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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): Anna Parkin 651-431-6225 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) left the facility without staff persons and/or was unsupervised in the community on five occasions. Date of Incident(s): June 9 to July 5, 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 10, 2024; from documentation at the facility, law enforcement records, and medical records; and through seven interviews conducted with two supervisory staff persons (P1 and P2), four facility staff persons (P3 and SP1-SP3), and the VA’s case manager (CM). Attempts were made via telephone and mail to contact the VA’s guardians (G1 and G2), but G1 and G2 did not respond to the requests. Background Information: 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. 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. 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. P1 stated that the VA had 1:1 staffing because of his/her targeted behaviors that required supervision. The VA began receiving services in approximately April of 2024 and during that month, s/he did not leave the facility unsupervised. In May of 2024, the VA started wandering away from the facility alone and staff persons verbally redirected the VA back inside. Because of this, the facility ordered an identification badge, identification bracelet, and a GPS tracker that stayed inside the VA’s shoe. The VA had another tracker that s/he wore when out in the community but it did not have a charger when s/he moved into the facility, so it did not work properly. Staff persons were trained to check on the VA every 15 minutes while at the facility and “ensured supervising” the VA in a “general sense.” P2 provided the following information: · The VA had 1:1 staffing while at the facility and out in the community, which meant there was a staff person “dedicated” to the VA each shift. The VA could spend time alone in his/her bedroom but staff persons checked on the VA while s/he was there. When the VA was anywhere other than his/her bedroom, the VA was always within sight of staff persons. · On an unknown date, the facility implemented a rule that staff persons only brought the VA out alone on outings and they were not allowed to bring any other clients. P2 was not aware of any times when there were not two staff persons working. If a staff person did not show up to his/her shift, a supervisory staff person found a replacement staff person to cover the shift, or the supervisory staff person worked. P3 stated that when the VA moved into the facility, G1 and G2 told P3 that the VA had a history of running away so staff persons needed to “pay attention.” Staff persons were with the VA “at all times” so s/he was not alone in the community. The VA could spend time alone in his/her bedroom but otherwise staff persons were by the VA when s/he was at the facility. When P3 brought the VA to the park, s/he only brought the VA and no other clients. Regarding June 9, 2024: Law enforcement records from June 9, 2024, provided the following information: · At approximately 7:55 p.m., law enforcement received a call to the facility for a “missing person” later identified as the VA. The report had conflicting information regarding how long the VA had been missing. It said both that the VA had not been seen since approximately 6:30 p.m., and that SP1 told law enforcement that the VA had been missing for “approximately three hours.” (Note: there were no other times provided throughout the report.) · A community person (CP1) called law enforcement to report that a person (later identified as the VA) was at his/her house. CP1 said that the VA was riding a child’s bike with no shoes and possibly had a cut on his/her foot. CP1 gave the VA shoes and a jacket while waiting for law enforcement who then brought the VA back to the facility. · SP1 identified the VA and said that SP1 was the only staff person working. According to googlemaps.com, the VA was found 0.6 miles away from the facility. According to wunderground.com, the temperature was between 64 and 70 degrees Fahrenheit at the time of the incident. P1 stated on June 9, 2024, SP1 and another staff person (P4) were scheduled to work but P4 did not show up for his/her shift. At some point, SP1 assisted another client (C) at the facility because s/he was physically aggressive and during that time, the VA left the facility alone. At approximately 5:45 p.m., SP1 realized that the VA was not at the facility and called 9-1-1. The VA was found by law enforcement and returned to the facility at 7:30 p.m. SP1 stated on June 9, 2024, a second staff person did not show up to work so SP1 called and told P2 that s/he was alone at the facility. P2 told SP1 that s/he made a “mistake” and scheduled the other staff person at two locations and that s/he would find someone to come in. The C was having “behaviors” and throwing items so SP1 assisted the C. After a while, SP1 went to check on the VA and s/he was not inside his/her bedroom so SP1 “immediately” called P2 and then law enforcement. SP1 saw that a window in the kitchen was broken and suspected that was how the VA left the facility. Approximately two hours later, law enforcement brought the VA back to the facility and the VA was not injured. At approximately 8 p.m., after the VA had already returned to the facility, another staff person (P5) showed up to work. P2 was not aware of a time when there was only one staff person working. Regarding June 10, 2024: Law enforcement records from June 10, 2024, provided the following information: · At approximately 3:17 p.m., law enforcement received a phone call that a person, later identified as the VA, was at CarMax car dealership and had been wandering the property barefoot “for a while.” A law enforcement officer (LEO1) arrived and spoke to a CarMax employee who said that the VA had been wandering around the building for approximately 10 to 15 minutes before an employee called 9-1-1. CarMax employees said they tried talking to the VA but s/he did not verbally respond to them. · LEO1 tried to talk to the VA, but the VA did not react or respond to the questions or conversation. While LEO1 stayed near the VA, another law enforcement officer (LEO2) used a data base to see if any persons were reported missing from facilities in the area. A short while later (no time was documented), LEO2 told LEO1 that s/he contacted the facility and a staff person confirmed that the VA lived there. That staff person also requested a picture of the VA to confirm his/her identity so LEO2 sent him/her a picture, and the staff person confirmed that it was the VA. · Approximately ten minutes later, P2 arrived at CarMax and provided the following information: o P2 was a supervisory staff person at the facility and the VA had lived at the facility for approximately three months. o The VA had a history of “wandering around the area” and P2 was not aware if the VA had interest in vehicles that would motivate him/her to walk to the business. o P2 said that the VA left the facility between 3:30 and 3:45 p.m. · LEO1 noted that P2’s statement that the VA left the facility between 3:30 and 3:45 p.m. was inaccurate since the 9-1-1 call was made at 3:17 p.m. LEO1 told P2 that a “better alternative” should be in place since the VA had a history of leaving the facility. LEO1 also told P2 that County Road 81 was “very close” to CarMax and was “very dangerous.” P2 said that the facility would implement “new ways” to keep the VA safe. (Note: there were no times listed in the report other than when the initial call came in.) According to googlemaps.com, CarMax was between one to two blocks from the facility. According to wunderground.com, the temperature was approximately 73 degrees Fahrenheit at the time of the incident. P2 provided the following information: · On June 10, 2024, P3, SP1, and P2 were working at the facility. P3 was working 1:1 with the VA and sat at the dining room table while the VA sat in the living room. SP1 was also in the living room interacting with the C. At approximately 3 p.m., P2 left the facility and went to the main office. Approximately 10 to 12 minutes after P2 got to the main office, P1 told P2 that s/he received a phone call from P3 that the VA was alone at a business near the facility. P2 drove to the business and saw the VA with two law enforcement officers. P2 took the VA (who was not wearing shoes) in his/her vehicle and drove to the facility. P2 denied that law enforcement told P2 about any injuries to the VA’s feet. · At the facility, P3 and SP1 were watching the C and another client. P2 saw the bottoms of the VA’s feet because of the way the VA sat in a chair. The VA’s feet were “red” but not burnt or injured. P2 told P3 and SP1 to monitor the VA and keep eyes on the VA at all times. P2 asked P3 what happened and P3 said s/he was cleaning the facility when the VA left. P2 did not recall much of the conversation because s/he was “furious” that the VA was allowed to leave the facility. P1 stated on June 11, 2024, P2 sent out an email to the VA’s team including P1, stating that the VA had been picked up by law enforcement but was “fine.” The CM responded to the email about the GPS tracker and that the VA’s feet were red because s/he was possibly not wearing shoes. P1 assumed this email thread was about the June 9 incident and was not aware of the June 10, 2024, incident until speaking to this investigator. SP1 and P3 each stated they did not remember this incident and were unable to provide information about it.
Regarding June 21, 2024: Law enforcement records from June 21, 2024, provided the following information: · At 4:03 p.m., a law enforcement officer (LEO3) was dispatched to Brooklyn Boulevard and Kentucky Avenue where a person later identified as the VA was walking in the middle of the road. When LEO3 arrived, traffic was stopped on Brooklyn Boulevard and a community person (CP2) had the VA sitting inside his/her vehicle with the door open. CP2 and the VA walked toward LEO3 and while speaking to CP2, the VA started to walk away. LEO3 spoke to the VA and asked him/her to sit inside the law enforcement vehicle which the VA did but the VA did not verbally respond to LEO3. · LEO3 went back and spoke to CP2 who was “very concerned” about the VA and was worried that the VA might get hit by a vehicle if CP2 did not assist him/her. CP2 then left and LEO3 tried talking to the VA but s/he did not respond. LEO3 contacted other law enforcement services and a social worker (SW1) came and identified the VA. LEO3 looked up the VA in his/her computer system and found the facility’s address. · LEO3 drove the VA to the facility and LEO3 spoke to P3. LEO3 asked P3 if the VA resided there and P3 confirmed s/he did. LEO3 asked P3 where the VA was and P3 responded that s/he “should be in [his/her] bedroom.” Then P3 said that the VA should have been with SP2 at the facility’s main office. LEO3 released the VA to P3. (Note: there were no times listed in the report other than when the initial call came in.) According to googlemaps.com, the Brooklyn Boulevard and Kentucky Avenue intersection was 1.5 blocks from the facility’s main office. According to wunderground.com, the temperature was approximately 69 degrees Fahrenheit at the time of the incident. P1 stated on June 21, 2024, SP2 and the VA drove to the main office because SP2 needed to complete some documentation. SP2 left the VA alone in the facility vehicle while SP2 went inside the main office. Approximately 45 minutes after P1 saw SP2 inside the main office, P1 received a phone call from P2 saying that law enforcement brought the VA to the facility and left him/her with P3. P1 went to where SP2 was at the main office and asked SP2 if the VA was with him/her. SP2 said that the VA was outside in the facility vehicle. P1 told SP2 that the VA was dropped off at the facility by law enforcement so s/he was not in the facility vehicle and that the VA was not allowed to be left alone. SP2 was suspended until s/he received additional training on the VA’s supervision. SP2 stated on June 21, 2024, s/he had to go to the main office so brought the VA with. The VA stayed inside the vehicle while SP2 went inside the main office. SP2 could not remember how long the VA was alone in the vehicle but a phone call was made to the main office that the VA was already back at the facility when SP2 realized that the VA had left. SP2 knew that the VA had 1:1 staffing but thought that the VA was safe inside the vehicle. Later, SP2 realized s/he was “wrong.” Regarding June 26, 2024: Per law enforcement, there was no report for the June 26, 2024, incident because SW1 responded. According to a case management entry, on June 27, 2024, the CM received a phone call from SW1 that the VA was found alone “in the middle of a busy road” and returned to the facility. When SW1 returned the VA to the facility, staff persons were not aware that the VA was not at the facility. The staff person working told SW1 that s/he saw the VA 15 minutes prior, which was “not possible” because the 9-1-1 call had been placed 20 minutes prior. P1 provided the following information: · On June 26, 2024, SP1 and SP3 were working at the facility. SP1 brought the C to a park while SP3 stayed with the VA and another client at the facility. SP3 was doing laundry at the facility when the VA left the facility. At some point, law enforcement brought the VA back to the facility. SP3 did not tell SP1, P1, or other staff persons about the incident that day. · On June 27, 2024, the CM notified P1 about the June 26, 2024, incident and P1 spoke to SP3 who said s/he was doing laundry during that time and then the VA showed up at the front door with law enforcement. P1 then spoke to SP1 who was unaware of the incident because s/he did not return with the C until after the VA was back at the facility. SP3 was suspended until s/he received retraining on the VA’s plans and reporting policy. P2 stated on June 26, 2024, the VA left the facility when SP3 was the 1:1 staff with him/her but P2 did not find out about the incident until later. SP1 stated on the day of the incident, SP1 and SP3 were working and SP3 brought the VA and the C to the park. At approximately 7:50 p.m., SP3, the VA, and the C returned to the facility. The C was dysregulated so SP1 decided to drive the C around to help the C calm. SP1 and the C were gone for approximately 45 minutes and when they returned, SP3 was watching the VA inside the facility and SP3 did not say anything to SP1. The following day, a supervisory staff person called SP1 and explained that the VA had left the facility the night before but SP1 was not able to provide information since s/he was not aware of the incident. SP3 stated on June 26, 2024, after dinner at approximately 7 p.m., SP1 took the C for a walk and SP3 was at the facility with the VA. The VA was in his/her bedroom so SP3 worked on laundry. The laundry room was on the same level as the VA’s bedroom in the basement. SP3 then cleaned up from dinner. SP3 was trained that when the VA was alone in his/her bedroom, staff persons checked on the VA every two hours. After approximately 30 to 45 minutes, there was a knock on the door and it was a community person with the VA. Later on, SP1 and the C returned to the facility and SP3 told SP1 about the incident. SP3 did not notify a supervisory staff person but P1 contacted SP3 the following day and suspended SP3 until s/he received further training. Regarding July 5, 2024: Medical records from July 5, 2024, provided the following information: · An emergency triage entry at 5:50 p.m. said that a person, later identified as the VA, was found by an ambulance driver standing on the side of the highway near 694 and County Road 81. They were not sure if the VA wandered off alone or was left on the side of the road. The VA did not speak, did not have injuries, and did not allow emergency staff to take his/her vital signs. Law enforcement was notified, who said they possibly had a missing person matching the description and provided SP1’s contact information. · At 6:08 p.m., a hospital staff person called SP1 who was able to provide the VA’s name but did not know his/her date of birth. SP1 said s/he was at a park with the VA and another client and when SP1 said it was time to leave, the VA and the other client ran away. SP1 was able to contain the other client but not the VA. SP1 said s/he was still at the park looking for the VA but would go to the facility to get the VA’s identification. · At 6:31 p.m., P1 told the hospital staff person that s/he was driving to the hospital to get the VA. The VA was given a snack and juice while waiting. At 6:56 p.m., a social worker (SW2) from the hospital called the facility and spoke with an unknown staff person who “continually asked [SW2]” to call another phone number to get G1’s and G2’s contact information because that staff person was doing laundry. SW2 “insisted” on getting the contact information because it was “imperative to the safety and well-being” of the VA. The staff person provided SW2 with P1’s contact information but refused to give out G1’s and G2’s information. · SW2 was able to get G1’s and G2’s contact information another way, called and notified them about the incident, and G1 and G2 agreed that P1 was able to leave with the VA. SW2 noted that the VA did not have a tracker tag or identification with him/her. At 7:15 p.m., the VA was discharged to P1.
P1 provided the following information: · On the evening of July 5, 2024, SP1 brought the VA and the C to the park. While at the park, the C “hit” SP1 in the face and ran away. SP1 followed the C and during that time, the VA ran away in another direction. SP1 caught up to the C and got him/her into the facility vehicle before looking for the VA. An ambulance was in the area, saw the VA, and transported him/her to the hospital. The hospital contacted the facility and P3 answered the phone, who then contacted P1 who went and got the VA from the hospital. The VA was not injured. The VA did not have the GPS tracker on him/her during that time and was in the community without a caregiver for approximately 30 to 40 minutes. · Later on, when P1 spoke to SP1 about the July 5, 2024, incident, SP1 said s/he “forgot” to put the GPS tracker on the VA. P1 said prior to this incident, s/he “did not make it clear” that a single staff person was not allowed to bring the VA and the C to the park together. After the July 5, 2024, incident, staff persons only brought the VA to the park without other clients, and on July 6, 2024, all staff persons received additional training on the VA. P3 stated that while P3 and SP1 were working, SP1 brought the VA and the C to the park. P3 stated they were gone for “one to two hours” before SP1 returned to the facility with the C but not the VA. P3 was not able to provide a specific amount of time that the VA was alone for. SP1 told P3 that while at the park, the C refused to head back to the facility and started choking SP1, when the VA ran away. SP1’s cell phone died so s/he was not able to use it while at the park. SP1 went and charged his/her cell phone while P3 went outside looking for the VA. During that time, a law enforcement officer called the facility and said that the VA was at the hospital and that P1 would bring the VA back to the facility. When the VA returned to the facility, s/he was “fine” and did not have injuries. P3 denied that the VA left the facility alone when P3 was supervising him/her. SP1 provided the following information: · At approximately 6 p.m., SP1 brought the VA and the C to a park. P3 stayed at the facility with the other client and cleaned. Prior to leaving the facility, SP1 was not able to find the GPS tracker for the VA’s shoe and the other tracker had not been charged. The VA had a history of hiding the GPS tracker and P2 previously told SP1 that s/he “had” to take the VA to the park as it was his/her routine. P2 was aware that SP1 could not find the tracker prior to leaving for the park. SP1, the VA, and the C were at the park for approximately 1 hour and 30 minutes when the C became “aggressive” and began “fighting” with SP1. Meanwhile, the VA ran away. · SP1 was not able to call anyone because his/her cell phone died. SP1 drove the C back to the facility. SP1 charged his/her cell phone and tried calling P2 from the facility phone but P2 did not answer so SP1 called law enforcement. At one point, SP1 also called P1 about the incident. SP1 said it had been approximately 45 minutes from when the VA ran away until s/he called P1. P1 said to go back to the park and look for the VA. As SP1 was about to leave for the park, s/he received a phone call that the VA was at the hospital. P1 got the VA from the hospital and brought him/her back to the facility. The VA did not have injuries.
· SP1 took the C and the VA to the park approximately eight times prior and there were no concerns. The VA needed a staff person with him/her “at all times.” Additional Pertinent Information: The CM had concerns with the multiple times the VA was unsupervised in the community. On some of these occasions, staff persons were not aware the VA was missing until they were notified by law enforcement. The VA had 1:1 staffing at all times, as well as a tracker s/he wore prior to moving into the facility. However, the CM asked staff persons “multiple” times if the VA wore the tracker and staff persons did not know what the CM was talking about. The VA had a GPS tracker inside his/her shoe but had left the facility barefoot. The CM had been contacted by SW1 and informed that the VA was found without shoes and had “burns” on his/her feet. The CM was unsure if the VA’s feet were physically injured. One staff person taking the VA and the C to a park together “should not have happened.” According to the facility’s Responding to and Reporting Incidents policy: · If there was an “unauthorized or unexplained absence” of a vulnerable adult, based on the vulnerable adult’s supervision level, staff persons determined when the person was missing from the facility or from supervision in the community. · Staff persons “immediately” called 9-1-1 if the vulnerable adult was deemed “missing.” Staff persons provided law enforcement with information about the person’s appearance, last known location, disabilities, or other information as requested. · Staff persons then “immediately” notified supervisory staff persons. A “more extensive” search was organized by checking locations where the vulnerable adult may have gone. · The supervisory staff person continued to monitor the situation until the vulnerable adult was located. · If there was “reasonable suspicion” that abuse and/or neglect led to or resulted from the absence, staff persons “immediately” reported suspected maltreatment according to policy. Facility documentation showed that staff persons, including SP1-SP3, were trained on the VA’s plans, the Responding to and Reporting Incidents policy, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incidents. Relevant Statute: 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 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.” Consistent information was provided that between June 9 and July 5, 2024, there were five incidents where the VA was in the community unsupervised. Regarding the VA being left alone in a vehicle in the community: On June 21, 2024, a community person called 9-1-1 because the VA was walking alone in traffic. When law enforcement arrived, the VA was sitting in an unknown community person’s vehicle. Information from all sources was consistent that SP2 had left the VA alone in a vehicle while SP2 went inside the main office. Approximately 45 minutes after SP2 arrived at the main office, P1 was informed that law enforcement had dropped the VA off at the facility. P1 approached SP2 at that time, who told P1 s/he thought the VA was still outside in the vehicle. Regarding the VA leaving the park: On July 5, 2024, SP1 brought the VA and the C to a park. While at the park, the C and the VA went separate ways. SP1 followed the C, and the VA then ran in a different direction. The VA was not wearing his/her GPS tracker, though there was conflicting information as to the reason (SP1 said s/he could not find a working tracker and P1 said SP1 forgot to use it). SP1 said his/her cell phone was out of power, so s/he could not call 9-1-1 until s/he returned to the facility with the C. Meanwhile, an ambulance driver in the area saw the VA standing on the side of the road and transported the VA to a hospital. P1 picked up the VA from the hospital and drove the VA back to the facility. Regarding the VA leaving the facility without supervision: On June 9, 2024, the VA left the facility when SP1, who was the only staff person working at the facility, was helping another client. When SP1 realized the VA was not at the facility, s/he “immediately” called P2 and then law enforcement. Information was inconsistent as to how much time elapsed before SP1 called 9-1-1 to report the VA missing, with estimates ranging from 85 minutes to “approximately three hours.” A community person called 9-1-1 because the VA was at the community person’s house, had no shoes, and possibly had a cut on his/her foot. On June 10, 2024, a community person called 9-1-1 after the VA had been wandering barefoot at a community business for 10 to 15 minutes, and there was no information that a staff person called 9-1-1 prior. P2 picked up the VA and bought him/her to the facility where SP1 and P3 were. SP1 and P3 were each working at the facility when the incident occurred, but did not remember this incident so were unable to provide information. On June 26, 2024, the VA left the facility while SP3 was providing 1:1 staffing to the VA. SP3 said s/he was doing housekeeping tasks while the VA was in his/her bedroom when the VA left the facility. The VA was found alone walking in traffic and returned the VA to the facility by SW1. SP3 was unaware the VA was alone in the community until SW1 brought the VA back to the facility. According to SP3, s/he had last seen the VA 30 to 45 minutes before law enforcement returned the VA to the facility. Given that the VA did not receive supervision according to his/her plans on each occasion; and that as a result the VA was in the community without supervision and engaged in dangerous behavior including walking in traffic, walking barefoot which resulted in possible injuries to his/her feet, 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 each incident represented 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. Regarding the VA being left alone in a vehicle in the community: On June 21, 2024, SP2 brought the VA to the main office and left the VA alone in his/her vehicle. SP2 received training on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Therefore, SP2 was responsible for the maltreatment of the VA. Regarding the VA leaving the park: On July 5, 2024, SP1 brought the VA and the C to a park. SP1 was assisting the C when the VA went in a different direction and left the park. P1 provided information that prior to the incident, it was not clear to staff persons to only take the VA to the park alone. Therefore, SP1’s responsibility for maltreatment was mitigated and the facility was determined responsible for the maltreatment of the VA. Regarding the VA leaving the facility without supervision on June 9, 2024: On June 9, 2024, SP1 was responsible for the supervision of the VA. However, given that SP1 was the only staff person at the facility; that SP1 was assisting the C at the time the VA left the facility; and once SP1 checked on the VA and realized that s/he left the facility, SP1 “immediately” called P2 and then law enforcement; SP1’s responsibility for maltreatment was mitigated and the facility was determined responsible. Regarding the VA leaving the facility without supervision on June 10 and 26, 2024: On June 10, 2024, P3 and SP1 were supervising the VA and the C at the facility. P3 and SP1 did not remember the incident and were therefore unable to provide detail about what happened. On June 26, 2024, SP3 said the VA was in his/her bedroom and SP3 was doing tasks around the facility including laundry and cleaning, when the VA left the facility without SP3’s knowledge. The VA was gone for at least 20 minutes and SP3 was not aware that the VA was gone until s/he was returned by a community person. Information from multiple staff persons was consistent that the common practice at the facility was to leave the VA alone in his/her bedroom and check on the VA at unspecified intervals while staff persons did household chores in other areas of the facility. This practice was not consistent with the VA’s Intensive Support Self-Management Assessment, which stated that staff persons were to keep the VA “in eyesight at all times” while at the facility, and was therefore a violation of Minnesota Statutes, section 245D.07, subdivision 1a. Because the common practice at the facility neither provided the VA with the required level of supervision, nor was it compliant with the VA’s support plans, P3’s, SP1’s and SP3’s responsibility was mitigated and the facility was determined responsible for the June 10 and June 26, 2024, incidents of maltreatment. 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. In addition, 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 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 SP2 was responsible did not meet statutory criteria to be determined “recurring” or “serious” because SP2 was responsible for a single incident of neglect for which the VA did not sustain an injury that reasonably required the care of a physician. It was determined that the four incidents of substantiated neglect for which the facility was responsible did not meet statutory criteria to be determined “serious” because the VA did not sustain an injury that required the care of a physician during any of the incidents. Action Taken by Facility: The facility completed an Internal Review and determined that policies and procedures were adequate but not followed. SP2 received additional training and corrective action. All staff persons received additional training on the VA on July 6, 2024, 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. Action Taken by Department of Human Services, Office of Inspector General: SP2 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP2 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 disqualification. The determination that SP2 was responsible for maltreatment is subject to appeal. On March 5, 2025, the license holder was ordered to forfeit a fine of $4000 as a result of the substantiated maltreatment for which facility was responsible ($1000 each for four incidents). The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal. In addition, it was determined that facility mandated reporters had knowledge of four alleged incidents and did not report the incidents as required. The license holder was ordered to forfeit a fine of $800 ($200 for each incident) for failure to report maltreatment. The Order to Forfeit a Fine is subject to appeal.
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