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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: 1080012-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070738-HCBS (Home and Community-Based Services) Investigator(s): Scout Peterson/Samantha Wueste Suspected Maltreatment Reported: It was reported that a staff person (SP) fell asleep during two consecutive overnight shifts that required the SP to remain awake which resulted in a vulnerable adult (VA) leaving the facility without the SP’s knowledge. It was also reported that on each of these evenings, the SP did not secure the staff office as required which gave the VA access to the facility van keys that the VA then took when leaving the facility, driving the van without a valid driver’s license. Date of Incident(s): Between January 5 and 7, 2025 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 January 27, 2025; from documentation at the facility; and through six interviews conducted with the VA, facility staff persons (P5 and the SP), two supervisory staff persons (P1 and P2), and the VA’s case manager (CM). Multiple attempts were made via phone to contact and interview two additional staff persons (P3 and P4), but the attempts were not successful. P3 initially responded to this investigator about scheduling an interview but then did not respond further by the completion of this investigation. The facility was a single-family home, where the VA lived with two housemates. The VA’s bedroom was in the basement of the facility with an egress window leading outside to the deck and the backyard. There were three exterior exits on the main level of the facility, which included a front door, a patio door, and a side door. The facility’s front door led directly into a living room that contained a couch positioned against a bay window that viewed the driveway where the facility van was parked. The van keys were kept in the staff office located to the right of the living room, which was to be locked when not in use. Diagonally across from the living room was a kitchen that contained access to the side door and to the basement stairs. To the left of the kitchen, was a dining area and second living room that led to the patio door. The VA enjoyed outdoor activities, playing video games, and completing hands-on mechanical projects. The VA was not subject to guardianship. The VA’s diagnoses included disruptive mood dysregulation disorder, attention-deficit hyperactivity disorder, episodic mood disorders, adjustment disorder with mixed disturbance of emotions and conduct, and oppositional defiant disorder. On November 12, 2024, the VA moved into the facility seeking supports and services relating to his/her diagnoses that included receiving transportation services and supervision from the facility. When assisting the VA with transportation needs, staff persons would use a company owned vehicle which at this time, was a 2016 Dodge Caravan. The CM and the VA’s Individual Abuse Prevention Plan (IAPP), Self-Management Assessment and Plan (SMAP), and Support Plan dated November 12, 2024, provided the following information: · Prior to moving to the facility on November 12, 2024, the VA’s care plans required “intensive” and “constant” supervision 24 hours a day, a 1:1 staffing ratio for 13 hours a day, and no unsupervised time in the community. Upon moving to the facility, the VA received a new care team who worked with the VA’s prior care team to reassess and update the VA’s care plans. The VA still required 24-hour care provided by the facility to maintain his/her health and safety, but the VA’s updated plans provided the VA “more independence” with facility assistance in “building life skills” and making “responsible” decisions that would allow the VA to reach his/her goal to safely and “successfully live on [his/her] own in the near future.” Quarterly meetings were scheduled by the VA’s care team to review the VA’s care plans and make any needed adjustments to the cares and supports that the VA required by the facility. · After November 12, 2024, the VA required a 1:4 staffing ratio that included an awake overnight staff person. When the VA was present within the facility, staff persons were required to “check on” the VA each hour during awake hours and every two hours during overnight hours. Additionally, the VA could remain at the facility unsupervised for up to six hours. The VA was able to arrive and/or leave the facility at any time and go into the community unsupervised for an unspecified duration of time. Staff persons were able to locate the VA using an application called Life360 that was installed on the VA’s phone to record “real-time” location data that helped the facility monitor and maintain the VA’s health and safety. The VA did not drive and needed assistance with transportation. · The VA had a history of putting him/herself in “unsafe positions” by making “quick, impulsive” decisions without fully understanding or considering the potential “dangers” and/or “consequences” that might result from these decisions. Staff persons provided the VA with cognitive behavior support to help “regulate emotions, mental health, and overall decision-making due to impulsivity.” P1, P2, P5, and the facility’s Internal Review completed by P1 and P2 provided the following information: · The VA arrived at the facility on November 12, 2024, and at this time, was in the process of life transitions that included no longer being subject to guardianship; moving from a rural area to an urban area; completing educational programming that previously provided consistency and structure to the VA’s daily schedule and routines; receiving a new care team; and updating his/her care and support plans. · The VA was able to “come and go” from the facility without needing assistance or supervision from staff persons unless requested by the VA. Since the VA was “new” to the Duluth area and in having “this type of freedom,” an “agreement” was made between the VA and his/her care team to communicate with staff persons when s/he was leaving the facility and then “check in” with staff persons every four hours when in the community. The VA had “some challenges” in “initially adjusting” to these responsibilities and communication expectations and would “frequently” use his/her bedroom window to “sneak” in/out of the facility or have friends come into the facility without staff persons being aware of these incidents. · On January 6, 2025, P4 worked at the facility from 8 a.m. to 4 p.m., P5 worked 9 a.m. to 9 p.m., and P3 worked 4 to 10 p.m. There were not any appointments or specific activities scheduled for any facility clients this day, and the VA slept “most” of the morning and afternoon. When P3 arrived at the facility, the VA asked staff persons “for a ride” to get a package that was delivered to the VA’s prior residence. At approximately 4:10 p.m., P3 and the VA exited the home and walked out to the driveway where the facility van was parked. After getting into the van, P3 saw that the van was out of gas and that a mileage log that was maintained by staff persons when using the van was not consistent with the mileage displayed on the van’s odometer, with over 150 miles being unaccounted for. · After driving the VA to get his/her package and returning to the facility, P3 asked P5 if any staff persons used the van earlier in the day. P5 stated that s/he did not drive the van and was not aware of P4 using the van either since there was not a client need or request for transportation that morning/afternoon. After speaking with P5, P3 immediately called P2 and told him/her about the concerns regarding the van’s usage, who then called P1. Shortly thereafter, P1 and P2 called P4 to confirm that staff persons had not used the van earlier that day. P4 told P1 and P2 that s/he did not use the van and was not aware of any other persons who might have needed to use the van during or prior to his/her shift. After the call with P4, supervisory staff persons “knew something was off” because the van was “clearly used” and not by staff persons working that day during the hours that the van would typically be needed. Prior to the facility’s daytime hours beginning that morning, the SP worked the overnight shift that started at 10 p.m. the night prior and went through the early morning until 8 a.m. Assisting clients with transportation needs during the overnight hours was not “restricted” but also not “common practice,” especially for a drive of 154 miles that would have taken “nearly three hours” to complete at a time when the facility was single staffed. · Upon inspection of the van during the evening of January 6, 2025, P1 and P2 did not see any damages to the van, the van was not broken into, and “appeared” to be driven by someone from the facility. Supervisory staff persons were aware that in the past prior to moving into the facility, the VA had a history of driving a vehicle without a valid driver’s license, leaving without staff persons knowledge/supervision, and theft. The VA was also the “only” client at the facility who could have “even potentially” taken the van. Additionally, there was a prior incident in 2020 when the SP fell asleep on the couch watching T.V. when working an overnight, awake shift. Shortly thereafter, P1 called the company’s Human Resource representative (HR) to provide information about the incident. P1 told HR that the SP was scheduled to work the overnight shift later that evening at 10 p.m. HR told P1 that additional information regarding the incident was needed and to speak with the SP and the VA at the facility in the morning. · On January 7, 2025, at approximately 8 a.m., P2 arrived at the facility to speak with the SP. P2 asked the SP “open-ended” questions regarding the SP’s overnight shifts on January 5 to 6, and 6 to 7, 2025. The SP told P2 that s/he didn’t “notice anything out of the ordinary” and that “all” of the hourly checks “went just fine.” The VA had an unknown friend (the U) stay the night at the facility on both nights, but they remained in the basement for “most” of the night besides coming upstairs to get food. Additionally, the VA told P2 that the VA and the U were sleeping during the SP’s hourly checks. · After speaking with P2, the SP left the facility. At approximately 10:30 a.m., P3 told P2 that when transporting a client that morning to an appointment, P3 saw that another 59 miles was unaccounted for when comparing the recorded mileage that P3 completed the evening prior, to the mileage that was displayed on the van’s odometer in the morning. P2 then immediately told P1 about the additional mileage and what the SP said during their conversation. P1 told P2 that they would need to speak with the VA once s/he was awake. · Later that morning, P1 and P2 spoke to the VA. The VA “initially” denied leaving the facility or driving the van and told P1 and P2 that s/he did not want to get “kicked out” of the facility. P1 and P2 “reassured” the VA that s/he would not be “in trouble.” Shortly thereafter, the VA “admitted” that s/he was the person who drove the van during the “last two nights” while the SP worked the overnight shifts. The VA told P1 and P2 that the U stayed the night both evenings and they “mostly” stayed in the basement. During the first night at an unknown time, the VA went upstairs and saw the SP sleeping on the living room couch with the door to the staff office open and not locked. The VA went into the office and saw the facility van keys on a desk. The VA took the van keys from the office, walked back downstairs to the U, and they left the facility using the side door while the SP remained asleep. Then on January 6, 2025, at approximately 12:30 a.m., the VA took the van and drove around without a valid driver’s license until the van was “almost out” of fuel. The VA and the U drove from the facility to Moose Lake and the surrounding areas and returned to the facility over three hours later, entering the facility through the VA’s bedroom window. The VA then “snuck upstairs” and returned the van keys to the staff office without the SP’s knowledge that any of this had occurred. At an unknown time shortly thereafter, the VA and the U went upstairs to ask the SP for something to eat. The SP was awake and helped the VA. · The VA then told P1 and P2 that s/he “repeated” the “same thing” the next night while the SP worked. Earlier in the evening prior to the SP arriving for his/her shift, the U came to the facility to spend another night with the VA. During the “middle of the night,” the VA went upstairs and saw that the SP was again sleeping on the living room couch with the office door open. The VA went into the office, took the van key, and went back to his/her bedroom where the U was waiting. The VA and the U then left via the VA’s bedroom window. At approximately 12:28 a.m., the VA and the U got into the van that was parked in the driveway and the VA drove to a residence located in Cloquet to pick up an unnamed friend who then returned to the facility with the VA and the U. After the VA parked the van, the VA and his/her friends re-entered the house using the VA’s bedroom window and remained in the basement except for times when they needed to go upstairs for food. The VA said during this incident, s/he was gone for approximately two hours and drove 59 miles without the SP’s knowledge. The VA then showed P1 and P2 his/her phone that contained time-stamped location data that was automatically logged within the VA’s Life360 application. The information that the application provided was consistent with the information that the VA told P1 and P2 regarding each incident and “completely aligned” with the “unaccounted mileage.” Additionally, P2 stated that s/he had “some” screenshots of this application data that was then provided to this investigator. · P1 and P2 stated that the SP received a prior “warning” and “re-training” for the incident in 2020 when the SP “unintentionally dozed off” while working an overnight shift but neither were aware of any additional concerns of the SP sleeping during his/her shifts after this. The SP was trained that his/her job position at the facility required the SP to remain awake at all times during overnight hours and s/he was to provide adequate supervision that included checking on the VA every two hours throughout the night. Although the VA was not injured during these incidents, P1 stated that the SP’s “lack of supervision” provided the VA the opportunity to make “poor decisions” that put the VA in multiple “unsafe situations” that could have resulted in the VA and/or someone else being injured. Additionally, the VA was on probation and could have potentially received “legal implications” that would have hindered the VA’s ability to achieve his/her goals outlined in the VA’s care plans if s/he would have been stopped by law enforcement while driving unlicensed. The VA provided information during the interview that was consistent with the information the VA provided to P1 and P2. The VA also stated that when s/he returned the van keys to the staff office upon arriving back to the facility, the SP was still sleeping. The VA was able to do this during both nights while the SP was asleep. The VA stated that s/he did not have a valid driver’s license. The VA was the only person who drove the facility van during these incidents and that despite not being able to “legally drive,” the VA “knew how” to drive. Additionally, no one was injured during these incidents. The SP provided the following information: · The SP worked alone at the facility during two overnight shifts on January 5 to 6, and 6 to 7, 2025. On both nights, the U was at the facility and remained in the basement during the SP’s shifts except for “sometimes” coming upstairs to get food. The SP stated s/he was required to check on the VA every two hours during the overnight shift to ensure the VA’s health and safety but did not go to the basement to complete these checks during either night because the VA’s friend was there, stating, “I just assumed they were downstairs watching TV or sleeping or whatever.” · The SP was not aware that the VA took the van keys, left the facility, and drove the facility van each of the nights during the SP’s shifts until told by P2 on January 7, 2025. The SP was “blown away” and “still bothered” that these incidents occurred and stated multiple times that s/he “wished to have those two nights back” to do things “differently.” · The SP was not aware of what time s/he fell asleep each night or for how long s/he slept but was aware that s/he was required to remain awake while working and that sleeping for “any amount was too long.” The SP said s/he was “probably” sitting in the living room, watching T.V., and fell asleep. For “some time now,” the SP had a “harder time” staying awake when it was “late” and s/he “probably should have” worked different hours or resigned from his/her position. · The facility policies required staff persons to lock the staff office door and the SP stated that his/her “big mistake” not having the office door locked “as I should have” each of these nights. The SP did not remember why the office door was unlocked during this time and “typically” had the door locked during prior shifts. The SP was not aware that the van keys were kept in the office because staff persons working at the facility during overnight hours did not transport clients during this time. The SP did not drive the facility van because s/he only worked overnight shifts and therefore, “didn’t really pay attention” to where the van keys were kept when not in use. The facility’s T-Logs dated January 5 to 7, 2025, written by staff persons working with the VA during this time provided the following information: · On January 5, 2025, P3 drove the VA to a family member’s residence after dinner. At unknown times later that evening and prior to 10 p.m., the VA returned to the facility and then the U came to the facility to stay overnight with the VA. · On January 6, 2025, the SP wrote that the VA and the U were in the VA’s bedroom “most” of the night. At approximately 5 a.m., the VA and the U came upstairs to eat and then returned to the basement. The SP did not have any concerns with the VA upon leaving the facility at the end of his/her shift. At approximately 9 a.m., P5 arrived at the facility and wrote that the VA was sleeping in his/her bedroom and would not wake up or “respond” to staff persons who were trying to give the VA his/her morning medications. At approximately 12:30 p.m., the VA woke up and used his/her cell phone to call the facility’s house phone and speak with staff persons who were on the main level of the facility. The VA remained in his/her bedroom and did not eat lunch. At approximately 4 p.m., P3 arrived at the facility and shortly after this, drove the VA to pick up a package and then returned to the facility. After dinner, the U came to the facility to spend time with the VA. The VA and the U played video games, cleaned up his/her items that were left in the back living room, and then went to the basement with the U for the remainder of the evening. · On January 7, 2025, the SP wrote that the VA and the U were in the basement for “most” of the night besides coming upstairs “several times” for food. According to the facility’s Program Abuse Prevention Plan updated November 2024, the facility was currently serving three clients, including the VA, with a 1:3 staff ratio during the night. Staff persons working the overnight shift were required to complete visual breathing checks for the clients every hour. According to the facility’s Employee Handbook updated August 2024, staff persons were “prohibited” from “sleeping on the job” to maintain the health and safety of the clients. Staff persons who worked “awake” overnight shifts were responsible for finding ways to “keep busy” and “avoid putting themselves in a position” where they might fall asleep. The facility’s Direct Support Professional Job Description was provided to the SP upon hire in April 2017 and stated the job responsibilities that were required of the SP, including providing care and supports that related to client care plans and “appropriate” supervision. Facility documentation showed that the staff persons interviewed for this investigation, including the SP, received training on the VA’s care plans; the facilities policies and procedures, including the Program Abuse Prevention Plan and the Employee Handbook; and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was also trained on his/her job description. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.07, subdivision 1, paragraph (a), 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 coordinated service and support plan and the coordinated service and support plan addendum. Conclusion: A. Maltreatment: According to the VA’s plans, the VA had a history of putting him/herself in “unsafe positions” by making “quick, impulsive” decisions. The VA received 24-hour care from the facility that included supervision. The VA required an awake overnight staff person and health/safety checks every two hours when the VA was present at the facility during the night. Information from all sources was consistent that the facility office door was to be locked when not in use. The VA, P1, P2, and facility documentation provided consistent information that during the overnights on January 5 to 6, and 6 to 7, 2025, the SP worked the facility’s overnight shifts from 10 p.m. to 8 a.m. On both nights, when the VA saw the SP sleeping and the office door open, the VA took the facility van keys, left the facility, took the facility van, drove the van without a valid driver’s license, returned to the facility, and returned the van keys to the staff office without the SP’s knowledge. On the first night, the VA was gone from the facility for over three hours and drove the van 159 miles. On the second night, the VA was gone from the facility for approximately two hours and drove the van 59 miles. Although there were no injuries to the VA during this time, the VA did not have a valid driver’s license and P1 stated that the SP’s “lack of supervision” provided the VA opportunities to make “poor decisions” that put the VA in multiple “unsafe positions” that could have resulted in injuries and/or legal implications for the VA. The SP was not aware of the VA leaving or driving until told by P2. Prior to receiving this information, the SP completed T-Log entries and told P2 that s/he completed hourly checks on the VA during each night without any concerns. However, the SP told this investigator that s/he did not check on the VA while working these shifts because the VA was with his/her friend and the SP “assumed” that they were in the basement. The SP also said that s/he was having a “hard time” staying awake during the overnight hours and “probably” fell asleep while watching T.V. during these two nights. The SP’s actions of leaving the office unlocked and falling asleep were not accidental or therapeutic conduct, and were a violation of the VA’s plans and therefore a violation of Minnesota Statutes, section 245D.07, subdivision 1, paragraph (a). Given the VA’s history of putting him/herself in “unsafe positions;” that the SP fell asleep during two consecutive overnight shifts that required the SP to remain awake and periodically check on the VA; that the SP also did not lock the staff office door as required which provided the VA with the opportunity to take the van keys and use the van; that the VA left the facility without the SP’s knowledge during two separate shifts; and that the VA was able to drive the facility van two times totaling 213 miles without a driver’s license placing the VA and others at risk and possibly cause the VA legal implications, there was a preponderance of the evidence that there was a failure or omission to supply the VA with care or service including supervision which were reasonable and necessary to obtain or maintain the VA’s physical 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 626.557, 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 responsible for the care and supervision of the VA at the time of each incident and was trained on the VA’s care plans and the Reporting of Maltreatment of Vulnerable Adults Act. Additionally, the SP was trained on the facility’s policies and job description that required the SP to remain awake at all times while working at the facility and to maintain adequate supervision. Consistent information was provided that the VA accessed the van keys because the SP did not lock the staff office door as required which allowed the VA to walk into the office and take and then use the van keys. Additionally, consistent information was provided that the SP fell asleep during his/her shift and was sleeping when the VA obtained the van key, left the facility, drove the van, and returned to the facility without the SP’s knowledge. 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 was “recurring” maltreatment but was not serious. On two dates, the VA took the van keys while the SP slept but the VA was not injured and did not reasonably require the care of a physician. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and found their policies and procedures adequate but not followed by the SP. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. Given that the facility took immediate corrective action, a Correction Order was not issued for the violation outlined above.
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