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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: 1070371-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh/ Anna Parkin 651-431-6225 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) left the facility without staff persons knowledge or supervision. Date of Incident(s): August 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 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 August 13, 2024; from documentation at the facility and law enforcement records; and through nine interviews conducted with three supervisory staff persons (P1-P3), three facility staff persons (P4-P6), the VA’s case manager (CM), a social worker (SW) who worked with law enforcement, and a community person (CP) who worked with the law enforcement agency. Attempts were made via telephone and mail to contact and interview the VA’s two guardians but neither responded by the completion of this report. The VA was diagnosed with autism and a moderate developmental disability. The VA moved into the facility on approximately March 25, 2024. The VA’s bedroom was in the basement of the facility and there was no direct exit to outside. The main level had two exterior doors, one in front and one in back and each had an alarm for when the door was opened. There was also an upstairs level that had other clients’ bedrooms. Consistent information was provided that two staff persons were scheduled to work at the facility at all times. According to the VA’s Coordinated Service and Support Pan (CSSP) Addendum, the VA had a “limited ability to communicate” and had staff persons with him/her “at all times” while at the facility and in the community. According to the VA’s Individual Abuse Prevention Plan (IAPP), the VA left without supervision in the past including walking to places s/he enjoyed like the park. The VA was susceptible to abuse because s/he had a history of taking off his/her clothes in public and urinating and defecating in inappropriate places in public. The VA had “zero” alone time in the community. When out in the community and at the facility, staff persons remained next to the VA “at all times.” The VA was unable to identify potentially dangerous situations, lacked community orientation skills, had inappropriate interactions with other persons, was not able to protect him/herself from verbally or physically aggressive persons, and was abusive towards other persons. The VA did not know his/her address, phone number, or “way around town.” According to the VA’s Intensive Support Self-Management Assessment: · The VA did not have unsupervised time in the community or at the facility. The VA did not understand how to read street signs and if the VA was separated from staff persons, s/he would get lost. In the past, the VA had attempted to smell other persons’ hair or grab keys from around other persons’ necks. Staff persons were to remain with the VA “at all times” while in the community. If they were separated, staff persons contacted 9-1-1 “immediately.” · The VA left the facility alone “once in the past” at night and walked down the street. In warmer months, s/he attempted to walk out the front door without staff persons. Staff persons were to keep the VA “in eyesight at all times” while at the facility. The CP provided the following information: · On August 1, 2024, sometime between 7 and 9 a.m., during rush hour while it was raining, as the CP drove his/her vehicle s/he saw a person, later identified as the VA, riding a scooter on a road. The VA was “coming right at” the CP’s vehicle. The CP saw the VA turn onto a “busy” road so the CP called 9-1-1. Other vehicles were honking at the VA and driving near the VA. The VA got off his/her scooter near a business, so the CP got out of his/her vehicle and walked over to the VA. The CP spoke to the VA and the VA went inside the CP’s vehicle. The VA was “soaking wet” from the rain, “really smelled” like urine, and was barefoot, but the CP did not see any injuries. · After approximately five to ten minutes, the CP called 9-1-1 again and said s/he was bringing the VA to the nearest police station. The CP met the SW at the police station and brought the VA inside. The SW provided the following information: · On August 1, 2024, at 9:27 a.m., the CP called and said that a person believed to be a child, later determined to be the VA, was “not paying attention” to traffic and vehicles were swerving to avoid hitting the VA. The VA was also barefoot and about to scooter onto Highway 81. · The SW responded to the 9-1-1 call with a paramedic. It took approximately five minutes for the SW to arrive at the location where the CP called from. When they arrived, they found out that at 9:37 a.m. the CP called 9-1-1 again to notify law enforcement that s/he was bringing the VA to the police station. The SW then met with the CP who said that the VA was about to go onto Highway 81 when the CP approached the VA and got him/her into the CP’s vehicle. The VA was not able to verbally communicate. · Shortly after the CP left the police station, there was another 9-1-1 call from P3 who stated that the VA was missing. P3 eventually came to the police station and got the VA. The Law enforcement report provided the following information: · On August 1, 2024, at 9:49:44 a.m., P3 called 9-1-1 to report that the VA was “missing.” P3 provided the VA’s first name but did not know the VA’s last name. P3 provided a description of the VA and said s/he was riding a scooter. · At 9:52:31 a.m., a law enforcement officer (LEO1) responded that s/he “likely” had the VA. At 9:55:28 a.m., another law enforcement officer (LEO2) met up with LEO1. · At 9:57:02 a.m., P3 was on his/her way to meet up with LEO1 and the VA at the police station. The call was then cleared. P2 provided the following information: · On the day of the incident, P2 had P3-P6 come to the facility to train on safety protocols. When P2 arrived at the facility, at approximately 8 a.m., the VA was in the living room. Unknown staff persons were doing laundry so the garage door was open and the door to the garage was not alarmed, which was supposed to have been on at all times. At some point prior to the meeting starting, the VA went downstairs to his/her bedroom. · During the meeting about safety of the clients, P3 sat specifically so s/he was able to see if the VA was on the main level. P2 did not see the VA throughout the meeting. The meeting last approximately 10 to 15 minutes. · After the meeting, P2 was outside in his/her vehicle about to leave when P4 ran outside and told P2 that the VA was not inside his/her bedroom and that P3 saw the VA walk outside but did not say anything. P2 drove around looking for the VA and after approximately 10 minutes, P3 called and said that the VA was found at a restaurant. The VA was with law enforcement and P3 was going to get him/her. P2 estimated that the VA was alone in the community less than 35 minutes but P2 was not aware of when the VA left. · Approximately ten minutes later, P3 met P2 at the main office. P2 discussed the seriousness of the incident with P3 and P3 said s/he saw the VA walk outside but did “not think anything of it.” P3 had been trained on safety protocols approximately two to three days prior to the incident when s/he started working at the facility. · The VA was allowed unsupervised time in his/her bedroom but staff persons were to check the VA every 15 minutes. Otherwise, staff persons were with the VA “at all times.” P3 provided the following information: · On August 1, 2024, at possibly 7 or 8:10 a.m., P3 arrived at the facility for the first time. Because it was P3’s second day working and first at the facility, s/he read through training documentation. At some point, P2 arrived at the facility and told P5 to take laundry outside into the facility vehicle so they could wash it at another site. P3 and P4 cleaned upstairs while P2 and P5 worked on laundry. During that time, the door to the garage was propped open so the alarm would not have sounded and the main garage door was open. P3 denied turning off the alarm. · P3 last remembered seeing the VA pacing around the kitchen at some point prior to P4 directing the VA to his/her bedroom. · At one point, P2 asked everyone to come into the living room. During this time, there was no discussion about which staff person was supervising the VA during the meeting and P3 sat where s/he was able to see the door to the garage. P2 went over a policy but P3 did not remember which policy. P3 denied seeing the VA leave the facility or telling anyone that s/he saw the VA leave. · After the meeting ended, P4 found an item belonging to the VA. When P3 asked P4 what was wrong, P4 said that s/he found the VA’s item in the garage. P3 and P4 then looked around the facility but did not find the VA. P4 ran outside in the rain to look for the VA, P2 and P3 got inside their respective vehicles to look for the VA, and P5 stayed at the facility. · P3 and P4 went to a nearby business where a community person who worked at the business said that s/he had seen a person matching the VA’s description riding a scooter near a restaurant. While driving to the restaurant, P3 called P2 and then 9-1-1. P3 continued to drive around by businesses and restaurants. At some point, a law enforcement officer called P3 and said they had the VA with him/her. P3 called P2 and said s/he was going to the police department to get the VA. · Once P3 at the police department, a law enforcement officer told P3 that a community person found the VA at a restaurant and drove the VA to the police department. The VA was wet from the rain and not wearing shoes or socks but P3 did not see any injuries on the VA. · P3 said that the VA had monitor s/he was supposed to wear during the day, but P2 told P3 that the VA only had to have it on during outings in the community. P1 provided the following information: · On August 1, 2024, at approximately 10 a.m., P2 came into the main office and said approximately 30 minutes prior, the VA left the facility alone. P1 asked how it happened because P2-P6 were at the facility. P2 said that s/he brought all the staff persons into the living room for a meeting on safety protocols while the VA was in his/her bedroom. · During the meeting, the VA must have left through the door from the kitchen to the garage. The garage door had been left open unlocked and disengaged the door alarm because s/he was bringing laundry out to a vehicle. P3 told P2 that s/he saw the VA walk out the door but did not say anything, and P3 was not able to say why s/he did not say anything when the VA walked out. The other staff persons in the living room were not able to see the kitchen door from where they were sitting. P1 spoke to P2-P6 individually but there was no consistent information on who disengaged the alarm. P3 told P1 that s/he saw the VA walk out the door but did not say anything and s/he did not say why s/he had not. · The facility did not require a staff person assigned to the VA but they worked as a team when at the facility. A staff person was assigned to the VA when s/he went out into the community. The VA was allowed alone time while in his/her bedroom. · Staff persons were required to have “eyes on” the VA at all times. The VA had an identification bracelet and air tag that s/he was encouraged to wear while on outings. P4 provided the following information: · On August 1, 2024, at approximately 7 a.m., P4 arrived at the facility. P4 checked on the VA who was still in bed asleep. P4 then checked on another client and spoke to P3 who was already at the facility. P3 told P4-P6 to clean upstairs while P3 cleaned on the mail level. P4 then told P3 that a staff person needed to be downstairs because the VA was still asleep in bed. · At approximately 7:30 or 8 a.m., P2 arrived at the facility for a meeting. Before the meeting, P2 said that the VA needed to be on the main level of the facility with them so P4 woke up the VA, assisted with his/her morning cares, brought the VA to the main level, and prepared breakfast. After the VA ate breakfast, s/he sat in the living watching television on the couch in the living room. P2 then told P3-P6 it was time for the meeting so they all went into the dining room. The VA came into the dining room, sat on the floor next to P3, and played with some items during the entire meeting. The meeting was about the VA and supervision of the VA. · When the meeting ended, P3 told P4-P6 to clean upstairs, where the other clients rooms were, so they did. At this time, the VA was standing next to P3. Prior to going upstairs, P4 checked the alarm on the kitchen door and it was activated. At that time, P3 turned the alarm off in front of P4 and P5 because P3 did not like the sound of the alarms. P4 and P5 told P3 not to turn off the alarms but s/he did not listen to them. P4 denied that the VA went to his/her bedroom prior to P4 going upstairs. P4 did not hear the door alarms while upstairs but was in the bathroom so might not have been able to hear it. · After approximately five to ten minutes, at approximately 9:15 or 9:20 a.m., P4 returned to the main level of the facility. P4 did not know where P2, P5, and P6 were. P4 saw an item the VA had been playing with earlier but the VA was not there. P4 grabbed the item and ran down to the VA’s bedroom but the VA was not there. P4 went back to the main level and told P3 that the VA was “gone.” P3 asked P4 where the VA was and P3 responded that “[s/he] did not know.” P2-P6 then began looking for the VA. · P4 went to the backyard area and then nearby businesses where the VA enjoyed going. P4 did not remembered where the VA was found but remembered that P3 brought the VA back to the facility. It was approximately 45 minutes between P4 realizing the VA was gone, until P3 returned with the VA to the facility. P4 said it was P3’s responsibility as a supervisory staff person to supervise the VA so P3 was responsible for the VA during that time. · P4 stated at the beginning of every shift, s/he made sure that the VA’s tracker was charged. The VA had the tracker on the morning of the incident but must have taken it off prior to leaving the facility because P4 saw it sitting next to the item on the floor. The VA required 1:1 staffing at all times unless s/he was inside his/her bedroom then staff persons stayed outside the bedroom door. P5 provided the following information: · On the day of the incident, when P5 arrived at the facility, the VA was sitting in the living room. P3 told P3-P6 to go upstairs and clean. P3 was on the main level with the VA and was supposed to supervise the VA. While upstairs, P5 heard P3 open and close the front and back doors. After P5 cleaned the bathroom, P4-P6 came back downstairs and looked for the VA. P4-P6 asked P3 where the VA was and P3 responded that s/he saw the VA walk out the back door and into the garage. · P5 then said that P2 was at the facility and had a meeting with P3-P6 in the living room. The VA sat in the living room during the meeting. P5 could not remember how long the meeting was but the VA was still in the living room at the end of the meeting. · After the meeting, P5 went to the kitchen and P3 said P2 wanted the laundry done so P5 went to get the laundry. P4 and P6 cooked food for another client and P2 told P3 to supervise the VA. When P5 came back, P4 asked P3 where the VA was and P3 did not know. P3 said s/he saw the VA go out the back door so P2-P6 began looking for the VA. P5 and P6 stayed at the facility and looked around the area while P2-P4 left out in the community. At some point, P3 brought the VA back to the facility. P5 did not know where P3 found the VA or how long s/he was gone. P5 did not see an injury on the VA. · P5 was previously trained to “keep eyes on [the VA] 24/7.” P3 previously told P5 that s/he did not like the sound of the door alarms so P3 turned them off. P6 provided the following information: · On P6’s second day of employment, P4 trained in P6 on the VA’s medications, plans, and bathing. At approximately 8:45 or 9 a.m., P3 arrived at the facility and gave P6 a tour and then P5 arrived. P6 read through policies and P3 then told P4-P6 to clean upstairs. P3 stayed on the main level with the VA and after approximately one hour later, P2 arrived at the facility. P2 told P4 and P6 to stay upstairs while P5 was in the living room close to the front door. P4 and P6 carried garbage outside and P6 did not see the VA. P2 called all staff persons to the living room for a meeting. · At approximately 11 or 11:30 a.m., P2-P6 were in the dining room at the table and P3 sat so s/he was able to watch the back door. P6 had not seen the VA since the shower so did not know where the VA was during the meeting. · After the meeting, P4 noticed the VA’s items in the kitchen or garage and “yelled” that the VA was “gone.” At that time, P3 said that the last time s/he remembered seeing the VA was when the VA was going into the garage. P2-P4 left in their vehicles while P5 and P6 stayed at the facility. Around lunch time, P3 returned with the VA to the facility. The VA did not have any injuries. The VA was allowed unsupervised time while in his/he bedroom otherwise s/he was supervised at all times. The CM stated on August 1, 2024, P1 emailed the CM that the VA left the facility unsupervised. The CM had concerns because there were multiple previous times when the VA left the facility alone in the weeks prior. Facility documentation showed that staff persons, including P1-P6, were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incidents. Information maintained by the Department of Human Services showed that between June 9 and July 5, 2024, there were five incidents where the VA was in the community unsupervised. (See Report 202405537) As a result of those incidents, the facility completed an Internal Review and determined that policies and procedures were adequate but not followed. All staff persons received additional training on July 6, 2024, regarding the VA that included use of the VA’s trackers and identification badge; protocol for charging the trackers and door alarms; supervising the VA in the community; and that staff persons were required to have eyes on the VA at all times instead of 15-minute checks. Relevant Statutes: Minnesota Statutes, section 245D.07, subdivision 1a states that the license holder must provide services in response to the person's identified needs, interests, preferences, and desired outcomes as specified in the support plan and the support plan addendum, and in compliance with the requirements of this chapter. Conclusion: A. Maltreatment: The VA’s plans stated that the VA required supervision at all times, including staff persons remaining “in eyesight at all times” when the VA was at the facility and remaining “next to” the VA in the community. The VA was at risk in the community without supervision because s/he was disoriented to his/her community, his/her communication was not understood by unfamiliar persons, and s/he had a history of removing his/her clothing, public defecation, public urination, and inappropriate actions towards others when s/he was in the community. If staff persons were separated from the VA, they were to call 9-1-1 “immediately.” On August 1, 2024, P2-P6 were at the facility in the living room for a staff meeting on safety. Inconsistent information was provided whether the VA was in his/her bedroom in the basement or sitting in the living room with staff persons during the meeting. There was also inconsistent information on when the VA left the facility but information provided by law enforcement showed it was approximately 23 minutes from when the CP called 9-1-1 after seeing the VA alone until P3 called 9-1-1 to notify them that the VA was missing. The VA’s ability to leave the facility without the knowledge or supervision of a staff persons was a violation of Minnesota Statutes, section 245D.07, subdivision 1a. Given that the VA required staff persons supervision in the community and that the VA left the facility without the knowledge or supervision of staff persons, was gone for at least 23 minutes before staff persons noticed, and engaged in dangerous behavior including scootering in traffic in the rain barefoot, and being in contact with and inside the vehicles of community persons who did not know the VA, there was a preponderance of the evidence that there was a failure to provide the VA with supervision which was reasonable and necessary to obtain or maintain the VA’s physical or mental health or 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 626.556, subdivision 10e, paragraph (i): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. P2-P6 were at the facility having a meeting in the living room either when the VA left or shortly before the VA left. Facility documentation showed that P2-P6, were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incidents. Information regarding the VA’s location during the meeting was inconsistent. The VA was either downstairs in his/her bedroom, which was inconsistent with the update to the VA’s plans made on July 6, 2024, as provided in the Internal Review for report 202405537 or sitting next to P3 during the meeting. P4 and P5 said that it was P3’s responsibility to supervise the VA, but P1 said that no single staff person was assigned to supervise the VA and that they worked as a team, and it was P3’s first day at the facility and second day working and was therefore, still in training. Information from P1, P2, and P5 was consistent that P3 said s/he saw the VA leave but P3 denied having seen the VA leave and/or saying s/he saw the VA leave. Given the VA’s history, and the VA’s continued ability to leave the facility while five staff persons were present and working, individual responsibility including that of P3 was mitigated, and the facility was determined responsible for the maltreatment of the VA. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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 facility was responsible did not meet statutory criteria to be determined “serious” because it was a single incident of neglect for which the VA did not sustain an injury that reasonably required the care of a physician. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an Internal Review and determined that policies and procedures were adequate but not followed. All staff persons received additional training on supervision of the VA. P1 conducted regular checks at the facility to ensure the alarms and safety procedures were followed. P2 and P3 no longer work at the facility. Action Taken by Department of Human Services, Office of Inspector General: On March 5, 2025, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal. Certification: The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right to obtain private data on themselves which was collected, created, or maintained by the Department of Human Services.
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