|
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: 1116211 -H_CRS (Home and Community-Based Services-Community Residential Setting) 1097629-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was not provided the required supervision and left the facility on two occasions. On one occasion, the VA entered a community person’s garage and attempted to abduct a minor. Date of Incident(s): May 25 and 29, 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 14, 2024; from documentation at the facility and law enforcement records; and through eight interviews conducted with the VA, facility staff persons (SP1, SP3, and P1), a facility supervisor (P2), the VA’s case manager (CM), the VA’s guardian (G), and an embedded social worker with law enforcement (ESW). The DHS investigator attempted contact with SP2 via phone call and United States mail to schedule an interview, but SP2 did not respond. Facility documentation provided the following information: · The VA liked to learn, listen to music, and spend time with his/her family; and enjoyed sugary coffees and hot chocolates. The VA was diagnosed with autism, developmental disabilities, and attention-deficit hyperactivity disorder. · The VA required 24-hour supervision, including 2:1 staffing during awake hours, and 1:1 awake overnight supervision. Staff persons were supposed to be within visual range of the VA when supporting the VA at the facility, and to be within arm’s reach of the VA while in the community to ensure his/her safety. · The VA displayed challenging behaviors in the community such as asking strangers to go home with them, walking into strangers’ homes without an invitation, engaging in “inappropriate touching” (mostly directed at females and minors), and exposing him/herself to minors. When the VA displayed these behaviors, staff persons were to place themselves between the VA and the community person if safe to do so and provide redirection to the VA. · The VA had a history of leaving his/her residence without supervision. The facility’s plan to reduce the risk of the VA leaving the facility unsupervised was to “ensure” the VA was “unable to elope from the home.” If staff persons lost sight of the VA, they were to follow the VA’s Elopement Plan. · The VA’s Elopement Plan provided the following information: o If the VA was missing or unaccounted for and staff persons were unable to find the VA on the facility premises, 9-1-1 should be contacted “promptly.” Staff persons should continue searching for the VA, and notify a facility supervisor immediately. o If the VA left the facility while staff were observing the VA, one staff person should follow the VA on foot, and the other staff person should follow in a vehicle. o During overnight shifts, the VA’s 1:1 awake overnight staff person was to position a chair by the VA’s open door while the VA slept to ensure ongoing observation. During overnight shifts if the VA left the facility staff persons should follow the VA and contact police for assistance if needed. o 9-1-1 should be contacted if staff persons lost sight of the VA and could not locate him/her after fifteen minutes. P2 said the facility had a monitoring system that included multiple cameras and sensors located on exit points (doors and windows) and if an exit point was opened a ringing alert was sent to a facility cell phone. Staff persons needed to “acknowledge” the alert, otherwise the alert would occur a second time. P2 said all staff persons were trained on the VA’s Elopement Plan which stated if the VA was not in the staff persons visual sight the staff person should contact 9-1-1 and report the VA as missing. Staff persons were trained to have the facility cell phone on their person while working with the VA. The facility had two floors, and the VA’s bedroom was located downstairs. The VA’s bedroom included a window which led to a fenced backyard, with a gate that opened to a driveway in the front of the house. A common area was located outside the VA’s bedroom door, and a stairway led from that common area to the front entry area of the facility. There was an alarm connected to exterior doors and windows that rang to a staff cell phone, which staff persons were supposed to have with them at all times. The VA completed an interview, but was unable to provide specific details regarding the incidents. During the interview the VA said s/he “ran away” and added that s/he planned to “elope” the day of the interview. The CM and the G provided the following information: § Prior to the VA’s crisis placement at the facility, Adult Protective Services were involved with the VA due to supervision concerns, and an emergency guardian was sought due to these concerns. The facility was aware of the VA’s history of challenging behaviors including the VA’s history of leaving caregivers without supervision. · The facility provided the VA with 2:1 staffing during awake hours, and 1:1 staffing during the overnight. As part of the VA’s placement at the facility an Elopement Protocol was created on March 28, 2024, to keep the VA and the community safe. The facility added monitoring technology in April 2024 to supplement the VA’s supervision. § The CM said law enforcement (LE) was made aware of the VA’s behavior, and although the facility said they were addressing incidents of the VA leaving the facility without supervision, it “just kept happening.” The G said there were ongoing concerns discussed with the facility regarding the staff persons’ training and staff persons not following protocol, and the G thought that if the VA’s protocol was followed some incidents could have been avoided. § The CM said there were instances when the VA left the facility and staff persons maintained visual contact until the VA returned to the facility without incident. However, the CM received information regarding the incident on May 25, 2024, that one staff person followed the protocol, but the other did not. The ESW said the VA had a “honeymoon period” after moving into the facility and the ESW thought the facility “had a really great plan in place” with the changes the facility made with the “security cameras and the alarms in the home.” However, things “started to turn” after the VA started leaving the facility unsupervised. Additionally, the ESW was informed the alarm had a delayed notification of approximately one and a half minutes. The following information was from a social media post, law enforcement records, the facility’s Internal Review (IR) of the May 25, 2024, incident, and interviews with SP1, SP3, P1 and P2: · A video was posted on social media that showed the VA while s/he was unsupervised in the community on May 25, 2024. The video showed the VA going onto a community person’s property in Savage, Minnesota, and having physical contact with a minor. The social media post had multiple comments regarding the VA potentially having developmental disabilities or a mental health diagnosis, the VA’s need for supervision, and multiple comments that suggested the VA should be physically harmed. · While investigating the May 25 and 29, 2024, incident, information was obtained that there were multiple prior incidents of the VA leaving the facility unsupervised: o On May 2, 2024, the VA “ran away” from the facility without supervision around 1 p.m., and was located in Lakeville, Minnesota around 3:30 p.m. The VA was transported back to the facility without further incident. o On May 5, 2024, at around 5 p.m., the VA was on a walk with SP3 and P1 and ran away from SP3 and P1. The VA touched a minor’s “small of [his/her] back/side” and “hip” before SP3 physically moved the VA away from the minor. § P1 said that while on the walk the VA started running, and both SP3 and P1 ran after the VA. However, the VA made it to the minor before SP3 or P1 could intervene. P1 said once s/he was able to get near the VA, the VA had ahold of the minor, but P1 got between the VA and the minor. Afterward, SP3, P1, and the VA returned to the facility. § This incident was not immediately reported to LE. LE was contacted by the facility on May 10, 2024, however the minor involved was unknown at that time. On or around May 17, 2024, additional information was provided to LE regarding the minor involved. o On May 13, 2024, at around 3 a.m., the VA left the facility without supervision. A staff person contacted LE fifteen minutes after the VA left the facility. LE located the VA around 7 a.m. when s/he was found sleeping in a medical facility hallway. The VA told LE s/he had “walked away” from the facility when staff persons were sleeping, and the VA did not tell anyone s/he left. · On May 25, 2024, around 5:15 p.m., SP1 and SP2 contacted LE after the VA left the facility without supervision. At 6:31 p.m., LE located the VA in Savage, Minnesota. · The IR included a review of camera footage dated May 25, 2024, which showed a maintenance person rang the facility’s doorbell and knocked on the door before walking away at 5:15 p.m. At 5:16 p.m., SP2 exited the house and walked towards a maintenance vehicle. The maintenance person walked towards the front door carrying supplies. At 5:17 p.m., SP2 walked towards end of the driveway, and the VA ran out the front door towards the street, crossing the yard, and passing by SP2. SP1 came out of the front door right after the VA. SP2 turned toward the direction the VA ran, and watched the VA leave, before walking towards the maintenance vehicle. SP1 told facility investigators that s/he told SP2 to follow the VA on foot while SP1 got his/her vehicle, and in the video footage SP1 “appeared to be trying to get [SP2’s] attention to chase [the VA].” SP1 and SP2 then got into SP1’s vehicle and went in the direction the VA had gone. SP1 believed s/he followed the Elopement Plan, but SP1 said SP2 did not because SP2 did not follow the VA on foot as instructed in the Elopement Plan and as SP1 instructed SP2 to do. · The IR noted, “Despite increased staffing and home modifications, [the VA] continues to elope frequently, often escaping staff supervision. . . [The incident on May 25, 2024] resulted in videos of [the VA’s] behavior circulating on social media, leading to threats against [the VA] and the identification of the program’s location. This has increased community hostility and the risk of harm to [the VA].” · During the internal investigation the facility determined that SP2 had not completed training on the VA’s client specific plans. The facility determined this was an oversight from a previous supervisor regarding SP2’s training at the facility. · SP1 and P2 said prior to the VA leaving the facility on May 25, 2024, SP1 was supervising the VA inside the facility and SP2 was assisting a facility maintenance person outside. SP1 said s/he followed the VA outside, but returned inside to get keys to a vehicle after the VA started running away. SP1 thought SP2 was following the VA on foot, however after returning outside s/he saw that SP2 was not following the VA. SP1 told SP2 to follow the VA, then SP1 and SP2 got into a vehicle and attempted to locate the VA by driving around the neighborhood in search of the VA. SP1 and SP2 were unable to find the VA and immediately contacted LE regarding the VA leaving the facility. · SP2 completed a “General Event Report” at 6:01 p.m., on May 25, 2024. SP2 noted that prior to the incident the VA was pacing around the basement, watching TV, and making indiscernible noises. A facility maintenance person arrived at the facility and SP2 helped him/her bring supplies into the facility. While SP2 was outside helping the maintenance person the VA sprinted out the front door and away from the house. A supervisor and LE were contacted, and SP1 and SP2 drove around attempting to locate the VA. · LE records included the following information about the May 25, 2024, incident: o LE received a missing person’s report about the VA at 5:19 p.m., on May 25, 2024. o On May 25, 2024, at 6:15 p.m., LE received and responded to a call reporting that the VA engaged in “suspicious activity” and attempted to “grab” a community person (minor). The VA was arrested for “Kidnapping – To Commit Great Bodily Harm/Terror.” It was noted the VA was “unable to provide a clear statement” regarding the incident with the community person. LE contacted the facility regarding the VA. o SP2 informed LE the VA had left the facility “out of nowhere in a full sprint.” After speaking with LE, the VA and SP2 returned to the facility. o The VA was not harmed while unsupervised in the community. However, while with LE the VA’s vitals were checked by paramedics due to the VA stating s/he was “feeling sick.” o The Scott County Attorney reviewed the case and declined to file criminal charges. · P2 said during an overnight shift on May 29, 2024, the VA left the facility after SP3 fell asleep. P2 said SP3 was sitting in the VA’s bedroom when s/he fell asleep. · SP3 said on the night of May 28 to 29, 2024, s/he was working the overnight shift and was in the VA’s bedroom. SP3 fell asleep, and the VA left the facility while SP3 was sleeping. SP3 did not have the facility cell phone with him/her (which sounded an alarm if a door or window was opened). When SP3 awoke and saw the VA was no longer in his/her bed, SP3 drove around the neighborhood for approximately 15 minutes trying to locate the VA, then contacted LE to report the VA missing. · LE records showed that on May 29, 2024, around 4 a.m., SP3 contacted LE to report the VA left the facility around 3:30 a.m. The VA was located by LE before 5 a.m., and returned to the facility unharmed. · P2 did not think the VA was being left unsupervised, but rather staff persons were not being “vigilant” in being “right next to” the VA “at all times,” which led to the VA leaving the facility without staff persons. P2 said there were around ten incidents where staff persons were able to redirect the VA after s/he left the facility and “convince” the VA to return to the facility. During those incidents LE was not contacted. The facility made changes to the VA’s care and services, which included a Rights Restriction for the following: · The VA could not have a lock on his/bedroom door and the door was to be open when in the VA was in the bedroom. · The VA’s community activities were conducted in areas that were further away from the facility and not near children's parks, playgrounds, or crowded places. · The VA enjoyed going on walks, and staff persons chose walking routes that were more secluded to minimize the risk of coming in contact with minors. · While the VA was in the community, staff persons took “proper steps” to avoid areas where there could be contact with minors. The facility’s Policy and Procedures on Responding to and Reporting Incidents stated the following: · If unauthorized or unexplained absence of a vulnerable adult occurred, staff persons should refer to the vulnerable adult’s support plan for specific instructions on elopement protocols. · Staff persons should immediately call 9-1-1 if a vulnerable adult was determined to be missing, and provide a description of the vulnerable adult. · Staff persons should also immediately notify a facility supervisor, and if possible, a more extensive search would be organized. A facility supervisor would continue to monitor the situation. · If there was reasonable suspicion that abuse or neglect led to or resulted from the unauthorized or unexplained absence, staff persons should report immediately in accordance with applicable policies and procedures for reporting and reviewing maltreatment of vulnerable adults or minors. P1, P2, SP1, and SP3 were trained on the VA’s client specific information including the VA’s Elopement Plan, the facility’s policy and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. SP2 was trained on the facility’s policy and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. However, SP2 did not complete training on the VA’s client specific information, including the VA’s Elopement Plan. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.09, subdivision 4a, paragraphs (a) and (c) stated in relevant part that before having unsupervised direct contact with a person served by the program, or for whom the staff person has not previously provided direct support; the staff person must review and receive instruction on the person's support plan or support plan addendum as it relates to the responsibilities assigned to the license holder, and when applicable, the person's individual abuse prevention plan, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. Conclusion: Regarding the incident on May 25, 2024: It was reported that on May 25, 2024, the VA left the facility unsupervised while SP1 and SP2 were assigned to supervise the VA. At 5:15 p.m., SP2 went outside the facility to help a maintenance person while SP1 remained inside with the VA. The VA ran out of the facility, and SP1 followed the VA outside, where SP2 was still located. The VA continued to run away, and SP1 told SP2 to follow the VA on foot. SP1 went inside the facility to get keys to a vehicle, found SP2 still outside the facility, then SP1 and SP2 drove around in an attempt to locate the VA. SP2 contacted a supervisor, and contacted 9-1-1 at 5:19 p.m. Approximately one hour later, LE received a report that the VA made physical contact with a minor in Savage, Minnesota. The VA was arrested for attempted kidnapping, but no criminal charges were filed. During the internal investigation the facility determined that SP2 had not completed required training on the VA’s client specific documentation, including the VA’s Elopement Plan, which was a violation of Minnesota Statutes, section 245D.09, subdivision 4a, paragraphs (a) and (c). Based on the information obtained SP1 followed the VA’s Elopement Plan, but SP2 did not follow some aspects of the Elopement Plan. Although the VA’s Elopement Plan was not completely followed, during the incident SP1 and SP2 took immediate action to try to follow and locate the VA, and contacted a supervisor as well as LE. Therefore, there was not a preponderance of the evidence as to whether there was a failure to supply the VA with care or services which were reasonable and necessary for the VA’s health and 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). Regarding the incident on May 29, 2024: Based on the VA’s plans and the facility’s policies, during overnight shifts, staff persons were to remain awake, maintain visual observation of the VA, and have the facility cell phone on their person. SP3 acknowledged that on May 29, 2024, s/he fell asleep while supervising the VA and did not have the facility cell phone on his/her. While SP3 slept, the VA left the facility without supervision, and LE was contacted by SP3 after s/he woke up. The VA was found by LE and returned to the facility. There was no harm to the VA or any other person. The VA had multiple previous and recent incidents of leaving the facility without supervision, including the incident on May 25, 2024, where the VA approached a child in the community and was arrested for attempted kidnapping. In addition, after the May 25, 2024, incident, multiple comments were posted to social media that suggested the VA should be physically harmed for his/her actions. The facility determined in its IR that, “This has increased community hostility and the risk of harm to [the VA].” Given the VA’s recent history and the community response, there was a significant risk of harm both to the VA and to others when the VA was in the community without supervision. Given that required supervision of the VA was not maintained, and the VA left the facility unsupervised, there was a preponderance of evidence that there was a failure to supply the VA with reasonable and necessary care and services. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The VA’s client specific documentation showed the VA required 1:1 awake overnight supervision, and that the VA had a history of leaving his/her residence. In addition, SP3 was present on May 5, 2024, when the VA was involved in an incident in the community with a minor. Further, SP3 was trained on the VA’s client specific documentation, was aware of the VA’s supervision requirements, and acknowledged that s/he fell asleep when s/he was responsible for supervising the VA on May 29, 2024. Therefore, it was determined that SP3 was responsible for the maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which SP3 was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident, did not result in an injury that required treatment by a physician, and did not result in criminal sexual conduct against a child or vulnerable adult. Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, but not followed. The report was similar to past events as the VA had a history of leaving his/her residence unsupervised. The facility retrained all staff persons on client specific plans for the VA and other service recipients. Facility supervisors were monitored to ensure they were physically present at the facility to provide support and guidance to staff persons, and reinforce the importance of adhering to established protocols, conducting regular drills, and reviewing protocols to ensure compliance. SP2 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP3 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP3 was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of SP3. The determination that SP3 was responsible for maltreatment is subject to appeal.
|
