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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: 1123830-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jason Pehler 651-431-6553 Suspected Maltreatment Reported: It was reported a staff person (SP) fell asleep and a vulnerable adult (VA) left the facility unsupervised. Date of Incident(s): July 3, 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 July 29, 2024; from documentation at the facility and law enforcement records; and through five interviews conducted with the VA, a facility supervisor (P), the VA’s guardian (G), the VA’s case manager (CM), and the SP. The facility was a single-story home which was located on 70th St. E in Inver Grove Heights, Minnesota. The street was a two-way street and there was not a sidewalk on the facility side, however there was a sidewalk on the opposite side of the street. The street had consistent traffic while this investigator was present at the facility. The facility utilized a camera system, with one camera located on the garage, which captured the driveway looking towards the street. Another camera was located in the kitchen and captured an area including a door which led out of the facility and onto the driveway. An alarm was located on the top corner of the door and sounded when the door was opened. Facility documentation showed the VA loved watching TV, and liked to go for walks, garden, play games, and craft. The VA was described as “funny,” had good conversational skills, and liked to joke. The VA was diagnosed with borderline personality disorder and schizoaffective disorder. The VA had reported seizure activity, but it had not been witnessed by other people. The VA did not have any alone time, and required 1:1 awake supervision 24 hours a day due to his/her medical and behavioral vulnerabilities. The CM said the VA had a history leaving his/her residences without required supervision. The VA did not require “eyes on” supervision if s/he was inside the facility or in the backyard, but staff person should “frequently check” on the VA while s/he was on facility property. The CM added, the VA required staff persons to be with him/her in the community. The VA’s Self-Management Assessment provided the following information: · The VA had a history of leaving his/her residence without supervision, however mobility issues interfered with this. The VA used a walker to assist him/her with mobility and was at a “higher risk” of falling due to previous injuries. · The VA had a history of self-injurious behaviors, including jumping in front of moving vehicles. · The VA lacked physical and sexual boundaries which made the VA vulnerable to abuse and exploitation in the community. The VA also had a history of stealing items from stores or other persons. · If the VA left the facility without staff persons, 9-1-1 should be contacted. Law Enforcement (LE) records provided the following information: · On July 3, 2024, at 12:43 p.m., LE was contacted by an unknown community person after the VA asked for water and the VA stated s/he had “escaped” from the facility. LE records showed an officer had observed the VA leaving the residence at an unknown time. · LE made contact with the VA at 12:51 p.m., near 70th St. E and Dawn Ave. The VA told LE s/he went for a walk, and the SP was napping. The LE returned the VA to the facility at 1:02 p.m. LE documented the SP was awake and appeared to be looking for the VA. The SP told LE the VA had “just left.” Based on an internet map, the intersection of 70th St. E and Dawn Ave. was 0.3 miles from the facility. The P provided the following information: · On the date of the incident, the camera located in the kitchen did not capture the VA leaving the facility due to the camera angle. The camera on the garage showed the VA leaving the facility without the SP, but did not capture what the SP was doing when the VA left the facility. · The P said the SP had a previous incident where s/he was found sleeping on the couch, however during that incident the VA had remained at the facility. The P said the SP was informed of the expectation of being awake during working time. · The P said the door alarm always “beeped” when s/he entered the facility, and there was no reason for the door alarm to have been disabled the day of the incident. The VA’s progress notes on July 3, 2024, were written by the SP and documented that the VA and SP went on a walk at 8:18 a.m., and returned to the facility at 8:56 a.m. The SP noted s/he did not feel well and asked the VA if the SP could close his/her eyes. The SP set an alarm for five minutes, however when the SP opened his/her eyes the VA was no longer at the facility. The SP went outside and saw LE returning the VA to the facility. The SP provided the following information during his/her interview: · On July 3, 2024, the VA and the SP went on a walk and upon returning the SP told the VA that his/her head hurt. The SP set an alarm on his/her phone for five minutes, and closed his/her eyes. The SP said s/he opened his/her eyes when the phone alarm when off, and the VA was not at the facility. The SP believed the VA left the facility “the minute I closed my eyes,” and did not state whether or not the door alarm went off. The SP immediately started looking for the VA, and went outside. At that time LE arrived at the facility. · The SP said s/he closed his/her eyes between 8:30 and 8:45 a.m., and LE returned the VA around 9:12 a.m. · The SP said there was a prior incident where s/he had fallen asleep and was aware of the expectation of being awake while working with the VA. The VA said s/he was unable to recall the incident and did not want to get anyone in trouble. The G described the VA as “inconsistent” when providing information, and said the VA was not harmed during the incident. The facility’s Employee Handbook stated staff person were prohibited from “falling asleep at any given time, nodding off, resting their eyes, taking cat naps, laying down, stretching out, bringing pillows, blankets, covers and/or comforters to work.” Staff persons were required to remain both awake and alert at all times. The P and the SP were trained prior to the incident on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s Employee Handbook, and the VA’s individual client specific programming. Conclusion: A. Maltreatment: It was reported that on July 3, 2024, the SP fell asleep, and the VA left the facility unsupervised. The SP acknowledged that s/he set an alarm for five minutes and closed his/her eyes between 8:30 and 8:45 a.m. The SP said when s/he opened his/her eyes about five minutes later, the VA was not at the facility, and LE returned the VA to the facility at 9:12 a.m. However, LE records showed 9-1-1 was contacted at 12:43 p.m., by an unknown community person, LE made contact with the VA at 12:51 p.m., and LE returned the VA to the facility at 1:02 p.m., approximately four hours after the SP said s/he closed his/her eyes. The VA required 1:1 awake supervision 24 hours a day due to his/her medical and behavioral vulnerabilities. The VA’s client specific documentation showed the VA had a history of leaving his/her home without supervision; a history of stealing items from stores or other persons when unsupervised; engaged in self-injurious behavior including jumping in front of vehicles; was at a “higher risk” of falling; and was vulnerable to abuse and exploitation when unsupervised in the community. Although the VA was not harmed when s/he was unsupervised in the community on July 3, 2024, during the time the VA was unsupervised in the community s/he required care and services from a community person, and LE was contacted to ensure the VA’s health and well-being. Therefore, there was a preponderance of the evidence that there was a failure to provide care and supervision which was reasonable and necessary to maintain the VA’s health and safety. 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 SP was trained prior to the incident on the facility’s Employee Handbook, the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s client specific programming. Additionally, the SP had previously been found sleeping at the facility, and was made aware of the expectation of being awake while working prior to the July 3, 2024, incident. Given the above, the SP was responsible for 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 the SP was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and did not result in an injury that required treatment by a physician. Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, but were not followed. The facility provided additional training to the SP on the VA, and the SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP 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 the SP. The determination that the SP was responsible for maltreatment is subject to appeal.
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