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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: 1109281-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scout Peterson Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) required 2:1 staffing and needed 24-hour approval for outings. It was alleged that a staff person (SP1) took the VA to a gas station alone and without prior approval. While at the gas station, the VA took and ingested two bottles of extra-strength Tylenol. The VA was later hospitalized. Date of Incident(s): May 29, 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 June 12, 2025; from documentation at the facility and medical records; and through four interviews conducted with facility staff persons (SP1 and SP2), a facility supervisory staff person (P1), and the VA. Attempts were made via certified mail to contact and interview P2 and P3, but neither responded. However, each provided information for the facility’s Internal Review that was included below. The VA’s guardian was also contacted for this investigation but did not have additional information to provide regarding the report. The VA was diagnosed with borderline personality disorder, unspecified mood disorder, intellectual disability, and posttraumatic stress disorder. The VA was the only resident who lived at the facility. The VA enjoyed watching crime detective shows, playing games, and going for walks. The VA’s support plans showed the following: · The VA’s Self-Management Assessment (SMA) stated that the VA had 2:1 staffing during awake hours from 6 a.m. to 10 p.m. and one awake and one asleep staff person overnight. Additionally, the facility was permitted to staff the VA 1:1 “in excruciating [sic] circumstances” or “emergency situations” with approval from the facility supervisor. · The VA had a history of leaving facilities and vehicles without supervision to gain access to over-the-counter medications and had stolen medications from stores in the past. The VA had a history of consuming non-edible items and overdosing on over the-counter-medications. · The VA’s Outing Protocol included a list of locations that the VA could visit without 24-hour supervisor approval. This list included parks and establishments with drive-thrus. If the VA wanted to go to a place that was not on the list of pre-approved locations, s/he had to fill out a worksheet and give it to P1 24-hours prior to the desired outings. It was required that there were always two staff persons with the VA on outings “unless otherwise noted.” The VA also had a rights restriction in place that prohibited the VA from going to gas stations or other establishments near gas stations. The VA provided the following information in an interview and in the facility’s Internal Review: · On May 29, 2025, SP1 and SP2 worked the evening shift. At an unknown time, SP2 took the VA to Dairy Queen without SP1, then at 9 p.m., SP2 left to work at a different home operated by the same license holder. After SP2 left, the VA “manipulated” SP1 into taking him/her to the gas station. The VA rode in the front seat of the facility vehicle and when they arrived, the VA asked if s/he could go in alone, and SP1 said, “Sure.” · While in the gas station, the VA took two bottles of 500 milligram extra strength Tylenol, 24 capsules, off the shelf and put them in his/her pocket. The VA then went to get a soda and SP1 came into the store. The VA told SP1 that s/he needed to use the bathroom, so s/he went to the bathroom and began ingesting the Tylenol. While the VA was in the bathroom, a gas station employee (GS) asked the VA if s/he was okay and if the VA wanted the GS to wait with him/her. The VA said s/he was okay and did not need the GS to wait, and the GS then left the bathroom. The VA finished ingesting both bottles of Tylenol, exited the bathroom where s/he found SP1 waiting for him/her. The VA left the gas station with SP1, and they went back to the facility. · After returning to the facility, the VA lay down. While the VA way lying down, P2 and P3 arrived for the overnight shift and SP1 left. After approximately 15-20 minutes the VA started feeling “pretty icky.” The VA left his/her room, wrote a note to P2 stating that s/he overdosed on Tylenol, and “threw it” at P2. The VA then went back to his/her room to lay down. P2 and P3 went to the VA’s room and P2 asked the VA where the pills were and P3 told the VA, “You can’t sleep right now.” The VA gave the empty pill bottles to P2 and they told the VA that s/he needed to go to the hospital. P2 and P3 then drove the VA to the hospital and the VA “passed out” after they got there. · The VA was in the hospital for a week and was treated at hospital A before being transferred to hospital B for additional treatment. The VA stated that while s/he was at the hospital s/he received an “IV antidote” for three days and was then transported to a psychiatric unit. The VA stated that s/he was doing “good” after being discharged from the hospital. SP1 provided the following information in an interview and in the facility’s Internal Review: · On May 29, 2025, SP1 and SP2 worked with the VA for the evening shift. Around 5:15 p.m., SP2 took the VA to Dairy Queen while SP1 stayed at the facility to prepare the VA’s nighttime medications. After SP2 and the VA returned, the VA ate dinner, took his/her medications, and went to bed. · Around 9 p.m., SP2 left the facility to work at another home operated by the same license holder. At 9:18 p.m., the VA woke up and asked SP1 if s/he would take the VA to the gas station. SP1 “kept saying, ‘No,’” but the VA told SP1 that SP2 just took the VA to Dairy Queen with one staff person and that SP1 was “obstructing [the VA’s] right to go places.” SP1 mapped out the route to the gas station and saw that it was only three minutes away so s/he agreed to take the VA. · As the VA and SP1 were on their way to the gas station, the VA asked SP1 if s/he could go inside alone. SP1 told the VA that s/he could not go in alone and that if s/he insisted on doing so, SP1 would not take the VA. · After they arrived at the gas station, SP1 parked the car and they went into the gas station. The VA went to the fridge aisle to pick out a drink, while the SP followed behind him/her. SP1 then thought that the VA was going to the register to pay for his/her items, but instead the VA went through another aisle and into the bathroom. Because SP1 and the VA were opposite genders, SP1 waited outside of the bathroom and “didn’t know what to do.” SP1 asked the CS to check on the VA, and “right away” after the CS checked on the VA, the VA came out of the bathroom. SP1 stated that when the VA came out of the bathroom, s/he did not have the drink s/he picked out and told SP1 that s/he did not want it anymore. The VA and SP1 left the gas station and went back to the facility. · At “almost” 10 p.m. the VA and SP1 returned to the facility and the VA went to bed. Shortly after, P2 and P3 arrived at the facility for the overnight shift and SP1 left the facility. SP1 stated that s/he did not know “what got into [him/herself],” and that s/he was trained to only take the VA on outings with two staff people and with 24-hour approval. SP2 provided the following information in an interview and in the facility’s Internal Review: · On the evening of May 29, 2025, SP2 worked at the facility with SP1 from 2 to 10 p.m. The VA was “calm” and “acting like [him/herself.” At some point, SP2 took the VA to Dairy Queen while SP1 remained at the facility. · At 9 p.m. SP2 left the facility to work at another home operated by the same license holder. SP2 stated that on a previous occasion when s/he worked at the facility and then another home operated by the same license holder s/he had permission from P1 to leave early, so SP2 “assumed” it would be okay to do so on May 29, 2025, without asking. P1 provided the following information in an interview and in the facility’s Internal Review, which s/he conducted interviews for: · On May 29, 2025, SP1 and SP2 worked at the facility with the VA from 2 to 10 p.m. At an unknown time, SP2 took the VA to Dairy Queen without SP1. P1 stated that the VA had prior approval to go to Dairy Queen but “never” with just one staff person and did not approve that SP2 do so. · SP2 was scheduled to work at another home operated by the same license holder at 10 p.m., however P1 specifically told SP2 not to leave the facility early, and that the staff persons at the other home were aware that SP2 would be arriving late and would wait to leave until SP2 got there. SP2 clocked out and left the facility at 9 p.m., P1 emphasized that s/he did not approve SP2 to leave early from the facility. · Around 10:30 p.m. that evening, P2 called P1 and told him/her that the VA ingested two bottles of Tylenol. P1 instructed P2 to search the VA’s room for any additional Tylenol or medications and take the VA to the hospital. · The next day, P1 reviewed camera footage from May 29, 2025, and saw that from 9:17 to 9:26 p.m. the VA repeatedly ask SP1 to take him/her to the gas station. P1 talked to SP1 later that day, and SP1 told P1 that s/he took the VA to the gas station and “ran in” after the VA and saw him/her go to the bathroom. · The VA had no unsupervised time in the community and was always required to have 2:1 staffing when on outings, regardless of whether 24-hour approval was required for that outing. P1 stated that SP1 and SP2 each took the VA on outings without required supervision on May 29, 2025. The Internal Review stated that P2 and P3 each provided information that on May 29, 2025, at 10 p.m., P2 and P3 worked the overnight shift and P3 was the assigned asleep overnight staff person. Shortly after arriving, P3 lay down to sleep in the staff bedroom. The VA was in his/her bedroom and at 10:28 p.m. came out , went outside to smoke a cigarette, came back inside, and wrote a note on a piece of paper. The VA handed the note to P2 that stated, “I overdosed at [the gas station] on Tylenol at 9:25 p.m.” Around 10:45 p.m. P2 woke up P3 and told him/her that the VA gave him/her a note that said s/he overdosed on Tylenol at the gas station. P2 called P1 and poison control. P1 said to search the VA’s room for more Tylenol, which they did, but they did not find any additional medication, and poison control told P2 that the concentration of Tylenol in the VA’s blood would “peak” at four hours after ingestion and to take the VA to the emergency room. “Eventually,” the VA gave P2 two empty bottles of Tylenol and told P2 and P3 that s/he was going to go back to bed. P2 and P3 told the VA that s/he could not lay down and that they were going to go to the emergency room and then they did so. While at the emergency room, the VA told hospital staff that s/he planned a suicide attempt and that SP1 took him/her to the gas station where s/he got the Tylenol and a drink. The VA also told P2 and P3 information that was consistent with the information the VA provided during his/her interview. According to T-Logs for the shift documented by SP1, at 9 p.m., the VA woke up and asked SP1 to take him/her to the gas station to get a beverage, which SP1 did. T-Logs for the shift documented by SP2 do not include that s/he took the VA to get ice cream, nor that s/he left the facility before his/her shift ended. According to SP2’s timecard, s/he clocked out of the facility at 9 p.m. and clocked into the other home at 9:20 p.m. The VA’s medical records provided the following information: · On May 29, 2025, at 11:32 a.m., the VA arrived at Hospital A for evaluation of an overdose and reported that s/he overdosed on two bottles of Tylenol. At 1:21 a.m. hospital staff tested the VA’s blood acetaminophen (Tylenol) level, and the result was 228.0 mcg/mL. [Note: A blood level of acetaminophen between 10-20 mcg/mL was considered safe and a blood level higher than 200 mcg/mL four hours after ingestion means there was a risk for liver damage.] Hospital staff administered an intravenous infusion of acetylcysteine. [Note: This medication was used to help prevent or lessen liver damage caused by an overdose of acetaminophen and was only available with a physician’s orders.] The VA was then transferred to the ICU for further management and monitoring. · On June 3, 2025, the VA was transferred to Hospital B for additional mental health treatment because medical staff at Hospital A deemed the VA’s intentional ingestion of 48, 500-mg tablets of Tylenol was a suicide attempt. Upon admission to Hospital B, the VA denied that the ingestion was a suicide attempt but instead was an “impulsive decision.” Facility documentation showed that SP1, SP2, P1, P2, and P3 were each trained on the Reporting of Maltreatment of Vulnerable Adults Act. SP1, SP2, P2, and P3 were also each trained on the VA’s plans and P1 assisted in the creation of the VA’s plans. Relevant Rule/Statute Minnesota Statutes Section 245D.07, subdivision 1and 1a states in part that the license holder must provide services as assigned in the support plan and must provide services in response to the person’s identified needs. Conclusion: A. Maltreatment: The VA’s support plans showed that s/he required 2:1 staffing at all times including when in the community, that the VA was not permitted to go to gas stations or near gas stations, and that the VA had a history of overdosing on over-the-counter medications. Information from all sources was consistent that on the night of May 29, 2025, SP1 and SP2 worked and at one point SP2 took the VA to Dairy Queen, which was an approved outing but without SP1 present. This was a violation of the VA’s plans and a violation of Minnesota Statutes Section 245D.07, subdivision 1and 1a. At 9 p.m. SP2 left the facility to work at another facility leaving SP1 the sole staff person with the VA. Between 9 and 10 p.m. SP1 took VA1 to the gas station without another staff person which was a violation of the VA’s plans and a violation of Minnesota Statutes Section 245D.07, subdivision 1and 1a. While in the gas station the VA took two bottles of Tylenol off the shelf and went into the bathroom and ingested 48 capsules. Information regarding whether SP1 was in the gas station with the VA was inconsistent. The VA said that SP1 initially allowed the VA to go into the store alone and that was when s/he got the Tylenol. SP1 provided conflicting information to this investigator and P1. SP1 told this investigator that s/he went into the gas station with the VA and that the VA initially got a soda and then went to the bathroom but SP1 told P1 that s/he “ran in” after the VA and saw him/her go to the bathroom. The VA did not tell SP1 that s/he took Tylenol but after SP1 left the facility, the VA wrote P2 a note that stated s/he had overdosed on Tylenol at the gas station. The VA was taken to the hospital, treated with an antidote for Tylenol, monitored in the ICU, and transferred to another hospital for additional mental health treatment. Given that the VA was not allowed to go to gas stations or be near gas stations, that the VA was not allowed to be in the community with a single staff person, yet despite this SP1 took the VA to the gas station where the VA obtained and ingested Tylenol, there was a preponderance of the evidence that there was a failure to supply the VA with reasonable and necessary care to maintain his/her physical or mental 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 and SP2 were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. Although SP2 left the facility early to work at another home, information regarding whether s/he had approval was inconsistent. Regardless, SP2 was not at the facility at the time of the incident and therefore s/he was not responsible for the maltreatment of the VA. SP1 was the sole staff person working and providing supervision for the VA at the time of the incident. SP1 took the VA to the gas station where s/he obtained Tylenol and subsequently overdosed. SP1 stated that s/he did not know “what got into [him/herself],” and that s/he was trained to only take the VA on outings with two staff people and with 24-hour approval. SP1 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 SP1 was responsible was not recurring because it was a single incident but it was “serious” maltreatment because the VA was hospitalized and required the care of a physician. SP1 was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. All staff who worked at the facility received retraining on the VA’s plans and signs were posted in the facility to remind staff of the VA’s plans and supervision requirements. Action Taken by Department of Human Services, Office of Inspector General: SP1 was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that SP2 was responsible for maltreatment and the disqualification of SP1 is subject to appeal. Because the facility took immediate corrective action, a Correction Order was not issued for the violations outlined in this report.
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