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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: 1122450-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that a staff person (SP) took a vulnerable adult (VA) to the SP’s friend’s home and the SP drank alcohol. The SP and VA then went to a soccer game where the VA remained in the facility vehicle. The SP returned to the vehicle intoxicated and drove the VA back to the facility. The SP then passed out in the driveway of the facility in the vehicle. There were also concerns that the SP took $30 from the VA. Date of Incident(s): September 1, 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 9, paragraph (b), clause (1); and subdivision 17, paragraph (a): In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. 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 September 16, 2024; from documentation at the facility, law enforcement records; and through five interviews conducted with two facility staff persons (P1, P2), the VA’s case manager (CM), the VA’s guardian (G), and the VA. This investigator spoke with the SP and s/he declined to be interviewed. The facility was a one level home with five bedrooms and two large living areas. There were steps up to the front door with a small platform. The driveway ran along the side of the house to a detached garage set back behind the house. The VA was diagnosed with developmental disabilities and bipolar disorder and enjoyed shopping, going out to eat, and going to the casino. The Annual Plan stated that the VA had no unsupervised time in the community and 15 minutes of unsupervised time at the facility. The VA had a history of engaging with community persons and giving them money, engaging in high-risk sexual encounters with people that s/he did not know, and displaying verbal aggression and threats of harm to others. The VA had a history of inaccurately reporting incidents and making complaints regarding services delivery. The VA provided the following information: · On the date of the incident, at approximately 3 p.m., the SP took the VA to the SP’s friend’s house. The VA remained in the vehicle while the SP went to talk with his/her friends in the driveway. The SP had a drink in a “beer bottle” but the VA was not sure if the drink had alcohol in it. · At approximately 3:30 p.m., the SP and the VA went back to the facility and the SP grabbed a camping chair that the VA used and grabbed a sweatshirt out of the VA’s bedroom. At that time the VA had $30 sitting on his/her mini refrigerator in his/her bedroom. The VA believed the SP took the VA’s money at that time, but the VA did not notice until later. The SP also packaged the VA’s 4 and 8 p.m. medications to bring along. · At approximately 4 p.m., the VA and the SP went to a soccer field and the SP got “drunk.” The VA did not want to watch soccer so during the soccer game, the VA remained in the running facility vehicle listening to music on the radio while the SP went to the field to watch the game. The vehicle was parked in the parking lot and the VA could see the soccer field. The VA stayed in the vehicle the entire time except when s/he went into a park building to use the restroom. The VA called/text messaged the SP several times throughout the evening and the SP checked on the VA several times by coming back to the vehicle. When the SP came back to the vehicle s/he had a cup with beer in it. · At some point the VA thought the SP was drunk because of the way the SP talked and s/he was swaying when s/he walked. At approximately 9-9:15 p.m., the SP came back to the vehicle and wanted to drive back to the facility. The SP and the VA argued for 20 minutes about who would drive the vehicle home as the VA did not feel the SP should drive. · The SP finally drove back to the facility but was swerving, driving erratically, weaving, and taking corners sharp. At approximately 9:30 p.m., the SP and VA retuned to the facility and pulled into the driveway. The SP shut the vehicle off and the VA went inside to use the bathroom. When the VA came back outside the SP was “passed out” in the vehicle. · The VA called a community person (CP) over to the facility. The CP saw the SP in the vehicle. After approximately 30-45 minutes, the VA called law enforcement and a law enforcement officer (LEO) arrived. It took the LEO 10 minutes to wake the SP. P1 and P2 provided the following information: · The VA had no unsupervised time in the community and staff persons were with the VA at all times. The VA had 15 minutes of unsupervised time at the facility. The VA managed his/her own money and usually kept his/her money on his/her person. The VA had recently lost his/her wallet. · In the past when the VA did not get his/her way s/he said things that were not true about staff persons. Often the VA said that s/he was going to make a staff person’s night miserable or get them fired. · The VA provided consistent information to P1 that the VA provided to this investigator about the incident. The medication administration record showed that the VA’s 4 p.m. and 8 p.m. medications were packaged and taken out of the facility. · P2 worked the overnight shift at the facility. On the date of the incident, when P2 arrived (likely 11 p.m. per time entry), there were no law enforcement officers at the facility. The SP was in the staff person office and the VA was outside. The VA said someone stole $20 from the VA and said something about the SP being drunk and sleeping in the vehicle. · P2 spoke with the SP, and it did not appear the SP had been drinking. The SP said that because the VA made up lies when s/he did not get his/her way, the SP (who only picked up occasional shifts at the facility) only wanted to work at other facilities within the company. P2 said that the previous evening the VA did not have cigarettes but that evening s/he had cigarettes. P2 thought that was likely where the VA’s money had gone. · Later in the evening, the VA said that s/he did not “feel right” and called the paramedics. Paramedics arrived and checked the VA’s vitals. The VA contemplated going to the hospital for a while and then finally was taken to the hospital by paramedics. · In past the VA had reported that the SP was sleeping during his/her shift. After reviewing video footage, it was determined that the SP was not sleeping but was not interacting with the VA. The SP was retrained after this occurred. The G provided the following information: · On the date of the incident, a friend of the G (F) called the G and said that the F saw the VA in a bad area of town. The VA had walked across the street to a group of people. The F pulled over to observe and noticed that some of the people were making fun of the VA. The F called the G and left the area. · At approximately 3:30 p.m., after receiving the call, the VA called the G and when the G asked what the VA was doing, the VA said that s/he was driving around with the SP. The VA said they had left the facility at approximately 2 p.m. The G thought s/he heard voices and said that it did not seem as if they were driving. The VA then said that the SP and the VA were at the SP’s friend’s home. · The following day, the G noticed multiple texts and messages from another family member and the VA. The VA said that after being at the SP’s friend’s house, they went to a soccer game. At some point, the VA saw the SP drink alcohol. The VA sat in the facility vehicle listening to music and smoking while the SP went to the soccer game. When the SP returned to the vehicle, the VA thought the SP was intoxicated. · The SP drove the VA back to the facility and the VA said they arrived back at approximately 9:30 p.m. The VA went to the emergency room that evening as this was a typical response when the VA was overstimulated. · The next day the VA noticed that s/he was missing $30. The G had no previous concerns with the facility. The CM said that s/he met with the VA on September 3, 2024, and the VA provided information consistent to what the VA told this investigator. The VA said that the CP had witnessed the SP sleeping in the vehicle. The CM talked with the CP who confirmed that the SP was sleeping in the vehicle. In the past the VA had said things about staff persons such as they took money from the VA, but the CM had never heard the VA “fabricate” a whole day or something of “this magnitude.” The CM believed the VA’s account of the “bigger picture” was likely accurate, but some details may not have been accurate. This investigator spoke with the SP and s/he declined to be interviewed for this investigation. The Investigation Report and Summary showed that the SP provided the following information to the facility: · The SP worked the 3-11 p.m. shift at the facility. When the SP arrived, the VA asked to go for a ride in the facility vehicle. The SP asked the VA where s/he wanted to go, and the VA did not know. The SP asked if the VA wanted to go to the park and watch people play soccer. The VA said, “Yes,” so the SP packaged the VA’s medications and they left for the park. · Before going to the park, the VA requested that the SP stop at Burger King for some food. The VA bought a hamburger and gave the change to someone on the side of the road. They then drove to the soccer field, but the SP could not remember the name of the field. The VA and the SP sat on the sidelines of the field and watched. · After approximately one hour, the VA said that s/he felt unwell because there were too many people at the park. They left the park but then returned 30 minutes later when the VA changed his/her mind. They again sat on the sidelines and watched the game. · At approximately 8 p.m., the VA went to the vehicle and got in the driver’s seat telling the SP that s/he drank so the VA was going to drive. The SP said that it was his/her job and eventually the VA moved over to the passenger seat and the SP drove back to the facility. · When they arrived at the facility, the VA sat on the porch and smoked a cigarette while the SP waited in the vehicle for the overnight staff persons to arrive. The SP said s/he waited in the vehicle because there was no other place to sit outside. At approximately 9 p.m. the VA called the police and they arrived at the facility. The LEO came to the vehicle to speak with the SP who was still inside. The SP said that s/he was talking “face to face” with the LEO and the LEO did not smell any alcohol. The LEO left shortly after. · The SP said, “I fell asleep at first, but when the cops got there, I was awake.” The SP did not know how long s/he was asleep but that “I just took a little nap; it wasn’t long.” The SP did not see the CP at the facility that evening. · The SP said s/he did not drink any alcoholic beverages while working but did have one non-alcoholic beverage that came in a glass bottle. The SP could not remember the name of the beverage but explained that it was some sort of juice or flavored water. · The SP said that s/he did not take the VA to the SP’s friend’s house and was not separated from the VA at any time while out in the community. · The VA took his/her 4 p.m. medications at the facility before they left and took the 8 p.m. medications when they returned to the facility. When asked why the medications were signed off at 5:30 p.m., the SP said that s/he signed off late on the 4 p.m., and was not sure why the 8 p.m. medications were signed off on at 5:30 p.m. · The SP said that the VA had spent money at the casino the day prior. On that day, the SP told the VA to put some money aside ($30-40) for a purchase the VA needed to make. The following day on September 1, 2024, the VA took that money and bought Burger King, bought cigarettes, and gave some to a homeless person. Law enforcement records showed that on September 1, 2024, at 10:22 p.m., a call from the VA was received stating that the SP was in the facility vehicle in the driveway sleeping. The VA said the SP had been drinking. At 10:51 p.m., the LEO arrived at the scene. The SP said s/he was asleep in the vehicle because the staff person that was supposed to replace the SP was eight hours late and the SP was tired. The LEO saw no signs of the SP being drunk. The LEO advised the SP to stay within earshot so the SP could monitor the VA. T-Logs provided the following information: · The SP made three separate log notes for September 1, 2024. The first note entered on September 1, 2024, at 9:41 p.m., said that the SP took the VA for a van ride and came back. The SP took the VA to a soccer field and dropped the VA back at the facility at 8 p.m. The VA took his/her medications and went to bed. · The second note entered on September 2, 2024, at 6:12 a.m., said when the SP arrived at 3 p.m., the VA was sitting in the vehicle and took his/her medications after the VA got back from a “van ride” with the SP. The SP asked the VA where s/he wanted to go, and the VA did not know. The SP took the VA to the soccer field to watch live games. At the soccer field the VA asked a community person to buy the VA cigarettes. The community person gave the VA money, so the SP took the VA to get cigarettes and then returned to the soccer field. The VA had a great time at the soccer field and the SP was with the VA “all [the] time.” In the entry the SP started to type “after the game the staff dropped” and then did not finish the sentence. A new paragraph was started that said that the SP took the VA on a “van ride” and later dropped the VA off at the facility. When the VA got to the facility, s/he took his/her medications and sat on the front porch to smoke. The SP was outside sitting in the vehicle and the VA called law enforcement and said that the SP was drunk driving which was not true. · The third note entered on September 2, 2024, at 7:20 a.m., said that the VA went to Burger King and bought a burger and drink with his/her money. The VA gave the change to someone on the street because the VA told the SP that the person was hungry and wanted a burger. · On September 2, 2024, P2 wrote that when s/he arrived, the VA was very upset and sitting outside. The VA said that the SP was drinking on the job and stole the VA’s money. The VA said that the SP purchased the VA a pack of cigarettes. The VA called 9-1-1 and paramedics arrived. The VA made the decision to go to the hospital. An administrative staff person said that the VA’s 4 p.m. and 8 p.m. medications were signed off by the SP at approximately 5:30 p.m. The SP told the staff person that the VA received the 4 p.m. medications before leaving the facility and the SP documented late. The 8 p.m. medications were prepackaged but not taken until the SP and the VA arrived back at the facility that evening. The staff person was unsure why the SP signed off on the 8 p.m. medications at 5:30 p.m. but thought the SP may have intended to show that the medications were prepackaged. A supervisory staff person said that time entry information showed that on September 1, 2024, the SP worked from 2:57 to 10:59 p.m. P2 worked on September 1, 2024, from 11:00 p.m. to 7:23 a.m. on September 2, 2024. All staff persons were trained on the Reporting of Maltreatment of Vulnerable Adults Act, the VA’s plans of care, and the facility policies prior to the incident. Conclusion: A. Maltreatment: Regarding the financial exploitation: The VA said that on the date of the incident, s/he had $30 sitting on his/her mini refrigerator in his/her bedroom. The VA believed the SP took the VA’s money at that time, but the VA did not notice until later (the following day). P2 said that on the date of the incident, the VA had cigarettes when the previous day s/he did not. The SP said that the VA had spent money at the casino the day prior. On that day, the SP told the VA to put some money aside ($30-40) for a purchase the VA needed to make. On the date of the incident, the VA took that money and spent it at Burger King, bought cigarettes, and gave money to a homeless person. Although the VA said that s/he believed the SP took the VA’s money, given that the SP said that the VA spent money that day on various items including cigarettes, that P2 noticed the VA had cigarettes the following day, that the money was sitting out where other staff persons and/or individuals would have access to it, and without any further information there was not a preponderance of the evidence that the SP willfully used or withheld the VA’s funds. It was not determined whether financial exploitation occurred (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). Regarding the neglect: The VA provided consistent information to the G, P1, the CM, in the Investigation Report and Summary, and to this investigator that on the date of the incident, the SP took the VA to a home that belonged to a friend of the SP. The VA remained in the vehicle while the SP was outside in the driveway drinking from a glass bottle. Later on, the SP took the VA to a soccer game and the VA remained in the vehicle while the SP went to the soccer field. Throughout the evening, the VA called and/or text the SP. The SP came back to the vehicle several times to talk with the VA. When the SP returned to the vehicle the SP carried a cup with beer in it. At some point the VA thought the SP was drunk because of the way the SP talked and s/he was swaying when s/he walked. At approximately 9-9:15 p.m., the SP came back to the vehicle and the SP and the VA argued about who should drive back to the facility. The SP drove back to the facility but was swerving, driving erratically, weaving, and taking corners sharp. At approximately 9:30 p.m., the SP and VA retuned to the facility. The VA went inside to use the bathroom and when s/he came back outside the SP was “passed out” in the vehicle. The VA called the CP and law enforcement. The G said that on the date of the incident, s/he was contacted by a friend who saw the VA exiting a vehicle and walking across the street to a group of people. When the G called the VA, the VA said that s/he was on a ride with the SP. When questioned further the VA said that s/he was at a home of a friend of the SP’s. The CM spoke with the CP who confirmed that s/he witnessed the SP sleeping in the vehicle on the evening of the incident. Law enforcement records showed that on September 1, 2024, at 10:22 p.m., the VA called to report that the SP was in the facility vehicle in the driveway sleeping and had been drinking. At 10:51 p.m., when the LEO arrived, the SP said s/he was asleep in the vehicle because the staff person that was supposed to replace the SP was eight hours late and the SP was tired. The LEO saw no signs of the SP being drunk. The SP said that on the date of the incident, s/he took the VA to Burger King and then to the soccer field to watch a soccer game. The VA and the SP watched the game from the sidelines. At 8 p.m., the SP and VA left the soccer field. The VA got into the driver’s seat and told the SP that the VA was going to drive because the SP drank. Eventually the VA moved over, and the SP drove back to the facility. When they got back to the facility, the VA went to smoke on the porch while the SP waited inside the vehicle because there was nowhere to sit outside. The LEO arrived at the facility and the SP was still in the vehicle. The SP said, “I fell asleep at first, but when the cops got there, I was awake.” The SP did not know how long s/he was asleep but that “I just took a little nap; it wasn’t long.” The SP said that s/he did not have any alcoholic beverages on the date of the incident but did have one nonalcoholic beverage in a glass bottle but did not remember the name of the beverage. The SP denied asking the VA to a friend’s home and/or being separated from the VA while in the community at any point. Although the SP denied drinking alcoholic beverages and/or leaving the VA unsupervised at any point during the evening, given that the VA provided consistent information about the events of the evening to multiple people, that the G received a report that the VA was seen out in the community (likely at the SP’s friend’s home), that the CP saw the SP sleeping in the facility vehicle (likely at least 30 minutes based on law enforcement records of the time of call and time of response), and that these further details supported the VA’s description of what happened, it was likely that the VA’s description of what occurred was more credible than the SP’s who had reason to minimize his/her actions. The VA required supervision at all times in the community and had 15 minutes of unsupervised time at the facility due to his/her behavioral vulnerabilities. The VA’s Annual Plan showed the VA had a history of engaging with community persons and giving them money, engaging in high-risk sexual encounters with people that s/he did not know, and displaying verbal aggression and threats of harm to others. Although the VA was not harmed when s/he was unsupervised in the community and at the facility on September 1, 2024, and when the SP likely drank alcoholic beverages, given that the VA could have required care and/or services during this time, and that law enforcement was contacted to ensure the VA’s health and well-being, 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 on the Reporting of Maltreatment of Vulnerable Adults Act, the VA’s plans of care, and the facility policies prior to the incident and was the staff person responsible for providing the VA with supervision during the time of the incident. 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 considered a single incident, and the VA was not injured. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed when the SP was not awake and alert at all times. 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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