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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: 1070764-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Brittany Dolen 651-431-6701 Suspected Maltreatment Reported: It was reported that a staff person (SP) fell asleep on an awake overnight shift and a vulnerable adult (VA) accessed the staff person’s office while the SP was asleep and swallowed a pen. Date of Incident(s): April 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 April 23, 2025, from documentation at the facility, and through ten interviews conducted with the VA, the VA’s guardian (G), the VA’s case manager (CM) a supervisory staff person (P1), and five facility staff persons (P2-P6 and the SP.) The VA was diagnosed with major depressive disorder, borderline personality disorder, mild intellectual disabilities, reactive attachment disorder, fetal alcohol syndrome, post-traumatic stress disorder and a traumatic brain injury. The VA had an extensive history of self-injurious behaviors and swallowing items which required line of sight supervision during awake hours. The VA enjoyed fashion, attending community events, photography, rapping and painting. To ensure safety for the VA, the facility had several safety precautions in place which included the following: · Two staff persons with line of site supervision during awake hours, from 7 a.m. until 10 p.m., and one awake overnight staff person with checks every 15 minutes from 10 p.m. until 7 a.m. · The VA did not have a bedroom door, and there were alarms on the VA’s bedroom, so staff persons knew if the VA left his/her bedroom at night. Staff persons carried an alarm monitor with them to hear when the VA left his/her bedroom, if they were doing other job-related duties during the overnight while the VA was sleeping. · The VA was not allowed access to all of his/her personal items at all times and was required to check out and be supervised with any personal items that were not allowed in his/her bedroom. · Any items that could cause harm to the VA were stored in the office, and the office door was to be closed and locked when not in use, and staff working kept the office keys on their person. · The facility, and the facility vehicle had Lexan windows so the VA could not break the glass. · The VA was not allowed access to any sharps, or anything small enough to swallow. The VA had an adaptive toothbrush and adaptive silverware because the VA had swollen those items in the past. The VA provided consistent information to P1-P3 and this investigator that on April 7, 2025, around 3:30 to 4 a.m. the SP fell asleep on two separate occasions during his/her awake overnight shift. The VA attempted to wake the SP each time when the VA needed to use the bathroom, and the second occasion, when s/he was unable to do so, the VA accessed the staff person office, which was unlocked, and took three pens. The VA swallowed one pen and hid two in the bathroom. The VA stated that after s/he used the bathroom each time, the SP was awake and “begged” the VA not to say anything. The VA did not tell staff persons what happened until approximately 12:45 p.m. The VA required medical attention, specifically an upper endoscopy, to have the pen removed. The SP arrived at work on April 6, 2025, at 9:30 p.m. and acknowledged that s/he fell asleep on the couch one time for an undetermined amount of time. The SP was required to remain awake for his/her overnight shift and said s/he had the alarm and the keys to the office with him/her on the couch. The SP denied telling the VA not to tell anyone that s/he fell asleep and denied that s/he left the office door unlocked. Staff person timecard punches for April 6-7, 2025, showed that P2, P4 and the SP were at the facility on the evening of April 6, 2025, prior to the incident and that P2 left work at 9:30 p.m. and P4 left work at 10:01 p.m. P2 said the office door had to be locked and that s/he “would have” locked the office door when s/he left the facility. P4 said if staff persons were not using the office, the door should be “locked and shut.” P4 did not “fully remember” if the office door was open or closed when s/he left but was “pretty sure” it was closed. If P4 saw the office door open, s/he would have closed it. P4 denied leaving the office door open and/or unlocked. The G and the CM were notified about the allegations and stated the VA had a history of swallowing objects and had no concerns regarding the care provided. The facility’s personnel files showed that all staff persons interviewed were trained on the VA’s plans and the Reporting Maltreatment of Vulnerable Adults Act. Relevant Rules/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 had an extensive history of self-injurious behaviors and swallowing items and required an awake overnight staff person who monitored and supervised the VA when the VA was out of his/her bedroom. On April 7, 2025, during the overnight, the VA accessed the staff office, got three pens, and swallowed one. The VA required an endoscopy to remove the pen. The VA’s ability to enter the office without staff supervision was a violation of the VA’s plans and a violation of Minnesota Statutes, section 245D.07, subdivision 1a. Given that the VA required a staff persons supervision when s/he was out of his/her bedroom, that the office door was unlocked, and that the SP was sleeping which allowed the VA access to pens which s/he swallowed and required medical intervention, there was a preponderance of the evidence that there was a failure to supply the VA with care or services which were 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 626.557, 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, P2, and P4 were trained on the VA’s plans and the Reporting Maltreatment of Vulnerable Adults Act. Regarding the unlocked office door: The SP, P2, and P4 all provided consistent information that staff persons were responsible for ensuring the office door was closed and locked at all times. Although the office door was left unlocked, the SP denied entering the office at any point during his/her shift and P2 and P4 worked prior to the SP. P2 said s/he “would have” locked the office door when s/he left, and P4 denied leaving the office door open and/or unlocked. Therefore, responsibility for leaving the office door unlocked was not able to be determined. Regarding the SP’s supervision of the VA: At the time of the incident, the SP was responsible for staying awake to supervise the VA. The SP acknowledged that s/he fell asleep for an undetermined amount of time. Falling asleep during a time s/he was required to be awake was inconsistent with the standards of a professional caregiver in a facility licensed by the Minnesota Department of Human Services and was not accidental or therapeutic conduct. Regardless of who left the office door unlocked, had the SP remained awake, s/he would have known the VA was out of his/her bedroom and the VA would not have been able to access the office and pens. The SP was responsible for the maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the SP was responsible did not meet statutory criteria to be determined as “recurring” because it was a single incident but was determined to be “serious” because the VA required the care of a physician to remove the pen. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. 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 in this report.
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