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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1105822-ADC (Adult Day Care) Investigator(s): Thomas Nixon 651-431-2155 Suspected Maltreatment Reported: It was reported that a staff person (SP) left a vulnerable adult (VA) unsupervised outside the facility. The VA left the facility without supervision, and was found hours later, intoxicated in another city. Date of Incident(s): August 9, 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 17, paragraph (b): 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 August 25, 2023; from documentation at the facility; and through ten interviews conducted with the VA, the VA’s family member (FM) and guardian (G), four residential staff persons which included a health care professional (R1 – R3 and HCP), two supervisory facility staff persons (P1 and P2), and the SP. The VA’s diagnoses included dementia and alcohol use disorder. The VA previously experienced homelessness and repeated hospitalizations for alcohol use, detoxification, and alcohol-related medical complications. The VA enjoyed talking with others, being out in the community with staff persons and family, playing Bingo, and making art. The VA attended the facility two days a week to socialize with others, do art projects, and participate in group exercise programs. The VA’s residence was a memory care facility. The VA provided the following information: · The VA attended the facility for a “couple months” prior to the incident. The VA said the facility was “good… culturally orientated… friendly… helpful… and an avenue for resources.” The VA did not have any concerns about the facility and enjoyed the activities and food. The VA took smoke breaks at the facility and was told to “stay close” when s/he went outside. · On an unknown date at an unknown time, the VA was at the facility and went outside to smoke while the SP was in an office. The VA was out of cigarettes and believed it was “harmless” to go and look for a close place to purchase some. The VA said, “It wasn’t like I [tried] to escape and go over the wall.” Prior to the incident, the VA was not told that s/he was not allowed to leave the facility to “go purchase something.” · The VA wanted to find a gas station within a “couple blocks” of the facility but eventually took a light rail train to the Government Center in Minneapolis. The VA stopped at his/her bank to get money and at Arby’s to get food. The VA went to Merwin’s Liquor Store and purchased cigarettes, a lighter, and “a beer” for him/herself and a “friend” s/he ran into. The VA said in his/her mind the situation was “innocent” and s/he “wasn’t bothering anybody.” · One of the facility staff persons “noticed my absence, [and] somehow it got escalated out of context.” The VA said facility staff found him/her, drove him/her back to the facility, and s/he was there in time for his/her usual ride back to his/her residence. There was no conversation with the VA about him/her having walked away from the facility until the next day. The situation was “inflated” and “blown out of proportion.” The VA said, “No one told me I couldn’t do this.” The FM provided the following information: · The FM supported the VA in several ways since s/he was admitted to his/her residence. The FM helped the VA cash checks, go out to eat, do small errands like buy cigarettes, and attend church. In the past, the VA might “wander off” if no one supervised him/her, especially due to his/her memory issues. When the FM took the VA into the community, s/he tried to have someone with who was the same gender as the VA due to concerns the VA might leave the bathroom and “wander off” without supervision. · The VA at times declined to talk about certain topics with the FM. The VA said s/he felt like the FM tried to parent the VA, despite the VA being older than the FM. When the VA did not like the questions the FM asked, the VA told the FM s/he acted like “the police” and the FM stopped that line of questions. · The FM did not have any interactions with the facility prior to the incident. The FM was aware the VA attended the facility and was “happy” s/he went to do activities there as opposed to when the VA chose to stay in his/her room alone other days. (Note: The FM was not listed as an emergency contact on the VA’s facility enrollment paperwork.) · On an unknown date, around 1 p.m. the FM received a call from R3 that while the VA was at the facility s/he “wandered off” without supervision. R3 said the VA wanted to go outside to smoke, though s/he did not have any cigarettes, and s/he was left unattended. The facility was supposed to have a staff person with the VA due to his/her dementia. The FM questioned why the VA was outside in the first place since s/he did not have any cigarettes at the time. The FM and R3 discussed the attempts that had been made to locate the VA. The FM asked R3 to see if law enforcement (LE) might issue a “Silver Alert” about a missing vulnerable adult. The FM also suggested R3 contact the shelters in Minneapolis the VA used to frequent when s/he was homeless years ago. · The FM drove to the facility, then drove around the community near the facility to search for the VA. The FM did not try to call the VA as the VA’s cell phone was not working. The FM believed the VA had money with him/her as they recently went shopping together. The VA did not have identification with him/her because s/he lost it before the date of the incident. · The FM continued to look for the VA and was in contact with the VA’s residence and the FM’s significant other. The FM was concerned the VA went to Minneapolis as s/he spent a lot of time there in the past. The FM believed that if the VA did not have cigarettes s/he likely went to either a light rail station or a bus stop to ask others for cigarettes or to ask how to get to Minneapolis. The FM drove to Minneapolis and looked for the VA. · Around 4:30 p.m., the FM went to pick up the FM’s significant other and together they continued to search for the VA. Around 5:30 p.m., the FM and his/her significant other drove to Minneapolis to look for the VA. Around 6 or 6:30 p.m., the FM saw the VA sitting by a bus stop near Broadway and Lyndale near a Cub Foods. (Note: Merwin’s Liquor Store was across the street from the Cub Foods.) · The VA was smiling as they pulled up and seemed to recognize the FM and his/her significant other. The VA said hello and asked why they were in the area. The FM explained they came to see the VA and asked why s/he was sitting there. The VA said s/he was “just sitting there,” but appeared to understand s/he was not supposed to be there alone. The FM asked why the VA was at the bus stop and the VA appeared to be “agitated” at the question and did not respond. The FM called the VA’s residence to inform them that s/he found the VA. · The VA stood up, walked over, and got into the FM’s car. The FM smelled alcohol on the VA, but did not see anything unusual about the way the VA walked, and the VA did not appear to be intoxicated. The FM attempted to ask the VA more about what happened, and the VA did not respond. On the way back the VA asked if the FM could stop to purchase cigarettes for the VA as s/he did not have any identification with him/her. They stopped at a store and bought the VA two packs of cigarettes. · When they got back to the VA’s residence, R3 was outside with a law enforcement officer (LEO). The VA and the LEO knew each other from previous interactions and the LEO assessed the VA to see if s/he needed any medical attention. It was determined the VA did not need to go to the hospital. The FM hugged the VA goodbye and the VA and R3 went back into the residence as the FM drove away. · The FM was in frequent contact with the residence over the next few days to get updates on the VA’s condition. The FM was concerned about the VA’s health after s/he drank alcohol after an extended period of sobriety. However, the VA showed no significant signs of withdrawal and appeared to be back to his/her baseline about three days later. · The FM was not aware of any of the VA’s bank accounts where s/he might have gotten money from, but said it was possible that there was an account the FM was unaware of. The FM denied s/he found the VA in a bar, but thought it was possible that the VA ran into someone s/he knew who could have purchased alcohol for the VA. R1, R2, R3, the HCP, and the G provided the following information: · The VA's dementia and memory loss were not always apparent to unfamiliar persons. The VA lived at the residence for about a year and a half. The VA was usually very friendly, charming, and excited to see people. The VA was not sober by choice, but had alcohol induced dementia and took medications that were negatively impacted by alcohol use. · Prior to August 9, 2023, the VA left the residence without supervision twice. Both times, the VA was gone less than an hour, went for a walk, and was unable to find his/her way back. The residence used a locked gate prevent the VA from leaving without supervision. The VA usually carried money on him/her, but his/her cell phone did not work. The VA knew “how to talk to people,” and was able to ask others for directions if s/he wanted. · On the morning of August 9, 2023, the VA jokingly told R3 that s/he did not have any cigarettes, showed R3 some money, and said s/he wanted to “track down cigarettes on [his/her] own.” R3 did not think the VA’s comments were noteworthy at the time. · Around 12:30 p.m., P2 called R2 and told him/her the VA “ran away” from the facility. R2 asked if LE were aware and P2 said they were not yet. R2 told P2 to call LE and to call R2 back. P2 told another staff person to call LE and stayed on the phone with R2. P2 told R2 the VA went out the facility front doors to smoke and the SP was “maybe watching [the VA]” and another service recipient. The SP went back into the facility to help the other service recipient to the bathroom, leaving the VA outside without supervision, and when the SP returned to the front door the VA was gone. R2 asked if P2 had a picture of the VA to show LE, P2 said s/he planned to go look, and let R2 know if s/he needed one. The call ended. · R2 returned to a meeting and updated the others present on the situation with the VA. For several hours, multiple residential staff persons went into the neighborhood to look for the VA at various local shops and asked community members if they saw the VA. R2 was in contact with LE, facility staff persons, and the FM while the search continued. · The FM called the residence and said the VA was found in a bar in Minneapolis near Broadway and Lyndale. (Note: The G said s/he was told LE located the VA in the bar, not the FM.) It was believed that the VA took the light rail and/or bus from the facility to a more familiar area where s/he knew people and shelters from when s/he was homeless. There was conflicting information on when the VA arrived back to the residence, with accounts ranging between 6 p.m. to 8 p.m. It was estimated the VA was unaccounted for four to five hours. · R3 said the VA was “very drunk” when s/he returned to the residence, shown by slurred speech and unsteady footing. The VA refused to do a breathalyzer for the LEO. R3 asked the VA what happened and the VA did not remember that s/he was out in the community. The VA denied s/he drank any alcohol. The VA was “upset” and “agitated” by the questions and answered with, “I don’t know what you are talking about.” · R3 called the HCP and the VA’s physician to discuss whether the VA needed any immediate medical attention. Their recommendation was to hold certain medications due to possible complications if mixed with alcohol; help the VA on stairs; do 30-minute checks on the VA until 6 a.m.; check the VA for signs of nausea and withdrawal; and if the VA was angry, abusive, or aggressive, call 9-1-1. There were no reported issues from the evening and overnight staff persons. · The G told residential staff persons not to send the VA to the facility the next day. · On August 10, 2023, the VA showed some agitation, possibly due to a hangover, and did not initially eat. R2 asked the VA what s/he remembered about the previous day and the VA did not recall any details. R2 told the VA s/he left the facility and the VA said, “I have no idea what you are talking about.” The VA said s/he went to get fresh air, but denied s/he left the facility. · R2 called the facility and explained the VA was no longer attending and to contact the G with any questions. R2 asked if the facility filed a MAARC (MN Adult Abuse Reporting Center) report. The facility asked what a MAARC report was and R2 texted MAARC information to the facility. R2 and R3 did not know if the facility was aware of the VA’s history of leaving caregivers without supervision. P1, P2, and the SP provided the following information: · P1 said the facility training stated staff persons “should always keep an eye on” the attendees, “be close enough to hear them,” and “always pay attention to them.” Most of the time the SP did not work alone at the facility and either P1 or P2 was present. The facility’s motion activated cameras were inconsistent and were intended to record activity when the facility was closed. P2 thought the cameras did not face towards the front door. At the time of the incident, the facility did not have policy or procedure that addressed what to do if an attendee left the facility without supervision. · The VA started attending the facility on March 20, 2023, and appeared to enjoy the services. P2 was informed the VA was there for socialization, to have time away from his/her residence, and to participate in activities such as exercises, art, and games. The VA got along with staff persons and others who attended the facility and there were no behavioral concerns. The staffing ratio was one staff person for every four attendees if one attendee was in a wheelchair, but if no attendees were in a wheelchair the staffing ratio was one staff person to every eight attendees. · P2 got limited information about the VA’s needs and risks at intake from the G and the CM. The facility was told the VA was independent and able to do many things on his/her own. The facility reached out to the VA’s physician for his/her medical records, diagnoses, and a letter that stated the VA was able to attend the facility and do exercises while there. The facility was aware the VA’s primary diagnoses were dementia, Alzheimer’s disease, and cognitive decline, and that the VA had a “drinking problem.” The VA was to be within eyesight of the staff person who was assigned to work with him/her that day. · The VA often asked to go outside to smoke outside the glass front doors. The staff person who was working with the VA could supervise the VA by watching him/her through the glass doors and windows or by going outside with the VA. The facility purchased an ashtray for the VA to use and placed it next to the entrance so the VA could stay close by while s/he smoked. The facility was not informed by the VA’s team that the VA might leave without supervision, nor of the previous incidents of the VA leaving his/her residence without supervision. Prior to August 9, 2023, there were no incidents where the VA left the facility without supervision. · On the morning of August 9, 2023, P1 dropped the VA off at the facility. P2 was not present this day. There was conflicting information on how many attendees were present that day. The SP said there were two attendees which included the VA, and P1 said there were three which included the VA. The SP said it was a “quiet morning,” P1 went to run errands, and the VA ate breakfast and socialized with the others present. · The SP said that around 11:20 to 11:25 a.m., the VA asked to go outside to smoke. The SP and the VA exited the front door of the facility and stood by the entrance. An attendee (A) came outside and asked the SP to help him/her use the bathroom. (Note: bathroom doors were locked at the facility and only staff persons had the key.) The SP told the VA that s/he was going to open the bathroom for the A, to “stay here” and “don’t go anywhere,” and that s/he planned to “come back for [the VA].” · The SP went inside, helped the A use the bathroom, and when s/he returned to the front door the VA was “gone.” The SP said s/he “wasn’t [inside the facility] that long,” estimating s/he was away from the VA for “less than ten minutes.” The SP went outside, did not see the VA, and went back inside. P1 said that “closer to 11:30-ish” the SP called him/her to say the VA was “missing.” The SP explained what occurred and P1 said s/he was on his/her way back to the facility and planned start to look for the VA. · About 10 to 15 minutes later, P1 arrived back at the facility and called the residence and law enforcement. The SP looked around the facility for the VA as the doors to the building were not locked and the VA may have walked back into the facility. P1 walked around the neighborhood for about ten minutes until the LEO arrived around 11:45 to 11:50 a.m. P1 talked with the LEO and was told they were familiar with the VA, and that this was not the first time LE got involved when the VA walked away from caregivers without supervision. P1 called the G and the CM separately and left messages for both. · P1 then drove around the neighborhood of the facility and looked for the VA. P1 stopped at various stores to look the for the VA and drove a route between the facility and the residence in case the VA walked that way. At 12:45 p.m., P1 returned to the facility and then the SP left and drove around looking for the VA. P1 was in continued contact with the residence and LE for updates. As the day progressed, the decision was made that if the VA was found they planned to take the VA to the residence as the facility closed at 2 p.m. · On August 10, 2023, P1 got a text message from R2 that said the VA was found the previous day intoxicated at a bar in Minneapolis, was back at the residence, and was “fine.” That afternoon, P1 saw the VA when s/he dropped another attendee off at the residence. The VA appeared “very happy” and said, “Hi,” to P1. The facility’s Individual Abuse Prevention Plan for the VA did not state the VA was at risk for lack of self-preservation skills or ignored his/her personal safety. The Individual Abuse Prevention Plan was not sent to the CM and the facility did not receive or request a Coordinated Service Supports Plan for the VA. The facility was to create an Individual Services Plan within 90 days of admission, this was not provided for the investigation. The facility’s Program Abuse Prevention Plan stated: All participants are always supervised regardless of their level of cognitive functioning. The facility has an open floor concept were [sic] the center staff can monitor the people receiving services at all times. Our center has an open concept with no hallways. The quite [sic] room is the only room that is not with in [sic] eye sight [sic] or hearing. Our staff will monitor the restrooms and quite [sic] room while those areas are in use or occupied. There are two (2) exit doors at the back and on [sic] the entrance and entrance and exit door in the front which present the risk of unauthorized individuals entering or unsupervised participants leavning [sic]. All entrance and exit doors are monitored to prevent any unauthorized individuals from entering or unsupervised participants from leavning [sic]. Regardless of their level of cognitive functioning participants are not permitted to be unaccompanied in the neighborhood. Staff members are trained to maintain a high level of vigilance outdoors to ensure their safety; as well as that of the participants. Facility documentation showed that the SP, P1, and P2 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Conclusion: Information was consistent that on August 9, 2023, the VA attended the facility and around 11:20 or 11:25 a.m., the VA went outside to smoke. The SP was outside with the VA until the A asked for help to use the bathroom. The SP went inside to assist the A and when s/he returned less than ten minutes later the VA was “gone.” The SP called P1, who called R2 and LE, and left messages with the G and CM. Facility staff persons, residential staff persons, LE, and the FM looked for the VA for several hours. Around 6 or 6:30 p.m., the FM found the VA intoxicated in Minneapolis and drove him/her back to the residence. The VA did not require medical attention and was monitored by residential staff persons until s/he returned to baseline. The VA gave inconsistent information about where s/he was and what s/he did for the hours s/he was gone. P1 said the SP was trained to “keep an eye on” on the attendees of the program, the facility was aware that the VA’s diagnoses included dementia and Alzheimer’s disease, and information from the FM and residential staff persons was consistent that the VA had left other settings without supervision in the past. However, P2 stated the facility was not informed that the VA was at risk or history of leaving facilities without supervision, which was reflected in the facility’s Individual Abuse Prevention Plan for the VA. The SP left the VA outside without supervision in order to provide active service to another service recipient, the facility was within ratio at the time, and timely efforts were made by the facility to contact the VA’s team and LE to assist in locating the VA. Although the VA drank alcohol while s/he was unsupervised in the community, and a medication was to be held due to possible complications, the VA experienced no medical complications as a result of drinking the alcohol or holding the medication. Therefore, there was not a preponderance of evidence as to whether there was a failure to supply the VA with reasonable and necessary care. 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 determined that their policies and procedures were inadequate and were not followed. The facility developed a Missing Participant Policy and trained all staff persons on the new policy. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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