|
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: 1119990-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 on April 14, 2024, a vulnerable adult (VA) showed signs of being under the influence of a substance. The facility began an investigation and learned that a staff person (SP) had provided the VA with a tetrahydrocannabinol (THC) vape device for about a year. The VA had a history of substance misuse. Date of Incident(s): Prior to April 17, 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 May 17, 2024; from documentation at the facility; and through interviews conducted with facility staff persons (P1, P2, and P3), and the VA. 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 to attempts to contact him/her by phone. Facility documentation showed that the VA’s diagnoses included antisocial personality disorder, post-traumatic stress disorder, borderline intellectual functioning, and the misuse of cannabis and other substances. The VA struggled with a desire to use substances that s/he thought helped him/her cope with life’s stressors. A Diagnostic Assessment showed that being around people who used substances was stressful for the VA and s/he attributed holding on to his/her negative emotions to substance use. The VA’s Behavioral Plan showed that seeing other people use or talk about using substances might trigger behavior problems for the VA. The VA had a history of leaving facilities without the knowledge or supervision of staff persons and had continuous one to one staffing, but his/her team recently approved a few minutes of unsupervised time in the community for the VA. Staff persons assisted the VA with medication administration and worked with the VA to ensure “good decision making.” The VA was friendly and enjoyed listening to music and going swimming. Facility documentation and information provided by the VA, P1, P2, and P3 in interviews with this investigator and the facility’s Internal Review, provided the following: · P1 said that on April 14, 2024, s/he and the VA were at a park for a community outing, when there was an unplanned meeting with a former facility staff person (F) and the VA used unsupervised time to take a short walk with the F without P1. When the VA returned from the walk, P1 drove the VA back to the facility and they began to prepare a meal. P1 noticed that the VA was unsteady and spoke with “elongated slurred speech,” then s/he contacted P2, an on-call supervisory staff person, and described his/her observations. The VA told P1 that s/he had used a substance and would not pass a urinalysis but did not want to say who provided him/her with the substance because s/he did not want to be a “snitch” and because s/he was afraid of retaliation. The VA did not seem to be in danger, ate the meal, and no other concerns were noted. P2 passed on the concerns to P3, who was an administrative staff person. · P2 and P3 talked with the VA about the information they received, and the VA told them that the F did not give him/her the substance, but the VA “caught” the SP smoking a THC vape device at the facility about a year ago, and since then, the SP shared the vape device with the VA on occasion but had recently shared it more frequently. THC was the main psychoactive ingredient in cannabis that caused people to feel high. The VA acknowledged that s/he had smoked some of the SP’s “cart[ridge]” when s/he was with the F and said that when s/he no longer resided at the facility, s/he planned to obtain a prescription to get medical cannabis and smoke marijuana. The VA became upset but later apologized and said that s/he needed space. There were no legal repercussions to the VA for using the vaping device. · P2 and P3 talked with the SP and asked him/her whether s/he gave the VA access to his/her THC vape device. The SP did not respond and did not deny the concerns. However, the SP later said in a phone call that s/he gave the VA THC twice on unspecified dates and that s/he realized it was wrong. P3 documented the information provided by the SP and reminded him/her that s/he was a mandated reporter. The facility’s Substance Abuse Policy stated that the manufacture, distribution, possession, sale, or purchase of controlled substances on facility property or being under the influence of illegal drugs, alcohol, or substances of abuse on company property were prohibited. In addition, using, selling, purchasing, transferring, manufacturing, or storing an illegal drug or drug paraphernalia during employment 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 prior to the incident. Conclusion: Information was consistent that the VA had a history of substance misuse including cannabis, and s/he might be triggered if others used substances or discussed substance use when s/he was present. According to P2 and P3, the VA told them that the SP had shared his/her vape device with the VA for about a year and shared it more frequently recently. On April 14, 2024, the VA used the device and his/her speech was affected, but no other concerns were noted. The SP did not respond to this investigator’s attempts to contact him/her but did not initially confirm or deny giving the VA access to his/her vape device when P2 and P3 asked him/her about it. Later, in a phone call, the SP said that s/he gave the VA THC twice and realized it was wrong. Although information showed that the SP might have given the VA THC, and the VA’s speech was slurred on the date of the incident, given that no information showed that the VA sustained an injury or was harmed by the SP’s actions, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services that were reasonable and necessary to obtain or maintain the VA’s health or 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. At the time 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.
|
