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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: 1069261-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) left the facility without the knowledge or supervision of staff persons (SP1 and/or SP2). First responders discovered the VA, “unconscious,” inside a neighboring house that was on fire. The VA was transported to an emergency room and diagnosed with smoke inhalation. Date of Incident(s): June 24, 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 July 21, 2025; from documentation at the facility; law enforcement and medical records; and through five interviews conducted with the VA’s guardian (G) who also the VA’s family member, the VA’s case manager (CM), facility staff persons (SP1 and SP2), and a supervisory staff person (P). The VA’s Coordinated Service and Support Plan Addendum-Intensive Services, Individual Abuse Prevention Plan, and Self-Management Assessment provided the following information: · In September 2023, the VA moved into the facility seeking support and services relating to his/her diagnoses, which included impulse-, major depressive-, and oppositional defiant-disorders. · The VA enjoyed spending time with his/her family and attending sporting events. The facility provided the VA with “staff supervision 24 [hours] a day, with a portion of the day being 1:1 staffing.” [Note: The facility’s documentation did not provide additional information regarding what “a portion of the day” or “1:1 staffing” entailed. The CM provided the VA’s RMS Worksheet, which stated the facility provided 22 hours of individual direct care per day, two hours of shared direct care staff per day, and five hours of shared direct care staff per overnight.] · The VA had a history of eloping (leaving without telling anyone). “When [the VA] chooses to elope, [s/he] moves fast. [S/he] gives minimal warning that [s/he] intends to elope. [S/he] will often hide behind buildings, bushes, trees, and objects. In the event that [the VA] elopes from staffs [sic] sight or sound, staff will call [9-1-1]. If it is safe to do so, staff may attempt to follow [the VA]. Staff will not trespass on private property. Staff are not trained in physical pursuit and apprehension and will defer to emergency services for safe response and recovery.” · “When [the VA] is on an exterior deck, staff will watch and listen for [him/her] through the window or screen door when they are not physically on the deck with [him/her]. If staff lose sight of [the VA], they will contact law enforcement.” · The VA was able to navigate the community and had “moderate” pedestrian skills. However, s/he was susceptible to abuse from others and might struggle to communicate; the VA was “difficult to understand.” Staff always supervised the VA when in the community. [Note: Information was provided that on the date of the incident, June 24, 2025, the VA wore a watch with a global positioning system (GPS). However, the watch was given to the VA on or around June 23, 2025, and not yet included in the VA’s support plans.] The facility was a single-family home where the VA lived with housemates. The front door opened into a living room. The next room over was a kitchen, which was also along the front of the house. The bedrooms were in the back. Outside, there was a narrow deck along the front of the house with a table and chairs. The surrounding area included several residences, woods, and city streets with stop signs. An unoccupied house was next door. The facility’s incident report stated that on June 24, 2025, at 7:45 p.m., the VA asked to take a walk. SP1 and SP2 told him/her to wait while they completed other tasks. “[The VA] became inpatient” and left the house without supervision or telling SP1 or SP2. When SP1 and SP2 became aware, they looked for the VA without success and called 9-1-1. Bemidji Law Enforcement and Ambulance Records, Sanford Health Medical Records, and Health Partners Records provided the following information: · On June 24, 2025, at approximately 8 p.m., SP1 called 9-1-1 dispatch stating that the VA left the facility “on foot approximately 20 minutes earlier.” SP1 stated that s/he did not know where the VA might go. SP1 provided a description of what the VA was wearing. Law enforcement officers searched the area but did not locate the VA. · At 8:36 p.m., a community person called 9-1-1 dispatch reporting a house fire at the vacant house next door to the facility and that they saw a person inside the house and/or running from the house. Descriptions were given that met the VA’s description. [Note: The cause of the house fire was under investigation at the completion of the maltreatment investigation.] · Firefighters discovered the VA inside the burning house and pulled the VA to the front door where EMS assumed care. The VA’s airway was covered in soot and his/her breathing was “shallow and irregular.” [Note: There was conflicting information in the records with some stating the VA was “unresponsive” and “CPR was in progress” and others stating the VA was “alert” and “no CPR was conducted.”] EMS transported the VA by ambulance to an emergency room where s/he was diagnosed with smoke inhalation injury, carbon monoxide poisoning, and acute toxic encephalopathy (brain dysfunction caused by exposure to exogenous substances). · At 11:34 p.m., the VA was airlifted by medical helicopter to a burn center in Saint Paul, MN. · On June 25, 2025, at 12:02 a.m., the VA was admitted to the burn center with inhalation injury. The VA was intubated and “mildly hypoxic” (low levels of oxygen in his/her body tissues). The VA had a “patch of partial and deep burn” on his/her upper back and abrasions on his/her back, elbow, and forehead; all treated with daily dressings and antibiotics. [Note: Information was provided the abrasions were likely caused when firefighters pulled the VA out of the burning house.] The burn center transferred the VA to a medical intensive care unit for “persistent hypoxia.” [Note: At the outset of this investigation, the VA was hospitalized on a ventilator and the VA remained hospitalized throughout this investigation. As of July 21, 2025, the VA was removed from supplemental oxygen and regaining his/her speech and mobility.] The G said that at the time of the incident, the VA was wearing a GPS watch and so staff should have been able to locate the VA in the neighboring house soon after s/he left by checking the GPS. Staff should be providing the VA with “1:1 supervision during the day.” The G had ongoing concerns that “1:1 supervision” was not happening. There were numerous times the VA left the facility without supervision and was discovered by community persons “miles from” the facility. The G was not always notified of these incidents and one time, heard about an incident while listening to the police scanner. [Note: Bemidji Law Enforcement Records stated that staff called 9-1-1 to report the VA missing on March 21 and 28 and May 21 and 23, 2025, and possibly June 14, 2025; however, the June 14 record was limited and unclear. During each of these incidents, the VA was located, unharmed, at various places in the community, including outside the county jail, an unspecified firehall, and “the industrial park area.”] SP1 and SP2 provided the following information: · On June 24, 2025, at 2:30 p.m., SP1 and SP2 arrived to start work at the facility with the VA and one other housemate (H). Around 4:30 p.m., SP2 and the VA walked to a nearby park and stayed for about one hour, at which point, the VA declined to walk back home. SP2 called SP1, who drove to the park with the H. SP2 said that it took them about 45 minutes to talk the VA into the car to drive home. Upon arriving home around 6:30 p.m., the VA declined to go into the house and instead, sat at the table on the deck out front. [Note: The VA ate food through a feeding tube and had already eaten at this point in the day. The H ate dinner at the house while the VA was at the park.] · SP1 and SP2 each said that SP1 pushed a wheeled chair into the front door threshold and watched the VA on the deck out front. SP2 was washing dishes in the kitchen and said that s/he could see the VA through an open window. At some point prior to 7:30 p.m., the H called out for help. The H was in his/her bedroom watching a movie. SP1 left the living room and went back to the H’s bedroom. · SP2 said that s/he was aware SP1 left the room. SP2 was sweeping the kitchen floor but could hear the VA on the deck through the window. The VA was “shuffling back and forth” or “twittling” with something. · SP1 said that at one point, s/he walked back out and checked on the VA, and upon seeing him/her still sitting on the deck, returned to the H’s bedroom. At some point later, SP1 again came out and checked on the VA, but this time the VA was gone. SP1 believed “five minutes” passed between when s/he last saw the VA on the deck and when s/he discovered the VA left. · SP2 said that while sweeping the kitchen floor s/he noticed the VA “got quiet.” SP2 looked outside and saw the VA no longer on the deck. SP2 believed “five minutes … or less than that” had passed between when SP1 left to help the H and when they discovered the VA missing. SP2 walked around the block looking for the VA but did not see him/her. · SP1 called 9-1-1. [Note: Bemidji Law Enforcement stated the call to 9-1-1 was “at approximately 8 p.m.”] SP1 said that the police were familiar with the VA from previous calls and said they would be on the lookout. · SP1 and SP2 each said that they waited at the house after calling 9-1-1. SP1 and SP2 each said that they were trained, in the event the VA eloped, to follow him/her on foot or in a car and call 9-1-1 and the P. However, SP1 and SP2 did not see the VA leave and did not know where to look for him/her. The VA had a history of going to various places in the community. The VA did not have a history of going to the house next door or starting fires. SP1 and SP2 tried several times to call the P but s/he did not answer. The day before or maybe two days prior, the VA received a new watch with GPS. SP1 and SP2 did not have access to the VA’s location using the GPS, but the P did. [Note: In September 2024, the VA started a loaf of bread or a box on fire using the stovetop but otherwise did not have a history of starting fires.] · SP2 said that about 30 minutes after calling 9-1-1, they heard a vehicle arrive and someone yelling the VA’s first name. A neighbor then ran into the house telling them the house next door was on fire, and they should evacuate as a precaution. SP1 and SP2 did not know who called 9-1-1 about the house fire or how it was known the VA was inside the burning house. · SP1 and SP2 each said that the VA had a history of leaving without staff. A few months prior, the VA was attempting to leave once every couple of weeks but recently, s/he was trying to leave “almost every day” or “once a week.” In response to this, the P told staff, “Don’t let [the VA] leave.” SP1 and SP2 were not aware of additional instructions or changes to the VA’s supervision requirements. · SP1 said that the VA might indicate s/he was about to leave when s/he started talking about “delusions,” like how the VA had to get to his/her shift at the police station or meet with his/her spouse and children. The VA did not work at the police station or have a spouse and children. SP1 did not hear the VA make any such statements of “delusions” leading up to his/her leaving on June 24, 2025, and if the VA had made such statements, SP1 was not aware of any immediate changes staff were supposed to make to the VA’s supervision requirements. · SP2 said that the VA had a history of leaving on days when s/he refused his/her medications, which caused him/her to “spiral.” The VA refused his/her medications the afternoon of June 24, 2025. SP2 was trained to continue to offer the VA’s medications every 15 minutes and sometimes s/he would take them and sometimes not. The VA continued to refuse throughout that afternoon. SP2 was not aware of any immediate changes staff were supposed to make to the VA’s supervision requirements when s/he refused his/her medications. · SP1 and SP2 each said that the VA could be by him/herself (without a staff person directly with him/her) in the house. The house was “small,” and staff were always present when the VA was home. The VA could sit on the deck alone if staff could see him/her through the door or window. The P said that the VA sometimes indicated s/he might leave when s/he started talking about his/her upcoming shift at the police station or taking a trip somewhere, and when this occurred, staff should stay by the VA and attempt to distract him/her. The P was not aware of the VA making such statements prior to leaving on June 24, 2025. The P said that staff should always be able to hear the VA but did not need to always have “eyes-on” supervision. At times there might be one staff working and if that staff needed to help a housemate, the VA could be left alone in the living room or wherever if the staff knew where s/he was and could hear him/her. There were alarms on the exterior doors and the VA’s bedroom window. It was acceptable for the VA to be on the deck without a staff person with him/her if staff could see him/her through a window. The P did not have concerns with SP1’s and/or SP2’s supervision of the VA on the day of the incident. Staff were trained to call 9-1-1 if the VA left. The P said that s/he initially missed SP1’s and/or SP2’s calls on June 24, 2025, because s/he was not working and was without his/her phone. When the P returned home and saw the missed calls, s/he called the staff back, at which time, the VA had already been located inside the house next door. The CM said that the VA’s interdisciplinary team had been meeting “quite a bit” prior to June 24, 2025, regarding the VA leaving without staff persons, which increased in Spring 2025 for unknown reasons. [Note: The VA’s interdisciplinary team consisted of the CM, the G, the P, and other supervisory or administrative staff.] During one of these meetings, a discussion was had about whether the VA could sit on the deck without staff directly with him/her and the CM agreed this was okay if staff were watching through a window. Staff did not need to have “eyes-on” the VA at all times. Even if staff were next to the VA, s/he could still run away at any time without staff being able to stop him/her. The VA moved into the facility in September 2023 and at that time, the facility agreed to provide 22 hours of 1:1 staffing for the VA. However, the facility was “typically short staffed” and so did not always have a staff person directly with the VA. The facility’s policies and procedures stated that staff should immediately call 9-1-1 if a person was missing and then immediately call a supervisory staff person. “Together a more extensive search will be organized, if feasible, by checking locations where the person may have gone.” Facility documentation stated that SP1, SP2, and the P received training on the VA’s Coordinated Service and Support Plan Addendum-Intensive Services, Individual Abuse Prevention Plan, and Self-Management Assessment; the facility’s policies and procedures; and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: On June 24, 2025, the VA left the facility from the front deck without SP1 or SP2 knowing, went to the house next door which started on fire. The VA sustained inhalation injuries and burns and was hospitalized. Regarding the VA’s supervision leading up to the incident: SP1, SP2, the P, the CM, and the VA’s Coordinated Service and Support Plan Addendum-Intensive Services each stated that the VA could be on the deck without a staff person directly with him/her and that staff could watch and listen for him/her through a window or screen door. SP1 was initially watching the VA on the deck before being called by the H who needed assistance. SP2 could see and hear the VA through a kitchen window. SP2 was sweeping the floor during that time and noticed the VA “got quiet.” SP1 discovered the VA was missing when s/he went to check on him/her. SP1 and SP2 each said that about five minutes passed between when they last saw the VA and when they discovered s/he had left. The VA’s Self-Management Assessment stated, “When [the VA] chooses to elope, [s/he] moves fast. [S/he] gives minimal warning that [s/he] intends to elope. [S/he] will often hide behind buildings, bushes, trees, and objects.” Although the VA left without SP1’s or SP2’s knowledge, the VA gave no indication s/he intended to leave on June 24, 2025, and the VA’s plans did not outline or provide details regarding how staff persons were to provide 1:1 supervision for the VA. Given that it was reasonable for staff to complete other tasks including caring for other housemates as needed and that even if SP1 and SP2 were directly next to the VA, s/he still could have outrun or hid from them, there was not a preponderance of the evidence whether there was a failure or omission to supply the VA with reasonable and necessary care. It was not determined whether 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). Regarding SP1’s and SP2’s response to the VA leaving: SP1 and SP2 each said that when they discovered the VA was missing, they looked around the yard and street, and walked around the block and then called 9-1-1 and the P. SP1 and SP2 did not have access to the VA’s GPS location, and the VA did not have a history of going to the house next door. SP1, SP2, and the P each said that staff were trained to call 9-1-1 if the VA left. The facility’s incident report stated that at 7:45 p.m., the VA asked to go for a walk and SP1 and SP2 asked him/her to wait. Bemidji Law Enforcement Records stated that at approximately 8 p.m., SP1 called 9-1-1 to report the VA missing. The VA’s Self-Management Assessment stated, “In the event that [the VA] elopes from staffs [sic] sight or sound, staff will call [9-1-1]. If it is safe to do so, staff may attempt to follow [the VA]. Staff will not trespass on private property. Staff are not trained in physical pursuit and apprehension and will defer to emergency services for safe response and recovery.” Given that once SP1 and SP2 discovered the VA left, they looked for the VA, and then called 9-1-1 and the P, which was consistent with the VA’s support plans and the facility’s policies and procedures, there was a preponderance of the evidence that there was not a failure to supply the VA with reasonable and necessary care. It was determined that neglect did not occur (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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed, and that there was not a need for additional training or corrective action. The VA had a history of eloping into the community and staff contacted law enforcement to report the VA eloped. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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