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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: 1069235-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Tessa Ripka gessner.rivas@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) left a vulnerable adult (VA) unsupervised in the facility vehicle and the VA drove 20 miles to a family member’s home. Date of Incident(s): May 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 June 5, 2024; from documentation at the facility; and three interviews conducted with two facility staff persons (P1, P2) and the VA. This investigator made attempts to reach the SP through mail and phone calls, but attempts were unsuccessful. The VA was diagnosed with a traumatic brain injury and epilepsy. The VA enjoyed listening to music and spending time with his/her family. The Individual Abuse Prevention Plan (IAPP) stated that the VA had no unsupervised time in the facility or in the community. The IAPP updated after the incident stated that the VA did not have a current driver’s license and with his/her diagnosis of epilepsy, it was not safe for the VA to be operating a motor vehicle. The Intensive Services Assessment (Self-Management Assessment) stated that if the VA was upset, s/he would attempt to get away from staff person and not pay attention to traffic or other dangerous situations. The VA had a history of seizures although s/he had not had one in some time. The VA provided the following information: · On the date of the incident, the VA went with the SP to a YMCA. The SP left the VA in the facility vehicle with the keys in the ignition of the vehicle and the vehicle still running. It was a warm day but did not get hot in the vehicle. The VA listened to music while s/he waited. · After approximately 15 minutes, the VA got “sick” of waiting for the SP, so the VA got out of the passenger seat, went around to the driver’s seat, and got in. The VA reversed the vehicle, backed out, and drove to his/her family member’s (FM) house which took about 20 minutes. · This was the first occasion that the SP had taken the VA out in the community. No other staff person had ever left the VA in the vehicle without supervision. P1, P2, and the Internal Review of an Alleged Maltreatment provided the following information: · On May 3, 2024, the SP was scheduled to work at the facility from 11 a.m. to 7 p.m. P2 was also scheduled to work that day. The SP and VA left the facility while P2 remained at the facility with other individuals. · At approximately 4:15 p.m., a supervisory staff person (P3) received a phone call from the FM saying the VA had arrived at the FM’s house and drove the facility vehicle. There was no staff person with the VA. P3 found a staff person to go to the FM’s home and bring the VA and vehicle back to the facility. · At approximately 4:40-4:45 p.m., P1 and another staff person went to the YMCA and found the SP inside playing basketball with some friends. A map indicated that the VA drove approximately 15.5 miles to the FM’s home. · Staff persons at the YMCA said that their records showed that the SP punched into the YMCA at 3:03 p.m. There was no indication that there was any damage to the vehicle. · The VA had no supervised time in the community or at the facility and staff persons were to be within sight or sound of the VA. The SP declined to interview with this investigator but provided the following information in the Internal Review of an Alleged Maltreatment: On the date of the incident, the SP worked at the facility with the VA. The SP stopped at the YMCA and left the VA in the facility vehicle in the parking lot while the SP went inside and played basketball with some friends. The SP initially said that s/he had left the VA in the vehicle for 10-15 minutes but later said it was approximately an hour. The SP said s/he was aware of the VA’s “level of supervision.” Driver Rules and Regulations policy stated that drivers were responsible to ensure the security of company vehicles. The vehicle engine must be shut off, ignition keys removed, transmission in park, and vehicle doors locked whenever the vehicle was left unattended. The SP was trained on Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, and the VA’s program plan. Conclusion: A. Maltreatment: Information was consistent that on May 3, 2024, the SP took the VA to the YMCA in the facility vehicle. The SP went inside at 3:03 p.m. and left the keys in the vehicle while the VA stayed in the vehicle. After approximately 15 minutes, the VA drove the vehicle to the FM’s home. At 4:15 p.m., the FM alerted P3 that the VA had driven the facility vehicle to the FM’s home. P1 went to the YMCA where they found the SP playing basketball. The SP was not aware the VA had left the YMCA parking lot driving the facility vehicle. Facility documentation showed the VA did not have a current driver’s license, had no unsupervised time in the community, and due to his/her epilepsy was not to operate a motor vehicle. Given that the VA was left unsupervised for likely over an hour while s/he had no unsupervised time, that while unsupervised drove the facility vehicle while s/he did have a license which was illegal, and that his/her diagnosis of epilepsy and traumatic brain injury posed a risk while driving, there was a preponderance of the 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 Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, and the VA’s program plan and was responsible for the care and supervision of the VA during the time of the incident. 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 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 left the VA in the vehicle without supervision for approximately an hour. Staff persons were trained the basic vehicle keys protocol. 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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