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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: 1083684- H_CRS (Home and Community-Based Services-Community Residential Setting) 1070806-HCBS (245D-Home and Community-Based Services) Investigator(s): Emily Kearns/Heidi Murphy 651-431-6513 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) left the facility unsupervised without two staff persons’ knowledge (SP1 and SP2) and was out in freezing cold weather for one to two hours, not dressed for the weather conditions. The VA was evaluated for frost bite and was at risk for being hit by a car after standing on the interstate. The VA was hospitalized for suicidal ideation. Date of Incident(s): January 6, 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 23, 2025; from documentation at the facility, law enforcement records, and medical records; and through 8 interviews conducted with the VA, four facility staff persons (SP1, SP2, P2, and P3), a supervisory facility staff person (P1), the VA’s guardian (G), and a community person (CP). The VA was diagnosed with autism spectrum disorder, adjustment disorder, and mild intellectual disability. The VA enjoyed drawing and playing board games and video games. The facility was a three-level split house in a rural setting. The main floor of the house had a kitchen and living room. The upstairs level had a bedroom, an office, and a bathroom. The lower level was where the VA lived and included a bedroom, living room area, laundry room, and a bathroom. There was a door leading from the lower level living room outside which had a lock, but the lock was not required to be used during daytime hours. The VA’s plans dated September 27, 2024, stated s/he had 15 minutes of unsupervised time in a local store, in which staff waited in the van. If the 15 minutes expired, staff would call the VA or go into the store to locate him/her. If the VA was not located after one hour, staff called 9-1-1 and filed a missing person report. The VA did not have unsupervised time at the facility. The VA’s staff ratio was as 1:1 awake staff support from 6 a.m. to 10 p.m. both at the facility and in the community. During the hours of 10 p.m. to 6 a.m., the VA had shared awake staff and shared asleep staff while at the facility. “When [the VA] begins to exhibit target behaviors, staff will redirect [him/her] to a different area or activity, giving [him/her] time to calm down independently. If [his/her] behavior escalates further, staff, trained in [his/her] BSP will implement de-escalation techniques.” The VA’s Behavior Support Plan dated November 8, 2022, stated, “[The VA] had been hit by a car in the past due to [his/her] unsafe [leaving without supervision] behaviors.” When the VA displayed agitated/disruptive behavior or verbal aggression, “Staff were to keep their eyes on [the VA] until [s/he] is back to a calm level or place themselves within auditory range of [his/her] bedroom or porch area.” When the VA was physically aggressive or involved in property destruction, “Staff will give [the VA] space and use distance to give [the VA] the opportunity to calm down. Staff will maintain eyes on [the VA] and respond to the situation until [the VA] is back down to baseline.” When the VA engaged in property destruction and was not in imminent harm, staff persons were to maintain “eyes on” the VA but distance themselves from the VA and continue to monitor the situation for safety. Staff persons were to continue to offer the VA “calming strategies.” The VA provided the following information: · The VA had been out with SP1 looking for the first star in the sky to make a wish. When they returned to the facility, a delivery truck was delivering packages. The VA asked if s/he could open the packages that were addressed to the facility and SP1 and SP2 both said, “No.” The VA stated s/he had always been able to open packages addressed to the facility. · The VA then asked to call P1. SP1 and SP2 stated s/he could not call P1 because it was after 5 p.m. The VA stated s/he had been allowed to call P1 in the past for similar situations. The VA got upset and used profanity. SP1 and SP2 went upstairs to the office. The VA found SP2’s cell phone in the living area and threw it, which broke the screen. · SP1 and SP2 did not go down to the main floor where the VA was when the phone was thrown. The VA then left through the door leading to the garage and through the open overhead garage door without SP1’s or SP2’s knowledge. · SP1 and SP2 thought the VA went downstairs, however, the VA stated s/he never went down to the lower level. · The VA left the facility with the intention of jumping off a bridge and stated, “If I miss, I’ll just get run over.” The VA decided that was a “hard death to do” and decided the “perfect death would have been a semi [truck]”. The VA went to the interstate and had intentions of getting hit by a vehicle. The VA stated s/he was still on the entrance ramp when the semi-trucks passed on the interstate, and s/he “missed [his/her] chance.” The VA walked in the middle of the traffic lanes and a car came close to him/her, which scared the VA. The VA laid in the median for about five minutes and then walked on the interstate and interstate entrance ramp to the gas station, which was approximately 2.8 miles from the facility. · The VA estimated s/he was gone from 5 to 8 p.m. The VA was wearing a sweatshirt with a hood, a beanie hat, fingerless gloves, pants, socks, and shoes. · The VA stated s/he was only allowed to go on walks when accompanied by staff. The VA was allowed unsupervised time in some small community stores. Staff persons stayed in the vehicle and allowed the VA 15 minutes unsupervised in the store before they checked in on him/her. SP1 provided the following information: · On January 6, 2025, SP1 worked from 2 to 10 p.m. Packages were delivered to the facility around 5:15 p.m. and the VA wanted to open them. SP1 told the VA s/he could not open the packages. SP1 had been told if packages were addressed to the facility, the first shift opened them. SP1 had told the VA on previous occasions that s/he could not open packages and there had not been any issues. · The VA got “boisterous” and SP1 went upstairs to the office to put medication away. SP1 heard the VA throw a glass and SP2’s phone. SP1 stated from the office, s/he saw the lower-level door open and close and “that’s how I knew [the VA] went downstairs.” SP1 put the medication in a locked cabinet and went downstairs to the main level to see what was going on. There was glass on the floor, stuff thrown around, and the door to the VA’s bedroom/living area was closed. SP1 stated when the VA’s door was closed, it meant the VA was downstairs. · SP2 started to clean up the broken glass and SP1 went back to the office. At 5:22 p.m., SP1 called P1 to notify him/her of the VA’s behavior. SP1 then called the G and the CM and left messages for both. SP1 estimated it took SP2 10-12 minutes to clean up the glass. They had trouble with the vacuum, and it was not used. · Within 10-15 minutes, SP1 stated s/he heard the VA “moving around down there [lower level]” through the vent system as the office was directly above the lower level where the VA had living quarters. Approximately half an hour later, SP1 heard a “loud bang down there” and stated no one else was on the lower level. SP1 believed the time was close to 6 p.m. SP1 and SP2 did not go check what the bang was or to confirm the VA was in his/her living area. · At approximately 6 p.m., SP1 asked SP2 to go up to the office to proofread the incident report regarding the VA’s earlier behavior. SP1 estimated SP2 was with him/her in the office for 10 minutes. SP1 believed s/he was finished writing the report at 6:15 to 6:20 p.m. SP1 stated s/he was in a position in the office where s/he would have been able to see “anything moving around” on the main level. (Investigator’s note: When in the office, if anyone walked past the stairs leading up to the office, they would be seen. However, if anyone walked past the stairs leading down to the VA’s bedroom, someone in the office would not see that.) · After the report was finished, SP1 finished checking in the medications and completed some administrative duties and SP2 went back to the main floor. About 15 minutes later, SP1 received a phone call from a 9-1-1 dispatcher notifying her/him that the VA was at a gas station. · SP1 was told by the 9-1-1 dispatcher to wait by the phone. SP1 was asked if the VA was at the facility. SP1 searched the residence and did not locate the VA. SP1 was told the VA was evaluated for frostbite. When SP1 got off the phone at 7:35 p.m., s/he called P1. P1 stated SP2 needed to go to the gas station. · SP2 went back to the facility and told SP1 that the VA had been transported to a hospital. SP1 then drove to the hospital. SP1 arrived at the hospital and was told the VA was not there. SP1 called another hospital, located the VA and drove to that hospital. Hospital staff told SP1 the VA had been wearing a T-shirt, sweatshirt, sweatpants, gloves, socks, and shoes. At approximately 10 p.m., SP1 was told the VA would be kept overnight and was not given any more information. SP1 confirmed that the VA did not have frostbite before s/he left the hospital at 10:19 p.m. · SP1 stated the front door was operable on January 6, 2025, and was equipped with an alert chime, which functioned when the packages were delivered earlier that day. The windows and doors had alarms, however, SP1 did not know if they were functioning and added that they had been disabled at one point because of problems with the air conditioner. SP2 provided the following information: · On January 6, 2025, at approximately 5:15 to 5:20 p.m., SP2 was in the facility cleaning when SP1 and the VA arrived from looking for stars. SP1 carried in some packages and the VA asked if s/he could open them. SP1 said, “No.” The VA got upset and asked to call P1 and SP1 said, “No,” because it was after 5 p.m. The VA then asked SP2 if s/he could call P1. SP2 “wanted to support” SP1 and said, “No.” The VA got upset, “lost [his/her] temper,” hit the refrigerator, and grabbed a glass jar and threw it on the floor. The jar broke and SP2 “disengaged” and went out the door into the hallway to be away from the VA. · SP2 went upstairs to the office and the VA went to the living room. SP2 heard the VA say, “I’m gonna throw this fucking phone,” and assumed s/he was referring to the staff phone. SP2 heard what was believed to be the phone being thrown while s/he was in the office with SP1. SP2 then heard the VA say s/he was going downstairs and heard the door to the lower level shut. SP2 heard the VA go downstairs. · SP2 stated s/he and SP1 were in the office for approximately 10 minutes. SP1 and SP2 went down to the main level and discovered the VA had thrown SP2’s cell phone, not the facility phone. SP2 started to clean up the broken glass from the jar and SP1 went outside to call P1. The door to the lower level was closed while SP2 cleaned, swept, and vacuumed. When SP1 came back inside, s/he went up to the office and SP2 continued to clean up the broken glass. SP2 stated when s/he was cleaning, the light was on in the lower level. · Around 6 p.m., SP1 asked SP2 to come up to the office to proofread the incident report. SP2 estimated s/he was upstairs proofreading for about 10 minutes. SP2 believed the VA left during the time both staff were in the office. · SP2 made a mental note around 7 p.m. that the light on the lower level was now off. SP2 stated it was common for the VA to nap around 6 p.m. and the light being off was an indication that the VA was asleep. · SP2 was not aware the VA had left the facility until the phone call from the 9-1-1 dispatcher at 7:20 p.m. SP2 drove to the gas station and was told s/he could not see the VA because s/he was in the ambulance. SP2 was told the VA made concerning comments about wanting to step in front of a semi-truck. · The VA was transported to the hospital by ambulance and SP2 went back to the facility and SP1 then drove to the hospital. · The VA had a “short fuse” and would go downstairs to calm down or to nap. SP2 stated, “I wasn’t ever trained specifically for [the VA],” and “never shadowed” anyone at the house. P1 told SP2 s/he “would be fine.” SP2 had read the VA’s plans, however, stated they were “dated.” · After work hours, requests to call P1 went through “different channels”. SP2 knew there was a protocol after 5 p.m., however, did not know exactly what the protocol was. The protocol was not written and was “just something we should do.” · SP2 stated s/he did not know if s/he signed training plans for the VA and added, “I grabbed the books and read them. I did not shadow at that house. I familiarized myself because I know to.” · The VA’s ratio was 1:1, other client was 2:1. SP2 said there had never been three staff on his/her shift when s/he has worked. P1 provided the following information: · The VA had been waiting for a package and on January 6, 2025, the VA saw packages being delivered, The VA asked SP1 if s/he could open the packages. SP1 told the VA that the packages were not addressed to the VA and therefore, could not open the packages, which upset the VA. The VA asked to call P1 and SP1 said, “No.” P1 stated the VA could have been allowed to open the packages and should have been allowed to call him/her, “which was part of the VA’s plans [call P1]”. P1 stated the VA’s behavior was an “avoidable behavior” and referred to the VA’s actions as a “staff induced behavior.” There was nothing that said the VA could not open packages. SP1 and SP2 should not have denied the VA access to the phone to call P1. · The VA told P1 s/he threw SP2’s cell phone and broke the screen and walked out of the facility without supervision or staff knowledge at approximately 5:15-5:20 p.m. · SP1 called P1 at 7:35 p.m. and told him/her that the VA had left the facility and was found at a gas station 2.5 miles away. The VA was not dressed for the weather and was evaluated for frostbite by an ambulance. There were no signs of frostbite. The VA was transported to a hospital for demonstrating suicidal behaviors and was kept overnight for observation. · The VA was allowed unsupervised time in his/her area of the facility and at select local stores, with staff close by. · P1 stated SP1 and SP2 should have kept visual contact on the VA when s/he had a behavior. P1 believed SP1 and SP2 were not in the kitchen like they stated and believed they were upstairs. The VA does not provide false information. P1 stated the VA was “honest to a fault. Bluntly honest.” P2 provided the following information: · P2 learned about the VA leaving the facility from a conversation that was overheard between the VA and P1. P2 also read about the incident in facility documentation. The only conversation the VA had with P2 after the incident was when the VA told P2, “They are not my staff [persons].” P2 added that in general, SP1 and SP2 did not have a good rapport and were not engaged with the VA. · P2 stated it was normal for the VA to open mail and packages that arrived at the facility and normal for the VA to call P1 when assistance or an answer was needed with an issue. · P2 stated when the VA needed to be deescalated, s/he would give the VA a three-minute break and then reengage to verbally deescalate. P2 would have a lot of 1:1 time with the VA as long as the VA allowed it. If not, P2 would “keep within in proximity and reengage when the opportunity seems right.” P3 provided the following information: · P3 worked from 6 a.m. to 2 p.m. on January 6, 2025. The VA had a “normal” day, however, was a little “worked up” because s/he had broken his/her phone a short time prior. · The VA could be difficult to redirect when s/he was focused on something. The VA was “not good at regulating emotions or talking about emotions.” P3 offered breaks and talked through situations to get the VA to calm when s/he got upset. When the VA was upset, “leaving him [unsupervised] is not the right route to go. Giving space and completely being all the way, upstairs is not a good thing.” P3 stated the SP2 worked at a different facility location in which when that client had a behavior, staff would go to the office. · The VA was allowed to open mail and packages that arrived at the facility. The VA was allowed to call P1 when s/he needed assistance. · P3 believed the VA “took advantage of the situation” and SP1 and SP2 “not knowing [the VA’s] background as well” as other staff and walked out the door. · P3 stated the VA gave signs when s/he was going to leave the facility. The VA told staff s/he was going to leave if staff were close by, if not, s/he would just leave. On previous occasions, the VA put on gloves and shoes and verbalized s/he was leaving. · When the VA slept, his/her bedroom door would be shut and “you would hear [snoring].” When the VA played video games, the door was kept open. The G provided the following information: · At 5:29 p.m. on January 6, 2025, the G had a voice mail message regarding the VA’s behavior. At 9:09 p.m., the G received a call from P1 and was told that the VA was brought to a hospital to be evaluated for possible frostbite and because the VA made suicidal comments. · The VA told a family member that s/he walked out the front door. The G stated the doors were supposed to be alarmed as part of the VA’s Coordinated Services and Support Plan (CSSP) addendum. The G had heard alarms/chimes on the door when at the facility, more than six months ago. The VA told another family member s/he walked out the front door. · The VA did not have any rights restrictions, and the G believed the VA had a 2:1 staff ratio. The CP provided the following information: · The CP worked at the gas station on the night of January 6, 2025, and helped the VA. The VA arrived at the gas station around or a little after 7 p.m. · The CP remembered that the VA was “pretty bundled up,” however, wore fingerless gloves. The VA told the CP s/he had walked there from the facility and pointed in a northwestern direction, toward the facility. · The VA asked for a phone to call 9-1-1. The CP gave the VA a phone and the VA called 9-1-1 him/herself. The VA asked for handwarmers, and the CP gave some to the VA and offered the VA some food. The VA stayed in the store until law enforcement arrived. According to www.wunderground.com, the temperature on January 6, 2025, at 5 p.m. was 20 degrees Fahrenheit. The temperature at 8 p.m. was 16 degrees Fahrenheit. According to the wind chill calculator on www.weather.gov, the wind chill at 5 p.m. was 10 degrees Fahrenheit and at 8 p.m. was 11 degrees Fahrenheit. The facility Investigation Report and Summary provided the following information: · SP1 stated that the day of the incident s/he last saw the VA at 5:30 p.m. and believed the VA was in the lower-level area after that. · SP2 stated s/he “went straight to the office” after the VA threw the glass jar. SP2 heard the VA say s/he was going to throw the phone, was “banging, kicking, throwing things, and swearing like crazy” before saying s/he was going to go downstairs. SP2 also stated s/he heard the VA say, “I’m getting the fuck out of here,” and slammed the door when s/he went downstairs. SP2 did not hear any noise come from the lower level after that. · P1 stated the garage door was alarmed; however, the chime did not always work, and the VA knew how to turn the chimes off. The VA did not have any phone restrictions. The VA told P1 that SP1 and SP2 ran to the office after s/he shattered the glass because they were scared s/he was going to hurt them. The VA stated s/he said s/he was leaving before going out the door. · The VA’s CSSP dated July 15, 2024, stated the VA had 1:1 staffing throughout awake hours. New staff completed three days of shadow training prior to working with individuals including training on their individual program plans, risk assessment, and health care/behavioral needs. Staff were required to attend training each month for two hours related to individual needs and follow the person’s individual plans. Facility training records showed that SP2 signed an Acknowledgement of Responsibilities for Continued Supervision, in which stated, “I understand that leaving an individual without adequate supervision as defined in the individual’s annual plan, is considered to be neglect and will be subject to disciplinary action up to and including immediate termination.” Facility training records showed SP2 signed off on November 19, 2024, that s/he had received training on “On-Site Program Orientation,” also signed off on “On-Site Shadow Training.” Facility training records also showed that all interviewed employees each received training on the Reporting of Maltreatment of Vulnerable Adults Act. SP2 also signed off on the Positive Support Techniques In-Person Test Out on Behavior Management for the VA on December 1, 2024. Conclusion: A. Maltreatment: Information showed that on January 6, 2025, around 5:15 p.m., the VA and SP1 arrived at the facility after an outing. The VA requested to open some packages that were just delivered. SP1 and SP2 both said, “No.” The VA asked to call P1 and was told, “No,” by SP1 and SP2. The VA threw a glass and SP1 and SP2 went upstairs to the office and did not keep the VA in visual contact. SP2 stated s/he heard the VA “banging, kicking, throwing things, and swearing like crazy,” however, neither SP1 nor SP2 interacted with the VA to deescalate him/her. The VA threw SP2’s cell phone and made a comment about getting “out of here” and slammed a door. SP1 and SP2 thought the VA went down to the lower level of the facility, however, neither confirmed that. SP1 and SP2 did not physically see the VA after 5:30 p.m. At some point, the VA left the facility unsupervised and without the knowledge of SP1 and SP2 until around 7:30 p.m. when the 9-1-1 dispatcher called the facility notifying the SPs that the VA was at a gas station. The VA was evaluated by medical personnel for frost bite and was transported to a hospital for evaluation after the VA stated s/he had tried to get hit by a car on the highway in a suicide attempt. The VA stated SP1 and SP2 did not let him/her open packages that were delivered to the facility or call P1 when requested. The VA got upset and threw SP2’s cell phone and left the facility through the garage door without the knowledge of SP1 or SP2. The VA said he did not go into the lower level. The VA walked to the interstate with the intention of getting hit by a vehicle. A car came close to the VA and scared him/her. The VA walked approximately 2.8 miles to a gas station and was not dressed for the below freezing temperatures. There were some inconsistencies between SP1’s and SP2’s accounts of the evening. SP2 stated s/he vacuumed up broken glass and SP1 stated the vacuum was not used due to it being broken. SP1 stated s/he saw the lower-level door open and close from two stories up and SP2 only heard the lower-level door shut. SP1 heard “moving around” on the lower-level and later heard a “loud bang” come from that area. SP2 did not mention any noises that came from the lower level. The VA stated s/he never went down to the lower-level and left after throwing SP2’s phone through the garage door. From the office where the SPs were, it was not possible to see the VA going down the stairs to the lower level. In addition, the SPs were doing things like paperwork and medication tasks so it was not likely they were looking down the stairs through the office door during that time. Given these inconsistencies and that information showed that the VA was an accurate reporter of information, it was more likely than not that the VA did not go to the lower level but instead left the facility at that time. The VA’s plans stated that “when [VA] begins to exhibit target behaviors, staff will redirect [him/her] to a different area or activity, giving [him/her] time to calm down independently. If [his/her] behavior escalates further, staff, trained in [his/her] BSP will implement de-escalation techniques.” When the VA displayed agitated/disruptive behavior or verbal aggression, “staff were to keep their eyes on [the VA] until [s/he] is back to a calm level or place themselves within auditory range of [his/her] bedroom or porch area.” When the VA was physically aggressive or involved in property destruction, “staff will give [the VA] space and use distance to give [the VA] the opportunity to calm down. Staff will maintain eyes on [the VA] and respond to the situation until [the VA] is back down to baseline.” Although SP1 and SP2 each stated they thought the VA was on the lower level, given that the VA’s plans stated that staff persons were to work with the VA to deescalate and have visual contact, that neither SP verified the VA was in the lower level, that the SPs did not attempt to calm the VA or remain with the VA until the VA was calm, that the VA left without staff person knowledge or supervision after the VA stated, “I’m getting the fuck out of here,” subsequently being exposed to below freezing temperatures and walking along and on the interstate with suicidal ideations, and the VA’s account was considered more credible than the SPs’ and the VA stated s/he never went to the lower level, there was a preponderance of the evidence that SP1 and SP2 failed to provide the VA with reasonable and necessary care, services, and supervision. 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 was 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 and SP2 were responsible for the care and supervision of the VA at the time of the incident and were trained on the Reporting of Maltreatment of Vulnerable Adults Act. SP1 and SP2 were 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 SP1 and SP2 were responsible did not meet statutory criteria to be determined as recurring or serious because this was a single incident and the VA did not require care of a physician as defined in statute. Action Taken by Facility: The facility completed an internal review and determined related policies and procedures were adequate and were not followed and that there was a need for further staff training. Staff were retrained on the VA’s behavior support plan, program abuse prevention plan, and annual plan. The facility took corrective action and SP1 and SP2 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 and SP2 were each 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 disqualification. The determination that SP1 and SP2 were each responsible for maltreatment is subject to appeal.
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