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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: 1120943-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Scout Peterson Suspected Maltreatment Reported: It was reported that three staff persons (SP1-SP3) and two vulnerable adults (VA1 and VA2) were involved in a car collision. It was also reported that SP1-SP3 were wearing seatbelts but that VA1 and VA2 were not wearing seatbelts. Date of Incident(s): October 29, 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 January 17, 2025; from documentation at the facility, law enforcement records, and medical records; and through 10 interviews conducted with three staff persons (SP1-SP3), three supervisory staff persons (P1-P3), VA1, VA2, VA2’s case manager (CM), and VA1’s guardian (G). VA2 was not subject to guardianship. VA1 enjoyed shopping, watching TV, and collecting coins. According to VA1’s Client Profile, VA1’s primary diagnoses included: diabetes, dysthymic disorder, generalized anxiety disorder, impulse control disorder, mild intellectual disability and chronic schizophrenia. There was no information in VA1’s plans that provided information regarding VA1’s ability to use seatbelts. VA2 enjoyed going out to eat and visiting with his/her family members. According to VA2’s Client Profile VA2’s primary diagnoses included: attention deficit disorder, autism spectrum disorder, borderline personality disorder, depression, generalized anxiety disorder and mild intellectual disability. There was no information in VA2’s plans that provided information regarding VA1’s ability to use seatbelts. VA1 provided the following information: · “Sometime around September [2024],” VA1, VA2, and SP1-SP3 were in the facility car leaving for an outing. VA1 was sitting in the middle back seat of the car with VA2 and SP2. VA1 stated that s/he could not get his/her seatbelt on because the back seat was “too tight,” and VA1 told SP2 that s/he could not buckle his/her seatbelt. SP2 responded, “See if you can,” and VA1 told SP2, “I will try to make it.” SP2 tried to assist VA1 with getting his/her seatbelt on, but “couldn’t.” VA1 said that SP1 and SP3 also knew that VA1 did not have his/her seatbelt on, but they were already in the street driving when VA1 told them. · As SP1 was driving, another driver was “driving real fast” and as SP1 started turning, SP1 “swiped” the other driver’s car. VA1 stated that s/he “went flying a little bit,” bumped his/her head and knees, and hurt his/her hand. · After the collision, law enforcement officer [LEO] arrived and approached the car. The LEO told VA1, “You better go to the emergency [room].” VA1 stated that s/he showed the LEO that s/he was not wearing his/her seatbelt, but the LEO “didn’t get mad.” SP1-SP3 then took VA1 and VA2 to the emergency room. SP1 stayed with VA1 at the hospital until s/he was discharged sometime after 3 a.m. VA1 told hospital staff that s/he was in a car collision and s/he was not wearing a seatbelt. The doctor told VA1, “Next time you gotta wear a seat belt,” and VA1 acknowledged that s/he would. VA1 stated that s/he did not wear a seatbelt at that time because “there were too many people” and they had to “squeeze” into the car to fit. · The next day, VA1 spoke to the G and SP1-SP3 about the collision. P1 and P2 both reminded VA1 to wear a seatbelt while in the car but P3 “didn’t say much” about the incident. VA2 provided the following information: · “Towards the end of October [2024],” SP1-SP3, VA1, and VA2 were in the facility car and got in a car collision. VA2 was sitting in the passenger rear seat, VA1 was in the middle rear seat, and SP2 was in the driver rear seat. SP3 was in the front passenger seat, and SP1 was driving. VA2 stated that they were in a “rush” to leave the facility and SP1-SP3 did not remind VA1 and/or VA2 to buckle their seatbelts and none checked to see if VA1’s and VA2’s seatbelts were buckled. After they left the facility and were approaching an intersection with a stopped car, another car was moving that SP1 did not see and SP1 “slammed into” the other car. VA2 stated that SP1 “stopped and looked” before pulling into the intersection, however, the other car did not stop. SP1 “slammed on the breaks” but their car hit the other car. · The LEO responded and spoke to SP1-SP3, VA1, and VA2. The LEO asked if they were wearing seatbelts, to which VA2 responded, “No.” After the LEO left, SP1-SP3, VA1, and VA2 returned to the facility. Because SP2 and VA2 were experiencing chest pain, SP1 drove them all to the emergency room. VA2 stated “everyone was cleared to be okay.” A nurse reminded VA2 that s/he needed to “start wearing seatbelts” because it “could have been much worse.” · VA2 stated that prior to the collision when staff persons took VA1 and VA2 on outings, there were three staff persons, totaling five people in the car. When there were three people in the back seat, the passengers, including VA1 and VA2, did not wear seatbelts because it was “so crowded.” Law enforcement records stated that on October 29, 2024, at approximately 4:55 p.m., SP1 was driving southbound into an intersection and struck another car that was traveling westbound through the intersection. The SP hit the front passenger door of the other car and there was damage two both cars. The facility’s vehicle had four additional passengers, SP2, SP3, VA1 and VA2 and all of the passengers in the vehicle were restrained with seatbelts. Body worn camera footage from the LEO at the scene of the collision showed VA1 and VA2 with no seatbelts on, however it was unclear the amount of time that had elapsed between the collision and when the officer spoke with them. During the duration of the 20:05 video, the officer did not ask VA1, VA2, nor any of the staff persons if they were wearing seatbelts during the collision. Law enforcement did not issue any driving violations (tickets) to either driver. Information obtained showed that the facility vehicle was traveling south on Xerxes Avenue towards West 76th Street. Xerxes Avenue was a residential two-lane road with one lane of travel in each direction (north and south). West 76th Street was a four-lane road, two lanes of traffic in each direction (east and west), with a speed limit of 30 miles per hour. There was a stop sign at the intersection for the cars traveling on Xerxes Avenue. The cars traveling on West 76th Street did not have a stop sign and approximately one block west of the intersection was a traffic light for traffic on West 76th Street. SP1 provided the following information: · On the day of the incident, SP1 was working with SP2 and SP3 and they were planning an outing with VA1 and VA2. There was a “rush” to get out the door and into the car because VA1 and VA2 were “excited” to go on the outing. SP2 and SP3 assisted VA1 and VA2 into the car, while SP1 was still inside the facility checking to make sure that they had everything needed for the outing. SP1 was the last person to get into the vehicle, and s/he got into the driver’s seat. SP3 was in the passenger seat, SP2 was behind SP1, VA1 was in the middle rear seat, and VA2 was in the passenger rear seat. · SP1 said, “Buckle up buttercups,” as s/he did “every time.” In the past when SP1 told VA1 or VA2 to buckle their seatbelts, they did so without issue. SP1 then checked the mirrors, adjusted the seat, checked behind the car, put the car in reverse, and pulled out of the driveway. SP1 did not know if any staff persons checked to make sure VA1’s and VA2’s seatbelts were buckled. · At the end of the block there was a stop sign and at that time the traffic traveling west on West 76th Street was stopped and backed up. SP1needed to turn left onto West 76th Street to go East. SP1 “inched forward” through the stopped traffic. A driver of a stopped car, “waved” at SP1 to turn and as SP1 did so, another car came from the second lane traveling west and “clipped” the front of the facility car. SP1 stated that s/he did not see the other car coming, and did not know how fast the car was traveling when it collided with the facility car. There was “very minor damage” to the facility car. SP1 then did a “verbal and visual inspection” to make sure the passengers were okay and called law enforcement and the house supervisor. VA1 said, “I think I hit my knee” and VA2 said, “I’m okay.” · Within six to eight minutes, the LEO arrived at the scene of the accident SP1 did not remember if s/he told the LEO that VA1 and VA2 were vulnerable adults but they did not interview VA1 or VA2. · SP2, SP3, VA1, and VA2 then walked the half block back to the facility and shortly after, SP1 returned to the facility with the facility vehicle. SP1 decided to take VA1 and VA2 to the emergency room to be examined for injuries and SP2 and SP3 also came. Around 10 p.m. that night, VA1 was asked by hospital staff if s/he was wearing a seatbelt and VA1 told the hospital staff that s/he did not. Around 10:15 p.m., SP1 left the hospital when s/he was relieved by another staff person. SP1 did not know about diagnoses or injuries to VA1 because s/he left the hospital before VA1 was discharged and did not see VA1 for “a month or two” following the incident. · SP1 completed a safety transportation as part of his/her training. Staff persons were instructed to do a vehicle check and make sure every passenger was “safe and secure” in the vehicle, which included ensuring that all passenger’s seatbelts were buckled. SP1 stated that if there were multiple staff in the car, it was everyone’s responsibility to ensure that all passengers were buckled. SP1 added that if s/he were a passenger, s/he would take the responsibility to ensure that all passengers were buckled so that the driver could focus on safe driving. When SP1 told VA1 and VA2 “buckle up buttercup,” SP1 turned around and looked to see that they were buckled. SP1 stated that s/he was unable to see the passengers shoulder straps from the driver’s seat. VA1 and VA2 typically “did well” with buckling their seatbelts, but occasionally needed a “single reminder.” VA1 had “occasional trouble” with the locking mechanism on the seatbelt. SP1 stated that s/he either heard a “click” or did a visual inspection to ensure that the passengers were buckled. VA1’s Progress Notes, documented by SP1 stated that while VA1 was at the hospital emergency room, VA1 told hospital staff that s/he was not wearing a seatbelt during the collision. SP2 provided the following information in an interview with the DHS investigator: · On the day of the incident around 5 p.m., SP1-SP3 were planning to take VA1 and VA2 on an outing. While SP1, SP3, VA1, and VA2 got in the car, SP2 was in the bathroom and was the last in the car. SP2 sat in the passenger seat, VA2 was behind SP2, VA1 was in the middle, and SP3 was behind the driver. SP2 stated that when s/he got into the car, everyone was already seated and SP2 “assumed” that everyone was buckled and “ready to go.” SP2 “thought” that VA1 and VA2 had their seatbelts on but did not remember looking back to check. SP2 stated that since there were three staff persons, it was “everyone’s” responsibility to make sure that VA1 and VA2 had their seatbelts on. · The facility car was stopped at the stop sign down the block from the facility and that SP1 was attempting to turn left across two lanes of traffic. A car in the lane closer to the facility vehicle was stopped, however, a car in the further second lane did not stop and hit the facility car as SP1 moved forward past the stopped car to turn. · SP2 called P3 who immediately came to the scene. When the LEO arrived they asked VA1 and VA2 if they were okay, but SP2 did not remember if they asked VA1 and VA2 if they were wearing seatbelts. After returning to the facility, SP1-SP3 took VA1 and VA2 to the emergency room. SP2 stayed with VA2 at the hospital, and after VA2 was examined, it was determined that s/he was “okay.” · SP2 stated that the back seat of the facility vehicle got “very crowded” and was “tight,” but staff persons and clients were required to have their seatbelts on at “all times.” SP2 added that VA1 had a “hard time” putting on his/her seatbelt when there were three passengers in the backseat, however, whichever staff person was sitting in the backseat with VA1 assisted him/her with buckling his/her seatbelt. · At the time of the incident, SP2 thought VA1 and VA2 had been wearing their seatbelts. But “weeks later” VA2 told SP2 that s/he and VA1 were not wearing seatbelts during the collision. SP3 provided the following information: · On the date of the incident, SP1-SP3, VA1 and VA2 were in the car. SP3 was behind the driver (SP1), VA1 was in the middle back seat, and VA2 was behind the passenger (SP2). SP3 stated, “I’m sure we made sure everyone had their seatbelts on. It is a routine we have.” VA1 tended to tell staff persons that his/her seatbelt was on when it was not, which prompted staff to double check and make sure that VA1 had his/her seatbelt on. SP3 did not remember doing so that day and it was “everyone’s” job to make sure that VA1 and VA2 had their seatbelts on. · After SP1 pulled the facility vehicle out of the driveway, they were “down the block” and SP1 was attempting to turn left at a stop sign onto West 76th Street. The road had four lanes and the first lane closest to the facility vehicle was stopped, and the other lane was not visible. The first car let SP1 into the intersection, and as SP1 was watching traffic coming from the other direction s/he pulled further into the intersection and they hit another vehicle. Law enforcement arrived at the facility, but did not “check on” VA1 or VA2. SP3 did not remember VA1 or VA2 telling law enforcement that they were not wearing seatbelts. · After everyone arrived back at the facility, SP1-SP3 took VA1 and VA2 to the emergency room. VA1 and VA2 were each examined at the hospital and sent home “without injury.” P1 provided the following information: · On an unknown date the middle of December 2024, the facility’s insurance company contacted P1 to schedule an interview with VA1 and VA2 about the car collision. On January 3, 2025, a representative from the facility’s insurance company interviewed VA1 and VA2 who each said that they were not wearing seatbelts during the collision. P1 then spoke with SP1-SP3 and none could confirm that VA1 and VA2 were wearing seatbelts. Each staff person told P1 that VA1 and VA2 were told to buckle up before leaving, and that VA1 and VA2 were able to buckle their own seatbelts. SP1 told P1 that s/he specifically stated that s/he told VA1 and VA2 to buckle before they left, but SP1 did not check to make sure that they had done so before driving. SP2 and SP3 told P1 that the driver (SP1) should have been responsible for ensuring that VA1 and VA2 were buckled, however, P1 reminded SP2 and SP3 that all staff persons were responsible for ensuring that VA1’s and VA2’s seatbelts were buckled. SP1-SP3 each told P1 that they were the last person in the car before they left the driveway. · P1 stated that it was documented that both VA1 and VA2 told hospital staff the night of the incident that they had not been wearing seatbelts during the collision. P2 provided the following information: · P2 was aware of the incident and “at some point” after the incident s/he saw VA1 and VA2 who seemed “fine,” “normal,” and “happy.” · P2 did not remember any information regarding VA1 and VA2 wearing seatbelts during the incident. Staff persons were trained that everyone in the vehicle needed to have their seatbelts on. Staff persons were to ask clients and ensure their seatbelts were buckled. VA1 and VA2 were able to buckle their seatbelts independently. In the past, staff persons said something about the car being small, however, the car came from another facility and the residents and staff fit “just fine.” P2 did not have any information regarding passengers not wearing seatbelts in the backseat because the vehicle was small. P2 never heard about it, saw it documented, nor was it discussed at any meetings. P2 stated that it was the responsibility of all staff persons in the car to ensure that VA1’s and VA2’s seatbelts were buckled while in the car. P3 provided the following information: · P3 arrived at the scene approximately 30 minutes after it occurred and SP1-SP3, VA1, and VA2 were still sitting in the car. P3 asked VA1 and VA2 how they were doing and they both stated, “Fine.” P3 did not remember if VA1 and VA2 were wearing seatbelts when s/he spoke with them, and did not remember asking them if they were wearing seatbelts. · After SP1-SP3, VA1 and VA2 returned to the facility and then went to the emergency room. “A few days later,” P2 told P3 that VA1 stated s/he was not wearing a seatbelt during the collision. · Staff persons were trained to tell the clients to wear their seatbelts and VA1 and VA2 were able to put on their seatbelts by themselves. “Every time” they go out in the car, VA1 and VA2 were reminded to buckle their seatbelts and all staff persons who were in the car were required to make sure they did so. P3 was not aware prior to the incident, that the car was tight, and persons were not wearing seatbelts in the backseat. P3 then had a meeting with all staff persons to “reinforce” that all staff and clients needed to wear seatbelts and that the seatbelts needed to be buckled before the car was in motion. VA1’s medical records stated that on October 29, 2024, VA1 presented to the emergency room “about” five hours after a motor vehicle collision in which VA1 was an “unrestrained” passenger in the back seat. VA1 had no complaints apart from mild neck pain. VA1 had a head computed tomography (CT) scan and x-ray of the chest which were “unremarkable,” and a full trauma workup showed no injuries. VA1 was monitored at the hospital for approximately seven hours. VA1 received no treatment or prescriptions for medications. VA2’s medical records stated that on October 29, 2024, VA2 was in the back seat of a vehicle that was involved in a motor vehicle collision. VA2 was not wearing a seatbelt and had mild sternal chest pain. VA2 received an X-ray of the sternum which determined that there was “very low suspicion” for an injury to the sternum. VA2 had a stable electrocardiogram (EKG), no cardiac contusion, a clinically cleared c-spine and a negative head to toe trauma exam. VA2 received no treatment or prescriptions for medications. The G stated that s/he did not know “much” about the incident but VA1 told another family member that s/he was not wearing a seatbelt at the time and that the unbuckled seatbelt buckle hit him/her in the head during the collision. The CM was aware of the incident and that VA2 told the facility’s insurance company representative that s/he was not wearing a seatbelt at the time of the incident. According to the facility’s Safe Transportation Policy, employees were required to “always use seat belts and ensure passengers do as well.” Each staff person interviewed for this report was trained on VA1’s and VA2’s plans, the facility’s Safe Transportation Policy, and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rule and Statute Minnesota Statute 169.686, subdivision 1, subpart (a), stated in part that a properly adjusted and fastened seat belt, including both the shoulder and lap belt when the vehicle is so equipped, shall be worn by the driver and passengers of a vehicle. Minnesota Statute 169.20 subdivision 2, stated in part that the driver of a vehicle intending to turn left within an intersection shall yield the right of way to any vehicle approaching from the opposite direction which is within the intersection or so close thereto as to constitute an immediate hazard. Conclusion: A. Maltreatment: Information provided by VA1-VA2 and SP1-SP3 showed that on October 29, 2024, SP1 was driving the facility vehicle, SP2 was in the passenger seat, SP3 was behind SP1, VA1 was in the rear middle seat, and VA2 was behind SP2. After leaving the facility for a planned outing, the facility vehicle was involved in a collision with another vehicle. Regarding the collision: Information provided by law enforcement and SP1-SP3 showed that SP1 stopped at the stop sign on Xerxes Avenue and then proceeded into the four-lane intersection at West 76th Street to make a left turn to go East. Traffic in the westbound lane closest to the stop sign was stopped, and a driver waved SP1 through but as SP1 pulled further into the intersection, s/he collided with a vehicle traveling west in the second lane. SP1 stated that s/he did not see the other vehicle coming, and SP3 stated that SP1 had his/her head turned so did not see the other car coming. While SP1 may not have seen the westbound car approaching in the second lane and was not issued a traffic citation, SP1 failed to yield to the oncoming car while attempting to turn left, which was a violation of Minnesota Statute 169.20 and lead to a collision. Therefore, there was a preponderance of the evidence that there was a failure to supply VA1 and VA2 with care or services which are reasonable and necessary to obtain or maintain the vulnerable adults’ 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 which is not the result of an accident or therapeutic conduct.) Regarding VA1 and VA2 not wearing seatbelts: SP1-SP3 provided conflicting information regarding who was the last person in the vehicle, and whether any ensured VA1’s and VA2’s seatbelts were buckled before leaving the facility. SP1-SP3 each stated that VA1 and VA2 were required to wear seatbelts and staff persons assisted them in doing so if they were unable. SP1 stated that s/he told VA1 and VA2 to buckle their seatbelts but acknowledged that s/he did not check to make sure they had done so. SP2 stated that s/he “assumed” that VA1 and VA2 had their seatbelts on, and SP3 stated that s/he was “sure” they had their seatbelts on but acknowledged that s/he did not check to make sure. SP1-SP3 and P1-P3 each stated that it was the responsibility of each staff person in the car to ensure that VA1’s and VA2’s seatbelts were buckled before driving. VA1 told this investigator, medical staff, a family member, and the facility’s insurance representative that s/he was not wearing a seatbelt at the time of the accident. VA2 also told this investigator and the facility’s insurance representative that s/he was not wearing a seatbelt at the time of the accident. The law enforcement officer’s body worn camera footage does not show that the officer asked VA1 or VA2 if they were wearing seatbelts at the time of the accident, however, VA1 and VA2 are each unbuckled in the footage. Although there was no information provided in VA1’s or VA2’s plan regarding their ability to use a seat belt, SP1-SP3 and P1-P3 each stated that it was the responsibility of each staff person in the car to ensure that VA1’s and VA2’s seatbelts were buckled before driving and SP1-SP3 each acknowledged that they did not check to ensure that VA1 and VA2 were wearing seatbelts. Therefore, there was a preponderance of the evidence that there was a failure to supply VA1 and VA2 with care or services, is reasonable and necessary to obtain or maintain the vulnerable adults’ 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. SP1-SP3 were each trained on the facility’s Safe Transportation policy and the Reporting of Maltreatment of Vulnerable Adults. SP1 was the driver of the car and responsible for following traffic laws and the safe transportation of VA1 and VA2 while driving. In addition, SP1-SP3 were each responsible for ensuring that VA1’s and VA2’s seatbelts were buckled. Therefore, SP1-SP3 were each responsible for maltreatment of the VA1 and VA2. 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 SP1-SP3 were responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and neither VA1 nor VA2 sustained an injury requiring 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 and SP1-SP3 were each retrained on the facility’s driving policy. Action Taken by Department of Human Services, Office of Inspector General: SP1-SP3 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1-SP3 were each notified by the Office of the 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, SP2 or SP3. The determination that SP1-SP3 were each responsible for maltreatment is subject to appeal.
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