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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: 1069304-H_DSF (245D-Home and Community-Based Service-Day Services Facility) Investigator(s): Emily Kearns Suspected Maltreatment Reported: It was reported that a staff person (SP) drove two vulnerable adults (VA1 and VA2) and fell asleep while driving and crashed into another vehicle. The SP later tested positive for cocaine and marijuana. Date of Incident(s): March 8, 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 27, 2024; from documentation at the facility, law enforcement records and medical records; and through 12 interviews conducted with a law enforcement officer (LEO), five facility supervisors (P1 - P5), VA1’s guardians (G1 and G2) who were also family members, VA2’s guardian (G3) who was also a family member, VA1, VA2, and the SP. The SP provided transportation using a facility van to take VA1 and VA2 from VA1’s and VA2’s residences to their place of employment each day and back to their residences at the end of the workday. The SP provided direct support while VA1 and VA2 worked, redirecting them when needed or reminding them of the tasks that needed to be completed. According to VA1’s plans, s/he was diagnosed with bipolar disorder, oppositional defiant disorder, and an intellectual disability. VA1 liked to go bowling, watch Disney shows, go for walks, and go shopping. According to VA2’s plans, s/he was diagnosed with oppositional defiant disorder and unspecified intellectual disabilities. VA2 liked watching TV and playing Tic Tac Toe. The LEO and LEO’s report provided the following information: · On March 8, 2024, the LEO received a call of a crash with no injuries at about 8:24 a.m. When the LEO arrived to the accident scene, which was at an intersection of an off-ramp, the SP told the LEO that s/he was transporting VA1 and VA2 to work and fell asleep after “a late night.” The SP did not seem tired or “under the influence” and was not “slurring words.” The LEO did not “cite” the SP as s/he felt that the SP’s employer would handle any “discipline stuff.” The only other thing the SP said to the LEO was that s/he was exiting the highway off ramp and woke up in oncoming traffic, before hitting the other vehicle. The weather was “clear,” and it was daylight at the time of the accident. All occupants of both vehicles were wearing seat belts. · Both vehicles were “totaled” and needed to be towed. There were no injuries to any of the occupants of either vehicle. The LEO then drove VA1, VA2, and the SP to the job site. VA1 provided the following information: · The SP fell asleep while driving VA1 and VA2 and crashed. The van was “broken,” and the LEO drove them to work after the accident. VA1 and VA2 were not hurt. The SP was “sad” and was a “good driver.”
· After work, they were driven back in a different van to the facility and then P1 drove VA1 to a doctor after work. The weather was sunny at the time of the accident. VA1 did not know if there had been previous accidents while riding with the SP. VA2 provided the following information: · VA1 was sitting in the back and VA2 was sitting in front during the accident. VA2 was “watching traffic” and the SP “fell asleep” and then they “hit the middle of it.” VA2 did not know how long the SP was asleep and told the SP “not to do that” because s/he did not “watch [his/her] driving.” Before the van crashed, VA2 told the SP, “Watch your lane,” because s/he was sleeping and told the SP, “We are going to crash.” The SP woke up after VA2 “nudge[d]” him/her with his/her hand. After the crash, VA2 said, “Watch the road.” The SP replied, “I know, I know.” The SP fell asleep only one time on the day of the accident. · The mirror was “knock[ed] off” and one of the tires was “turned”. The van was “totaled.” The driver’s door was unable to be opened. Law enforcement, including the LEO arrived and talked to them. VA1, VA2, and the SP were not hurt. The LEO took them to work and VA2 did not go to the doctor because “we aren’t supposed to do that.” The weather was “nice” that day. · The SP’s “normal driving” was “regular” and the SP did not fall asleep otherwise. P5 provided the following information: · On March 8, 2024, at approximately 8:30 to 8:45 a.m., the SP called P5 and said that s/he was in a car accident while driving VA1 and VA2 and it was the SP’s “fault.” When P5 asked what happened, the SP said that s/he fell asleep “at the wheel.” P5 asked the SP if everyone was okay, and the SP said, “Yes.” P5 asked the SP if s/he had fallen asleep before, and the SP stated that s/he had had “some issues” with it, but not while working at any facility or driving clients. The SP said that s/he could work the rest of his/her shift that day and P5 asked if VA1 and VA2 were okay to work. The SP said that they were. P5 told the SP that s/he would arrange for another vehicle after learning that the current one could not be driven. The LEO drove the SP and the clients to their job site after the accident. · P5 contacted another supervisor to get instructions on what to do next. The other supervisor contacted P3 to assist with getting another vehicle to the SP and told P5 to contact VA1’s and VA2’s residences. P5 talked to someone at VA2’s residence to let them know about the accident but was unable to get in contact with anyone from VA1’s residence so P5 let P1 know that. P5 was told by one of his/her supervisors that in a situation like this, facility staff persons would ensure that the clients involved and staff persons were okay and if the staff person was okay, they could finish out their shift unless they did not feel comfortable doing so. P5 asked the SP several times if s/he was “fine.” The SP was a “little shaken up,” but was “fine” to work. The SP said s/he did not think s/he would fall back asleep that day. Once that was determined, the facility would bring out a replacement vehicle, get people where they needed to go, and contact the residences where the clients lived to let them know about the incident and that a report would be written. P5 had to step away from handling the accident incident at this time for a meeting and another supervisor took over. · When P3 dropped off the replacement vehicle, s/he went inside the job site to check on the clients and the SP to make sure that they were okay. P3 was picked up at the job site by P4. · After the meeting, P5 talked to P1 and was told that P2 and P5 would meet with the SP to ask questions and “find out [his/her] story.” P1 and P5 talked and decided to contact the SP to have the SP bring VA1 and VA2 to the facility after they finished working so that they could be checked out by physicians. At approximately 1 p.m., the SP arrived and P1, P2, and the SP met to fill out an accident report and see if the SP was saying the “same thing” as earlier when the accident details were first given to P5. Everything that the SP said was consistent with what s/he said earlier in the day. P2 asked the SP if s/he was “under the influence” of anything and the SP said, “No,” that s/he had a “late night,” and that s/he was “tired.” After the meeting, the SP was instructed by P2 to go to a clinic to do a medical check and take a “drug test.” The SP was currently “suspended” pending the outcome of the investigation. · P5 thought that P1 contacted VA1’s and VA2’s guardians. P1 took VA1 and VA2 to an urgent care facility to make sure they were both okay before driving them each home. · P5 did not have previous concerns with the SP’s driving but had concerns about the SP’s attendance and there had been times when the SP overslept, was “late,” due to not hearing his/her alarm, and times where s/he didn’t “show up.” P1 provided the following information: · On March 8, 2024, the SP contacted P5, who was the SP’s direct supervisor, and then P5 contacted P1 to let him/her know about the SP’s accident. P1 then contacted P2 and another supervisor to “take instruction” from them on how to proceed. P2 contacted P3 to find another employee to respond to the accident scene and to bring out another vehicle as the original vehicle was no longer drivable. P1 was told that law enforcement was called. P1 later found out that the LEO did not give “tests” to anyone and no narrative statements were included on the law enforcement report. · The SP, VA1, and VA2 were “doing well” so the LEO drove them to the work site. They worked their shift and a vehicle was dropped off for them by P3, who also stopped into the work site to check in on everyone. At about 1 p.m., the SP drove VA1 and VA2 back to the facility after they worked. When they got to the facility, P1 brought VA1 and VA2 to urgent care and later assisted in filling out the incident report. · When the SP returned to the facility, s/he met with P2 and P5 to complete the accident report, to inform the SP that s/he needed to get a medical examination and drug testing done that day. The SP’s appointment was scheduled for 2:30 p.m. No medical issues were discovered at the appointment. · While P1 was driving VA1 and VA2 to urgent care, P1 did not want to ask a lot of questions and VA1 did not say much about it other than s/he was okay, that it was scary “when it happened,” and s/he wanted to go to work after. VA2 said s/he “yelled” to the SP that the SP needed to “wake up” as s/he was “about to crash.” VA2 said s/he was fine and was “happy” s/he went to work afterwards. · P5 spoke with G3 “right away after it happened,” and then P1 later “connected with” G1 later in the day and spoke with G1 on the phone the next day. · The SP typically picked up a van from the facility each morning, then picked up clients and then drove them to the work site. There was usually a third client along in the van, but s/he was not working that day. P1 did not have “safety” concerns regarding the SP, but the SP had overslept or missed his/her driving route, but there were not previous driving “issues.” P2 provided the following information: · On March 8, 2024, P1 notified P2 of an accident and asked that s/he get involved. P2 had not had such a “serious accident” in the time that s/he had been in his/her role, so s/he contacted a supervisor and asked what their process would be. A meeting was scheduled between several supervisors, P1, P2, and P4 to understand what had already been done and who would do the next steps. · P2 was not aware that the SP was driving after the incident or that P5 said that s/he could drive. While the SP was driving back to the facility, P2 found out that the SP was driving a replacement vehicle. P2 informed P5 that the SP was not supposed to drive until more information was available. · P2 then met with the SP that afternoon to get an understanding of what happened. After the meeting, the SP went for a scheduled “drug” test and medical appointment. The SP was notified that s/he was not to work until the results came back. On March 18, 2024, the results of the drug test were back and the SP was notified, in writing, of the results, and that the SP was not to work while next steps were determined. P3 provided the following information: · On March 8, 2024, the SP was driving VA1 and VA2 when there was a “minor” accident. P3 was told by another supervisor who had talked to P5. Throughout the entire process, P3 was told that there were no injuries to any of the vehicle’s occupants. P3 never talked to the SP directly but saw him/her later that day. The SP looked “nervous.” P3’s role was to get the accident vehicle taken care of once it was determined that everyone was “okay.” · P3 contacted P4 to let him/her know that there was an accident, where it was, and made a plan to get a working vehicle to the SP. P4 drove the replacement van to the SP at the job site, and then P3 picked P4 up afterwards. P4 did not say anything to P3 about the specifics of the accident on the drive back to the facility. P3 later found out from P5 that law enforcement had the facility vehicle towed from the scene. · P3 was not involved in determining if the SP was going to keep driving that day. In previous situations where there had been accidents, if P3 was supervising the staff person involved, s/he would take it “case by case” if the staff person should continue driving that day or not. Sometimes the staff person would be “rattled” and may not want to continue driving that day. P3 later saw the van and the damage was “significant.” · Training for drivers at the facility included going through a motor vehicle history background check first, and then a two-day training program with a ride-a-long with another driver to see how things were done, and then on the second day, the driver would be evaluated by the trainer. There were additional trainings if someone were to drive a bus instead of a van. A driver’s manual and annual training for drivers was also part of the training program. P4 provided information mostly consistent to P3 regarding being notified of the accident and dropping off the extra vehicle. P4 provided the following information: · P3 and P4 spoke and determined that there was a spare van available, so P4 was instructed to drive the replacement van to the job site. Once P4 was at the job site, P1 contacted P4 to ensure that VA1, VA2, and the SP were okay. This included a “visual check over” as well as checking to see how they were “acting and looking.” P4 did this when s/he dropped the keys off to the SP. VA1 and VA2 “hugged” P4 and were “excited to see” P4. The SP seemed like his/her “normal self.” P4 was unsure how they got to the job site from the accident site but added that the job site was “maybe two turns” from the accident site. P4 drove past the accident site on the way to the job site, but the vehicles were no longer at the scene. P4 was at the job site for about ten minutes. P4 had no involvement in determining if VA1 and VA2 would go to the job site from the accident site. P3 met P4 at the job site and s/he drove back to the facility with P3. P3 did not go inside of the job site. On the way back, P4 contacted P1 to update him/her and let P1 know that everyone seemed “normal.” · The SP did not say anything to P4 about the accident and had not told P3 about the accident either. P3 and P4 did not directly supervise the SP so the SP would not have told them “anything.” As of about May 2023, the SP had been driving for the facility. · The SP’s role was to provide transportation to the VAs to their work site and then the SP oversaw and guided the VAs while they worked to ensure they were accomplishing their tasks. Each day, the SP would arrive at the facility, take a set of keys kept in the “transportation office” and then the transportation office would establish the route that the SP drove that day using a Garmin GPS device and that was what the SP would follow. The SP worked a “direct route” which meant that s/he picked up the clients from their residence and they went directly to the job site, not ever going to the facility. Then the SP would bring them back to their residence each day. · There were no concerns with the SP’s driving prior to this incident and the clients “adored” the SP. Both VA1 and VA2 were “pretty good” with providing “reliable” information. The SP provided the following information: · Approximately two weeks prior to this interview, the SP was driving VA1 and VA2 in the facility van and was in a car accident. The SP had follow-up “drug testing” and “failed on” two substances. · The SP generally arrived at the facility at 7:30 to 7:45 a.m. and left the facility by about 7:45 a.m. in a facility van. From there, the SP would pick up the first client but the day of the incident, that client was not working or on the route that day, so the SP only had VA1 and VA2 to pick up. The SP went straight to VA2’s residence to pick him/her up, and then picked up VA1 in a different nearby city. From there, the SP said they would go to the VAs’ job site, which, according to www.google.com, was located approximately 13 miles from VA1’s residence, arriving a little before 8:30 a.m. most mornings. (The crash site was located approximately .5 miles away from the job site according to www.google.com). At about 12:45 p.m., they generally left the job site, and the SP would drop off the clients in reverse order. · The day of the incident, the SP was having a “tired day” and did not get coffee or breakfast before working that morning. After picking up VA1 and VA2, the SP was driving up the exit ramp that had a stoplight at the top of the ramp. At about 8:20 a.m., the SP “fell asleep” and when s/he woke up, s/he was turning right into oncoming traffic. The SP stated that s/he “missed a few cars,” got “struck” and went over the median. The SP called law enforcement and then called his/her direct supervisor, P5. When law enforcement arrived, the LEO “took information,” and asked the SP a few questions. The LEO did not give the SP a “field sobriety check.” The LEO asked the SP if everyone was okay, checked on everyone, and asked what happened. The SP told the LEO that s/he fell asleep “behind the wheel” but the LEO “didn’t think [the SP] was impaired.” At that time, no one was injured. Everyone in the van was wearing their seatbelts. · When the SP spoke with P5 on the phone, P5 asked if “everyone” wanted to go to work and both VA1 and VA2 said they did not want to miss work. The SP told P5 that s/he fell asleep but could work the rest of the shift. The LEO then drove VA1, VA2, and the SP to the job site at about 10:30 a.m. VA1 and VA2 seemed “excited” to ride in the back of a “cop car.” P4 and another supervisor (later determined to be P3) dropped off another van for the SP at the job site, and VA1 and VA2 “went about [their] day.” The SP was “shaken up,” while at the job site, continued to check on VA1 and VA2 during the day, and “didn’t process [the accident] until I got back,” but otherwise seemed like a “normal day.” The SP was just “disappointed.” · After finishing up at the job site, the SP then drove VA1 and VA2 to the facility and then the SP had a meeting with P2 and P5. P2 and P5 asked the SP questions and determined that because the SP fell asleep while driving, that s/he needed to go in for a “drug screening.” The SP drove to a health facility for the drug screening and medical check after the meeting. No injuries were found during the medical check. The SP stated that several weeks later, P2 informed the SP that s/he “failed” the drug screening on two substances. The SP was given an opportunity to “retest” but was trying to figure out the facility’s “timeline” for retesting. · The SP had previously been tired while driving, calling it “a problem” at times and said that s/he usually would get coffee or pull over during late night drives. It was not “always” an issue. The SP was not aware of any medical conditions that would cause him/her to fall asleep. · The SP “tested positive” for cocaine and marijuana. The SP admitted to knowingly and “intentionally” using marijuana earlier in the week likely two days prior to the incident but stated that s/he did not “intentionally ingest” cocaine. The SP bought the marijuana “off the streets” so was unsure if it contained cocaine. The SP could not “pinpoint” when s/he may have ingested cocaine. · The SP was “pretty sure” s/he was not supposed to use “substances” like marijuana, according to the facility’s substance abuse policy. The SP’s drug test results showed that s/he tested positive for cocaine and marijuana metabolites. G1 and G2 provided the following information: · VA1 was involved in an accident on March 8, 2024, while on his/her way to work and G1 had “concerns” over how it was handled. G1 first heard of the incident when VA1 called G1 later that evening after the accident and told G1 that s/he was “hit by a car.” VA1 was “upset” about the accident. G1 did not get much more information from VA1 about the accident but learned that s/he was inside the vehicle with the driver (the SP) who was taking him/her to work. The SP “dozed off” and drove into “oncoming traffic” and the vehicle they were in was hit by another vehicle or the SP’s vehicle hit another vehicle. G1 knew that law enforcement was called. VA1 stated that s/he was okay and went to work, and later went to urgent care. The facility tried calling VA1’s residence but no one answered. The facility did not notify G1 which “shocked” G1 and G1 found it “odd,” and that the facility took VA1 to work prior to taking him/her to the doctor. · G1 explained that sometimes VA1 did not understand the “gravity” of things and thought that since VA1 did not have “broken bones” that VA1 then said s/he was “okay,” taking his/her word rather than going to the doctor first. G1 got an email from P1 about the incident after hearing about it from VA1. P1 apologized to G1 for not notifying him/her earlier. · G2 was notified by G1 who had received a call from VA1 about an accident. After the accident, G2 recently attended a meeting with G1, VA1, and some others on VA1’s care team, and VA1 said talked about a car accident several weeks earlier and it was “really scary,” and s/he did not want to talk about it. G2 asked VA1 if s/he was hurt and VA2 “shook” his/her head to indicate “no.” VA1 went to work after the accident and “assumed” that the facility would not let the SP drive anymore if s/he “fell asleep.” VA1 was taken to urgent care a few hours later, but G2 did not know who brought VA1 there. VA1 was not found to have injuries after being medically examined. G3 provided the following information: · G3 received a phone call from VA2’s residence letting him/her know about an accident involving VA2. G3 was initially told that the SP was driving, turning on an exit, and hit someone “head on.” No one from the facility called G3 or brought VA2 to urgent care until after s/he worked his/her shift. G3 thought that it was “unprofessional.” G3 received an email containing a full “incident report” later that day from P1 but was not notified by the facility at the time it occurred and was not called. · VA2 called G3 later that night and VA2 told G3 that s/he was “trying to wake” the SP, “yelling” his/her name before the SP hit a car then “went on the curb.” G3 was not “clear” about what happened with the accident and the SP falling asleep “at that hour” or without “medical explanation.” · VA2 did not complain of injuries the day of the accident or the day after. G3 learned from the facility that VA2 was driven back to the facility by the SP and then another facility staff person drove VA2 to urgent care and then home, arriving by 2:50 p.m. G3 said that it was two to three hours after the accident before VA2’s residence heard about the incident. According to VA1’s and VA2’s medical evaluations, medical records following the accident, and the LEO, there were no injuries to either VA1 or VA2 and neither of them complained of any injuries. The facility’s Drug and Alcohol-Free Workplace Policy stated that staff persons were to not be in any manner under the influence of a chemical that impairs the staff person’s ability to perform all job duties. The SP was trained on the VA1’s and VA2’s care plans, however there was not signed documentation that the SP was trained in the VAs’ care plans. All staff persons interviewed for this investigation were trained on the Reporting of the Maltreatment of Vulnerable Adults Act. Conclusion: On March 8, 2024, the SP picked up VA1 and VA2 from their residences in a facility van and drove them to their job site. Shortly before arriving at the job site, the SP was exiting the highway and turning onto another road when s/he fell asleep while driving and crashed into oncoming traffic. The SP stated s/he had a “late night” the night prior and was tired after not getting breakfast or coffee that morning. VA1, VA2, and the SP were not injured. Law enforcement, including the LEO went to the accident scene and the SP told the LEO that s/he fell asleep while driving. The LEO determined that the SP was “not slurring” words and was “not under the influence.” The SP was not given any field sobriety tests or cited. The SP called P5 to let him/her know that there was an accident. It was determined that since VA1, VA2, and the SP were “okay” and that they wanted to keep working, that they would go to their job site. The LEO drove all three of them to their job site while a new vehicle was dropped off for the SP by P3 and P4. After VA1, VA2, and the SP finished working at the job site, the SP drove VA1 and VA2 back to the facility to complete an accident report. P1 took VA1 and VA2 to get a medical evaluation. No injuries were found and P1 drove VA1 and VA2 home after the appointments. The SP was interviewed by P2 and P5 and went for a medical examination and drug testing. The results of the drug test sample taken on March 8, 2024, came back positive for cocaine and marijuana metabolites. The SP admitted to knowingly using marijuana as recent as two days prior, March 6, 2024. The SP denied knowingly ingesting cocaine. The SP driving VA1 and VA2 while tired after a “late night” and subsequently falling asleep causing an accident was behavior inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. Although the SP tested positive for marijuana and cocaine and it was possible the SP’s use of marijuana two days prior could have affected his/her level of alertness the day of the incident, given that it was unknown what effect using marijuana two days prior had, that the LEO stated the SP did not seem tired or under the influence so was not given a citation or field sobriety tests, and that VA1 and VA2 were not injured, there was not a preponderance of the evidence whether the SP failed to provide the VA1 and VA2 with reasonable and necessary care and supervision to maintain the VA’s 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 policies and procedures were followed but were not adequate. The facility did not have an outlined procedure in place for if a driver was suspected of maltreatment while driving and was working to revise their policy. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On June 12, 2024, the facility was issued a Correction Order for failure to maintain training records.
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