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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: 1078462-Intensive Residential Treatment Services/Residential Crisis Stabilization Investigator(s): Beth Virden beth.virden@state.mn.us Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) made suicidal ideation statements and that staff persons did not intervene or take immediate action. The VA died later that same morning by suicide. Date of Incident(s): June 23, 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 site visits conducted on June 25 and July 3, 2024; from documentation at the facility and law enforcement records; and through interviews conducted with the VA’s family members (FM1, FM2, and FM3), the VA’s case manager (CM), facility staff persons (SP1 and SP3), a staff person (SP2) who was also a healthcare professional, and supervisory staff persons (P1 and P2). Attempts were made via telephone, email, and mail to contact and interview another staff person (SP4), but SP4 did not respond to the requests. The VA’s support plans included the following information: · On March 17, 2024, the VA was living in his/her own apartment in the community. The VA was struggling with his/her mental health and “had intention to hang [him/herself].” The VA was hospitalized and referred to the facility. The VA initially declined to go to the facility but then agreed after a delayed start. · On April 22, 2024, the VA moved into the facility seeking support and services relating to his/her diagnoses, which included generalized anxiety disorder and bipolar disorder. At that time, the VA presented with “more thoughts on anxiety than depression … significant agitation and ruminating on specific thoughts, events, problems, etc.” The VA said that his/her previous suicidal ideation on March 17, 2024, was “not bad” and that s/he had “exaggerated [his/her] symptoms.” “[The VA] reports that [his/her] suicidal ideation comes and goes, and that was the first and only time [s/he] had a plan to harm [him/herself].” “[The VA] denies any current suicidal ideation as well as self-injurious behaviors or homicidal ideation.” The facility provided the VA with intensive residential treatment services, medication management and psychiatry, psychotherapy, housing supports, and social supports. · On May 29, 2024, the VA’s treatment plan stated that s/he was attending group every day and was “very active” in programming. The VA took his/her medications without prompts and understood his/her mental health diagnoses. The VA identified 16 coping skills for his/her mental health symptoms and was working on developing more skills. The VA continued to struggle with anxiety and was “not open to getting” a therapist at that time. · On June 21, 2024, a functional assessment was completed. “[The VA] can be observed to become easily anxious with daily tasks, personal responsibilities, and any other concerns related to physical, dental, and/or mental health … [The VA] can be observed to display high anxiety when discussing food.” The VA was working towards identifying additional coping skills and appropriate foods for a balanced diet. The VA had a psychiatrist and a case manager and was working to identify a therapist. The VA met with facility counselors “consistently” and was “open” to discussing his/her mental health concerns and services. The VA planned to move back to his/her apartment when s/he completed treatment, participate in intensive nonresidential treatment, and get a job. The facility was a three-story renovated apartment building. Each floor had hallways with client bedrooms, bathrooms, meeting rooms, and common areas. Most of the staff offices were on the first floor. There were cameras throughout recording movement, but not audio. There were no cameras in the bedrooms or bathrooms. The VA’s bedroom was on the third floor. The VA did not have a roommate. The facility’s policies and procedures included the following information: · Staff provided 24-hour supervision of the clients. Staff had regular in-person contact with the clients and continually monitored to assess any changes in their mental health and cognitive abilities. At a minimum, staff conducted an “eyes-on check” of each client every four hours. Eyes-on checks might increase in frequency based on the client’s current need and/or when determined by the treatment team. · Between each shift, staff exchanged information with the oncoming shift in a crossover meeting. Any specific changes in a client’s needs, such as increased checks or specific interventions, were shared at this meeting. · Staff completed specialized screenings if a client presented with suicidal ideations or behaviors. Based on the screenings, staff might contact the clinical on-call staff person and increase eyes-on checks. If there were immediate concerns about a client’s safety, staff called 9-1-1. It was reported that on June 23, 2024, the VA died by suicide, and that in the hours prior, the VA told staff s/he “couldn’t go on” and “felt like a burden to everyone.” There was no information staff intervened following these statements by the VA. There was also conflicting information regarding timing. This included one account that staff discovered the VA deceased at 8 a.m., and another that it was 10 a.m. Another account stated that staff last saw the VA at 3:45 a.m. and then discovered the VA four to six hours later. The facility’s Incident Report stated the following dated June 23, 2024, at 10:49 a.m.: Staff was aware that [the VA] had not taken [his/her] morning medication and [SP3] went up to check on [him/her]. [SP3] found [the VA] hanging from [his/her] closet door and appeared deceased. [SP3] ran downstairs to main office where [SP2] called 9-1-1 and [SP3] and [SP1] returned to [the VA’s] room and tried to get [him/her] down. [The VA] was purple in face, cold and clammy. They were unsuccessful in being able to get [him/her] down. Law enforcement arrived and were able to get [him/her] down and called the coroner's office. Facility documentation, SP1, SP2, SP3, P1, and P2 provided the following information: · Facility documentation dated Saturday, June 22, 2024, stated that the VA was sleeping at the 12, 4, and 8 a.m. safety checks. The VA was awake in his/her bedroom at the noon check. The VA took his/her medications without prompts, and attended a check-in group, a health and wellness group, and a community outing. Later that evening, the VA participated in karaoke, took a walk, and spent time in the main level living room. Throughout the day, the VA appeared “anxious, worried, and fearful.” Staff administered the VA’s PRN (as needed) sleep and anxiety medications. · SP1 and SP2 worked the evening of June 22, 2024. The VA was “active” and sang in karaoke with other clients. SP2 said that the VA was prescribed a new insulin and made plans to start it June 23, 2024. SP1 and SP2 did not notice anything noteworthy about the VA’s demeanor that evening. · Facility documentation dated Sunday, June 23, 2024, stated that the VA was “sleep(ing) in RM” (room) at the 12 and 4 a.m. safety checks. The staff person who recorded this information was not identified in the documentation. · At 7 a.m., SP3 arrived at work for the start of his/her shift, and at 7:55 a.m., SP2 arrived. · At 8 a.m., SP2 and SP3 attended the crossover meeting, where the previous shift relayed information to the oncoming shift. SP2 also reviewed the previous shifts’ logs. Nothing was shared about the VA, including that the VA made any statements of suicidal ideation. · Facility documentation stated that also at 8 a.m., SP4 completed a safety check of the clients. For the VA, SP4 checked the box for “8 a.m.” and wrote “awake.” SP4 did not make any other notations. SP4’s shift ended around this time and s/he left for the day. · SP2 said that between 8 and 10:30 a.m., most clients had scheduled medications, and they independently came to the medication window where staff administered their medications. The VA typically came between 10 and 10:30 a.m. · At 10 a.m., SP1 arrived at work for the start of his/her shift. SP1’s shift started at an “odd” time and so s/he typically missed the crossover meeting. SP1 read through the shift logs and there was nothing noted about the VA, including that the VA made any statements of suicidal ideation. · At 10:30 a.m., the clients and staff met together for a daily check-in meeting. Prior to this, SP1 and SP3 hollered down the hallways, “Check-in. Come down.” If a client missed the check-in, staff conducted the meeting and then after, checked on those absent. On June 23, 2024, the VA did not attend the check-in meeting. SP3 said that the VA “usually” attended all groups, including check-ins. The check-in ended around 10:45 a.m. · SP2, who also did not attend the check-in, noticed the VA had not come for his/her medications. SP2 typically prompted clients if they did not arrive by 11 a.m. Around that same time, SP1 entered the staff area and stated that the VA did not attend check-in, and that SP3 was headed to his/her bedroom to check on him/her. · At 10:49 a.m., SP3 knocked on the VA’s bedroom door, which was closed, but the VA did not respond. SP3 said that the VA was “usually” awake by this time of day so SP3 opened the bedroom door. The VA’s bed was directly inside the room and the bed was made. SP3 pushed the door further open and saw the VA hanging in his/her closet. “I knew [s/he] was dead. [His/her] tongue was a blue, purple color.” SP3 immediately ran downstairs and alerted SP1 and SP2. [Note: Staff did not carry portable radios or have other means of communicating with one another.] · At 10:51 a.m., SP2 called 9-1-1, while SP1 and SP3 went back to the VA’s bedroom. · SP1 brought a pair of scissors. However, SP1 saw that the VA had used a vacuum cord, which was wrapped around his/her closet door and rod, and the scissors were ineffective at cutting it. SP1 and SP3 tried lifting the VA and untangling the cord, but they were unable. The VA’s face was “purple,” and his/her body was “cold and clammy.” SP1 and SP3 were not able to start cardiopulmonary resuscitation (CPR) because they could not get the VA lowered to the floor. · At 10:58 a.m., law enforcement officers (LEOs) arrived and took over the scene. · P1, SP2, and SP3 each said that the LEOs told them they found a “suicide note” on the VA’s bed. The note said that the VA “couldn’t go on” and “felt like a burden to everyone.” Staff did not see the note and the LEOs took it with them. · P1, SP1, SP2, and SP3 provided consistent information that the VA was “very kind” and “considerate of others.” However, the VA experienced “anxiety.” SP2 said that the VA had “an anxious aura around [him/her].” If the VA approached staff for his/her scheduled medication time, s/he seemed to think s/he was being a bother. Staff reminded the VA that s/he should take his/her time, that s/he was not a bother, and that s/he needed to take care of him/herself. The VA seemed more concerned about taking care of others first. · P1, P2, SP1, SP2, and SP3 each said that they were not aware of any statements on June 23, 2024, or any other day, of the VA contemplating self-harm. P1 added, “If [the VA] made statements, we would have definitely had more eyes on [him/her].” SP3 added, “We would’ve done more if [the VA] had” made statements of suicidal ideation. · P1, SP1, SP2, and SP3 each said that if a client made self-injurious statements, staff completed a screening and contacted the clinical on-call staff person. Clinical on-call might make changes to the client’s care plan (e.g., increased safety checks) depending on the screening. The VA was not on increased safety checks while at the facility, including June 23, 2024. · P2 had no concerns that staff might disregard or not react to statements of suicidal ideation. “I would say it’s the opposite. It’s like, they’re very vigilant” about responding. · P1, P2, SP1, SP2, and SP3 each said that staff completed safety checks every four hours. Staff needed to have “eyes on” at each check. The checks included knocking on the client’s bedroom door and waiting for the client to respond. If the client did not respond, staff announced that they intended to enter the room and then did so. · P1, P2, SP1, SP2, and SP3 each said that at the time of the incident, the vacuum cleaners were stored in an accessible place on each floor. The clients were encouraged to work on life skills, which included keeping their bedrooms clean. The VA liked to stay busy and enjoyed cleaning and repairing the vacuum cleaners. There was nothing unusual about the VA taking a vacuum cleaner into his/her bedroom. · P1 and P2 each did not have concerns with SP1’s, SP2’s, and/or SP3’s conduct. “Absolutely not.” The facility’s camera footage showed the following: · A camera was mounted, which showed a hallway with a bathroom at the end. The VA’s bedroom was along this hallway. The camera did not show inside the VA’s bedroom. · On June 23, 2024, at 3:10:37 a.m., the VA exited his/her bedroom, walked down the hallway, and grabbed a vacuum cleaner from the hallway entryway. The VA carried the vacuum cleaner back to his/her bedroom. · Note: The camera was motion activated and so when there was no movement on the screen, it stopped recording. The camera footage for this incident jumped from 3:10:37 to 4:08:06 a.m., meaning, unless the camera malfunctioned, there was no movement to activate the camera during that timeframe. [Note: As previously stated, facility documentation stated that the VA was “sleep(ing) in RM” (room) at the 12 and 4 a.m. safety checks. A staff person was not observed on the camera walking down the VA’s hallway between 3:10:37 and 7:50:23 a.m.] · At 4:08:06 a.m., the VA exited his/her bedroom and entered the bathroom turning on the light. The VA did not close the door but stepped out of view into the bathroom. At 4:08:26 a.m., the VA exited the bathroom and returned to his/her bedroom. · At 4:11:36 a.m., the VA again walked to the bathroom turning on the light. The VA did not close the door but stepped out of view into the bathroom. At 4:12:00 a.m., the VA exited the bathroom and returned to his/her bedroom. · At 7:50:23 a.m., SP4 walked into the hallway. At 7:50:27 a.m., SP4 stopped outside of the VA’s bedroom door. SP4 stood facing the door. It was not clear what SP4 was doing. SP4 did not open the bedroom door. [Note: The VA’s bedroom door opened into the room, and it was not visible on camera. It was not clear if the door was open or closed at that point.] At 7:50:38 a.m., SP4 walked away from the VA’s bedroom door. SP4 stopped and wrote on a clipboard before leaving the hallway. [Note: As previously stated, facility documentation stated SP4 wrote “awake” for the VA at the time of this check.] · At 10:13:10 a.m., SP3 walked into the hallway. At 10:13:17 a.m., SP3 stopped outside the VA’s bedroom, facing his/her door. It was not clear what SP3 was doing. SP3 flipped through paperwork that s/he was holding. SP3 did not open the bedroom door; however, it was also not clear if the door was open or closed at that point. At 10:13:46 a.m., SP3 walked away from the VA’s bedroom door leaving the hallway. · At 10:34:43 a.m., SP1 walked into the hallway. SP1 walked up to the VA’s bedroom door and then immediately turned and walked away without stopping. SP1 was holding paperwork. SP1 did not open the VA’s bedroom door; however, it was also not clear if the door was open or closed at that point. · At 10:51:03 a.m., SP3 walked into the hallway. At 10:51:09 a.m., SP3 stopped outside the VA’s bedroom, facing his/her door. The camera then jumped to 10:51:36 a.m., showing SP3 walking at an accelerated pace away from the VA’s bedroom door. SP3 was holding his/her hands over his/her heart and looking toward the ground. · At 10:52:59 a.m., SP1 entered the hallway walking at an accelerated pace toward the VA’s bedroom and at 10:53:03 a.m., SP3 followed. · At 10:57:10 a.m., the LEO entered the hallway walking toward the VA’s bedroom. A Bloomington Police Report stated, “I observed [the VA] hanging from the cord of the vacuum, it appeared that [the VA] had been there for a while and was obviously deceased. [The VA] was cold to the couch [SIC] and [his/her] extremities were already turning purple. The cord was wrapped around the top hinge of [his/her] closet door, knotted, and then also ran to the clothes bar.” The facility’s internal review included additional information about the safety checks on June 23, 2024, including the 8 a.m. check completed by SP4. “Regular checks were completed on the 4-hour rotation as per policy. Within this policy, staff are asked to have eyes on each client and know the whereabouts of clients if they are not onsite … Staff are trained to have eyes on each client, [SP4] noted that [the VA] was awake because [s/he] was not in [his/her] bed at 8am checks. However, when interviewing [SP4], they did not have eyes on [the VA] and did not open [his/her] bedroom door fully to see the whole room.” The internal review did not mention or state concern with the 4 a.m. check. FM1, FM2, FM3, and the CM provided consistent information that the VA experienced anxiety. The VA did not want to be at the facility and asked more than once for someone to pick him/her up and take him/her home. The VA did not like the other clients’ music choices and use of marijuana, the facility’s food options and cleanliness, and the safety checks while s/he was sleeping. The VA did not believe s/he was receiving adequate time at the facility with his/her counselor. FM1, FM2, FM3, and the CM called the facility on the VA’s behalf and encouraged the VA to share his/her concerns with staff. FM2 also expressed concern that given the VA’s history of wanting to hang him/herself in March 2024, the facility should have taken greater action to limit the VA’s access to such things, like a corded vacuum cleaner. Facility documentation stated that SP1, SP2, SP3, SP4, P1, and P2 received training on the facility’s policies and procedures and the Reporting of Maltreatment of Vulnerable Adults Act. Information was provided that the facility did not notify the commissioner within 24 hours of receiving knowledge of the VA’s death. This was a violation of Minnesota Statutes section 245A.04, subdivision 16, which states in part that within 24 hours of receiving knowledge of the death of an individual served by the program, the license holder shall notify the commissioner of the death. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245A.04, subdivision 14, paragraph (b), clause (3), states the license holder shall monitor implementation of policies and procedures by program staff. Conclusion: On June 23, 2024, the VA died by suicide in his/her bedroom and there was concern that the VA made statements of suicidal ideation prior to the incident and/or earlier that morning. SP1, SP2, SP3, P1, and P2 each said that the VA had not made any statements of self-harm or thoughts of suicide, and they were not informed of any such statements made by the VA. The facility’s shift logs also did not contain this information. Facility documentation stated that the VA was sleeping in his/her bedroom at 4 a.m.; however, camera footage did not show a staff person checking on the VA at or around 4 a.m. Similarly, SP4 did not have eyes on the VA at the 8 a.m. check. SP4 marked the VA as “awake” at 8 a.m. because the VA was not in his/her bed. SP4 did not fully open the VA’s bedroom door to confirm the VA’s whereabouts. This conduct was inconsistent with the facility’s policy, which stated that at a minimum, staff conducted an “eyes-on check” of each client every four hours; and it was a violation of Minnesota Statutes 245A.04, subdivision 14, paragraph (b), clause (3). The VA was observed on camera awake and getting the vacuum or using the bathroom at 3:10:37, 4:08:05, and 4:11:36 a.m. Although there was a failure to conduct safety checks or have eyes-on the VA every four hours, given that it was unknown exactly what time the VA died, it was also unknown if checking on the VA or having eyes-on him/her at 4 and/or 8 a.m. would have resulted in a different outcome. After the 8 a.m. check, the next four-hour check was scheduled for noon. However, staff happened to check on the VA earlier, when at 10:50 a.m. the VA did not show up for his/her medications or the daily check in. At that time, staff did not have information the VA was contemplating suicide and there was no information provided that staff should have known or anticipated what actions the VA was taking or that they should have acted or checked on the VA sooner. Therefore, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services, which were reasonable and necessary for the VA’s physical or mental health or safety, considering the VA’s physical and mental capacity or dysfunction at that time. 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 policies and procedures were adequate. “Basic policies and procedures were followed, however, there [were] some procedural items that were not. Regular checks were completed on the 4-hour rotation as per policy. Within this policy, staff are asked to have eyes on each client and know the whereabouts of clients if they are not onsite … Staff are trained to have eyes on each client, [SP4] noted that [the VA] was awake because [s/he] was not in [his/her] bed at 8am checks. However, when interviewing [SP4], they did not have eyes on [the VA] and did not open [his/her] bedroom door fully to see the whole room. Additionally, Touchstone has a clinical on-call policy that requires on-call staff to return calls within 30 minutes of receiving them. On-call provider at that time did not respond until 6 hours after the phone call was made. The call was made to on-call staff after initial 9-1-1 call was made. Calls were made and answered by the Treatment Supervisor, program supervisor and interim director in addition to the on-call staff. Treatment supervisor, interim director and program supervisor arrived on site within an hour of being informed of [the VA’s death.” “We will be replacing all vacuums with cordless versions, all closet doors removed, current rods will be replaced with anti-ligature rods, anti-ligature blinds will be installed, and the city of Bloomington Fire Marshal has been contacted to consult on receiving approval for sealing windows. Staff will receive training on how to increase awareness of physical risks for our clients in their environment.” Action Taken by Department of Human Services, Office of Inspector General: On September 18, 2024, the facility was issued a Correction Order for the violations outlined in this report.
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