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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: 1108424-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Scott.j.brandt@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) provided a THC (tetrahydrocannabinol) vape to a vulnerable adult (VA), who had a history of substance use. Date of Incident(s): Prior to 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 9, 2025, from documentation at the facility, and through four interviews conducted with the VA, the SP, a management staff person (P1), and a facility staff person (P2). Although this investigator contacted the VA’s guardian (G), the G did not respond to requests to be interviewed. The VA’s Individual Abuse Prevention Plan showed that if the VA “reports to using chemical substances, the team will be notified, and the administration of a drug test will be discussed by [his/her] team.” The VA’s Coordinated Service and Support plan (CSSP) Addendum showed that some of the VA’s diagnosis included depression, bipolar disorder, and polysubstance use disorder. The VA “requires supervision and support to maintain [his/her] sobriety. [S/he] does have a 24-hour plan of care and requires a controlled environment free from alcohol and illegal drugs.” The VA enjoyed being “independent,” “demonstrates self-injurious behaviors in the form of [substance use],” and “does require a controlled environment free from substances that may cause harm or addiction.” The facility had a Consultation Form for the VA, which stated that the VA was diagnosed with cannabis use. P1 provided the following information: · Although P1 did not remember the date, P1 assisted the VA with a move from one location within the organization to another location that was also within the organization. P1 saw the VA use a vape and the VA “only vapes THC.” When P1 asked the VA about the vape, the VA said that s/he obtained the vape from a family member, but the VA did not disclose the contents of the vape. A few days later, the VA told P2 that the SP provided the THC vape to the VA. · When P1 asked to describe how the VA was affected by using the THC vape, P1 said that the VA was “isolating a bit more.” · When P1 talked to the SP on an unspecified date, the SP stated that s/he provided the THC vape to the VA. The VA stated that on an unknown date, the VA and the SP talked about “marijuana” and the VA told the SP that s/he could not use marijuana. After that, the SP said, “I can get you one.” A few days later, the SP gave the THC vape to the VA and the VA used it when the VA thought no one was around. However, on an unspecified date, P2 saw the VA use the THC vape. Because the VA was “hurting,” the VA asked his/her medical doctor to provide written documentation that it was okay for the VA to use THC, but the doctor “would not prescribe it.” P2 stated that s/he did not remember the date but when P2 saw the VA use the vape, P2 asked the VA about it and the VA said that the SP gave the THC vape to the VA about three or four weeks earlier. The VA had a history of use and THC was “not approved through [his/her] physician to use it for medicinal purposes.” The VA showed P2 a text message from the SP that said, “I will have one for you on Saturday,” but the text did not disclose what would be given to the VA. P2 did not know of any ill effects the VA had from using the THC vape. The facility’s Internal Review provided information that was consistent with the information provided above, but the review included dates: · On June 6, 2025, P1 saw the VA “smoking a vape” and the VA said that s/he only vapes THC products. The VA did not tell P1 what was in the vape. · During the week of June 9, 2025, the VA told P1 that s/he obtained the THC vape from the SP. When P2 talked to the SP, the SP “denied any involvement in providing [the VA] with said THC vape.” · During the week of June 16, 2025, the VA “again” told P1 that s/he obtained the THC vape from the SP. · On June 20, 2025, the VA shared a text message, from the SP to the VA, which stated, “I will have one for you on Saturday.” · On June 24, 2025, the SP “admitted to obtaining the THC vape” for the VA. A photograph of the text message, from the SP to the VA on May 28, 2025, stated, “I will have one for you on Saturday.” The facility had a policy and Procedure on Alcohol and Drug Use that addressed the use of substances by staff persons, but the policy did not address staff providing substances to clients. The SP’s job description stated that one of his/her responsibilities was “implementing care plans and consumers programs.” The SP stated that s/he thought that in March 2025, the VA told the SP that s/he “wanted a THC vape.” Because of that, the SP “got” the VA the THC vape that contained “marijuana.” The VA used the THC vape on more than one occasion. Although the SP did not know that the VA had a history of substance use, the SP “knew I shouldn’t have done it.” The facility’s documentation showed that the SP, P1, and P2 were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plan prior to the site visit on July 9, 2025. Conclusion: A. Maltreatment: On June 6, 2025, P1 saw the VA smoking a vape, but the VA did not tell P1 what was in the vape. A few days later, the VA told P2 that the SP provided the THC vape to the VA. The VA was consistent with telling facility management on more than one occasion that the SP provided the THC vape to the VA and the VA provided the same information to this investigator. On June 24, 2025, the SP admitted to facility management that s/he provided the THC vape to the VA and when this investigator talked to the SP, the SP also admitted providing the THC vape to the VA. Given that the VA had a history of substance use, that the VA’s plans showed that the VA required a “controlled environment free from substances that may cause harm or addiction,” that the VA needed support to maintain sobriety, and that the VA used substances as a form of self-abuse, and that the SP provided the VA with THC which the VA used, there was a preponderance of the evidence that the SP did not provide reasonable and necessary care and services to the VA. 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 the VA’s care plan prior to the site visit on July 9, 2025. The SP was responsible for neglect 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 did not meet statutory criteria to be determined as recurring because the maltreatment was a single incident of neglect and was not serious because the SP’s action did not meet the definition of serious maltreatment. Action Taken by Facility: The facility’s internal review showed that although policies and procedures were adequate, they were not followed by the SP and that additional training was not needed. The SP was no longer employed by 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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