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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: 1068586-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Elisa Montgomery 651-431-6474 Suspected Maltreatment Reported: It was reported that a staff person (SP) poured his/her urine in a vulnerable adult’s (VA) Keurig coffee machine on an unknown date unbeknownst to the VA. Date of Incident(s): Unknown, Between March or April 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 May 14, 2025; from documentation at the facility and law enforcement records; and through ten interviews conducted with facility staff persons (P1-P5), the staff person (SP), guardians (G1-G3), and the VA. The VA was diagnosed with mild intellectual disability, bipolar disorder, and anxiety. The VA enjoyed hiking, spending time with family, playing basketball, and watching TV. The VA received 24-hour supervision and worked three days a week with supportive employment services. The VA provided the following information: The VA stated that prior to the incident around April of 2025, s/he had gotten into an altercation with the SP in March of 2025 which may have caused tension between the VA and the SP. The VA was not aware that the SP poured urine into his/her Keurig coffee machine but was given a new Keurig coffee maker from the facility in April 2025. The VA was the only one who used the Keurig coffee machine as the VA and housemates each had their own coffee machines. The VA would use his/her Keurig coffee machine almost daily. P1 provided the following information: · On an unknown date in April 2025, P1 was working at the facility where the VA resided. The SP had been transferred to another facility location but went to the facility where the VA resided to pick up his/her belongings that were in the staff office. · P1 recalled that it was around 11:35 p.m. when the SP arrived. The SP put his/her bag on the counter in the kitchen and went to the staff office. P1 followed the SP to the staff office and was conversing with the SP. · At some point, P1 was cleaning, and the SP was gathering his/her snacks and other belongings from the kitchen. P1 did not see the SP put anything into the VA’s Keurig coffee machine but did not watch the SP closely. · P1 and the SP went outside, smoked a cigarette and talked, and then the SP left the facility. P1 said that the SP was at the facility for about 10 to 15 minutes. · P1 did not have concerns with how the SP interacted with the VA or the VA’s housemates but would make comments to coworkers about how the SP did not like the VA/hated the VA and was “glad” to not have to work with the VA after being transferred to another facility location. P2 provided the following information: · P2 worked with the SP after the SP had transferred to the facility location where P2 worked. While working with the SP, the SP had discussed with P2 how s/he had poured his/her urine into the VA’s Keurig coffee machine. · The SP shared with P2 that this had occurred on a Saturday in April 2025, after s/he left the facility location s/he was working at following his/her shift and went to the facility where the VA resided to gather the belongings that the SP left. The SP brought a small bottle of his/her urine and poured it into the Keurig coffee maker. At some point, the SP spit in the VA’s hat and poured the remainder of the urine in the small bottle on a chair that the VA used and left the facility with his/her belongings. · P2 was not able to recall the date that this had occurred by had notified his/her supervisor following the conversation with the SP regarding the incident. · P2 said that the SP had a “morbid sense of humor” and initially did not think that the SP had put urine into the VA’s coffee maker but was concerned after the SP continued to provide details like when it had occurred, how the SP had gotten the urine into the Keurig coffee machine, and that the SP had expressed a general dislike for the VA. P3 provided the following information: · On April 12, 2025, P3, P2, and the SP were working together, and the SP was laughing while washing dishes. P3 asked the SP what s/he was laughing about the SP told P3 s/he was laughing about telling the SP’s friends about how the SP was going to urinate in the VA’s Keurig coffee machine because the VA was the only one who used that Keurig coffee machine. · P2 interjected while the SP was still laughing and making jokes and told the SP to stop making the jokes as it was not appropriate. P3 walked away from the SP and P2 as s/he no longer wanted to engage in the conversation with the SP. · P3 believed that the SP went to the facility where the VA resided on or around April 20, 2025, but was not sure. The SP also told P3 that s/he had also spit in the VA’s hat when the SP went to the facility to gather the items that s/he left at the facility. · P3 said that the SP had a “dark sense of humor” but did not have concerns with how the SP interacted with clients. P4 provided the following information: · P4 worked with the SP at the facility where the VA resided, and the SP assisted P4 with supervisory duties. In March 2025, the SP and the VA engaged in a “power struggle” and the SP was injured by the VA. Following that incident, the SP was transferred to another facility location for the safety of the VA and the SP. After being transferred, the SP no longer assisted P4 but still had access to the facility. · P4 was familiar with the SP’s “dark humor” and that the SP would makes comments in private about how s/he “hated” the VA. The SP worked with the VA for approximately nine years and was able to set aside his/her feelings toward the VA and work with the VA professionally. · Around April 12 to 14, 2025, P4 believed that the SP had stopped by the facility to gather his/her belongings that were left behind as P4 observed that the SP’s belongings were missing from the staff office. P4 was not aware that there were concerns that the SP had poured urine into the VA’s Keurig coffee machine until P5 had contacted P4 on May 4, 2025, and informed P4 that a new Keurig coffee machine would be purchased for the VA. P5 provided the following information: Around April 12 to 13, 2025, the SP was believed to have stopped by the facility where the VA resided. The SP was able to access the facility as the code to the lock pad was not changed and staff were not informed that the SP was not to access the facility. On May 4, 2025, P2 called P5 with concerns that the SP might have poured his/her urine into the VA’s Keurig coffee machine and a new Keurig coffee machine was purchased for the VA. G1-G3 provided the following information: G1-G3 were concerned that the SP had access to the facility after transferring to another facility location following the incident in March 2025. Prior to the incidents in March and April 2025, G1-G3 had expressed concerns with the SP’s behavior/attitude toward the VA to a former supervisor. It was unknown to G1-G3 if the facility or former supervisor addressed G1’s-G3’s concerns. G1-G3 were concerned that they did not receive notification of the incident regarding the VA’s Keurig coffee machine in a timely manner and were notified on May 6, 2025. The SP provided the following information: · On March 7, 2025, the SP woke the VA up to take medications. The VA attempted to slam his/her bedroom door, but the SP stopped the door from slamming. The VA began to hit the SP resulting in the SP receiving a concussion. Due to this incident, the SP was transferred to another facility location. · Sometime before March 15, 2025, the SP went to the VA’s facility and brought a small shampoo bottle (less than three ounces) filled with the SP’s urine and poured approximately a quarter of a teaspoon of the urine into the VA’s Keurig coffee machine. The SP went to the facility around 11:00 p.m. to avoid being seen by the VA and the VA’s housemates. · While at the VA’s facility, the SP talked with P1, gathered his/her belongings, and left after smoking a cigarette with P1. · The SP wished that the VA had “actual consequences” for his/her actions since the VA had “attacked staff” in the past and that the VA was “rewarded” for harming staff persons. The SP denied pouring urine on the VA’s chair and denied spitting in the VA’s hat stating s/he was “upset” and that did not occur. Law Enforcement (LE) records provided the following information: · On May 12, 2025, the SP stated that s/he worked with the VA for “multiple years” and had been “assaulted by or had physical confrontations” with the VA in the past. The SP did not report any incidents of physical assault to LE because “nothing ever happens” if it were to be reported. · Following the incident on March 7, 2025, the SP was upset and wanted to “get back” at the VA because the VA was not going to receive any other “repercussions” for the physical assault that occurred. The SP explained that s/he made “bad decision” in his/her concussed state. · The SP described that s/he urinated into a small travel sized shampoo bottle and kept it on his/her person and went to the VA’s facility. The SP waited until P1 was outside and poured a quarter of a teaspoon of urine into the water reservoir of the VA’s Keurig coffee machine. · The SP was charged with a gross misdemeanor as a result of pouring his/her urine into the VA’s Keurig and that more than likely, the VA had ingested the urine over an unknown period of time until the Keurig was replaced by the facility. The facility’s internal review provided the following information: P5 was notified on May 4, 2025, of the concerns regarding the SP putting urine in the VA’s Keurig coffee machine. P5 did not notify G1-G3 of possible maltreatment until May 6, 2025. P5 received a review of reporting maltreatment procedures and timeliness of notifications to external parties. Concerns regarding the SP’s behavior/attitude had been reported to a former supervisor but were not addressed by the former supervisor. The former supervisor no longer worked at the facility. All staff person’s interviewed were trained on the Reporting of Maltreatment of Vulnerable Adult’s Act. P1, P4, P5, and the SP were trained on the VA’s plan of care. P2 and P3 did not work with the VA and were not trained on the VA’s plan of care. Conclusion: A. Maltreatment: P2 and P3 provided consistent information to this investigator that while working with the SP on April 12 or 13, 2025, that the SP “made jokes” about putting urine in the VA’s Keurig. P1-P4 discussed that the SP seemed to have a “morbid” or “dark” sense of humor, and that the SP was believed to be “making jokes” about putting his/her urine into the VA’s Keurig. P2 and P3 were told by the SP that the SP poured urine on the VA’s chair and spit in the VA’s hat, but the SP denied this and claimed that s/he was “upset,” and this did not occur. Around April 12 to 14, 2025, P4 believed that the SP had stopped by the facility to gather his/her belongings that were left behind as P4 observed that the SP’s belongings were missing from the staff office. P4 was not aware that there were concerns that the SP had poured urine into the VA’s Keurig coffee machine until P5 had contacted P4 on May 4, 2025, and informed P4 that a new Keurig coffee machine would be purchased for the VA. The SP provided consistent information to this investigator and law enforcement that the SP went to the VA’s facility and brought a small shampoo bottle (less than three ounces) filled with the SP’s urine and poured the urine into the VA’s Keurig coffee machine. The SP went to the facility around 11:00 p.m. to avoid being seen by the VA and the VA’s housemates. The SP believed that the VA needed receive “repercussions” following the incident that occurred on March 7, 2025, between the VA and the SP. The SP acknowledged that they had made a “bad decision.” Given that the SP intentionally put his/her urine, a bodily fluid, into the VA’s Keurig machine which the VA used to make beverages that s/he consumed, there was a preponderance of the evidence that the SP failed to provide the VA with reasonable and necessary care and services. 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 trained on the Reporting of Maltreatment of Vulnerable Adults Act and facility policies and procedures. The SP was responsible for 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 not “recurring” because it was a single incident or “serious” because the VA did not require care of a physician. Action Taken by Facility: The facility completed and internal review and determined that the facility’s policies and procedures were adequate but were not followed by the SP. Additionally, the facility updated internal policies that outlined that staff persons belongings who were transferring to another facility location would be taken to the main office to be picked up and that staff persons transferring would not be able to return to the former facility. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP 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 the SP. The determination that the SP was responsible for maltreatment is subject to appeal.
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