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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: 1104285-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: Allegation One: It was reported that more than once, a vulnerable adult (VA1) engaged in self-harming behaviors and there were concerns regarding the staff supervision and intervention during these incidents. Allegation Two: It was reported that more than once, a vulnerable adult (VA2) engaged in self-harming behaviors and there were concerns regarding the staff supervision and intervention during these incidents. Date of Incident(s): Ongoing 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 site visits conducted on July 16 and August 11, 2025; from documentation at the facility and law enforcement records; and through 11 interviews conducted with VA1, VA2, VA1’s case manager (CM1), VA2’s case managers (CM2 and CM3), law enforcement personnel (LE1 and LE2), a facility staff person (P1), and supervisory staff persons (P2, P3, and P4). VA1 and VA2 were not subject to guardianship. The facility was a single-family home with staffing to provide crisis respite (short-term) services to residents, like VA1 and VA2. The facility’s Program Policies, including Emergency Use of Manual Restraints, stated the following: · “It is the policy of this company that emergency use of manual restraint (EUMR) is not allowed at any time.” Staff were prohibited from other procedures, including the use of mechanical restraints, seclusion, chemical restraints, or punishment. · “Alternative measures must be used by staff to achieve safety when a person’s conduct poses an imminent risk of physical harm to self or others and less restrictive strategies have not achieved safety.” This might include moving others away from the immediate area, removing objects that might cause harm, and calling a mental health crisis line or crisis intervention team. “If no other positive strategy or alternative measure was effective in de-escalating the person’s behavior, staff will contact 9-1-1 for assistance.” While waiting for 9-1-1 first responders, staff continued to offer alternative measures. Facility documentation stated that the staff persons interviewed for this investigation received training on VA1’s and VA2’s support plans, including Individual Abuse Prevention Plans; the facility’s Program Policies; and the Reporting of Maltreatment of Vulnerable Adults Act. LE1 and LE2 provided law enforcement services in the community and were familiar with the facility and VA1 and VA2. LE1 said that there was multiple 9-1-1 calls to the facility for VA1 or VA2 having access to razorblades or other objects to self-harm. LE1 believed there might be “a lack of supervision” or “a lack of training” at the facility. LE2 said that the law enforcement community was concerned about the frequency of the calls to 9-1-1 and they wanted to work with the facility to develop alternatives to calling 9-1-1 and build a collective safety plan. P4 said that the facility provided crisis respite services, which meant that most of the residents were “not the most stable.” The facility did not always know a lot about the resident until they arrived, and their behaviors emerged. A lot of the residents had spent years hospitalized or receiving inpatient services, and the facility was their first step toward a permanent home in the community. The residents did not always have coping mechanisms for dealing with the increased freedoms of living at a home, like the facility. “Staff are there and doing their best.” Allegation One: It was reported that more than once, VA1 engaged in self-harming behaviors and there were concerns regarding the staff supervision and intervention during these incidents. VA1’s Individual Abuse Prevention Plan provided the following information: · On February 12, 2025, VA1 moved into the facility. VA1’s diagnoses included autism spectrum disorder. · VA1 had a history of self-harming behaviors, including cutting and scratching him/herself or using any object to cause self-harm. “Staff will remain in the immediate vicinity of [VA1] at all times including sitting outside [his/her] room or bathroom … Staff will do a room check at least once per shift, may be twice or as needed to ensure there are not any objects that can be used to self-harm.” Staff encouraged VA1’s coping skills, which included reading, listening to music or a sound machine, talking, and coloring. VA1 said that staff “ignored” and “didn’t engage” with residents. A resident told VA1 that there was one time when this resident told staff they were going to self-harm, and the staff “ignored” him/her. Another time, a different resident told VA1 that an unnamed staff held their fists in front of that resident’s face and told the resident that they would give him/her a “knuckle sandwich.” The staff did not strike or touch the resident. CM1 said that VA1 was “extremely vulnerable” and worked “really hard” to progress from inpatient services to living at a home, like the facility. CM1 expected there would always be two staff with VA1, and staff would stop VA1 from self-harming “before it happens.” However, VA1 was “very smart about ways to self-harm and good at hiding it.” Law enforcement reports, P1-P4, and the facility’s Internal Review provided the following information: · A law enforcement report stated that on March 14, 2025, at 2:13 p.m., a staff person called 9-1-1 reporting VA1 had razorblades and threatened self-harm. Responding law enforcement officers (LEO) saw VA1 sitting on his/her bed with a small box containing multiple razorblades. The LEO asked for the box and VA1 handed it over. The LEO talked with VA1, who agreed to “work with staff to try some different things in hopes to feel a little better for the day.” The LEO then left. · P1 said that s/he was working when VA1 received an Amazon package with razorblades. This was the first time VA1 received a package at the facility. P1 asked VA1 to open the package in front of him/her and VA1 did so, revealing multiple razorblades. P1 asked for the package and VA1 refused. VA1 went into his/her bedroom with the package and repeatedly refused to hand it to staff. P1 called P3 and then 9-1-1. · P3 and P4 provided consistent information that staff “can’t rip the box out of [VA1’s hands]” and so they called 9-1-1 “hoping [law enforcement] had more ability to take something harmful” from VA1. VA1 never removed any of the razorblades or used them to harm. Staff were with VA1 the entire time s/he had possession of the box. VA1 did not have a history of ordering inappropriate things in the mail. Following this incident, P3 asked VA1 if staff could start checking his/her mail and VA1 was agreeable to this. · P4 added that VA1 was not subject to guardianship and so any restriction of his/her rights (i.e., mail) had to be approved by VA1 and could also be revoked at any time by VA1. “This made it tricky.” Staff asked VA1 to go through his/her mail or make other changes and typically VA1 was agreeable, but s/he might also refuse. “We can’t prevent [VA1] from ordering in the mail. We can’t restrict their rights without any issues … Something has to happen in order to restrict all of these things. Even then, [VA1] was [his/her] own guardian. They can choose what to do or not do. We are trying to keep them as safe as possible.” · Law enforcement reports stated that also on March 14, 2025, at 4:30 p.m., an unidentified staff person called 9-1-1 reporting VA1 tied a sweatshirt around his/her neck to self-harm. “The sweatshirt was wrapped around [VA1’s] neck but not preventing breathing or blood flow. Officers were able to remove the sweatshirt from [VA1’s] neck, without issue,” and then left. At 10:17 p.m., a staff person called 9-1-1 reporting VA1 again tied a sweatshirt around his/her neck to self-harm. “[The LEO] observed [VA1’s] face turning purple, and [his/her] voice clearly strained by the sweatshirt around [his/her] neck. [The LEO] told [VA1] to remove the sweatshirt or [the LEO] would remove it. [VA1] did not. [The LEO] removed the sweatshirt from [his/her] neck without incident.” VA1 told the LEO that s/he did not want to live anymore. An ambulance transported VA1 to an emergency room. · P1 said that s/he was working when VA1 tied sweatshirts around his/her neck. P1 saw VA1 “acting like” s/he was gathering something from his/her closet, only to quickly grab a sweatshirt and tie it around his/her neck. P1 grabbed VA1’s arms and tried pulling them away from the sweatshirt while another staff tried untying the shirt. While this was occurring, VA1 repeatedly struck his/her head against a wall. “It took a minute” because VA1 was “so strong” and “moving and kicking” but staff were able to remove the sweatshirt and move VA1 away from the wall. However, then VA1 lay on the floor and repeatedly struck his/her head against the floor. P1 called 9-1-1 while the other staff tried holding VA1’s head and put a pillow under VA1’s head. · P2 and P4 each said that they were informed by staff of the incidents where VA1 tied a sweatshirt around his/her neck and were told staff tried, or were “actively trying,” to remove the sweatshirt and then called 9-1-1. VA1 was allowed access to his/her clothing and prior to March 14, 2025, did not have a history of tying clothing around his/her neck. P2 said that following this incident, they considered a rights restriction to remove the clothing from VA1’s bedroom. · A law enforcement report stated that on May 5, 2025, P2 called 9-1-1 reporting VA1 had a razorblade and intended to harm him/her. The LEO arrived and asked VA1 for the razorblade more than once and VA1 repeatedly declined. The LEO grabbed VA1’s arms and removed the razorblade, and an ambulance transported VA1 to an emergency room. · P2-P4 each said that VA1 routinely visited his/her family’s house and did not want staff in the house, so staff waited outside. P4 said that VA1’s interdisciplinary team (e.g., CM1) was aware staff waited outside during these visits. When VA1 left the family house or arrived back at the facility, staff asked to search VA1’s belongings and VA1 typically was agreeable to this. Staff routinely found razorblades in VA1’s belongings, which they believed s/he was taking from his/her family’s house. Staff also routinely asked to search VA1’s bedroom, and at times, found items of unknown origin, like razorblades and one time, a knife. One time, VA1 hid a razorblade in his/her phone case and staff did not think to check the phone case. · A law enforcement report stated that on May 8, 2025, at 1:35 p.m., P2 called 9-1-1 reporting VA1 had a kitchen knife and intended to harm him/her. The LEO asked for the knife and VA1 handed it to the LEO. An ambulance transported VA1 to an emergency room. [Note: The facility’s Internal Review stated, “During an incident of [VA1] making a [peanut butter and jelly] sandwich with a butter knife [s/he] asked staff to get [him/her] something and when they did this [VA1] attempted to use the butter knife as a self-harm tool.”] · A law enforcement report stated that also on May 8, 2025, at 10 p.m., VA1’s family member called 9-1-1 reporting VA1 sent a “goodbye” text message, and the family member was concerned. Around this same time, a staff person called 9-1-1 reporting VA1 repeatedly striking his/her head and attempting to strangle him/herself with clothing. An ambulance transported VA1 to an emergency room. · A law enforcement report stated that on May 13, 2025, an unidentified staff person called 9-1-1 reporting VA1 swallowed a button battery. An ambulance transported him/her to an emergency room. · P2 said that s/he was with VA1 when s/he swallowed the button battery. P2 saw VA1 “moving sneakily” in VA1’s bed and while doing so, removed a button battery from a string of LED lights hanging on his/her wall. VA1 then told P2 that s/he swallowed the battery. P2 called poison control, who recommended VA1 go to an emergency room; however, VA1 declined to go and so P2 called 9-1-1. Conclusion for Allegation One: Although there were concerns with staff supervision and responses to incidents with VA1, P1-P4 provided consistent information that staff were present and attempted to intervene with VA1’s self-harm and called 9-1-1 for assistance. Law enforcement Reports stated that staff were present when the LEOs arrived at the house. VA1 was not subject to guardianship and therefore, was able to make his/her own decisions about the cares s/he received. VA1 routinely visited his/her family’s house without staff, which his/her interdisciplinary team was aware of. VA1 was agreeable to staff searching his/her belongings and bedroom, which uncovered razorblades and a knife, which were believed to be from his/her family’s house. However, VA1 might also refuse the staff searches. Given the aforementioned, and that although VA1 was repeatedly transported to the emergency room, there was no information that his/her self-harm resulted in a serious injury, which indicated the staff supervision and response was adequate to prevent a serious injury from occurring, there was not a preponderance of the evidence whether there was a failure to provide care or services to VA1, which was reasonable and necessary to maintain VA1’s physical or mental health or safety. 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). Allegation Two: It was reported that more than once, VA2 engaged in self-harming behaviors and there were concerns regarding the staff supervision and intervention during these incidents. VA2’s Individual Abuse Prevention Plan and Attendance Log included the following information: · On May 5, 2025, VA2 moved into the facility. Between May 5 and June 20, 2025, which is 47 days, VA2 was hospitalized four times and was only at the facility a total of four days out of the 47. On June 17, 2025, VA2 was hospitalized and did not return to the facility pending a move to a different residence. · VA2 had a history of self-injurious behaviors, which might include swallowing toxic substances or inedible items, or other forms of self-harm. “Staff will remain in line of sight with [VA2] at all times … If staff witness [VA2] exhibiting self-injurious behaviors, staff will provide verbal prompts and redirection regarding what the possible consequences are. Staff will continue providing verbal redirection and processing of events until [VA2’s] potentially unsafe actions stop. The VA had a rights restriction in place restricting his/her right to privacy to ensure staff could monitor him/her at all times. VA2 said that staff were supposed to be with him/her at all times, but sometimes they were in other areas of the house, not with VA2. At least once, VA2 saw staff sleeping while at work. CM2 said that VA2 had a “long history of self-harm behavior,” and “strived” to go to hospitals. CM2 did not have specific concerns with the overall facility or staff. CM3 said that s/he expected there were always two staff available to VA2, one staff would have “eyes on” VA2 and the other staff was present to switch out as needed. However, VA2 told CM3 that “often times” the staff would leave VA2 “alone,” which would be concerning to CM3 if this occurred. Law enforcement reports and P1-P4 provided the following information: · A law enforcement report stated that on May 5, 2025, P2 called 9-1-1 for another resident (VA1), who had a razorblade and threatened self-harm. While emergency responders were at the house for VA1, VA2 began repeatedly striking his/her head on a corner of his/her dresser. The LEO told VA2 to stop, and s/he did. VA2 then started striking his/her head with his/her own fist. The LEO told VA2 to stop and s/he did. An ambulance transported VA2 to an emergency room. · P2 and P3 each said that regarding the incident on May 5, 2025, VA2 started striking his/her head, most likely, in response to the attention emergency responders were giving VA1. Staff were with VA2 and tried to stop him/her but once law enforcement officers came into VA2’s room, staff stepped aside to allow the officers to interact with VA2. [Note: Following this incident, VA2 was admitted to a hospital and discharged back to the facility on May 30, 2025.] · A law enforcement report stated that on June 1, 2025, an unidentified staff person called 9-1-1 reporting VA2 swallowed a marker. An ambulance transported VA2 to an emergency room. [Note: VA2 was admitted to a hospital and discharged back to the facility on June 2, 2025.] · A law enforcement report stated that on June 2, 2025, P2 called 9-1-1 reporting VA2 running toward a nearby highway and attempting to climb over the fence separating the highway. VA2 told the responding LEO that s/he wanted to “kill” him/herself and “will continue to try.” The LEO placed VA2 in handcuffs and transported him/her to an emergency room. [Note: VA2 was admitted to a hospital and discharged back to the facility on June 16, 2025.] · A law enforcement report stated that on June 17, 2025, an unidentified staff person called 9-1-1 reporting VA2 running toward the highway “in order to commit suicide.” The LEO placed VA2 in handcuffs and transported him/her to an emergency room. [Note: VA2 was admitted to a hospital and did not return to the facility.] · P1 said that s/he was present during an incident when VA2 ran towards the highway. P1 ran after VA2 and held his/her hand to prevent him/her from climbing the fence. VA2 did not have a history of running away but had a “main goal of hurting [him/herself],” with things like running into traffic. · P3 said that one time, when an ambulance arrived to drop VA2 off at the facility following his/her hospital discharge, as soon as VA2 stepped out of the ambulance, s/he took off running towards the highway. Staff were right there following him/her. “[VA2] seemed determined to go to the hospital.” Conclusion for Allegation Two: Although there were concerns with staff supervision and responses to incidents, P1-P4 provided consistent information that staff were present and attempted to intervene with VA2’s self-harm and called 9-1-1 for assistance. Law enforcement reports stated that staff were present when the LEOs arrived at the house. At least twice, the LEOs needed to apply handcuffs to VA2 to remove him/her from self-harming situations. The facility did not allow staff to use manual- or mechanical-restraints. Given the aforementioned and that although VA2 was repeatedly transported to the emergency room, there was no information that his/her self-harm resulted in a serious injury, which indicated the staff supervision and response was adequate to prevent a serious injury from occurring, there was not a preponderance of the evidence whether there was a failure to provide care or services to VA2, which was reasonable and necessary to maintain VA2’s physical or mental health or safety. 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). Action Taken by Facility: The facility completed internal reviews for Allegation One and Allegation Two and determined that policies and procedures were adequate and followed and that there was not a need for additional staff training or corrective action. VA1 and VA2 no longer lived at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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