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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: 1070419-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) was alone in the community and tried getting into a community person’s house. It was alleged that staff persons failed to provide adequate supervision. Date of Incident(s): January 31, 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 February 10, 2025; from documentation at the facility, law enforcement records, and medical record; and through seven interviews conducted with a supervisory staff person (P1), three facility staff persons (SP1, SP2, and P2), a community person (CP1), the VA’s case manager (CM), and the VA’s guardian(G). This investigator met the VA but the VA did not provide information about the incident due to his/her disability. Attempts were made to contact SP1 to obtain additional information but SP1 did not respond. The VA was diagnosed with cognitive impairments and autism spectrum disorder and received 13 hours of 1:1 staffing daily from 7 a.m. until 8 p.m. The VA’s bedroom was in the front of the facility on the main level next to the front door. If the VA slept during 1:1 staffing hours, staff persons used a live video camera with a monitor in the kitchen for supervision. According to the staff schedule, on January 31, 2025, SP2 worked the overnight shift until 8 a.m., SP1 (who worked the overnight shift at another location operated by the same license holder) worked 7 a.m. to 2 p.m.; and P2 and P1 worked from 8 a.m. to 2 p.m. and 4 p.m. respectively, providing direct cares. According to the VA’s Support Plan Addendum for Intensive Services: · The VA had no unsupervised time at the facility or in the community. The VA was “impulsive” which put him/her in danger in the community. When the VA was “upset, excited, or distracted” s/he displayed unsafe behaviors regarding vehicle and pedestrian safety. · The VA historically demonstrated socially unacceptable behaviors in public such as self-stimulation, screaming, aggression, and property destruction. The VA also pulled his/her pants down while out in public. Staff persons were “always” present and in “visual range” when the VA was in the community. · The VA had a history of not respecting personal privacy and entered “private areas” without knocking or seeking approval. Staff persons reminded the VA to respect other person’s personal privacy and redirected him/her from an area that was inappropriate. · The VA had a history of leaving the facility or area without informing staff persons. Staff persons used verbal or physical assistance with the VA while maintaining an appropriate distance between the VA and other persons. · The facility had a door alarm on the front and back doors to alert staff persons if either door was open. [Note: At the time of the site visit, both door alarms were working.] If the VA left the facility or area, staff persons redirected the VA and kept him/her in direct supervision while returning the VA to safety. The VA’s Individual Abuse Prevention Plan (IAPP) stated that the VA lacked community orientation skills and was not able to defend him/herself against physical abuse. Staff persons remained within visual range of the VA in the community and provided the VA directions as needed for pedestrian safety and maintaining appropriate behavior. CP1 provided the following information: · On the morning of January 31, 2025, CP1 was not home when s/he received a phone call from another community person (CP2) who was his/her family member. CP2 told CP1 that when s/he returned home s/he should stay inside his/her car because there was a person breaking into their house and that 9-1-1 had been called. A few minutes later, CP1 arrived at the house and saw the VA in the entryway and then a law enforcement officer (LEO1) arrived. LEO1 spoke to the VA who began undressing in the entryway. · CP1 told LEO1 that s/he recognized the VA from working at a licensed program unrelated to the facility. CP1 then invited LEO1 and the VA inside the house to “get out of the cold.” CP1 assisted the VA to get dressed and brought him/her inside. The VA was “very cold;” not wearing a jacket, hat, gloves, long sleeves, or underwear; and was “soiled.” CP1 did not see injuries on the VA but the VA’s hands were “bright red,” and CP1 was concerned about hypothermia. · The VA indicated s/he was hungry so CP1 gave the VA some food and water. The VA ate food and CP1 assisted him/her to the bathroom while LEO1 attempted to locate the facility. · CP2 also told CP1 the following information: o That morning at 7:18 a.m., CP2 went outside the house and saw a person, later identified as the VA, near an apartment building. The VA was walking towards baseball fields and CP2 noted the VA’s gait and “confusion” as the VA walked. CP2 then went back inside their house. o At 7:48 a.m., CP1’s and CP2’s dogs barked at the back door to their house. CP2 went to let them inside and saw the VA in an entryway to the house between the back door and another door to the house. The VA attempted to open the door to the house but CP2 stopped the VA. The VA did not verbally communicate but showed CP2 his/her “very pink hands.” The law enforcement report provided the following information: · On January 31, 2025, at 8:03 a.m., CP2 called 9-1-1 because a person, later identified as the VA, was breaking into CP2’s house. LEO1 was driving to CP2’s house when dispatch told him/her that the VA was “pounding on the door” and “trying to force the door open.” · LEO1 arrived “a few minutes later” and saw the VA in the entryway without pants and naked from the waist down. LEO1 looked at the VA and noted his/her hands, feet, and body were “shaking from being cold.” LEO1’s watch said it was 26 degrees Fahrenheit outside so LEO1 called for an ambulance. · LEO1 assisted the VA multiple times with putting his/her pants on but the VA refused so LEO1 covered the VA with a blanket and had another law enforcement officer (LEO2) go to the facility to determine if the VA lived there. LEO1 then interviewed CP2 who provided information that was consistent with the information CP1 told this investigator. · At 8:43 a.m., LEO2 went to the facility and spoke to staff persons who did not know that the VA was “missing.” SP1 told LEO1 that s/he last saw the VA at 7:40 a.m. when s/he administered the VA his/her medication. P1 and SP1 then followed LEO2 to CP1’s and CP2’s house where the VA was. · An ambulance then arrived and LEO1 requested that the VA was taken to a hospital for evaluation because s/he was outside “for so long” and LEO1 “was worried about [his/her] safety.” The ambulance then brought the VA to a hospital. · LEO1 then spoke to P1, who provided the following information: o P1 arrived at the facility at 8 a.m. and SP2 was working. SP2 told P1 that the VA was asleep in his/her bedroom and that at 7 a.m. s/he gave the VA his/her 8 a.m. medication. P1 asked how the VA was sleeping since s/he generally did not sleep so late and SP2 responded that the VA was awake “all night” so s/he was “probably tired.” o P1 was not aware the VA was missing until LEO2 arrived (at 8:43 a.m.) and told them. P1 told LEO1 that the VA would not have climbed out his/her bedroom window because the VA was not able to open it and it was closed when P1 was at the facility. The back door to the facility was “open” and did not have an alarm. · LEO1 spoke to SP1 on two occasions. Initially SP1 told LEO1 that s/he arrived at the facility around 7 a.m. and SP2 told SP1 that the VA was still sleeping so SP1 assisted the other clients with getting ready for the day. At another time, SP1 “admitted” s/he did not get to the facility until 7:55 a.m. Text messages between SP1 and SP2 provided the following information: o SP1 texted SP2, “When they ask you I’m here with you.” SP1 later texted SP2 that s/he “left while [s/he] was still here and [s/he] saw you leaving.” o LEO1 saw that there were eight previous times that SP1 and SP2 clocked each other in and out of work. · LEO1 spoke to SP2 on two occasions. SP2 stated that on the day of the incident s/he gave the VA his/her medications between 7:30 and 7:40 a.m. LEO1 told SP2 that it was “impossible” that SP2 gave the VA’s his/her medications between 7:30 and 7:40 a.m. because the VA was already gone from the facility at that time. SP2 said s/he must have given the VA his/her medication at 6:40 a.m. SP2 “admitted” that SP1 texted SP2 asking him/her to sign into work for SP1, so SP2 did. SP2 provided text messages and screen shots of their conversation.
· The report was submitted to the County Attorney for possible charges. However, the County Attorney declined to charge. Medical records showed that the VA was seen on January 31, 2025, for “cold exposure.” The doctor completed an exam and there was no evidence of hypothermia or frostbite. There was no diagnosis but the VA was discharged with instructions to “please avoid [the VA] eloping from [the facility] in the future to avoid this issue.” According to Googlemaps.com, the distance between the facility and where the VA was located was 0.6 miles and a 12-minute walk. According to wunderground.com, on January 31, 2025, between 7 and 8 a.m., it was 21 to 23 degrees Fahrenheit. P1 provided the following additional information to this investigator and LEO1: · On the day of the incident, P1 arrived at the facility at 8 a.m. and SP1 and SP2 were working. SP1 walked another client (C1) to a bus and SP1 then walked back inside the facility, sat down at a desk, and charted for C1. The VA was usually pacing around the living room at that time of day, so P1 asked SP2 where the VA was and SP2 responded that the VA was sleeping because s/he was awake all night. P1 asked additional questions about the night and if the VA received his/her morning medications and SP2 said s/he gave them to the VA at 7:40 a.m. SP2 was assisting another client (C2) in the bathroom with a shower. · When P1 went to clock in, there was a knock on the front door so P1 answered it. LEO2 asked P1 if a client was missing and P1 responded that s/he was not aware of a client missing. P1 then went to the VA’s bedroom and the VA was not there. SP2 walked out of C2’s bedroom so P1 asked if s/he had seen the VA and SP2 responded that s/he had not. · LEO2 then said that the VA was found in the community and that P1 should get a change of clothing for the VA. P1 and SP1 followed LEO2 and when they got to the VA, the VA was “soaked” and “soiled” so P1 assisted the VA with changing clothes. The VA then went in the ambulance to the hospital where s/he was “cleared” shortly after. Later on, P1 notified another supervisory staff person (P3) about the incident. · On the day of the incident, SP1 was assigned as the VA’s 1:1 staff person. P1 was not aware that SP1 was late or that SP2 clocked SP1 in until LEO1 told P1. P1 said that staff persons should have contacted the on-call supervisory staff person if they were going to be late to work. When the VA was asleep in his/her bedroom, staff persons monitored him/her on the camera that was visible in the kitchen. From the desk that SP1 sat at in the living room to chart, s/he would have been able to see the VA leave his/her bedroom but would not have been able monitor the VA via the camera in the kitchen. · Staff persons were trained that if the VA was in his/her bedroom, they visually checked on him/her every 15 to 20 minutes. The VA was not able to open his/her bedroom window to go out because s/he did not have the knowledge or motor skills. P1 was unsure if the VA left through the back or front door. There were alarms on the front and back door but the back door batteries were “dead” so the alarm did not work and the door did not seal properly since P1 started working at the facility in November 2024. P1 said that it was his/her “mistake” that s/he did not tell any other supervisory staff persons about the alarms not working. SP1 provided the following information: · On the day of the incident, SP1 did not know what time s/he arrived at the facility but s/he was late because of car problems. SP1 was scheduled to be the VA1’s 1:1 staff person. SP2 told SP1 that the VA was asleep in his/her bedroom and had already taken his/her medication. C1 then began having “behaviors” so SP1 assisted C1 and then assisted C2 with getting ready for the day. SP1 stated that even though s/he was the VA’s 1:1 staff person, s/he did not look in the VA’s bedroom or check on the VA during that time. At some point, LEO2 arrived at the facility and that was when SP1 realized the VA had left the facility. SP1 said that LEO1 later told him/her that the VA left the facility prior to 7 a.m. which was the start of SP1’s shift. · When SP1 started working at the facility approximately one month prior to the incident, SP1 received eight hours of training on the VA. SP1 was not trained that the VA was a high risk of leaving the facility. Staff persons were required to supervise the VA when s/he was awake by being near the VA. When the VA slept, staff persons went into the VA’s bedroom to check on him/her but since SP1 did not work overnights, s/he was not aware of how often to check. SP1 also used the camera to supervise the VA if s/he was inside his/her bedroom. · The front door alarm worked but the back door alarm had not been working since SP1 began working at the facility. In addition, the sliding glass door at the back of the facility did not have an alarm on it. SP2 provided the following information: · On the day of the incident at an unknown time, SP2 gave the VA his/her medication “early” at 6:40 or 6:45 a.m., and the VA went to his/her bedroom to sleep. That was the last time SP2 saw the VA. When SP2 and P1 each arrived, SP2 told them that the VA was asleep in his/her bedroom. SP2 did not know what time SP1 arrived and said that P1 arrived about 7:55 a.m. P1 went into the office and SP1 assisted C2 with a shower. P2 arrived at 8 a.m., and SP2 and P2 began working on the clients’ medication counts and documentation when LEO2 arrived and they learned that the VA had left the facility. · The VA had a history of leaving the facility approximately once per week and none of the three doors had working alarms. SP2 said that the door alarms were not working. P1 was aware but did not fix it nor did any other supervisory staff person. If the VA was asleep in his/her bedroom, staff persons used the camera in the kitchen to supervise the VA but that was difficult to do because SP2 also had to assist C1 or C2. There was no training provided on how often to visually check on the VA while in his/her bedroom. SP2 did not receive training on what to do if other staff persons were late, but said they should call the on-call supervisor. P2 worked at the facility for a few weeks prior to the incident generally from 2 to 10 p.m. and filled in throughout the day. The VA had 1:1 staffing “all the time” and was not allowed to be alone. P2 was not aware of a time when the VA was alone. The G stated on the day of the incident, LEO1 called the G and said that the VA was found alone in the community and was taken to the hospital. The G was unsure how the VA was able to leave the facility since s/he was supposed to have 1:1 staffing. The CM stated on a previous occasion, s/he received an email from P1 that the VA was found alone in the community. The CM contacted P1 because of the concerns of the “bitter cold” weather and what the VA was wearing. The CM wanted to know why there was not 1:1 staffing during the incident. According to the Residential Attendance Policy, staff persons were expected to arrive on time and work all shifts that were scheduled. If circumstances arise resulting in a staff person not able to work a shift as scheduled, it was the staff person’s responsibility to find replacement coverage for that shift and communicate the replacement coverage to the staff scheduler. Facility documentation showed that staff persons, including SP1 and SP2, were trained on the VA’s plans, Residential Attendance Policy, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Relevant Statutes: Minnesota Statutes, section 245D.07, subdivision 1a stated 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: On January 31, 2025, at 7:18 a.m., CP2 saw the VA alone approximately 0.6 miles from the facility which according to googlemaps.com, was a 12-minute walk. The VA then tried to get into CP2’s house so CP2 called 9-1-1. At 8:43 a.m., LEO2 went to the facility where P1, SP1, and SP2 did not know that the VA was missing which was approximately one and a half hours after the VA was first seen by CP2. When LEO1 found the VA, the VA had “bright red” hands and was “very cold;” not wearing a jacket, hat, gloves, long sleeves, or underwear; and was “soiled.” In addition, the VA had taken off his/her pants. LEO1 was concerned about the VA because of how long the VA had been outside in 21 to 23 degrees Fahrenheit weather. An ambulance took the VA to the hospital for an evaluation and there were no concerns and the VA was discharged back to the facility. According to the VA’s plans, the VA had no unsupervised time at the facility or in the community and had 1:1 staffing from 7 a.m. to 8 p.m. However, SP1 and SP2 provided information to LEO1 that because SP1 was late to work, the VA did not have 1:1 staffing from 7 a.m. until approximately 7:55 a.m. when SP1 told LEO1 that s/he arrived. The VA’s plans also stated that the facility had a door alarm on the front and back doors to alert staff persons if either door was open. However, consistent information was provided by P1, SP1, and SP2 that one or more of the door alarms were not working. The VA’s ability to leave the facility without the knowledge or supervision of a staff persons, not having working alarms, and not having the VA’s 1:1 staffing were violations of the VA’s plans and therefore violations of Minnesota Statutes, section 245D.07, subdivision 1a. Given that the VA required staff persons supervision at the facility and in the community and was able to leave the facility without the knowledge or supervision of staff persons; that the VA was gone for at least one and a half hours before LEO2 notified staff persons and they realized the VA was gone; and that the VA was exposed to and engaged in dangerous situations and behaviors including not wearing proper clothing in 21 to 23 degrees Fahrenheit weather, soiling his/her clothing, and attempting to go inside and being in contact with CP1’s and CP2’s house, 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 626.556, 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. SP1 and SP2 were each trained on the VA’s plans, Residential Attendance Policy, and the Reporting of Maltreatment of Vulnerable Adults Act. Information showed that SP2 was scheduled to work the overnight shift until 8 a.m. the morning of the incident and SP1 was scheduled to work at 7 a.m. and was assigned as the VA’s 1:1. Although SP1 and SP2 initially provided LEO1 with inaccurate information, SP1 and SP2 then provided consistent information that SP1 text SP2 that s/he was going to be late and asked SP2 to clock in for him/her, and SP2 did so. P1 and SP2 each stated that if a staff person was going to be late, the on-call supervisory staff person should be notified, but this was not done by either SP1 or SP2. Information was consistent that one or more door alarm was not working, however, this did not mitigate SP1’s and/or SP2’s responsibility to ensure the VA’s plans were followed and the VA was supervised. In addition, SP1 and SP2 did not notify any supervisory or on-call staff person that SP1 was going to be late so there was no opportunity for the facility to ensure the VA’s 1:1 supervision requirement was met prior to SP1’s arrival. Although SP1 was assigned to be the VA1’s 1:1 at 7 a.m. and failed to arrive on time or notify the on-call supervisory staff person, and asked SP2 to clock him/her into work when s/he in fact was not working, and that despite being the 1:1 assigned did not check on the VA upon arriving to work, SP1 was not at the facility when the VA left and was therefore not responsible for the supervision of the VA. Therefore, SP1’s responsibility for the maltreatment was mitigated. SP2 told LEO1 that s/he administered the VA his/her medications between 7:30 and 7:40 a.m. and then the VA went to bed. However, the VA was seen by CP2 at 7:18 a.m. and therefore, it was not possible that SP2 saw the VA at the facility after that. Given that it was approximately a 12-minute walk from the facility to CP2’s house, and that CP2 first saw the VA at 7:18 a.m. it was most likely that the VA left the facility around 7 a.m. SP2 stated that the last time s/he saw the VA was at 6:40 or 6:45 a.m. when s/he administered his/her medication. SP2 was aware that SP1 was scheduled to be the VA’s 1:1 and clocked SP1 despite SP1 not being present. In addition, SP2 did not notify the on-call supervisory staff person so as a result, at the time the VA left the facility, SP2 was the sole staff person at the facility and responsible for the supervision of the VA. Therefore, SP2 was responsible for 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. 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 “serious” or “recurring” maltreatment because it was a single incident and although the VA was seen by a physician at the hospital, the VA did not sustain an injury or reasonably require the care of a physician. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. Staff persons received training to check on the VA every 30 minutes while sleeping or alone in his/her bedroom. The facility alarms were checked daily for proper functioning. SP1 and SP2 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 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 the disqualification of SP1. The determination that SP1 was responsible for maltreatment is subject to appeal. On May 21, 2025, the facility was issued a Correction Order for the violations outlined in this report.
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