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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: 1108406-HCBS (Home and Community-Based Services) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was struck by a vehicle in an attempted suicide. When a law enforcement officer (LEO) notified a staff person (SP), the SP did not realize the VA left the location. Date of Incident(s): September 1, 2024 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 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 September 10, 2024; from documentation at the facility, law enforcement records, and/or medical records; and through five interviews conducted with the VA, three facility staff persons (the SP, P1, and P2), and a case manager (CM). The VA enjoyed mall shopping, going out to eat, playing sports, especially soccer, and watching TV. The VA’s diagnoses included schizoaffective disorder, bipolar type, and psychoactive substance abuse. At the time of the incident, the VA received HCBS crisis respite services in a hotel setting. The VA was not subject to guardianship. Documentation provided by the CM showed that on August 29, 2024, (the day the facility began providing services), the CM emailed referral information to the facility regarding the VA. The CM included information about the VA’s “substance use, poor mental health, not being medication compliant, and needing to find long term placement.” The VA’s plans showed the following information: · The VA’s Coordinated Services and Supports Plan (CSSP) stated that s/he was “working on becoming stable with [his/her] housing and mental health.” · The VA’s Individual Abuse Prevention Plan stated s/he was susceptible to self-abuse regarding managing self-care needs and taking medications. The plan was for staff persons to “provide consistent supervision and regular reminders and cues” for self-help activities such as personal hygiene, taking medications, and eating. · The VA’s Support Plan Addendum stated that the services provided included “daily 1:1 staffing 24 hours a day.” · The VA’s Safe Smoking Assessment dated August 30, 2024, showed that the box for “independent” was marked and the boxes for “indirect” and “direct” supervision were not marked. An Incident Report from local law enforcement stated that on September 1, 2024, at 9:23 p.m., law enforcement officers (LEOs) were dispatched to a location where the VA was reported to be “unconscious” and “in the middle of traffic bleeding.” When the LEOs arrived, the VA had been moved to a parking lot and was sitting on a curb. Blood was observed on the VA’s head, hands, legs, and arms. The VA initially provided an inaccurate name for him/herself (information showed s/he told the LEOs his/her family member’s name). The VA said s/he went to a nearby gas station and was on his/her way back to the hotel. The VA was taken by ambulance to a nearby hospital. While at the hospital, the VA told one of the LEOs that s/he was feeling “depressed and alone” and “intentionally jumped out in front of a car.” One of the LEOs also spoke to the driver (D) of the vehicle who stated the VA came “out of nowhere” from the right side of the road and “jumped in front of [the D’s] car as if [the VA] was doing it intentionally.” The D said they had no chance to stop, and the VA was struck by the front driver’s side of the D’s vehicle. There was no evidence of “negligence on [the D’s] part or a traffic infraction being committed.” The LEOs went to the hotel to inform the staff persons about the incident. When directed to the VA’s hotel room, a staff person (determined to be the SP), answered the door and said that s/he believed the VA was “still in the hotel room.” Information from the VA’s hospital record stated that on September 1, 2024, the VA wanted to go a smoke shop and walked there from the hotel. It was dark outside, the VA did not really know where s/he was going, and s/he crossed the road in the “wrong spot.” The VA “adamantly denied” that this was “a suicide attempt and doesn’t remember answering yes to any suicidal screening questions.” The VA was diagnosed with a large subdural hematoma (a collection of blood between the covering of the brain and the surface of the brain) and a “closed fracture of right zygomatic arch (broken cheekbone).” Photos of the VA’s body showed abrasions on his/her right shoulder, right knee, face, head, right hip, left wrist, and right knuckles. The VA was discharged on September 3, 2024. When interviewed by this investigator, the VA provided the following information: · On an unspecified evening, the VA told an unidentified staff person (determined to be the SP) that s/he was going outside to smoke a cigarette. While outside the VA decided to walk in the dark to a nearby gas station and then to a smoke shop a few more blocks away. The VA was on his/her way back to the hotel when the incident occurred. The VA estimated s/he was gone from the hotel room for approximately 30-60 minutes before s/he was hit by a car. The VA said that was the longest amount of time that s/he was “away from staff.” · The VA said s/he did not remember talking to a LEO after the incident because s/he was “incapacitated, I was unconscious and woke up the next day in the ER (emergency room).” The VA remained in the hospital for two days before returning to the facility. · The VA did not remember telling anyone that s/he felt depressed or suicidal at the time of the incident. P1 was not present at the time of the incident on September 1, 2024; however, was informed of the incident and went to the hospital to check on the VA. P1 learned that prior to the incident, the VA went outside to smoke and left the hotel. At the time of the incident, the SP was working with the VA and was in the VA’s hotel room.
According to a P2, a management staff person, the VA moved into the hotel on either August 29 or 30, 2024. The SP was assigned as the 1:1 staff person for the VA at the time of the incident. P2 said that a 1:1 meant that a staff person “was assigned” to work with the VA and no additional clients. Upon admission, the VA’s smoking was assessed, and s/he was determined to be safe to smoke alone/without supervision. On the days before the incident, the VA’s pattern was to go outside to smoke and return to the hotel room. No concerns were noted. At the time of the incident, the SP was in the hotel room cooking dinner for the VA. Clients were allowed to be outside smoking for “up to 20 minutes” and the VA generally returned within 15-20 minutes. The SP provided the following information: · The SP stated his/her shift at 8:30 p.m. on September 1, 2024. At an unidentified time, the VA said that s/he was going outside to smoke and returned within a few minutes, told the SP that s/he was hungry, and said s/he was going back outside to smoke while the SP prepared dinner. Approximately 10 minutes later, while the SP was preparing dinner, a LEO knocked on the hotel room door and showed the SP a picture of the VA and told the SP about the incident. · P1 and the SP went to the hospital; however, were not able to see the VA because the VA said s/he did not want visitors. · Prior to the incident, the SP believed s/he worked with the VA “four consecutive nights” and when asked what s/he knew about the VA, the SP said, “Nothing really, just [the VA’s] name.” The SP said that s/he talked to the VA about his/her “schedule and what [s/he] does,” but there was no paperwork to read about the VA. P1 said that “no one really knew much about [the VA].” · The first couple of days, the SP went outside with the VA when s/he smoked; however, the SP “started to trust” the VA and believed s/he was “like every other crisis client” who was allowed to smoke outside without staff persons. The facility’s Program Abuse Prevention Plan stated that the staffing pattern “ensures that each client has dedicated staff based on their individualized care plans, with supervision ratios of either 1:1 or 2:1. This personalized approach allows for tailored support and close monitoring to meet each client’s specific needs.” An internet search showed that the distance from the hotel to the address where the LEOs located the VA was a 27-minute walk. Information showed that the SP was trained regarding the VA’s program plans and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: The VA provided information that on September 1, 2024, s/he went downstairs to smoke and then left the facility without informing the SP, who was assigned as the VA’s “1:1” staff person. The VA’s Support Plan Addendum stated that the VA was provided “daily 1:1 staffing 24 hours a day.” No further explanation of what that entailed was documented; however, P2 said that a 1:1 meant that a staff person “was assigned” to work with the VA and no additional clients. The VA’s Safe Smoking Assessment stated the VA was “independent.” While the SP was aware that the VA left the hotel room to go downstairs to smoke, the SP was not aware that the VA left the hotel and went to a nearby store and was subsequently hit by a car. The SP said that s/he became aware of the incident when a LEO came to the hotel room after the VA was gone for approximately 10 minutes; however, according to an internet search, the VA would have been gone over 27 minutes since the VA said the incident occurred on his/her way back to the hotel. Given the conflicting information regarding the amount of time the VA was unsupervised, that the VA was not subject to guardianship so could leave as s/he wanted to, that the SP was engaged in work related duties, and that the VA’s plans provided ambiguous supervision requirements, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. It was not determined whether 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and were followed. Staff persons were retrained regarding an updated smoking policy that stated all persons served were to be supervised at all times when smoking. In addition, staff persons were retrained regarding mandated reporting requirements. Action Taken by Department of Human Services, Office of Inspector General: On March 26, 2025, the facility was issued a Correction Order after it was determined that facility mandated reporters had knowledge of the alleged incident and did not report the incident as required and that a serious injury report was not submitted as required.
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