|
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: 1118740-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns 651-431-6513 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) told a staff person (SP) that s/he was going to leave the facility during the night and that the SP failed to prevent the VA from leaving and did not attempt to follow the VA as is stated in the VA’s plans. Date of Incident(s): June 18, 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 24, 2024; from documentation at the facility, facility surveillance video and audio, and law enforcement records; and through seven interviews conducted with three supervisory staff persons (P1, P2, and P3), one facility staff person (P4), the VA, the VA’s guardian (G), and the SP. The VA was diagnosed with anxiety, depression, and post-traumatic stress disorder. The VA’s Individual Abuse Prevention Plan stated that the VA had a history of being sexually trafficked and was at risk of sexual exploitation. The VA had a history of leaving the facility without supervision to meet with unfamiliar individuals and has attempted to engage in risky sexual activities for monetary compensation or goods like cigarettes. The VA was “very outspoken” and might put him/herself in situations that could become dangerous. The VA enjoyed socializing, meeting new people, doing crafts, and going shopping. The VA was the only client who resided at the facility. The VA was subject to guardianship, had no unsupervised time in the community, and had a history of leaving the facility without supervision. The VA had two to one supervision during the day and overnights, with three to one supervision in the evenings. The SP’s position was a scheduled “awake” position that was scheduled from 11 p.m. to 7 a.m. Another staff person was scheduled during those hours as a designated “asleep” position. The VA’s “Elopement Plan” stated that the VA typically planned and took specific steps when s/he planned to leave without supervision. The VA would “announce” his/her desire to leave, would don weather-appropriate clothing, and would bring a backpack. Staff persons were to provide the VA a structured routine, offer spaces where the VA could “calm down” and keep a line of sight on the VA. Talking to the VA in an “upbeat tone” or reminding him/her of relaxation skills helped. Staff persons were to make every effort to follow the VA on foot, or in a vehicle if the VA was moving quickly. Staff person were to ask the VA about his/her destination and the people s/he planned to meet to understand the VA’s intentions. If a staff person were to lose sight of the VA after 30 minutes or it was after dusk, staff persons were to call 9-1-1. The facility was a split-level house with an attached garage. The VA’s bedroom was upstairs at the end of a hallway, along with an office, a living room area, a bathroom, and a kitchen. The lower level had another office, a bedroom for designated asleep staff persons to be in during overnights, a common space, and a laundry area. Two cameras were present and working in the main floor common areas; one in the living room pointing toward a sofa, a love seat, a front door area, and down the hall, showing part of the VA’s bedroom, and another in the kitchen, the latter of which was not used for this investigation. Another camera was outside mounted on the garage, pointing toward the driveway and the house. The VA provided the following information: · A few months prior to the interview, there was an incident where the VA left the facility without supervision and the SP did not follow the VA, or even get up to follow the VA when s/he left the facility. The VA walked to McDonald’s and stayed there. In the morning, P3 and another staff person picked up the VA from McDonald’s and drove him/her back to the facility. The VA was not hurt. · The SP was supposed to follow the VA when s/he left without supervision. There were no other issues with the SP, but the VA did “not like” the SP. · The SP was “making [the VA] mad,” was “being rude,” and was “telling [the VA] to shut up” ten times and said, “Shut the fuck up.” The VA said s/he was not going to let people disrespect him/her and the VA said, “Fuck you,” to the SP and left through the front door. The VA could not recall what led up to this argument. (Investigator’s note: this exchange was not observed or heard on the video recording). · The VA could not recall who else was working that night as there were always two staff persons during the overnights and morning shifts. There were always three staff persons during the evening hours. · The VA was not sure what time this happened but called him/herself a “night owl” and said s/he liked to stay awake at night. · The VA did not have unsupervised time in the community. This investigator viewed the video from two camera angles including the living room camera and the front outside camera which provided the following information: · On June 18, 2024, prior to 1:18 a.m., the VA was on his/her cell phone speaking with a family member and having a disagreement. The VA appeared to be upset and angry. · At 1:18 a.m., the SP was laying on a sofa in the living room with his/her lower body under a blanket and the VA was still talking on the phone in the hallway. Lights in the facility living room area and in the VA’s bedroom were turned on. At 1:19 a.m., the VA went outside through the front door. The SP sat up, looked at his/her cell phone, got up, turned off the kitchen and living room lights before laying back down on the sofa under the covers. The VA was standing outside through the front door. · At 1:25 a.m., the VA entered back into the facility and went into his/her room. At 1:26:44 a.m., the SP who was still on the couch pulled the blanket up to his/her neck. The only visible part of the SP’s body was his/her head. The SP picked up his/her cell phone again and was speaking into his/her phone and was back under the covers from the neck down. The phone was visible and the SP was facing the phone, away from the camera angle. Based on what this investigator could hear, the conversation was not to law enforcement. At 1:27 a.m., the facility phone rang and the VA answered the facility phone. It was the VA’s family member. The SP continued to speak into his/her cell phone. After talking to the VA, the family member asked to speak with the SP. The VA walked out the front door at about 1:30 a.m. The SP then told the family member, “[The VA] left already.” The SP was still on the couch under the blankets from the waist down. The family member was heard telling the SP that the VA said that s/he was going to leave the facility and that the family member had called law enforcement. The family member was letting the SP know in the event that the SP was unaware that the VA was going to leave. · At 1:32 a.m., a law enforcement officer (LEO) was seen standing outside of the facility. The SP and the family member stopped talking when the LEO entered the facility and asked to talk to the SP. At 1:34 a.m., the law enforcement officer told the SP that they were going to try to get the VA back into the house, but that they would not be “chasing” the VA all night, that they would not be “dragging” the VA back into the facility, and that the LEO “did not want [the SP] to have to chase” the VA “all night.” The SP told the LEO that the VA would be out front but would come in and that the VA wanted “attention like that.” (Investigator’s note: the LEO never told the SP not to follow the VA). · At 1:44 a.m., the LEO walked outside and the SP laid back down on the couch and made another phone call. · At about 1:48 a.m., the VA opened the front door and called the SP by name. The SP responded, “What?” The VA said, “I’m leaving.” The SP replied, “Okay, [VA’s name].” The VA then walked toward the end of the facility’s front driveway. The LEO’s vehicle was still parked across the street. The VA walked off camera and the LEO drove away. It did not appear as though the LEO saw the VA leaving at that time as neither the LEO nor the VA returned to the facility’s surveillance video. At the time the LEO left and the VA did not return inside the facility, the SP was observed on the video laying on the couch and under a blanket. · At about 3:11 a.m., the SP looked at his/her phone and then turned his/her body toward the back of the couch. The SP’s eyes and face could not be seen from the camera angle. At approximately 4:04 a.m., apparent snoring was heard coming from the SP. · The SP did not appear to get off the couch until approximately 6:49 a.m., when P3 arrived. P3 said, “Good morning,” two times, and the SP sat up from a lying down position on the couch. P3 asked the SP if the VA was still sleeping and the SP responded, “We called you the whole night, like damn.” It did not appear as though P3 heard the SP. Approximately one minute went by as the SP entered the VA’s room and the bathroom, then asked P3, “Do you know that [the VA] run out during the night?” P3 responded, “What’s that?” and the SP sat down on the couch and replied, “[The VA] run out in the night.” P3 asked the SP, “[The VA] ran out in the night? Where did [s/he] go?” The SP replied, “I don’t know. [The VA] had a misunderstanding with [his/her family member].” P3 asked, “Okay, where is [the VA] now, sleeping?” The SP replied, “No, [the VA] just left again.” P3 asked, “Just now?” The SP, still seated on the couch and looking at his/her phone, said, “No. [The VA] left about, uh, let me see the time. Yeah, six.” P3 asked, “You guys didn’t follow [the VA]?” The SP replied, “Huh?” P3 repeated the question. The SP responded, “I followed [the VA], and then [s/he] kept insulting me and insulting me.” · At about 6:57 a.m., P4 went to the entryway of the facility and P3 told P4 that the VA left during the overnight. P4 could be heard saying, “Why didn’t you tell me anything?” P3 then called the VA and spoke with the VA for several minutes. The SP could be heard telling P4 that the LEO was there and told P4 that nothing could have been done. P4 left for the day at about 7:02 a.m. Later in the video, the SP, appeared confused and asked another staff person if s/he heard the SP knocking on the door during the overnight. P3 told the SP that the staff person s/he asked was not P4 and that it was P4 who had worked the overnight. P3 provided consistent information with the video and added the following information: · The SP did not call or text P3 after the VA left without supervision. P3 had told staff persons to “blow up” his/her phone if P3 was sleeping and could not be reached. · The SP told P3 that s/he called law enforcement twice and that the VA had left “multiple times,” and that law enforcement told the SP not to go look for the VA. · P3 called the VA’s cell phone after s/he realized that the VA was gone. No one had attempted to call the VA prior to that point. The VA answered P3’s phone call and told P3 where P3 could pick him/her up. The VA was “okay” and had been at a local McDonald’s several miles away the whole night until the McDonald’s opened in the morning and started serving breakfast. P3 and another staff person picked up the VA and brought him/her back to the facility. As the VA was saying goodbye to one of the McDonald’s employees, P3 saw the VA “take a hit” off a vape pen. The VA got into the facility van and told P3 and the other staff person that it was a “weed vape” and that the VA was “going to be high right now.” The VA was not of legal age to use marijuana or vape products. Once back at the facility, the VA slept most of the rest of the day. · The SP handled everything “inappropriately” and appeared to have “zero investment” in the things staff persons were trained on. The SP did not “support” the VA, and did not guide or redirect the VA. · If the VA left without supervision, two staff persons were supposed to follow the VA; one “on foot” and the other in the facility van. If the VA left the view of staff persons, staff persons were to call law enforcement. If staff persons felt it was unsafe to follow the VA at night, they were to contact law enforcement to ask for assistance. P3 was also to be notified “immediately.” · Awake staff persons were always scheduled as awake positions and asleep staff persons were always scheduled as asleep positions so that there was no confusion over which staff person would be awake or asleep. The SP provided the following inconsistent information over the course of several interviews and compared to the video/audio footage: · On the night of the incident, the SP was working an awake overnight shift while P4 was downstairs working the asleep shift. The VA had a history of leaving without supervision during the overnight hours so awake duties consisted of “checking on” the VA, and making sure s/he stayed at the facility, and calling “supervisors” if s/he left the facility. The SP was “not to follow” the VA if s/he left without supervision but instead to call law enforcement. · At around 1 a.m., the VA was having an argument with his/her family member via a telephone call where both the VA and the family member were “angry” with one another. The VA told the SP that s/he was “leaving,” and the SP said that s/he replied “Okay, [VA’s name].” The VA then told the SP that s/he was going to “kill [him/herself] and if you follow me I’ll kill you.” The VA then left the facility so the SP “ran downstairs” and “called for [P4]” telling P4 that the VA was leaving. The SP “ran out” and “called the cops.” Law enforcement was “close” and arrived within “five minutes.” The SP told the LEO that the VA did not want to see the SP and was “gonna kill me.” The LEO then told the SP to “stay inside” so that they could talk to the VA and bring him/her back inside the facility. After the LEO brought the VA back in the facility, the VA went into his/her bedroom and “was sleeping.” · The SP could “hear [the VA] talking” once the VA was inside his/her bedroom. The SP turned off the TV at around 5 or 6 a.m. and “discovered [the VA] was not” in his/her room. The SP ran outside to look for the VA and took the facility phone with to call the VA. The VA was “rejecting calls,” and the SP then called P3, and then P3 called the VA and said s/he was coming to get the VA. · The SP stated that s/he sent text messages so s/he would “have proof” and one call went to voicemail and with the second one, the SP “had to make sure” that s/he called. The VA came back to the facility on his/her own at “3 something” in the morning and when the VA arrived, s/he again left, and “overnight staff” persons looked for the VA. “Overnight staff” persons could not see the VA, and since staff persons were “not supposed to run after [the VA] at night,” the SP called law enforcement again. Law enforcement could not find the VA. The SP stated that the LEO called the SP and they “both updated one another.” The SP then updated P3, and at 3 a.m., the VA “came back and opened the door.” The SP then asked the VA why s/he left without telling the SP. · The SP insisted that s/he followed the VA the “first and second time.” Upon further questioning, the SP stated that after the VA left without supervision, the SP called law enforcement “immediately” and the VA was at the front door. When the LEO came into the facility, s/he told the SP to “stay put” and then the VA came back inside. · The SP did not know if there were video cameras in the facility and denied sleeping. The SP usually laid down on the couch in the living room while working. The SP denied snoring when awake. · The SP insisted that s/he knocked on the door where P4 was sleeping when the VA left and that P4 “didn’t wake up” and the SP later told P4 “not to lock the door again.” The SP talked to the VA and told the VA to “calm down” and the VA replied, “I am going to kill you.” · The SP did not see what happened as “abuse or maltreatment” because the SP stated that s/he called P3 and law enforcement, with the LEO arriving around 1:30 a.m. · The SP said that s/he did not follow the VA at night because it was against facility policy to do so. · The SP was usually watching television, chatting, or documenting something when s/he worked. The SP was supposed to document every hour what the VA’s status was. The SP said that sometimes the “service did not work” and staff persons would document in the morning. When asked why the SP documented that the VA was at the facility if the VA was gone all night, the SP said the VA was on a phone call for a while before s/he fell asleep. The SP did not answer this investigator’s question and reiterated that the VA was at the facility, asleep. The SP insisted that s/he could hear the VA on the phone in his/her room. The SP later called this investigator to talk more about the incident and provided the following additional information: · The SP was working a lot of hours and was in school, and had picked up “a lot of shifts, working sixteen hours for three days.” The SP insisted s/he called law enforcement and that the VA’s family member also called law enforcement. The LEO arrived and about 30 minutes later, the VA went to his/her bedroom, before coming back out and telling the SP that s/he was “leaving.” The SP replied, “Bye,” to the VA and the VA went outside. The SP thought that the VA was smoking outside and would come back in, so the SP sat on the couch. The SP was not “feeling well.” The SP tried to “call in” for the overnight shift but could not find coverage. When the VA left the facility, the SP insisted s/he called law enforcement and P3 and when the VA left the “second time,” the SP did not know what time that was. · The SP would “never intentionally neglect” the VA or “allow [the VA] to be in danger.” After calling P3, the SP wrote an incident report. P3 reviewed the report and told the SP to add what time the VA left the facility because s/he was unsure what time the VA left. The SP “did not feel comfortable” writing what time the VA left the facility because the SP “did not feel comfortable saying things that aren’t actually true.” · The SP told this investigator that the VA snuck out “without my notice,” and could not explain how the VA snuck out “without my knowledge.” “It wasn’t intentional, sorry about it.” · The SP was unable to provide screenshots of his/her call log or documentation that showed that s/he called law enforcement or notified P3 on June 18, 2024. The SP also was unable to provide documentation of the text messages s/he sent to the VA. The SP stated s/he texted the VA through Snapchat but that the VA did not “pick up.” The SP could not recall what time s/he sent the VA a message via Snapchat. The SP could not find the call log of his/her calls to the VA. The SP provided documentation that the SP was present on the night of the incident at the facility. · The SP stated that s/he slept during the overnight shift the day of the incident because s/he was “tired” and “had a headache.” · When the SP called P3, it went to voicemail but the second time the VA left without supervision, the SP did not call P3 because s/he “did not know” the VA left. The SP thought that the VA left a second time at around 2 a.m. and on that occasion, did not follow the VA. When the SP woke up, s/he told P3 that s/he had “been calling” P3. The SP also said that P3’s number was “not going through.” The SP said that s/he was trying to call P3 in the morning while P3 might have been on his/her way into work because the SP thought that P3’s phone was “maybe” set to “do not disturb.” · The SP stated that s/he should not have come in for the shift when asked what s/he could have done differently. The SP stated that s/he could have observed the VA and called law enforcement the second time so that they could look for the VA. The SP could have woken up P4 and if P4 had not locked the door, P4 may have heard the SP knocking. The SP stated that s/he knocked very loud “several times” the first time the VA left without supervision at around 1 or 1:30 a.m. (Investigator’s note: this description does not align with the video and audio). The VA was not heard on video telling the SP that s/he would “murder” the SP and the SP was not seen following the VA. The VA did not leave the facility again around 6 a.m. as the SP told P3 as s/he never returned to the facility after approximately 1:48 a.m. The SP was not observed attempting to wake P4 at any point nor did the SP call law enforcement to have them search for the VA again at around 6 a.m. as the SP told P3 s/he had done. At around 7:43 a.m., P3 and another staff person left to pick up the VA. The video ended before they arrived back to the facility. P4 provided the following information: · P4 worked overnight asleep shifts. When s/he arrived, the VA was awake and P4 talked with the VA for a little bit. P4 then went to sleep in the lower-level bedroom. P4 woke up at around 6:40 a.m. to do shift notes, but when s/he came out of the bedroom, P3 was there and P4 learned that the VA left without supervision during the overnight hours. P4 and the video showed that P4 asked the SP why the SP did not wake P4 up. The SP said that there was nothing that s/he could do because the SP called law enforcement. · P3 then called the VA and the VA answered, telling P3 that s/he was at McDonald’s. It was not a 24-hour McDonald’s but the VA stated that s/he sat outside until it opened and an employee there bought him/her breakfast. · P4 was not woken up by the SP. P4 was to be woken up if the VA left the facility without supervision. Generally, the awake overnight staff person would call law enforcement and P4 would go outside and start looking for the VA walking on various streets in the area. P4 would circle the block using his/her cell phone flashlight. · When the VA left on foot, P4 sometimes searched on foot, but other nights, staff persons would get in the facility van to locate the VA. The VA was “pretty fast” and there were times when P4 arrived and the VA was preparing to leave. P4 usually got the car keys ready so that staff persons could follow him/her. · Generally, staff persons would talk to the VA or attempt to calm the VA down and engage with the VA to “relate” to the VA. This sometimes prevented the VA from leaving. P1, P2, and the Internal Review provided information mostly consistent with the video footage and added the following information: · P1 stated that the scheduled overnight shifts were designated as awake or asleep and that the SP was hired for an awake position. · P1 stated that the VA sometimes made threats of “physical aggression” towards staff persons, but that the VA had not shown that behavior in “a while.” · According to the Internal Review the VA was “unaccounted for” and without supervision from 1:48 a.m. until 8:09 a.m. · The SP told P2 that the VA left the facility without supervision “three times throughout my shift” and “[The VA] was home by 6:15 a.m. in the morning.” The SP told P3 that the LEO “told me not to follow [the VA].” · The SP did not attempt to intervene or prevent the VA from leaving and made no attempts to bring the VA back to the facility. The SP told P2 that s/he heard the VA on phone calls and then it was quiet in the VA’s bedroom. The SP did not check on the VA because s/he felt going in and out of the VA’s room would disturb the VA’s sleep. · The SP “insisted” that the VA was at the facility throughout the overnight and that the SP “had eyes on” the VA while doing his/her shift notes but could not “recall the time.” The SP also stated that s/he saw the VA smoking outside the facility in the morning and was “focused on completing” the shift notes. · “[The SP] did not submit” any of the required documentation in real time. Instead, the SP “submitted all entries between 7:01 and 7:09 a.m.” The SP indicated that the VA was awake and present from 1 to 5 a.m. and then indicated that from 5 to 6 a.m. the VA was not present. The SP was not awake for all those time slots and was not observed on video filling out the documentation in real time. · The SP provided conflicting and inaccurate reports regarding the events of June 18, 2024. The SP’s statements did not align with one another or with the video. The SP’s actions were found to be non-compliant with the facility’s established protocols and procedures in that s/he failed to make any significant attempts to prevent the VA from leaving the facility or ensure his/her safe return to the facility. The SP did not attempt to alert on-call staff persons. The SP appeared to be sleeping from approximately 2 a.m. until 6:49 a.m. during an awake overnight shift and did not adhere to the documentation practices of real time tracking. The G provided the following information: · The VA had a history of leaving during overnight hours without supervision and if the VA had something in his/her mind that s/he wanted to do, s/he would “do it.” The VA was “very impulsive” and did not like to be told no. The VA was very “extroverted” and enjoyed going out into the community without supervision to socialize with new people or talk to people on the phone or online. It was a “big thing” for the VA to socialize with others. · The VA was able to relay information but the G was not sure if s/he was always “reliable” when recalling information. · Staff persons were supposed to at least “attempt to intervene” or “deescalate” the VA when the VA had behaviors that led him/her to wanting to leave the facility without supervision. Information from law enforcement reports showed that the SP did not call 9-1-1 on June 18, 2024, but that the VA’s family member called 9-1-1. The LEO incident report did not list the SP as a 9-1-1 caller on June 18, 2024, nor was the SP observed on video making a call or talking to 9-1-1 on the phone. On August 4, 2024, the SP called the police department and spoke with one of the responding officers to ask him/her to create a supplemental report showing that s/he was working the night of June 18, 2024. Facility documentation of the VA’s progress notes filled out by the SP showed the following: · The VA told the SP that s/he was going to murder the SP. The SP documented that the VA left the facility and that the SP followed the VA and “pleaded” with the VA to come back, and the VA came back. After the VA came back to the facility, s/he got angry again and left. The SP tried to wake the asleep staff person P4 and called law enforcement who arrived and calmed the VA. · The VA then slept for a while then told the SP that s/he was leaving the facility and repeated to the SP that the VA was going to “murder” the SP if the SP followed the VA. The SP then called law enforcement again and law enforcement said that the SP should stay at the facility and that law enforcement was going to look for the VA and bring the VA to the facility. All staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans. Conclusion: A. Maltreatment: Information and video surveillance showed that on June 18, 2024, the VA was upset and told the SP that s/he was going to leave the facility. The SP replied, “Okay, [VA’s name]” and failed to follow the VA or attempt to deescalate the VA’s behaviors prior to the VA leaving. P3 and P4 were not contacted by the SP, nor did the SP call 9-1-1. The VA’s family member called law enforcement and the LEO arrived at about 1:32 a.m. The LEO talked to the VA and to the SP separately and said that they were not going to be “chasing” the VA all night or “dragging” the VA inside the house and that the LEO did not want the SP to have to chase the VA all night. The SP replied that the VA wanted “attention like that” and would come in eventually. The VA entered back into the facility and then at 1:48 a.m. left again. The SP continued to lie down on the couch prior to the LEO leaving the facility premises and eventually fell asleep. The SP could be heard snoring at around 4:04 a.m. P3 arrived at the facility at about 6:49 a.m. and the VA was not there. P3 stated that s/he was never notified that the VA left. P4, who had been downstairs sleeping in a facility bedroom used for staff persons working overnight asleep shifts was not woken up by the SP. According to the Internal Review and facility video, the VA was “unaccounted for” and without supervision from 1:48 a.m. until 8:09 a.m. The SP appeared to be sleeping from approximately 2 a.m. until 6:49 a.m. during an awake overnight shift that night. The SP was not seen on video attempting to follow or find the VA and was not seen attempting to wake P4 for assistance. Information from the VA’s plans and interviews with staff persons showed that when the VA was attempting to leave without supervision, staff persons were to use “positive support strategies” with the VA to deescalate the situation, such as reminding the VA of using “relaxation skills.” Staff persons were to provide “visual supervision” of the VA “at all times” and were to wake the sleeping staff person if the VA left without supervision. Staff persons were to follow the VA on foot or in the facility vehicle when the VA left and if they lost sight of the VA or it was dark out, law enforcement was to be called. Information showed that some of the conflicting and inconsistent information that the SP gave the facility and this investigator but that was not supported through video, audio, or law enforcement records was that the VA threatened to kill the SP, that the SP called law enforcement, that the LEO told the SP to stay inside the facility, that the SP checked on the VA hourly, that the VA “rejected” the SP’s phone calls, that “overnight staff persons” looked for the VA, and that the VA came back, and left again at 3 a.m. and at 5 or 6 a.m., Although the SP stated that s/he was not supposed to follow the VA, given that the SP provided information that was inconsistent with facility video; that the VA, who had no unsupervised time in the community was outside from 1:48 to 8:09 a.m. when s/he walked to a local McDonald’s which was closed until they opened in the morning, several hours later; that the VA had vulnerabilities of seeking out people in the community that tended to take advantage of the VA sexually; that the VA smoked a “weed pen” and was not of legal age to do so; and that the SP slept through most of the hours the VA was unsupervised not making an attempt to locate the VA or get help, there was a preponderance of the evidence that the SP failed to provide 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 SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act and on the VA’s plans. 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 the VA was not injured. Action Taken by Facility: The facility’s Internal Review showed that policies and procedures were not followed, nor adequate. The facility made updates to the VA’s protocol for when s/he would leave without supervision. There was a need for additional staff training on the updated protocol. The SP no longer worked for 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.
|
