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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: 1097669-HCBS (Home and Community-Based Services) Investigator(s): Emily Kearns Suspected Maltreatment Reported: It was reported that a staff person (SP) was texting on their cell phone while driving a vulnerable adult (VA) and that the SP got into a car accident. Date of Incident(s): May 31, 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 for this investigation was obtained remotely, including documentation from the facility and law enforcement officer (LEO) records; and through four interviews conducted with a facility supervisor (P), the VA’s case manager (CM), the VA’s guardian (G), and a staff person (SP). Attempts were made to contact the VA by phone and United States mail, but s/he did not respond to the requests. This investigator talked to the G but the G chose not to provide information regarding the allegations. According to the VA’s plans, the VA was diagnosed with anxiety, attention-deficit hyperactivity disorder and a mild intellectual disability. The VA enjoyed going to the movies, swimming, riding his/her bike, and had a goal of living on his/her own. The facility provided services to the VA 25 to 30 hours per week. The SP started working at the facility on March 18, 2024, and began providing services for the VA on March 29, 2024. On a weekly basis, the SP worked with the VA for around ten hours and provided assistance by helping the VA apply to jobs, run errands, go shopping, and do other activities. The P provided the following information: · The P was notified by the G of a non-injury car accident involving the SP and the VA on May 31, 2024, at about 1 or 1:30 p.m. The G told the P that the SP used his/her cell phone while driving with the VA and the P told the G that it was the first time they were hearing of that issue with the SP. The G wanted the SP to continue working with the VA. · When the P spoke with the VA, the VA said that the SP used his/her phone “all the time.” The VA told the P that s/he liked the SP and that s/he was a good staff person but that the SP had used his/her phone multiple times before while driving. · The SP did not notify the P of the accident, so when the P learned of the incident, s/he called the SP and asked why s/he was on his/her cell phone while driving. The SP stated that s/he was not on his/her phone and that it was “one time” where the SP “grabbed” the phone and it was an “unintended incident” that occurred. There was no damage to either vehicle. · The P had weekly check-ins with the G and the VA and said that things with the SP were going “extremely well” and that no one mentioned any “issues” until the day of the accident. · The P stated that an incident report was written, and the SP was “terminated immediately.” The SP was told on Friday, May 31, 2024, that s/he was suspended pending the outcome of the investigation. The SP was terminated several days later on June 3, 2024. The CM provided the following information: · The G called the CM to let him/her know that there had been a non-injury car accident involving the SP and the VA on the way to a planned activity for the VA. The SP had been on his/her cell phone texting and according to a law enforcement officer (LEO), the SP’s foot slipped under the brake pedal when s/he tried to stop the car. The VA was “fine” but was “upset.” · When the CM later spoke to the LEO, the CM found out that neither the VA nor the SP told the LEO that the SP had been on his/her cell phone at the time of the accident. · When the CM met with the VA prior to the accident, the VA told the CM that the VA felt “uncomfortable” and “unsafe” when the SP would text and drive. The VA would sometimes take the SP’s phone and hold onto it while the SP was driving. The SP provided the following information: · The SP was driving his/her personal vehicle several weeks prior to this interview and was in a car accident. It was about noon. The VA wanted to go to a golfing event before going to work and they were stopped at a stop light when the SP picked up his/her phone to check a text message from the SP’s family member who was needing medical assistance. The SP was wearing slippers and his/her slipper “rolled” off of the brake, the SP’s foot came off and the car moved forward, bumping the car in front of it. The slippers were described as open toe, with a pointy front and the front toe got caught and the SP could not stop on time. No one was hurt and neither vehicle had damage. · The SP called law enforcement and a law enforcement officer arrived to help the SP and the driver of the other car exchange insurance information. · The VA had previous back injuries, so the SP asked the VA if s/he was okay, and the VA stated that s/he was “fine.” · After the golf outing, the SP drove the VA back home and talked to the VA’s family member (FM) who lived at the VA’s residence. The SP explained what happened and the FM talked to the G shortly thereafter. The next day, the G and the SP spoke, and the G told the SP that it was “okay” and that no one was hurt. The SP worked with the VA the following day. · The SP did not use his/her phone while driving except to update directions on his/her phone or to have the VA pick a song to play. Prior to the accident, the SP asked the G and the VA if there were any issues with the SP and there were not issues with the SP. · The SP did not remember being trained on the facility’s driving policy. (Investigator’s note: the facility provided documentation that showed that the SP was trained on the facility’s Safe Transportation policy on March 20, 2024.) The SP was insistent that the facility did not give him/her driving training. The SP stated that s/he knew that it was against the law in the state of Minnesota to be texting while operating a motor vehicle. · The SP stated that there were “not a lot” of times when s/he texted while stopped at stop signs or stop lights to help with an ongoing family member’s recent medical condition. The SP did not answer calls while driving and later on, the SP was made aware that the VA and the G let the P know that the VA had a problem with the SP playing music while they were in the car. The SP stated s/he would have turned the music off if the VA had asked him/her to. · The G notified the SP’s supervisor and the day after the accident, the SP spoke with his/her supervisor and was told that the G wanted the SP to keep working with the VA. Several days later, the SP was let go from the facility. · The SP was not informed that s/he was “mistreating” the VA and said that the G had not been giving negative reports to the facility or the P about the SP. The G provided the following information: · The SP had a “little incident” involving a car accident with the VA, but the G did not want to get the SP in “trouble” and said that it was an “accident.” · The SP was on his/her phone at the time and the G did not want to be involved any further in the investigation and that the SP “learned” his/her lesson. On May 29, 2024, the P sent a text message to the VA asking how things were going with the SP. The VA replied, “Good.” Law enforcement records showed that a non-injury car accident involving the SP’s car and another vehicle occurred on May 31, 2024, at around 1 p.m. The VA was with the SP at the time and the report stated that the SP hit the gas instead of the brake and was unable to hit the brake in time before hitting the other vehicle. A small dent was observed by the law enforcement officer (LEO) on the other vehicle consistent with the SP’s license plate bolt. The report noted that it was unsure if this was previous damage or not. A supplemental report accompanied the accident report, stating that the CM called law enforcement to report that the VA told the CM that the SP was on his/her cell phone at the time of the accident. The facility’s Safe Transportation Policy stated: · Staff persons were to report all accidents immediately. · All staff persons were required to follow all traffic safety laws while operating the program vehicle. · All staff persons were prohibited from smoking, eating, drinking, or using cellular phones, or other mobile devices while operating the program vehicle. 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 May 31, 2024, the SP was driving the VA to an activity and was stopped at a stoplight. The SP had his/her phone in his/her hand and was texting and/or reading a text message when his/her slipper came off the brake, resulting in the SP’s vehicle moving forward and making contact with another vehicle. Although the SP was texting or reading a text message on his/her cell phone while operating a motor vehicle with the VA inside which was behavior inconsistent with the standard of a professional caregiver in a facility licensed by the Department of Human Services, given that the VA was not injured, that there was minimal or no damage to either vehicle, that it was not determined if the SP looking at his/her cell phone caused the SP’s foot to come off the brake, and that there was conflicting information whether the SP used his/her cell phone while driving on other occasions, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. 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 stated that the facility’s policies and procedures were adequate but were not followed. The incident was not similar to past incidents. Additional training was needed, but the SP no longer worked for the facility. There was no need for corrective action. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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