|
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: 1070650-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that a staff person (SP) used alcohol while working at the facility and then provided transportation to a vulnerable adult (VA), and that the SP had vehicle accidents while transporting the VA. Date of Incident(s): Prior to June 15, 2024 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on June 28, 2024, from documentation at the facility and through 13 interviews conducted with the VA, two facility clients (C1 and C2), a management staff person (P1), 9 facility staff persons (P2-P10), and the SP. The VA, C1, and C2 lived at the facility, which was a rambler style home. Although this investigator talked to the VA, the VA chose to not provide information. The VA’s support plan showed that the VA enjoyed going into the community. The VA’s Self-Management Assessment showed that the VA was diagnosed with a mild developmental disability and had “difficulty with [his/her] organizational skills and memory due to [his/her] cognitive abilities.” P2 provided the following information to this investigator: · Although P2 did not remember the exact date, there was an incident “at least a month or so ago,” in which the SP was “drunk” while the SP worked at the facility. P2 also stated that similar incidents have happened in the past, that the SP was “slurring” his/her words, and that the SP fell asleep while working. · P2 remembered one time when the SP left the facility and went to his/her home to get something and was gone for about one and a half hours. When the SP returned, the SP tried to “hug” P2, which made P2 “very uncomfortable.” · P2 also said that s/he found alcohol bottles inside the facility and on facility property, but P2 did not remember when that happened. · P2 remembered a time over a year ago when the SP took the VA on a community outing and when the VA and the SP returned, the VA stated that the SP had been in a minor car accident and that there was some damage to the facility’s vehicle. P2 also remembered a time when the SP went into the ditch during winter weather and while transporting the VA and that the SP needed assistance getting the vehicle out of the ditch, but P2 did not remember when that happened. C1 stated that the SP was “slurring” his/her words while the SP worked, but C1 did not know when that happened. C1 also said that although s/he did not see the SP drinking alcohol while working, C1 “smelled alcohol” on the SP’s breath. C1 did not have information about the SP being involved in an accident or going in the ditch. C2 stated that s/he did not see the SP drinking alcohol while working and did not have knowledge of the SP being involved in an accident or doing in the ditch. P1 stated that s/he had not seen any evidence that the SP drank alcohol while working, but that other staff persons had brought concerns forward to P1, about five or six times, that the SP was under the influence of alcohol while working. When those staff persons brought concerns forward to P1, P1 addressed those concerns with the SP and the SP denied being under the influence of alcohol at the time. P1 did not have any knowledge of previous accidents or incidents involving the SP. P3 was not aware of a time that the SP worked while under the influence of alcohol and did not have knowledge of past accidents/incidents involving the SP while driving. P4 stated that s/he had not observed the SP being under the influence of alcohol and was not aware of past accidents/incidents involving the SP driving while under the influence of alcohol. P5 said that there was two or three times when P5 “smelled alcohol” on the SP’s breath in March 2024, and on one occasion, the SP appeared to be “drunk,” but P5 did not have concerns related to the SP performing his/her duties at the time. P5 also said that s/he had heard from an unknown staff person that the SP was involved in some type of car accident with C1, but P5 did not know when that was or whether there was any damage to the facility’s vehicle. P6 stated that there were instances where alcohol bottles were found inside the facility and on the facility property on several occasions. P6 also said that on “numerous” occasions, P6 smelled alcohol on the SP’s breath and that there were times that the SP fell asleep while working at the facility. When P6 had concerns, P6 brought those concerns to P1 and certain changes occurred, such as the SP working at another facility location, or the SP being required to work with other persons. P6 did not have knowledge of the SP having an accident or incident while driving. P7 said that s/he did not smell alcohol on the SP’s breath but thought that the SP might have been under the influence of alcohol because P7 noted some “swings” in the SP’s “personality.” P7 did not have concerns with how the SP interacted with the clients and did not have knowledge of the SP sleeping at the facility or having past accidents/incidents while driving clients. P8 stated that there was one time that P8 heard that the SP left work early and was later arrested for driving while under the influence of alcohol, but P8 did not remember when that was. P8 had not observed any signs that the SP was under the influence of alcohol when s/he worked with the SP and P8 did not have knowledge of past accidents/incidents involving the SP driving a client while under the influence of alcohol. P9 stated that s/he had smelled alcohol on the SP’s breath some time ago several times, but not within the past five years and not while the SP worked. When that happened, the SP acted “giggly.” P8 remembered a time when C1 told people that while C1 and the SP were in the community, the SP went into the ditch during winter weather and the SP’s family member assisted them out of the ditch. P8 also remembered a time when C1 returned from an outing with the SP and C1 told others that the SP “hit a car” in the community some time ago. P9 said that there was some damage to the facility’s vehicle but did not remember the extent of the damage. P10 did not remember the exact date but stated that the SP took the VA on an outing and before they left the facility, the SP seemed “fine,” but when they returned about an hour later, the SP was “slurring” his/her speech. Even though P10 never smelled alcohol on the SP’s breath, P10 believed that the SP had used alcohol while working because there were times that the SP “passed out” while working. P10 also said that there were times that the SP was moved to another facility location or that double staffing was used when the SP worked after concerns were noted. P10 heard “secondhand” that the SP was in some type of accident/incident with the facility’s vehicle, but P10 did not remember when that was or what happened. The facility had a policy and procedure which stated that the use of alcohol or drugs while working at the facility was not allowed. The SP stated that on two occasions, management talked to the SP about using alcohol while working, which the SP denied. The SP acknowledged that there was one time when s/he was in the community with C1 and the vehicle was stuck, but denied going in the ditch, denied being involved in an accident, and denied that there was damage to the vehicle. P1 provided written documentation that stated, “There were no motor vehicle accidents/incidents of [the SP] driving into the ditch, so there are no incident reports to provide.” The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s specific care plans prior to June 28, 2024. Conclusion: It was reported that the SP consumed alcohol while working and was involved in accidents/incidents while providing transportation services to clients. C1, P2, P5, P6, P7, and P10 had concerns that the SP consumed alcohol while working, but no one witnessed the SP doing so and there was no information that the SP provided transportation to clients after consuming alcohol. The VA, C2, P1, P3, P4, and P8 did not have those concerns. There was no information that the clients were harmed. P1 stated that there was no record of the SP having a vehicle accident/incident with the facility vehicle. Some staff persons heard that the SP was involved in an accident/incident, but no one witnessed it. Although there were concerns that the SP was consuming alcohol and then transporting clients and was in vehicle accidents while working, given that there was inconsistent information as some staff persons had these concerns based off the SP’s behavior or smell and some did not, that no one saw the SP consume alcohol or have accidents and there was no further information regarding details of occurrences of either of those, and that the SP denied the allegations, there was not a preponderance of the evidence whether the SP failed to provide reasonable and necessary care and services to the VA or any client. 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).
The facility’s Internal Review Conclusion and Evaluation showed that policies and procedures were adequate, followed, and that “staff are trained on vulnerable adult and how when/where/how to report it.” Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
|
