MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

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:

1096055-H_CRS (Home and Community-Based Services-Community Residential Setting)
1070961-HCBS (Home and Community-Based Services)

Investigator(s):

Christine Cavanaugh
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
christine.cavanaugh@state.mn.us

651-431-3444

Suspected Maltreatment Reported:

Allegation One: It was reported that there were several incidents that a vulnerable adult (VA), left the facility without supervision. During one incident, on July 21, 2023, the VA was in the community unsupervised for eight and a half hours and had sexual intercourse with a community person (CP).

Allegation Two: It was reported that a supervisory staff person (SP) told the VA s/he was “close” to “punching” the VA and pushed the VA onto his/her bed.

Allegation Three: It was reported that there were concerns the VA did not receive some of his/her medications for several days and that the VA was missing medications when s/he went to visit his/her guardian (G).

Date of Incident(s): Ongoing prior to August 21, 2023

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 2, paragraph (b), clauses (1) and (2); and subdivision 17, paragraph (a):

Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to:

· Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult.

· The use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening.

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 September 7, 2023; from documentation at the facility, law enforcement records, and the VA’s medical records; and through eleven interviews conducted with two administrative staff persons (P1-P2), two facility staff persons (P3-P4), a supervisory staff person (P5), the VA’s case manager (CM), the VA’s guardian, who was also a family member (G), two residents who also lived at the facility (R1-R2), the VA, and the SP, who was a supervisory staff person.

The VA’s Coordinated Services and Supports Plan and Community Support Plan provided the following information:

· The VA enjoyed reading and had a tablet. The VA also liked to bake, go to the library, bead, swim, and shop at thrift stores. Books were important to the VA on a daily basis.

· The VA was diagnosed with ADHD, anxiety, depression, sensory disorder, and shaken impact syndrome (a head injury which resulted in a lengthy hospitalization when s/he was a baby due to fluid on his/her brain). The VA had a sleep disorder and “stimulating activities prior to sleep should not occur” including the use of electronics. The VA also had a “daily bowel program” which included completing an enema procedure.

· The VA was able to use the landline at the facility to make phone calls but needed to be monitored to assure that the conversations were “appropriate” and was not to use any phone in his/her bedroom. The VA would like to have a phone again one day but understood why it was something that put him/her “at risk.”

· One of the VA’s “goals” was to “decrease” his/her time spent on electronic equipment in order to build relationships with people who were present with the VA. The VA had a Nintendo DS and watched TV/Netflix and YouTube. The VA was to turn off electronics by 10 p.m. but was able to read until 11 p.m. and then staff persons were to “[take] [the VA’s] book away.” That routine worked for the VA, and s/he did not want to change anything in his/her routine at that time.

· The VA worked with staff persons to learn more independent living skills including safety skills while in the home, community, and while using technology.

The VA’s Positive Behavior Supports: Summary of Services that was developed on April 25, 2023, stated staff persons should “encourage” the VA to “create and follow” a “daily routine/schedule.”

On June 1, 2014, the VA began receiving services from the license holder but lived at a different location. On February 2, 2023, the VA moved into the facility. The facility was a multi-level home. The main level had three bedrooms (including the VA’s), a living room, a kitchen, and a bathroom. The basement/lower level had one bedroom, a bathroom, a living room, and an office. According to the VA’s service agreement, (April 10through December 31, 2023), the VA required awake overnight staff and was to receive 6.86 hours of daytime one-to-one staffing. However, there was no information stating what timeframe that was to occur. The CM said that s/he thought it was up to the facility to apply those hours at their discretion. On August 30, 2023, the G removed the VA and his/her belongings from the facility. Following that date, the VA no longer resided at the facility or received services from the license holder.

Facility records showed that all staff persons interviewed were trained on the VA’s plans including the VA’s Elopement Protocol and the Reporting of Maltreatment of Vulnerable Adults Act.

Regarding the VA’s rights:

Relevant Rules and Statutes:

Minnesota Statutes, section 245D.04, subdivision 3 states in:

· paragraph (a), clauses (15) and (16), that a person’s protection-related rights include the right to engage in chosen activities; and access to the person’s personal possessions at any time, including financial resources.

· paragraph (b), clauses (1), (2), and (4), that a person’s protection-related rights include the right to have daily, private access to and use of a non-coin-operated telephone; receive and send, without interference, uncensored, unopened mail or electronic correspondence or communication; and choose a person’s visitors and time of visits and have privacy for visits including in the person’s bedroom.

Minnesota Statutes, section 245D.04, subdivision 3, paragraph (c), states restriction of a person's rights under paragraph (a), clauses (13) to (16), or paragraph (b) is allowed only if determined necessary to ensure the health, safety, and well-being of the person. Any restriction of those rights must be documented in the person's support plan or support plan addendum. The restriction must be implemented in the least restrictive alternative manner necessary to protect the person and provide support to reduce or eliminate the need for the restriction in the most integrated setting and inclusive manner. The documentation must include the following information:

(1) the justification for the restriction based on an assessment of the person's vulnerability related to exercising the right without restriction;

(2) the objective measures set as conditions for ending the restriction;

(3) a schedule for reviewing the need for the restriction based on the conditions for ending the restriction to occur semiannually from the date of initial approval, at a minimum, or more frequently if requested by the person, the person's legal representative, if any, and case manager; and

(4) signed and dated approval for the restriction from the person, or the person's legal representative, if any. A restriction may be implemented only when the required approval has been obtained. Approval may be withdrawn at any time. If approval is withdrawn, the right must be immediately and fully restored.

At the time of the investigation the VA had no rights restrictions in place.

The G said that s/he and the facility “butted heads” on issues regarding the VA. Because of the VA’s diagnoses, a “routine” and “plan” was needed. When the VA visited the G, there was a “routine” that worked “very well” for the VA--when the VA woke up, s/he ate, took her medications, and did his/her enema procedure and at that point received “electronics” to “motivate” the VA. However, the facility told the G that they could not “restrict” items for the VA and would need a “rights restriction” in place. Because of that, the VA would not do his/her enema and was able to watch TV and have electronics whenever s/he wanted. “A lot of [the] issue” surrounded the VA’s routine. The facility/staff persons let the VA stay up all night long; sleep until 1, 2, or 3 p.m.; and not eat when s/he should be, but they said it was the VA’s “right.” Additionally, the G would later find out the VA refused his/her enema for a week.

P1 said the VA was “very sexually motivated” and the facility encouraged a psychosexual assessment with the CM in hopes for better support to the VA in that regard, but the G declined it. The G was concerned with the VA’s sexuality and encounters in that area, which was a “sticking point” for the facility because they were “person-centered” and if a resident wanted to have a consensual relationship including sexual contact, that was acceptable. The G wanted to limit any interaction the VA had with anyone that could turn into something sexual such as internet access and phone calls and wanted staff persons to screen them. Because of that, it was “kind of a contentious piece” for the facility because a lot of those things the G wanted them to do were “restrictive in nature.” All of the VA’s electronic devices were provided from the G. The G also screened the materials the VA read, but P1 said that on the facility’s side of things, that was not their “forte.” The VA also frequently tried to take the facility laptop and phone and would then hide the phone and use it to call sex lines, but due to emergency reasons, the facility could not lock the phone away. Additionally, the VA had a GPS watch and the facility was “adamant” that they could not “lock” it on the VA’s wrist. However, they said they could encourage the VA to charge it and wear it, but that was the extent that the facility could do. The VA had the ability to take the watch off him/herself if s/he wanted to.

P2 said that the VA had a watch, but the facility could not “force” the VA to wear it. P5 “cared” for the VA and his/her safety, but also “felt bad” for the VA and wanted the VA to be “independent” and “do the things that [s/he] wanted.”

The SP provided the following information in his/her interview and in the Internal Review:

· The G wanted the facility to do “all these kinds of restrictions” with the VA. For example, not making phone calls without staff persons being able to listen on speaker. However, the SP said the VA had a “right” to a private conversation. Additionally, when the VA moved to the facility, the G wanted staff persons to take away the VA’s “gadgets” (electronics) before the VA went to bed at night/before 11 p.m., but the SP told staff persons that they could not do that without a rights restriction in place and because the gadgets were not facility property; however, staff person could “prompt” the VA to go to bed at 11 p.m. so s/he would “get a good night’s rest.” The only item that staff persons prompted the VA to give back was the facility’s laptop. The G also wanted the VA to complete things such as his/her enema routine before watching TV, but the facility said they could not stop the VA from watching TV. Instead, staff persons “only prompt[ed]” the VA. The G wanted the SP to “track” the VA on his/her GPS watch, but the SP said that unless a restriction was in place, staff persons could not track the VA and could only “prompt” the VA to charge and wear the watch.

· R1 was friends with one of the VA’s family members and at some point, R1 told the SP that the family member told R1 that the G “hated” the SP. The SP thought the conflict was regarding the “restrictions” the G wanted the facility to implement that they could not do.

· The SP said that things seemed to change when the VA’s doctor changed the VA’s enema routine to every other day instead of every day and the VA stopped doing it all together a lot of the time. The VA said stuff such as, “I have the right to refuse,” and so the facility “honor[ed]” that.

Although information obtained showed that there was some conflict between the facility and the G regarding the VA’s rights and restrictions in regard to the VA’s personal cares/routine, responsibility/wearing of the VA’s GPS watch, and withholding electronics to incentivize the VA’s personal cares/routine/treatments and the VA’s routine for when s/he would sleep and or wake, Minnesota Statutes, section 245D.04, outlines statute requirements regarding service recipients’ rights. Given that there was no information provided that it was necessary for the VA to have a rights restriction to ensure his/her health, safety, and well-being; and no justification for a rights restriction for the VA, it was determined that the facility provided services to the VA that were in accordance and compliance with the Statutes outlined above.

Allegation One: It was reported that there were several incidents that the VA left the facility without supervision. During one incident, on July 21, 2023, the VA was in the community unsupervised for eight and a half hours and had sexual intercourse with the CP.

The VA’s Coordinated Services and Supports Plan and Community Support Plan provided the following information:

· The VA was “very vulnerable,” requiring a 24-hour plan of care and did not have any unsupervised time. In the past, when given unsupervised time, the VA put him/herself in “unsafe situations.” The VA had “no inhibitions” and “could easily” be manipulated by others. The VA did not use appropriate boundaries or topics of conversation.

· The VA was at risk of “eloping/wandering” and was to “always wear” a GPS tracking watch due to the VA’s “impulsivity” in case s/he left the facility without supervision or got lost. The VA needed reminders to put the watch on and charge the battery. The watch was also monitored by staff persons to ensure it was working. The VA did not have a cell phone, but the GPS watch had an SOS (emergency) button.

The VA’s Risk Assessment Detail (approved on August 8, 2023) provided the following information:

· The VA required 24-hour awake supervision and wore a GPS watch. The VA had a history of leaving the facility without supervision and a protocol was in place for staff persons to follow for the VA’s safety.

· The VA had a history of “unwanted touch” with strangers and/or acquaintances. The VA hugged people at times “too tightly” or for “too long” and did not notice when those interactions were unwanted. If the VA exhibited unwanted touch towards another person such as “long hugs, bear hugs, or touching private areas,” staff persons asked the VA to “stop touching,” and asked the person being touched to ask the VA to stop. Staff persons increased the “firmness” of their voice as needed but should attempt to intervene with the “least intrusive method” for both the VA and the other person.

· The VA stated that s/he understood the “mechanics of a sexual relationship and would like to experience it.” However, the VA was “inconsistent” in his/her explanation of a “sexual act.” The VA had difficulty separating reality and the “fantasy world” as s/he observed through books, movies, and TV. If the VA engaged in sexual conversations, upsetting conversations, or participated in an unsafe situation, staff persons cued the VA to leave the area and provided the same aforementioned interventions. While at the library, staff persons remained next to the VA if s/he used Facebook and if the VA engaged in sexual conversation while on Facebook, staff persons discontinued the session and told the VA it was time to leave. “Use of the library computers for sexual conversation or contact [was] against [the library] rules.”

· The VA had a history of putting him/herself in “some unsafe situations” engaging in physical activity with strangers, calling dating/sex lines, sending pictures of his/her body parts using other people’s phones, and talking to people s/he did not know about sexual acts. Additionally, the VA shared personal information about him/herself and an unknown person has called the house/facility asking for the VA. The Risk Reduction Plan was the same as above. If the VA was spending time in his/her room, staff persons were to check on the VA every “5-15 minutes during normal wake hours or time of illness/distress.”

· The VA had a history of ignoring personal safety which could put him/her in “harm’s way.” The VA took on “deep emotional sympathy for others” that were in physical or emotional pain--that could be in person, TV, books, hearsay/gossip, movies, etc. Staff persons were not to discuss physical or emotional pain in front of the VA which included personal relationship information, loss, divorce, abuse, etc. If the VA became focused on another person’s physical or emotional pain, staff persons verbally redirected the VA to another area or topic of conversation. Staff persons also encouraged the VA to avoid books and movies that may cause extreme emotional distress.

The VA’s Elopement Protocol and Plan provided the following information:

· The VA had a history of leaving his/her home/facility without supervision. On November 12, 2022, prior to the VA living at the facility, the VA went across the street, but staff continued to supervise the VA. Two incidents that occurred on March 27 and April 1, 2023, both times, the VA went to his/her bedroom, locked the bedroom door, left the facility through the bedroom window, and returned “independently” at the “urging” of staff.

· On April 4, 2023, an Elopement Protocol and Plan was completed and implemented. From April 4 to August 7, 2023, the protocol stated staff persons were to “attempt” to call LE after five minutes of searching for the VA and ask LE for assistance in locating a vulnerable adult. After an incident on July 21, 2023, where the VA left the facility without supervision and was not found for over eight hours, a team of supervisory and administrative staff persons and a positive support analyst met on July 25, 2023, to discuss the incident and better meet the needs of the VA. On August 7, 2021, P5 and the SP provided an updated protocol for staff persons to call LE after 15 minutes, instead of 5.

· Additionally, the Elopement Protocol and Plan stated that if the VA was “missing” staff persons should check the other rooms at the facility, the yard, and other familiar places near the house where s/he might be and attempt to determine where the VA was last seen.

· If the facility was single staffed and if the VA was “in the process” of leaving the facility by walking away or not responding to staff prompting, staff should attempt to “redirect” the VA using methods outlined in the Positive Behavior Support Plan. Staff should then attempt to contact the program supervisor (PS, who was also the SP at that time) and make them aware of the situation “immediately.” Staff should then utilize the “call tree” listed on the protocol and ask for assistance from the other trained staff at the home. The second contact after the SP was the program director, (PD, who was also P5 at that time.) If staff “lose visual sight” of the VA at “any time,” staff should attempt to search the immediate area for 5/15 minutes (Note: The time depended on the date of incident and what version of the protocol was in place at that time) and then “attempt to contact” LE or 9-1-1 and “ask for assistance in locating a vulnerable adult.” Additionally, if the VA was missing “less than 24 hours” staff should inform LE of the VA’s age, and status of a vulnerable adult receiving services and if possible, give a description and photograph of the VA.

· If the facility was “double staffed” and if the VA was in the process of leaving the facility and not responding to staff prompting, one staff should attempt to redirect the VA. Staff should then take their personal cell phone and attempt to follow the VA either on foot if it is safe or in a vehicle if it is safe. While following the VA, staff should “immediately” attempt to contact the SP to inform him/her of the situation. Staff were to continue to follow the VA and attempt redirection if and when possible until more assistance arrived. If staff lost visual sight of the VA “at any time” staff should attempt to search the immediate area for 5/15 minutes and then contact LE or 9-1-1 and ask for assistance as stated above when also single staffed.

· If the VA left without staff knowing, staff should “immediately” contact the SP and inform him/her of the situation. Staff should then continue to follow the above steps in locating the VA.

· The “anticipated outcome” was that staff would be able to locate the VA “without needing to call law enforcement or 9-1-1” for assistance and that they would be “successful in redirecting” the VA to return home.

· Once a situation/incident was “resolved” and the VA returned home and was checked for any potential injury or abuse, staff should alert the SP and the SP would contact the following persons: P5, the G, the CM, and a facility nurse.

· (Note: P1 stated that although the protocol provided a call tree for who to call for immediate notification and assistance purposes, it did not specify which staff person should call LE, just that staff should call LE after the designated time of searching for the VA. Additionally, in an email thread between P1, P5, and the SP, P1 stated that even though 9-1-1 would be called after 15 minutes of losing sight of the VA, it was unlikely that LE would assist until a report was filed, “but at least we are doing what we need to do and perhaps [the VA] will be on their ‘radar’, [sic] so to speak.”)

The VA did not provide information regarding the incidents because s/he ended the interview before information could be obtained.

Law Enforcement (LE) records provided the following information:

· On March 27, 2023, the facility reported that the VA left the facility earlier that day. When a law enforcement officer (LEO1) called the facility back, an unnamed staff person stated the VA returned to the facility and LE response was no longer needed.

· On April 1, 2023, the VA left the facility through his/her bedroom window and was gone for approximately a half hour before staff located the VA. When LE arrived at the facility, the VA had returned safe and uninjured.

· On July 21, 2023, around 8:45 a.m., LEO2 took a call from the SP, who said the VA walked away from the facility around 7 a.m. and had not been seen since. The LE report provided the following information from that incident:

o The SP said the VA wanted to walk to Kwik Trip and usually returned afterwards. The VA wanted to go to the gas station around 5 a.m. that morning, but staff “talked [the VA] into staying until 7 a.m.” LEO2 met up with the SP and asked that s/he sign a missing person’s report. The SP was “hesitant” to sign the report at that time and said that the VA had a lunch date with the G around noon and felt that the VA would be back by then. LEO2 advised the SP to call back if s/he wanted to sign the VA as “missing.” The SP stated the VA was “very smart” but did suffer from some issues due to his/her diagnoses. At that time, the SP was “not concerned” with the VA’s safety.

o Around 11:22 a.m., a Kwik Trip employee called and said the VA was at the store. The VA talked to the G on the phone while the SP was enroute to Kwik Trip. However, the VA left the gas station before the SP arrived. Around 1:30 p.m., the SP and the G went to the police department to sign the VA as a missing person. The report was completed and sent to dispatch. LEO2 went to Kwik Trip and asked staff to check the cameras. They found the portion of the video that showed the VA walking in the store and speaking with staff. The video then showed the VA running out of the store heading west in the parking lot. Camera angles were not clear but looked as though the VA walked away and did not get into a vehicle.

o LEO2 reviewed camera footage from a store across the street from Kwik Trip and saw a person walking across the parking lot of the gas station, but it was not clear who it was.

o Around 2:34 p.m. LE received a call from a nearby hotel regarding a “suspicious [fe/male].” Dispatch advised that a fe/male came into the hotel wanting an employment application and “asking customers for sex.” The fe/male was “refusing to leave” and had been “soliciting [wo/men] for sex in the lobby.”

o LEO2 arrived at the scene and learned that the fe/male left out the back door of the hotel. Officers searched the area and found the VA in a parking lot, who was identified because of the Kwik Trip video footage as the VA. LEO2 contacted the G and gave him/her their location.

o The G arrived and spoke to the VA. The VA told the G that s/he was “just out walking all day” because s/he does not like the facility and was asking for employment. The VA went on a hotel computer in the lobby for a “long time” and asked a community person (CP) if s/he wanted to have sexual intercourse with him/her. The CP agreed and they had sex in a hotel lobby bathroom. The VA said it was “consensual” and protection was used. The VA did not know the CP’s name and did not tell the CP s/he “had a disability.” The G was concerned about a sexually transmitted disease and was going to take the VA to a clinic to be checked out and then to the G’s home for the weekend.

· On July 29, 2023, there was a report that the VA walked away because s/he was “upset.” The SP was with the VA outside of the police department and said LE assistance was not needed.

· On August 19, 2023, around 11:38 a.m., LE was called to a location of a report of a “suspicious” person at their door. The complainant stated that a fe/male came to the door, saying that his/her boy/girlfriend was a “cop” and was “beating [him/her].” The fe/male stated s/he “needed help,” but was “not to call the police.” LE arrived in the area shortly after the call was given out. LE located the fe/male and identified him/her as the VA. The VA said s/he “walked away” from the facility when a staff person was using the restroom. The VA was “upset about living arrangements” and wanted to live with the G. An unnamed staff person arrived and took the VA back to the facility.

Facility documentation provided consistent information as above in the LE reports regarding the VA leaving the facility without supervision. Additionally, on May 10, 2023, P3 worked 7 a.m. to 2 p.m. and documented in a shift note that the VA left the facility sometime around 8 a.m. P3 then called the SP. The SP documented in the shift notes that s/he met the VA walking and the VA said s/he was going to Kwik Trip and refused to get in the SP’s vehicle. The SP then walked besides the VA the rest of the way to the gas station. After the VA purchased a soda and candy, s/he sat on a bench outside and ate the candy and drank the soda. After 30 minutes, the SP and VA walked back to the facility together. P3 wrote that they came back to the facility at 10 a.m. On May 24, 2023, the SP was contacted at 6:30 a.m. by the overnight staff person that the VA walked out of the facility saying s/he was walking to a gas station. The SP drove to look for the VA and saw him/her walking towards the gas station. The SP then walked with the VA to the gas station and then back to the facility.

Medical records stated that on July 21, 2023, the VA went to the clinic for STD screening after soliciting sex from a stranger/community person earlier that day at a local hotel. The VA left the facility at 7 a.m., walked to Kwik Trip and then to a hotel. At the hotel, the VA met the CP who gave him/her “one shot” of Jack Daniels and told the VA his/her age. They talked “for a bit” and then the VA told the CP s/he wanted to “jump [the CP’s] bones,” and the CP replied, “Let’s do it.” The VA said the CP brought the VA back to his/her hotel room and they had sexual intercourse in the bathroom. The VA said protection was used. After that incident, the VA walked back to the gas station and then back to the hotel again where LE found the VA. At that time any testing that was done had negative results; however, since the incident occurred earlier that day, there had not been an “incubation period.” The VA was “unharmed.” The VA had additional screening completed in August and October 2023 and all follow up test results were negative.

The facility’s Internal Review, shift notes, Incident Reports, and staff schedule provided the following information:

· On March 27, April 1, July 21, and August 19, 2023, the VA left the facility without supervision, “most of which were through [the VA’s] window.” Each time staff persons searched for the VA and LE was contacted. Additionally, the VA was taken home by the G after each incident. After the March 27, 2023, incident, an “initial discussion” of an “elopement protocol implementation” for the VA was discussed and after the April 1, 2023, incident there was a “discussion of window alarm sensors being placed. (Note: The G said that the alarms were put on doors and the VA’s window).

· On July 21, 2023, the VA had a “lengthy period” where s/he left the facility without supervision. Information from that incident showed the following:

o According to the staff schedule, on July 21, 2023, P3 was scheduled 7 a.m. to 2 p.m., the SP was scheduled 9 a.m. to 5 p.m., and P6 was scheduled 2 p.m. to 8 p.m.

o According to a shift note summary written by P7, on July 21, 2023, around 6 a.m., the VA tried to “escape” through his/her bedroom window but returned to his/her room when a staff person said they would call LE. At 7 a.m., which was also during a shift change, P3 heard the VA’s window alert sound and went to check on the VA. P3 saw that the VA was going to jump through the window and “redirected” the VA to use the door instead of the window. At that point, the VA came out of his/her room and told P3 s/he wanted to go to Kwik Trip to get some snacks. P3 asked if s/he could wait until the second staff arrived and tried to “redirect” the VA, but the VA was “adamant” s/he wanted to go get snacks. The VA then left the facility through the front/main door. P3 “immediately” called the SP for assistance (at 7 a.m.) but because the facility was single staffed, P3 was unable to leave to follow the VA due to supervision requirements for the other residents.

o The SP “immediately” drove to the gas station to meet the VA, but the VA was not there when the SP arrived. The SP spoke with employees at the gas station who were familiar with the VA from previous visits and provided his/her phone number to call should they see the VA. The SP then continued to search until 8:40 a.m. when s/he contacted P5 who advised the SP to call 9-1-1 because the VA was missing longer than the defined timeframe on the elopement protocol (15 minutes). The G was notified and said s/he thought the VA would be back for their lunch date at noon. LE was not able to offer assistance to locate the VA unless a missing person’s report was filed, and they said a couple hours was not really long enough to be considered missing even though they were informed that the VA was a vulnerable adult. The G also expressed that s/he did not feel a missing person’s report was necessary at that time. The G showed up to the area and with help of the SP, searched for the VA. At 11:22 a.m., the G messaged the SP that the VA was at Kwik Trip. However, the VA left Kwik Trip before the SP got there, and the Kwik Trip staff informed the SP that the VA left five minutes prior.

o By 12 p.m. the VA had not been found, so the SP and the G went to police department to file a missing person report. At 3 p.m. LE called and informed the SP that they had found the VA close to a local hotel. The SP and the G “linked up” and picked up the VA. The VA told them that s/he had sexual intercourse with a community person (CP) in the hotel bathroom. The VA stated that s/he “liked it” and s/he would “do it again if [s/he could].” The G took the VA to a clinic to run some tests and said s/he was going to that the VA home with him/her for the weekend. Staff followed protocol and called 9-1-1 when they could not find the VA. However, the elopement protocol stated 9-1-1 should be called after 15 minutes of the VA being “out of sight.” On the date of the incident, the CM was also notified about the incident.

On August 19, 2023, the VA left the facility without supervision through a window. The G was aware of the incident through the VA’s GPS watch and then contacted the SP. LE found the VA and called the SP to give him/her the location. The VA told LE that s/he did not know where s/he was going or why s/he left. When the SP arrived at the location where the VA was, s/he “tried to redirect” the VA back to the facility, but the VA said s/he was “not going” and that the other residents “had been mean to [the VA].” The VA also told LE that it was on his/her “bucket list” to ride in a “cop car” so LE offered to drop the VA off at the facility, but “suggested” that if they did, the VA would try to not leave the facility without supervision again. The VA said s/he could not “promise.” The SP “suggested” to the VA to “at least go” and “sit at the park close to the house,” but the VA declined. The SP spent 30 minutes trying to redirect the VA and even called the G for help but the VA refused to talk to the G. The VA told the SP s/he had removed her GPS watch and “threw it in a trash can” nearby. The SP and VA went to go look for the watch and retrieved it. Eventually, the VA started crying and told the SP that s/he was “sorry” and asked the SP to drive him/her back to the facility. The SP did so. The G asked the SP to have the VA call him/her but the VA again refused. The SP offered the VA his/her PRN (as needed medication) to help him/her calm, but the VA declined it and said s/he was “fine” and stayed in his/her room playing games.

The G provided the following information:

· On February 1, 2023, the VA moved into the facility because of changes at the other location. The G was “very apprehensive” to “any change” for the VA because it did not “work well” and the VA did not want to leave the other residents at that time. The G “made it clear” to supervisory staff persons at the new facility that the VA needed 24/7 supervision, but the SP, P2, and P5 thought the VA was “capable” of having some unsupervised time and that it could “create an issue” if staff persons needed to “run somewhere” because they would have to take the VA. Regardless, at the new facility, the G was told there was more staffing than the previous location as well as awake staff. Additionally, at some point after the move, the VA was to have a one-to-one staff person each day for six hours. The purpose of the one-to-one staffing was so the VA could be “active” and get out of the house, but the G was concerned that was not happening because staff persons told the G the VA “[did not] want to do anything.”

· Sometime after the move/towards the end of March 2023, the VA started leaving the facility unsupervised and usually walked about two miles to a Kwik Trip. The VA had a GPS watch, but it was only working “part of the time,” or the VA would take it off.

· Around May 2023, a protocol was put in place for staff persons to do a “visual check” of the VA every 30 minutes. An Elopement Protocol was also made for the VA by a positive support analyst. However, the G was concerned that staff persons did not follow it.

· The G provided consistent information regarding the July 21, 2023, incident that the Internal Review, Incident Report, and LE report provided. Staff persons were supposed to notify the G per the protocol, but the G was not notified by the SP until 2 hours after the VA left. (Note: According to the protocol, staff persons were to notify the G after the VA returned to the facility.) However, it was reported to LE. At that time, the VA’s GPS watch was broken, so there was no way for the G to track the VA. Additionally, the facility/supervisory staff persons told the G that they would not help the VA charge, use, or wear the watch because “it was not their responsibility.”

· At some point after the July 21, 2023, incident, the VA got a new GPS watch so the G could track where the VA was and the watch would notify the G if the VA left the area. On August 19, 2023, the G got a notification that the VA left the facility. The G then called the facility, but P4 said the VA was sleeping in his/her bedroom. The G asked P4 to look in the VA’s bedroom and to ensure s/he saw the VA’s face. P4 looked and then told the G the VA was not in his/her bedroom. The G asked P4 to go find the VA and sent P4 the VA’s location. P4 looked for the VA, but had some trouble with directions and was unable to locate the VA. The G also texted the SP about the incident and the SP said that s/he would also go look so the G also sent the coordinates to the SP. The G was unsure who called LE, but at some point, LE found the VA and brought the VA back to the facility. The VA had “fabricated” a story to a community person why s/he was outside by him/herself.

· At some point, the SP and P5 told the G that the “reason” the VA was “running away” was the G’s “fault” because the G picked up the VA at the facility after each incident. P2 also told the G that s/he picked the VA up “all of the time.” The G said s/he picked the VA up three times and other times s/he did not. At some point, the SP talked to the G about the books the VA was reading and mentioned a book about a person who “ran away” in the 1930s.

· The G said s/he asked “the house” (supervisory staff persons) to come up with a “solution” to “help keep” the VA “safe,” but they said, “No” and that the other residents did not have a problem there and that they could not “move staff around [for the VA].” They also said the facility was not a “good fit” for the VA and that the other residents “did not like [the VA].”

· The VA was able to communicate and provide information, but after time passed, the VA might not be able to remember all the details such as what day something occurred.

The CM said s/he received information from the G regarding the VA leaving the facility without supervision and provided consistent information that the G did in his/her interview. The CM initially thought the new facility would be a “better fit” for the VA. The VA was able to verbally communicate and was “very impulsive and smart.” The CM was not sure how accurate the VA’s information was but was not aware of any times the VA provided false information.

P1 said the VA had no unsupervised time and had a history of leaving the facility without supervision. Sometime in July 2023, the VA left the facility unsupervised and was gone for eight hours after saying s/he was going to a gas station. The VA’s Elopement Protocol said staff persons were to call LE after 15 minutes if they did not know where the VA was, and during that incident, they were not called for two and a half hours. [Note: As stated above in the LE report, on July 21, 2023, around 8:45 a.m., LEO2 took a call from the SP, who said the VA walked away from the facility around 7 a.m. and had not been seen since (1 hour 45 minutes).] However, the G, the SP, and another supervisory person had been contacted. The protocol for contacting LE was discussed with the SP following the incident. P1 did not have any concerns with the SP and said that the SP really tried to make an effort to build rapport with the VA and would often read a lot of the same books the VA read.

P5 provided the following information:

· The VA was “intelligent,” “smart,” and had a “huge vocabulary,” but was “not so accurate” in “talking the truth” and “[made] up stuff” to not get “in trouble.” P5 cared about the VA and his/her safety and also wanted the VA to be “independent” and “do the things that [s/he] wanted.”

· The VA moved to the facility in February 2023, and prior to that, only left the previous location without supervision to go across the street. At the facility, the VA had awake staff overnight and one-to-one staffing in the afternoons, but the VA “never used it” and always wanted to be in his/her room and “decline[d]” to come out when staff persons tried.

· Since moving into the facility, the VA was “always taking off on us” so a protocol was put in place. P5 was not sure why the VA was leaving the facility without supervision; however, each time the VA did so, the G would come and get the VA, so P5 thought maybe the VA was leaving so s/he could go home with the G for the weekend. At some point, the VA told P5 s/he did not like living at the facility. Staff persons were supposed to check on the VA every 30 minutes. The VA had an alarm on his/her bedroom window and door, but sometimes the VA left out the front door. The VA also had a tracker watch s/he wore, but staff persons could not “force” the VA to wear it. P5 said the protocol was always followed including a couple of incidents when LE had to be called.

P2 said that the VA did not have any issues with leaving the facility unsupervised prior to COVID and was unsure what changed in the last six months or so (prior to September 7, 2023), that caused the VA to do so. Towards the end of the six months, the VA was leaving the facility without supervision about once a week and would go to a gas station. Staff persons then drove to the gas station to check for the VA. Staff persons were also trained to check on the VA frequently if s/he was in his/her room, but P2 did not remember the exact timing of the protocol. If the VA left the facility, staff persons were to do an immediate search of the area and if they did not find the VA within 15 minutes would start notifying people.

P3 stated during his/her interview and in the Internal Review that the VA had “some issues” with leaving the facility without supervision about twice a week “usually in the morning.” The VA would say s/he wanted to go to Kwik Trip and P3 asked the VA to wait and reminded the VA s/he has no unsupervised time. If P3 was only one staff working and the VA left the facility, P3 called the SP and then looked for the VA for 15 minutes (because another resident at the home had 15 minutes of unsupervised time at the facility). The SP then “took it from there.” The SP looked for the VA because P3 could not then leave the other residents unsupervised. P3 did not know of any incidents where staff persons did not follow the VA’s protocol. The VA was not able to report accurate information and had a history of providing inaccurate information/lying to “get out of situations.” P3 said the protocol stated to call LE after one to two hours.

P4 said that the VA had a history of leaving the facility unsupervised once or twice a week including a couple of weeks prior to September 7, 2023. P4 was the only staff person working at the time of that incident and at some point, towards the end of his/her shift around 1 or 2 p.m. another resident asked P4 where the VA was. About 10 to 15 minutes prior the VA had been in the living room. P4 went to check on the VA in his/her room and the VA was not in there. After P4 realized the VA had left the facility, s/he texted the SP and got in his/her vehicle and looked for the VA. The VA was wearing his/her tracking watch, and when the G saw the VA’s location change, the G called P4. P4 could not find the VA and could only be away from the facility for 15 to 30 minutes due to the other residents’ supervision plans. P4 was not sure what happened after that because his/her shift was over but thought that “maybe” LE was called. P4 thought the VA was able to accurately report information. However, P4 said the VA sometimes provided inaccurate information about things such as taking a phone or computer and telling staff persons s/he cannot find it.

The SP provided the following information:

· After the VA moved into the facility (February 2023), the VA did not leave the facility without supervision for about one month. The SP thought the “change of environment” was “good” for the VA. “At first” the VA liked the change from his/her previous home/facility but then the VA got to a point where s/he “got used to it” and “became bored.” The VA also used to go to a day program. The first time the VA left the facility without supervision was a “surprise” because everything seemed to be going well, but then the VA started getting into “disagreements” with other residents and they avoided the VA, so the VA spent more time in his/her room. After the VA started to leave without supervision, there was a team meeting regarding how to help the VA and a protocol was developed for when the VA left the facility unsupervised.

· The SP usually came into work at 8 or 9 a.m. and was the second staff person. Sometimes the VA left unsupervised before the SP arrived and while there was only one staff person working.

· “At least twice a week,” the VA “threatened” to leave the facility and sometimes s/he left and other times staff persons were able to talk to the VA and s/he would not. The SP said that “most of the time” when the VA left the facility, staff persons followed the VA and walked with the VA, so technically s/he was not always without supervision.

· Typically, when the SP got a call that the VA wanted to leave the facility, the SP asked the VA where s/he wanted to go and offered the VA a ride. However, the VA liked to walk to Kwik Trip, which was about two miles from the facility. The VA could not go to a closer gas station because s/he was “banned” there from a previous incident when s/he stole items. The SP then walked with the VA to Kwik Trip and back. Twice when the VA left the facility without supervision, staff persons were unable to locate the VA right away. The first time was during February 2023 or sometime when it was “still cold” outside. The VA left the facility via a window, was gone for about 30-40 minutes, and eventually came back to the facility. The second time was sometime in July 2023, early in the morning around 7 a.m. before the VA took his/her morning medications, the VA left. After a staff person called the SP, the SP drove around trying to find the VA. The SP also called the PD and Area Director and told them it had been more than 15-30 minutes and that s/he could not find the VA. The VA left the GPS watch, so they were unable to track him/her. The SP also told the G and at some point, 9-1-1 was called. The SP thought 9-1-1 was called around 8 a.m. because the protocol was that 9-1-1 was to be called after the VA could not be located after 30 minutes. When the SP called 9-1-1, LE asked the SP if s/he wanted to file a missing person’s report, however, it was “less than two hours” and was too short of a time period to file a missing person’s report. The LE then found the VA at 3 p.m.

· The last incident the VA left the facility (prior to the VA moving out of the facility), the VA threw his/her GPS watch in a trash can so the G could not track him/her. The SP was driving around looking for the VA and got a call from LE. The SP was not working that date but helped look for the VA. LE found the VA and after the SP joined them, both the SP and LE spent more than 30 minutes trying to convince the VA to return to the facility. At some point, the SP called the G. The VA told the LE that it was on his/her bucket list to ride in a police car so one of them asked the VA if s/he would promise to stay at the facility, they would take the VA home in the police car. The VA said s/he could not make promises and did not like the other residents.

· The VA’s Elopement Protocol was to check on the VA every 30 minutes. If the VA responded, staff persons would know the VA was there. If s/he did not respond, such as if s/he was sleeping, and the door was locked, staff persons could use an extra set of keys to open the door to check on the VA.

· The SP and the VA both liked reading books and they talked about them. The SP said it was a way to “distract” the VA from leaving the facility unsupervised.

· “Every time there was an incident,” the G came to pick up the VA “immediately.” The SP thought a solution to the VA leaving the facility without supervision was if the VA got to go home with the G over the weekends and might reduce the number of times s/he left the facility unsupervised.

Conclusion for Allegation One:

There were seven incidents between March 27 and August 19, 2023, when the VA left the facility without staff persons supervision or when staff persons lost sight of the VA. On April 4, 2023, after the first incident, an Elopement Protocol and Plan was put in place that stated, if possible, a staff person was to follow and look for the VA, the SP was to be called, who then looked for the VA, and if after 5/15 minutes, the VA had not been found, LE was to be contacted.

Although the VA was able to leave the facility, there was no information provided that after the protocol was put in place, that staff persons failed follow the protocol. If staff persons were able to follow and look for the VA, they did so, the SP was notified and looked for the VA and if required LE was notified. While at times, the LE may not have been notified within 5/15 minutes, it was unknown whether the delay in notifying LE delayed the time the VA was located because at times, a missing persons report was not filed, or if it would have changed the outcome and prevented interactions the VA had when s/he was in the community. Therefore, there was not a preponderance of the evidence whether staff persons failed to supply the VA with care or services that were reasonable and necessary to maintain the VA’s physical or mental 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.)

Allegation Two: It was reported that the SP told the VA s/he was “close” to “punching” the VA and pushed the VA onto his/her bed.

The VA and an audio recording between the VA and the G that the VA played during his/her interview provided the following information:

· On August 20, 2023, at an unknown time the VA and the SP were “sitting on the couches” at the facility and the SP told the VA s/he could “take” the facility’s laptop, so the VA did. But then the SP “took it back” and said that the SP could “easily break the laptop.” The VA replied, “Yeah, it’s pretty easy to break a laptop.” At some point, the SP “got in [the VA’s] face,” and held up his/her thumb and index finger, which were close to touching, and said "how close" he/she was to "hitting" the VA. At some point, the VA walked into his/her bedroom and “moved” his/her bed and dresser in front of the bedroom door. The VA was on his/her bed with the laptop and the SP knocked on the bedroom door. The VA held the laptop near his/her chest with his/her hands over the laptop. At some point the SP was able to get into the VA’s room and the SP “wrestled” with the VA. As they wrestled, the VA’s legs came up over his/her head, but the VA did not remember how that happened. Then the SP “broke” the laptop “against” the VA’s bedroom door, so the VA called the G on his/her watch “crying” because the laptop was broken. The VA then stated that s/he did not remember if the SP touched him/her during the incident, but thought maybe the SP did because the VA had about three scratches each approximately one inch long and a “dime”-sized “purplish” bruise on his/her left arm that a family member (FM) noticed the following day around 11:30 a.m. The VA thought maybe the SP’s fingernails and “pressure” caused the scratches during their “fight,” but the VA also said s/he did not remember if the SP’s fingernails touched him/her. The VA said that the SP had an aura that was “sinister” and the VA “realized how mean [the SP] can be.”

· After the incident, around 7:18 p.m., when the VA was with the G away from the facility, the VA and the G had a conversation about the incident. The G recorded a conversation and during the VA’s interview, the VA played the audio recording which provided the following information:

o The VA told the G that after the VA took the laptop off of the couch, the SP went up to the VA and put his/her face in front of the VA’s and said, “I am this close to punching you.” The VA set the laptop down and walked away and the SP followed the VA to his/her bedroom.

o The VA also told the G that s/he and the SP “wrestled” over the laptop. The SP tried to take the laptop from the VA, but the VA tried to keep it. At some point during the incident, the SP “flipped [the VA] over” trying to get the computer and the VA’s legs went “up in the air” and the SP “broke” the laptop against the VA’s bedroom door. The VA was “scared” and started “hyperventilating.” The VA asked the SP for lorazepam and the SP gave the medication to the VA. In the recording, the VA told the G that s/he “always thought” the SP was a “nice [person]” but “emotionally” hurt the VA because the laptop broke.

· The VA did not provide any additional information regarding the incident and ended the interview before the completion of the interview.

The G provided the following information:

· The VA was “not allowed” on WiFi and staff persons were not to leave any electronics out. (Note: The VA did not have a rights restriction related to WiFi or electronics.) After the incident occurred on August 20, 2023, the G talked to both the SP and the VA about it. The G provided information that was consistent with the information the VA provided. Additionally, the VA told the G that at some point, the SP “taunted” the VA, and said, “I could break this (laptop) if I wanted to and say you broke it and they won’t believe you, they’ll believe me.” The SP then proceeded to “crack it.” The VA was upset and “worked up” over the incident. The VA also told the G that the SP “flipped” or “threw” the VA on his/her bed trying to get the laptop away from the VA causing the VA’s legs to go up “over” his/her head as the SP tried to pull the laptop out of the VA’s arms. At some point, the SP got in VA’s face and said, “I am this close to hitting you.”

· After the incident, the VA hit the SOS button on his/her watch, which called the G. The G heard the VA “screaming at the top of [his/her] lungs” that the SP was “going to hurt [the VA]” and was saying, “Get out.” The G heard the SP in the background asking the VA if s/he wanted to “rearrange [his/her] room.” The VA asked the G to come get him/her and the G said s/he could be there in about two hours and to wait in his/her room.

· The G then called the SP and asked the SP to put the VA’s medications together and said that s/he was going to take the VA home for a few days. The SP said, “No, don’t come until tomorrow.” But the G said s/he was coming that day because the VA was “afraid” of the SP. The SP was “called in” on his/her “day off” and when the G arrived at the facility, the SP look “tired” and “out of it." The G also described what the SP looked like as though s/he was “three sheets under,” “stoned,” or “on a medication” and the G had never seen the SP look like that before. The G thought the SP “could have been sick,” but was “not sure.” The G wondered if the SP’s “behavior” during the incident was part of the aforementioned suspected reasons. The G asked the VA about the SP’s demeanor and the VA told the G that on the day prior, the SP was “stumbling down the hallway” and “hitting the walls” at the facility. The VA said s/he thought the SP was either “high,” “drunk,” or “on something.” After the G and VA left the facility, the G recorded the conversation s/he had with the VA about the incident with the SP.

· On August 21, 2023, (the following day), a family member of the VA’s noticed bruises on the VA’s arm and the G took pictures of them.

· The G had no concerns with the previous location that the VA lived in for eight years but said there were “too many red flags going on” at the new facility and thought that the facility “didn’t really want” the VA to be there. However, the G said it was “still their job” and the G was “trusting” the facility to “keep [the VA] safe.”

· The G provided an audio clip (different than the one the VA played for this investigator) between the G and the VA regarding the incident which provided the following information:

o The VA said that prior to the incident, the SP and the VA were in the living room and the SP told the VA s/he could take the laptop, so s/he did. But then the SP asked for it back and the VA gave it back. A few minutes later, the SP said s/he “could break the laptop.” The SP “kept saying [that]” and the VA “got sick of it” so the VA went to his/her room, closed the door, and “barricaded” him/herself because if the SP “did” break the laptop, the VA “didn’t want to see it.”

o Then the SP walked to the VA’s room and knocked. The VA did not answer because s/he was “trying to calm down” and was “kind of falling asleep.” However, the VA then opened the door, and the SP broke the laptop in front of the VA by “snap[ping]” it. The SP then walked to the kitchen with the laptop and set it on the kitchen table. The VA followed the SP, “grabbed” the laptop and said, “It’s broken, no one would want to use it.” The VA took the laptop to his/her room and the SP followed. The SP tried to get the laptop back and they “wrestled” and “somehow [the VA] was on his/her back with his/her “legs over [his/her] head.” The VA said “most” of the incident was “unclear,” “foggy,” and “messy in [his/her] head.” Sometime later, the VA was crying and called the G.

R1 said that s/he liked living at the facility and had no concerns with any staff persons. Sometime during the summer (2023), on a Saturday or Sunday, R1 was in the living/dining room and saw the VA take the facility laptop and bring it to his/her room. R1 then saw the SP stand in the VA’s doorway asking the VA for the laptop. The SP did not go into the VA’s room at any point. During the incident, the VA broke the laptop and was “screaming” that the laptop was “[his/her] baby” while holding it and said, “Oh my God, my baby is broken.” The SP continued to ask the VA for the laptop. R1 said that the SP’s voice was a “little tone-y,” but s/he was “not mad,” “yelling,” or saying anything inappropriate. After the incident, the SP and the VA sat at a table and talked about what happened and it was a “good talk.” R1 did not see any scratches or bruises on the VA’s arm at that time but the VA left the facility later that day. R1 did not remember seeing any scratches or bruises the day prior and said the VA would have showed him/her if s/he had any. The SP worked at the facility with R1 for about four years and R1 had no concerns with the SP.

P1 said the VA had a history of making false allegations and most recently made allegations involving the SP. The VA said that the SP pushed and sat on him/her. The CM told P1 about some scratches and bruises on the VA’s arm and P1 thought they could have been from when the VA recently climbed out his/her bedroom window. Both the window sensor and backyard sensor that was on a tree went off and needed to be replaced. P1 thought the VA might have climbed the tree to reach the sensor and sustained the scratches from that. P1 did not have any concerns with the SP and said that the SP really tried to make an effort to build rapport with the VA including reading the same books the VA read so they could talk about them.

P2 said that the CM called him/her and told him/her about some bruises and scratches on the VA’s arm. P2 talked to staff persons and found out that the weekend of August 18, 2023, the VA climbed out his/her window, ripping through the screen, and then tried to remove a motion sensor that was outside. P2 thought the scratches and bruises could have occurred then. P2 had no concerns with the SP but heard that the G did. P2 said the SP used “proper English” and used words that were “normal” to him/her but the G felt the SP was “condescending” to him/her. The SP had a “great relationship” with the VA and read books the VA liked to read so they could discuss them together. P2 had not heard of any complaints with the SP from the VA.

P3 provided the following during his/her interview and in the Internal Review:

· The VA had a history of taking the facility’s laptop to his/her bedroom and locking the door. At some point, the SP told P3 that the VA broke the laptop, but P3 was not working when the incident occurred. P3 did not have any concerns with the SP and said that s/he was “understanding” and “genuine” with the residents.

· P3 had “no idea” about any bruises or scratches on the VA the end of August 2023. P3 never saw the SP “taunt” or be “physically abusive” to the VA and had no concerns about staff persons “mistreating” or “abusing” the VA “in any way.”

P4 provided the following during his/her interview and in the Internal Review:

· (Note: According to the facility’s schedule, on August 20, 2023, P4 was scheduled from 7 a.m. to 2 p.m.) P4 was not working at the time of the laptop incident and did not have additional information to provide about it. However, at some point later, R1 told P4 about an incident with the computer and that the VA broke it.

· P4 did not have any concerns with the SP other than “sometimes” the SP argued with the residents when s/he wanted them to do something but was not anything “big.” P4 did not have any specifics regarding the arguments. P4 never saw the SP “talk bad,” “use bad words,” or speak in a way that would frustrate the residents. P4 never heard the SP “taunt” or be “physically abusive” to the VA.

· P4 had no concerns about any staff persons “mistreating or abusing” the VA “in any way” and never saw any bruises or scratches on the VA’s arms around the end of August 2023.

P5 said that the SP was “the best supervisor” and was “to the book” and cared about the residents. P5 read about the laptop incident and provided consistent information that was in the shift note. Additionally, P5 stated the VA had a history of self-injurious behavior and would blame others for it “deliberately” when s/he scratched him/herself.

R2 said that the staff persons including the SP were “nice” and did not have “any problems” with any of them. R2 did not remember the VA and did not provide additional information that was relevant to this allegation.

The SP provided the following information in his/her interview and in the facility’s Internal Review, which also included a shift note the SP wrote:

· On August 20, 2023, around 2 p.m., the SP arrived at the facility and upon arrival was informed that sometime that morning the VA “tried to climb up a ladder” in the garage to try to get R1’s bike off a rack.

· Later that day, while the SP was serving dinner, the VA took the facility laptop from the dining room table and ran to his/her room “crying” and saying that s/he wanted to chat online with his/her “stranger friend” and that s/he “cannot help [him/herself].” While the VA was in his/her room, the SP knocked on the VA’s locked door and requested the VA to give the facility’s laptop back, but the VA refused. The SP then got the spare key, unlocked the door, and tried to open it. However, the VA had pushed his/her dresser to block the door. The VA said s/he was “not giving the laptop back.” At some point when the SP was trying to open the door, the VA asked the SP, “How strong are you?” The VA thought the SP would not be able to open the door. However, the SP was able to open the door “a little bit” and there was a “small gap” or “just enough to [fit] half of [his/her] body.” The SP saw that the VA’s bed was close to the door and the VA was sitting on his/her bed with one leg on the floor. The SP saw that the laptop lying on the bed while the VA was looking at the SP. At that point, the SP “grab[bed]” the laptop with half of his/her body inside the door. When the VA saw that, s/he “grabbed the screen” of the laptop and when the SP tried to pull it away, the laptop broke and it “snapped on one edge.” One “hinge” on the laptop was “broken” but it was “still working; however, the screen “couldn’t support itself.”

· The VA cried and at some point said the laptop was “now [his/hers]” because it was broken. The SP tried to “redirect” the VA and said that it was “property damage” but the VA “cried loudly” and then called the G using his/her GPS watch and asked the G to come pick him/her up because s/he “didn’t like it there.” The GPS watch had a loud speaker, and the SP heard the VA tell the G that the SP “sat on [the VA] which was not true.” The SP then asked the G if s/he could call the SP once s/he was done talking to the VA so the SP could explain the situation, which the G did, and the SP told the G what happened. The G said s/he would come pick up the VA and the SP told the VA that the G would be coming to pick him/her up later that evening.

· The SP told the VA that the G was on his/her way to pick up the VA and the VA stopped crying and started packing. The VA was ready in 15 minutes and waited for the G in the living room. The VA was “excited” the G was picking him/her up. The VA also said s/he did not understand why s/he could not live with the G because s/he wanted to and talked about how s/he liked going home and spending time with the G. The SP told the VA to talk to the G about those things. The SP tried to redirect/distract the conversation and started talking about books and the VA was then in a “good mood.” At that point, things “calmed down a bit” and the SP, VA, and some of the residents talked about books. However, at some point, the VA got upset and went to his/her room saying s/he wanted to live with the G and not at the facility. When the G arrived at the facility, the SP prompted the VA to tell the G what they talked about, but the VA said, “No,” and “walked out.”

· The SP said that during the laptop incident, the SP did not go inside the VA’s bedroom or have any physical contact with the VA. The SP never saw any bruises or scratches on the VA and denied ever harming the VA physically or “even inadvertently” or “by accident.” The SP never saw any scratches or bruises on the VA’s arm on the date of the incident. The day prior, the VA was wearing red shorts and a long-sleeve black top and “semi-open” slip-on shoes. At that time, the SP did not see any bruises or scratches on the VA’s arms either, but they were covered by clothing. However, the SP did notice a “small mark” on the VA’s right leg that looked like a “scratch.” The SP did not know what caused the mark but said when the s/he arrived at the location where LE found the VA, the VA was sitting in a tree. (Note: That was the August 19, 2024, incident where the VA left the facility without supervision.)

· The SP denied stating anything to the VA regarding being close to punching the VA and said that s/he had “never said anything like” that to anyone. The SP said that would have been “out of line” and had worked at the facility for three years and nothing like that had ever come up in conversations or even in a joking manner. The SP denied stating that s/he could break the laptop and say the VA did it.

· The VA previously told the SP that s/he was one of the VA’s “favorite staff” because they would talk about books and things the VA liked. The VA was “very intelligent,” and the SP and the VA like to talk about books. The VA told the SP a lot of times that s/he “liked talking” to the SP.

· The VA’s ability to report accurate information depended on the topic—sometimes s/he left out information or if s/he was “guilty of something,” the VA tried to “change” the information. However, if the VA talked about books s/he was honest. For example, a couple months prior to September 2023, the VA took an extra laptop that was in the SP’s office. When asked about it, the VA said s/he did not take it. However, at a later unknown date SP was helping the VA clean his/her room and found the laptop under the VA’s bed.

A LE report stated that on August 21, 2023, LE spoke to the G, who said that earlier in the day it was “discovered” that the VA had some “bruising/redness” on his/her arms/shoulder from “wrestling” with the SP “over a laptop.” The G did not want LE involved at that time and would work with the CM and additional persons to “remedy the issue.” LE took no further action.

Conclusion for Allegation Two:

The VA said that on August 20, 2023, the SP told the VA s/he could “take” the facility’s laptop, so the VA did. But then the SP “took it back” and said that the SP could “easily break” it. At some point, the SP “got in [the VA’s] face,” held up his/her thumb and index finger, and said “how close” s/he was to “hitting” the VA. The VA walked to his/her bedroom with the laptop and the SP followed. While the VA was in his/her room, the SP and the VA “wrestled” over the laptop and the VA’s legs came up over his/her head, but the VA did not remember how that happened. The SP “broke” the laptop “against” the VA’s bedroom door. The VA did not remember if the SP touched him/her during the incident but thought maybe the SP did because s/he obtained about three scratches on his/her left arm that a family member noticed the following day. The VA thought maybe the SP’s fingernails and “pressure” caused the scratches during their “fight,” but the VA also said s/he did not remember if the SP’s fingernails touched him/her.

P1 said the VA had a history of making false allegations. P1 did not have any concerns with the SP and said that the SP really tried to make an effort to build rapport with the VA. P2 had no concerns with the SP, had not heard of any complaints with the SP from the VA, and said that the SP had a “great relationship” with the VA and read books the VA liked to read so they could discuss them together. The weekend of August 18, 2023, the VA climbed out his/her window, ripping through the screen, and tried to remove a motion sensor that was outside, so P2 thought the scratches/bruises could have occurred from that incident. P3 stated the VA had a history of taking the facility’s laptop to his/her bedroom and locking the door and heard from the SP that at some point VA broke the laptop. P3 did not have any concerns with the SP and said that s/he was “understanding” and “genuine” with the residents. P3 never saw the SP “taunt” or be “physically abusive” to the VA and had no concerns about staff persons “mistreating” or “abusing” the VA “in any way.” Additionally, P3 had “no idea” about any bruises or scratches on the VA.

R1 said that on the date of the incident, s/he saw the SP stand in the VA’s doorway but the SP did not go in the VA’s room at any point. R1 had no concerns with the SP, other then the SP’s voice was a “little tone-y,” but the SP was “not mad,” “yelling,” or saying anything inappropriate. R1 did not see any scratches or bruises on the VA’s arm at that time or the day prior and said the VA would have showed him/her if s/he had any. R1 told P4 about the incident with the computer and that the VA broke it. P4 did not have any concerns with the SP other than “sometimes” the SP argued with the residents when s/he wanted them to do something but was not anything “big.” P4 never saw the SP “talk bad,” “use bad words,” or speak in a way that would frustrate the residents and never heard the SP “taunt” or be “physically abusive” to the VA. Additionally. P4 never saw any bruises or scratches on the VA’s arms around the end of August 2023. P5 said that the SP was “the best supervisor” and was

“to the book” and cared about the residents. P5 stated the VA had a history of self-injurious behavior and would blame others for it “deliberately” when s/he scratched him/herself.

Although the VA said that the SP told him/her “how close” s/he was to “hitting” the VA and “wrestle[d]” over the laptop with the VA causing the VA’s legs came up over his/her head, given that there were no other persons to corroborate the VA’s account of the incident; that R1, who was present during the incident did not observe the SP engage in the actions as described by the VA; that the VA also said s/he was unsure if the SP actually touched him/her during the incident; that no staff persons including supervisory staff persons had any concerns with the SP; and that the SP denied having any physical contact with the VA during the incident, there was not a preponderance of the evidence whether the SP spoke to the VA in a nontherapeutic manner that would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening or that the SP had any non-therapeutic physical contact with the VA which caused the VA to sustain bruises/scratches or could reasonably be expected to produce physical pain, injury or emotional distress to the VA.

It was not determined whether physical or emotional abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult and conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening.)

Allegation Three: It was reported that there were concerns the VA did not receive some of his/her medications for several days and that the VA was missing medications when s/he went to visit the G.

The Health Needs Record from June 28, 2023, completed by the SP and P5, stated that the facility was responsible for meeting the health needs and medication administration and assistance needs for the VA. Staff persons were to dispense the VA’s medication according to the Medication Administration Record (MAR). The VA took medication in the presence of staff persons and the staff persons would reorder medication when needed.

The VA did not provide information regarding the above allegation because s/he ended the interview before information could be obtained.

Information from interviews and facility documentation was consistent that the VA’s medications were delivered monthly to the facility. Staff persons were not aware of the VA missing any doses of medications unless s/he refused or when s/he left the facility without staff supervision. According to the Internal Review, a review of the MAR for July and August 2023 showed that there were “numerous refusals” by the VA as well as “numerous no pass designations” due to the VA being with family. On July 21, 2023, the VA missed several medications because s/he was not at the facility because s/he left without staff supervision. However, there were “no serious adverse effects” due to the VA missing medications. On August 20, 2023, the G said that s/he was on his/her way to pick up the VA and asked if the SP could pack the VA’s mediations for a few days. When the G arrived at the facility, s/he picked up some of the medications that were in stock; however, more were to be delivered that evening. Once they were delivered, the SP sent a notification to the G and the G responded s/he would send a family member to pick them up.

The G provided the following information:

· The G had concerns regarding the VA’s medications including that the VA did not receive a medication for 17 days in July 2023 and that the SP did not pack all of the VA’s medication in August 2023 when the G took the VA home for a visit.

· On the weekend of July 21, 2023, the G brought the VA home for the weekend and was missing three of the VA’s “controlled” medications: Concerta, Lunesta, and lorazepam. The G called the SP about it and the SP told the G to “call the pharmacy” because the medications had been ordered. However, the next day the G called the pharmacy and was told nothing had been ordered and that the SP had sent an electronic notification/order from the VA’s doctor on June 28, 2023, to discontinue the Concerta. The pharmacy said someone at the facility picked up the Concerta on June 7, 2023, which was the last date it was “filled.” The G said that based on that, the VA had not had Concerta since July 7, 2023, (the date the medication would have run out), which at that point was 17 days and due to that, the VA’s “behaviors” were “worse.” At some point, the G called the SP again and asked the SP about the medication. The SP said that the pharmacy must have “got it mixed up” because the SP sent a cancellation for a different medication. The G called the doctor’s office and asked if the VA’s Concerta had been discontinued and was told it had not been. The G then asked for a refill for which the VA later received. The G told the SP what the pharmacy and doctor said. The SP denied discontinuing the medication and said that only the doctor could do that and to call the doctor. The G said that the SP should have known there was no Concerta and should have questioned where it was. The, G said the cancelled was for Paxil, not Concerta so the SP thought the pharmacy got it “mixed up” between the two medications. (Note: According to the pharmacy, paroxetine [Paxil] was to “automatically be delivered every 28 days.” However, the Renewal Response showed “renewal request denied: noted as discontinued on December 9, 2022. The response was issued by the VA’s doctor which was faxed to the facility on April 12, 2023.)

· On the evening of August 20, 2023, the G brought the VA home from the facility and when the G looked at the VA’s medications, they had “fallen out of the pill tray” and inside of a bag. The G had asked the SP to pack the VA’s medications for a “couple of days,” but the SP only packed the night and the next mornings medications. The medications sent by the SP were missing guanfacine and Lunesta and the VA only had one Trilectol. The G called the SP and asked where the medications were. The SP then asked what “a couple of days [was] meant to mean,” and directed the G to call the pharmacy for more. The G said that there were supposed to be nine pills at night and four in the morning, but the G only had six out of the nine for night, so was short three. The next day, the G called the pharmacy to ask about the medications and was told there should have been enough medications to be sent home with the VA. The G called the SP again and told the SP that a family member would come to pick up all the medication. Once the G had all of the VA’s medications, s/he counted them, and the VA had enough to send home; the SP “just didn’t do it.”

The CM was aware of the above information from the G and provided consistent information that the G did regarding the medication concerns.

Records from the VA’s pharmacy stated that on June 27, 2023, at 6:05 p.m., the VA’s Concerta 54 milligrams (mg) was “discontinued” per “doctor request.” The SP’s name was on the log as the employee who sent in the information to the pharmacy.

Records from the VA’s clinic/prescribing doctor showed that methylphenidate (Concerta) was prescribed on June 7, 2023, for 30 days and it had no refills.

The MAR showed the following information:

· June 2023, Concerta 54 mg tab was prescribed and to be taken one tablet by mouth every morning. The prescription start and end date stated May 8 through June 7, 2023, and was again filled June 7 through June 27, 2023. June 27, 2023, was listed as the “end date” and there was no additional information whether a refill was prescribed after that date. June 1 through June 27, 2023, Concerta was signed off by staff persons as administered or the VA was away from the facility with family. On June 23, 2023, at 9:02 a.m., P3 documented that the VA refused Concerta which was the only time Concerta was refused that month. June 28 through June 30, 2023, the MAR was blank.

· July 1 through July 24, 2023, the MAR for Concerta was blank but it was administered on July 25 through July 31, 2023.

· August 1 through August 29, 2023, it was documented that Concerta was either administered or the VA was with family. (Note: After that date, the VA no longer lived at the facility).

The SP provided the following in formation in his/her interview and in the Internal Review:

· According to the SP, the pharmacy usually delivered medications to the facility between the 20th and 30th of the month and staff persons called if they were not delivered. The pharmacy then provided information if there was no refill on the medication, and the doctor had to be contacted. All staff persons were trained to reorder medications and could make a call if they were running low. The SP thought there was this issue with the VA’s Concerta. The pharmacy would not give a timeframe regarding when the VA would get the medication and the pharmacy told staff persons they would have to wait.

· The facility staff persons did not take the VA to doctor/medical appointments because the G handled all of the VA’s medical appointments and medications, so staff persons did not always know the status of the VA’s medications/if something changed until the G told them. The G also handled the VA’s medications/changes and notified the facility of them. Because of that, at times, there was some confusion on which medications were changed/discontinued. The VA’s medications were usually prescribed one month at a time. If the VA’s medications had refills, they were delivered to the facility. If medications were running low, staff persons called the pharmacy and they usually refilled them towards the end of the month, between the 20th and the 27th. If the medication was a controlled substance and there were no refills, the pharmacy contacted the prescribing doctor to get a medication order. There was nothing else staff persons could do until that was completed.

· The SP did not recall the VA missing medications because they were not refilled. The SP did not know anything about the VA missing medications when s/he went home with the G. However, the SP said that if the VA was missing any mediation, it could have been because the G picked up the VA at the facility before the medications were delivered.

· On August 20, 2023, when the SP talked to the G on the phone after the laptop incident, the G asked if the SP could pack the VA’s mediations for a few days because s/he was taking the VA to his/her house. The SP asked the G if s/he would like to pick up the VA the following day instead because some of the VA’s medications were being delivered that evening. The G said that s/he was “on [his/her] way” and was “busy” the following day. The G brought the VA to his/her house and later texted the SP that the VA was supposed to take nine medications at night but was missing some. The SP said the VA did not take nine medications at night and was unsure if the G was counting them correctly and was possibly counting the topical medications and the VA’s as needed medications. The SP told the G that s/he packed all the medications the VA took. The next day, the pharmacy delivered medications to the facility; however, they were the same medications the SP had originally packed (replacement meds). (Note: This investigator saw screen shots of the text messages between the G and the SP regarding the VA’s medication. On August 21, 2023, the SP texted the G that the medications were delivered at 7:58 p.m. and the G replied with a thumbs up. On August 22, 2023, the G texted the SP and asked what medications were delivered last night and that one of the G’s family members would pick them up later that day. On August 23, 2023, the SP stated s/he was at a medication appointment for another resident and asked if they got all the medications that were delivered, and the G said that they did.)

Conclusion for Allegation Three:

The G had concerns regarding the VA’s Concerta being missed in July 2023 for 17 days, which caused additional “behaviors” for the VA.

The facility’s MAR for June 2023 showed the Concerta prescription was filled June 7 through June 27, 2023, which was the “end date” and there was no additional information if a refill was prescribed after that date because there were no refills per the prescription. June 1 through June 27, 2023, Concerta was signed off as being administered by staff persons or the VA was away from the facility with family. The VA did not receive Concerta from June 28 through July 24, 2023 (27 days). There was no additional information stating why the medication was not administered. (Note: this was after the G questioned the missing medication and put in a new order.)

Records from the VA’s pharmacy stated that on June 27, 2023, at 6:05 p.m., the VA’s Concerta 54 mg was “discontinued” per “doctor request.” The SP’s name was on the log as the employee who sent in the information to the pharmacy.

The SP stated that s/he was not authorized to discontinue a medication and that the doctor had to do it. The SP thought there was a “mix up” with the pharmacy and the medications.

Although there was conflicting information between the SP and the G regarding the VA’s Concerta and that the SP denied discontinuing a the Concerta and stated only the VA’s doctor could do that, pharmacy documentation showed the SP notified that the VA’s Concerta was discontinued per doctor request. Given that it was unclear what caused the issue with Concerta being discontinued or refilled; that the Concerta prescribed on June 7, 2023, had no refills; that it was possible there was some sort of miscommunication between the clinic, the SP, and/or pharmacy; and that it was unknown if had the medication been administered that the VA would not have left the facility without supervision since s/he had a history of doing so, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services that were reasonable or necessary.

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 and stated that their policies and procedures were adequate. However, the established Elopement Protocol for the VA stated LE should be contacted after 15 minutes of losing visual sight of the VA, which did not occur on July 21, 2023, when the VA left the facility without supervision. There was “no formal document” indicating re-training of the Elopement Protocol procedure following the July 21, 2023, incident and when to contact LE; however, the SP had a “verbal conversation” with P5 regarding the protocol. The VA no longer received services at the facility.

Action Taken by Department of Human Services, Office of Inspector General:

No further action taken.

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