struggles with his/her memory and might have impaired judgment. The VA enjoyed going to parks, watching movies, and spending time with his/her family members. The VA wanted to improve his/her baking/cooking skills. Facility documentation, records from the law enforcement agency, information provided in interviews with this investigator, and information from the facility’s Internal Review provided the following: · P1 said that at about 11:20 a.m., on March 2, 2024, s/he bumped into the SP’s bag in the facility office, and some of the SP’s personal items fell out of the bag, including a pipe that appeared to have residue on it, a small bag containing a white substance, and a glass tube, all of which were inside a sock. P1 picked up the items, photographed them, and put them back in the bag. The SP then entered the office and told P1 that s/he was taking the VA on a planned outing, and they left the facility in a facility van. P1 looked for a protocol to know what steps to take next but could not find any written guidance, so s/he contacted P2, who was a supervisory staff person. P2 quickly came to the facility to assist P1 and the law enforcement agency was called. · According to information the SP provided for the facility’s Internal Review, the SP said that while s/he was on the outing with the VA, P2 contacted him/her to ask when s/he and the VA would return to the facility. The SP told P2 that they would be there in a “little bit” and soon returned to the facility. A law enforcement officer (LEO) came to the facility and asked the SP whether s/he could look in the SP’s bag. The SP agreed, and the LEO located a pipe in the bag, but there were no methamphetamines in the bag. The SP said that s/he did not use methamphetamines, but the pipe belonged to his/her significant other who put the pipe in the SP’s bag. · Records from the law enforcement agency showed that at 2:12 p.m. on March 2, 2024, the LEO responded to a call regarding an employee who possibly had methamphetamine and drug paraphernalia in his/her bag at the facility. The LEO talked with P1 and P2 and saw the photos that P1 took of the items from the SP’s bag. The LEO obtained permission from the SP to look inside his/her bag and found a glass pipe, but no methamphetamines. When the LEO interviewed the SP, the LEO noticed that the SP smelled like alcohol. The SP told the LEO that s/he occasionally used “drugs,” but was “hesitant and evasive,” and told the LEO that s/he did not know whether s/he had used the substance that was in the bag. The LEO told the SP that possession of a pipe was not an issue because laws had changed and did not look into the SP’s bag any further. The LEO asked the SP whether methamphetamine was the SPs “drug of choice,” and s/he said that it was. However, the SP did not appear to be too impaired to drive, and s/he left the facility in his/her personal vehicle at P2’s request. No information showed that the law enforcement agency took additional action. · This Investigator obtained copies of the photos taken by P1, and met the VA, who said that s/he had no concerns regarding his/her care at the facility and loved living there. · P3, who was an administrative/supervisory staff person, said that regardless of the decision made by the law enforcement agency, the SP’s actions violated the facility’s policies and procedures. No information showed that the VA sustained an injury during the outing with the SP. The facility’s Drug and Alcohol policy stated that the workplace was to be free from the effects of drugs, alcohol, chemicals, and abuse of prescription of medications. The use, sale, manufacture, distribution, dispensation, or possession of alcohol, illegal drugs, controlled substances, or chemicals while on company business, providing services to individuals, using company vehicles, or on company property was prohibited. The facility’s personnel and training records showed that staff persons interviewed for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procured prior to the incident. Conclusion: Information was consistent that on March 2, 2024, P1 said that s/he saw a glass pipe and tube, and a bag of a white substance, fall out of the SP’s bag. P1 photographed the items then returned them to the SP’s bag and the SP and VA left the facility for an outing, but P1 called P2 for assistance because s/he did not know what to do. P2 came to the facility and a law enforcement agency was called. The SP did not provide information directly to this investigator. However, records from the law enforcement agency and information in the facility’s Internal Review showed that the LEO searched the SP’s bag with the SP’s permission and found a glass pipe in the bag but no methamphetamines. The SP smelled like alcohol, said that s/he occasionally used drugs, and was evasive when s/he spoke with the LEO, but did not seem too impaired to drive and left the facility in his/her vehicle. The law enforcement agency took no further action and no information showed that the VA was injured by the SP’s actions. P3 said that the SP did not follow the facility’s policies and procedures which maintained that the facility was to be free from the effects of drugs, alcohol, chemicals, and abuse of prescription of medications. In addition, the SP’s actions of bringing items to the facility that might be used with substances were not consistent with the actions of a professional caregiver in a DHS licensed facility. The SP had a glass pipe, a tube, and a bag of white substance at the facility, but it was unclear whether the SP used the items on the outing or was under the influence of substances while transporting the VA. Given this, and that no information showed that the VA sustained an injury as a result of the SP’s actions and that the law enforcement agency investigated the allegation in this report, but took no further action, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or supervision which was reasonable and necessary to obtain or maintain the VA’s physical or mental 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 which determined that its policies and procedures were adequate but were not followed. The facility retrained P1 on the facility’s Drug and Alcohol Reporting policy. When this report was written, the SP was no longer employed at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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