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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: 1121576-H_CRS (Home and Community-Based Services-Community Residential Setting) 1104769-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-6553 Suspected Maltreatment Reported: It was reported a staff person (SP) left a vulnerable adult (VA) unsupervised during a community activity and the VA was observed by community persons touching him/herself inappropriately in public. Date of Incident(s): July 10, 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 30, 2024; from documentation at the facility and law enforcement records; and through four interviews conducted with the VA, a facility supervisor (P), the VA’s case manager (CM) and a law enforcement officer (LEO). This investigator attempted to contact the SP via phone call and via United States Postal Service to request an interview with the SP, however the SP did not respond. Facility documentation showed the VA enjoyed playing computer games, listening to music, and playing drums. The VA was diagnosed with autism spectrum disorder, developmental disabilities, attention-deficit hyperactivity disorder, and hyperkinesis. The VA had a history of engaging in self-injurious behaviors, damaging property, theft, exposing his/her private body parts, inappropriately touching people, and struggled to regulate his/her emotions. The VA’s Community Support Plan showed the VA required a 24-hour plan of care to ensure his/her health and safety. The VA’s Behavior Plan showed the VA required 1:1 supervision, “should never be left unattended,” and might undress him/herself while in public. The VA’s daily progress note on July 10, 2024, was completed by the SP. It stated the VA went to Valleyfair at 4:30 p.m., and was there for an hour. The VA made a “mistake,” as s/he was touching him/herself in a public place and the VA spoke with LEO. Law Enforcement records and an interview with the LEO provided the following information: · On July 10, 2024, at 5:40 p.m., the LEO was contacted by Valleyfair security after community persons observed the VA “inappropriately touching” him/herself while at Valleyfair. The LEO spoke with two Valleyfair employees who believed they observed the VA “masturbating” while at Valleyfair. The LEO noted that there were children of all ages at Valleyfair, including “several children” under sixteen years of age. · The LEO spoke with the VA, who said s/he lived in a “group home” and the SP was in the parking lot. The VA told the LEO the SP asked the VA if s/he wanted to go into Valleyfair alone, and the SP remained in the car. The LEO had the VA call the SP on a phone and the SP responded to the front entrance of Valleyfair in “a few minutes”. The LEO said the SP was unable observe the VA while the VA was in Valleyfair. · The LEO spoke with the VA’s legal guardian, who stated the VA required 24-hour assistance from staff persons, and should not be unsupervised. The VA was informed charges were being filed for indecent exposure in presence of a minor under the age of 16. The VA said s/he was not supervised by the SP while s/he was inside of Valleyfair, and the SP stayed in the parking lot to pray. The VA did not provide any additional details or information related to the incident. The P said the VA should not have been left unsupervised in the community, and the SP was trained to provide 1:1 supervision of the VA. The CM said the VA required 1:1 supervision by staff persons and the VA had several previous incidents at stores where s/he stole items. The CM said the VA was susceptible to abuse and neglect. The SP’s job description included the responsibility of providing supervision to the VA. The P and the SP were trained on Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, and the VA’s client specific programming. The training the SP received included information related to the VA’s supervision requirements, and the SP signed an acknowledgment of completing the training on March 26, 2024. Conclusion A. Maltreatment: The VA’s client specific programming showed s/he had history of engaging in criminal activities in the community, required 24-hour supervision, and did not have any community alone time. It was reported that on July 10, 2024, the SP left the VA unsupervised at Valleyfair, and the VA was observed masturbating in public. Information showed the SP took the VA to Valleyfair at 4:30 p.m., and law enforcement was contacted at 5:40 p.m. due to concerns with the VA’s behavior. Law enforcement records showed the SP was not present when law enforcement approached the VA. Law enforcement records, the LEO, and the VA stated the SP was in the parking lot during the time of the incident at Valleyfair. Furthermore, the LEO stated it took the SP “a few minutes” to respond to front entrance of Valleyfair after the VA called the SP. This investigator attempted to complete an interview with the SP, but the SP did not respond interview requests. Although the total duration of time the VA was left unsupervised was unknown, there was consistent information the VA was unsupervised for some duration, if not all of the time between 4:30 and 5:40 p.m., on July 10, 2024. While unsupervised the VA engaged in behaviors which led to him/her having direct contact with law enforcement and being charged with indecent exposure. Given that required supervision of the VA was not maintained, that the VA was unsupervised in the community, and that the VA engaged in behavior that resulted in criminal charges while s/he was unsupervised, there was a preponderance of evidence that the SP failed 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 SP was trained on the VA’s client specific documentation, was aware of the VA’s supervision requirements, and was responsible for the care and supervision of the VA during the incident at Valleyfair on July 10, 2024. Therefore, the SP 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 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 the facility’s policies and procedures were adequate, but not followed. There was no history of similar events and facility did not complete any additional training. The facility did not complete any corrective action to protect the persons that received services as the SP was no longer employed by 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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