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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: 1070562-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt/Jamie Randall 651-431-6556 Suspected Maltreatment Reported: It was reported that on January 14, 2025, a vulnerable adult (VA), who was not wearing weather appropriate clothing, ran outside when the temperature was -2 degrees Fahrenheit and sat on a facility driveway. Two staff persons (SP and P2) were able to get the VA inside after 30 minutes. The VA sustained frostbite, blisters, and scratches on his/her back. It was also reported that the SP pushed the VA in the snow. Date of Incident(s): January 14, 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 2, paragraph (b), clause (1); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. 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 28, 2025; from documentation at the facility; and through ten interviews conducted with a facility supervisor (P1), five staff persons (P2-P5 and the SP), the VA, a family member of the VA (FM), and the VA’s guardians (G1 and G2). The VA enjoyed arts and crafts, socializing with new people, going out in the community, and going for drives to a local lake to see animals. The VA’s diagnoses included moderate intellectual disability, organic personality disorder, depression, and osteoporosis. The VA liked to talk with staff persons but sometimes would have trouble communicating. The VA did not like to be talked down to or being “bossed” around. The VA had a history of leaving the facility without supervision including not wearing weather appropriate clothing. Staff were to follow the VA on foot or in a vehicle with a facility cell phone to contact the facility if needed. If the VA were to sit outside on the property, staff were to monitor within eyesight and allow a safe distance as to not agitate the VA. Staff were to call emergency services when a situation became “dangerous/unsafe.” The facility had two stories with a main floor and a basement. The VA’s bedroom was on the main floor. The facility had three exit doors including a garage door, a back door, and a front door. The front door had a ramp outside that led to the driveway. The facility had no alarms on any of the exits. The facility’s Emergency Use of Manual Restraint Policy said that the use of manual restraint was to be used when an individual posed imminent risk of physical harm to self or others. The procedure must be the least restrictive intervention to achieve safety. The facility’s policy on Inclement Weather said staff persons were to monitor the status of the weather and determine what steps needed to be taken to ensure the safety of the individuals receiving supports. Weather underground information for January 14, 2025, in Cloquet, MN, showed that the temperature was between -1 and -3 degrees Fahrenheit and the wind speed between 6 and 8 miles per hour at the time of the incident. Consistent information was provided that P2 and the SP were working at the facility at the time of the incident. P3 and P4 worked that day until 8 p.m. and left prior to the incident. P1 provided the following information to this investigator and for the facility’s internal review: · On the morning of January 15, 2025, P1 overheard the VA tell another staff person that “me outside in the snowbank last night, [the SP] pushed me down in the snowbank, held my feet.” P1 observed a large red area on the VA’s back that was below the shoulders to the top of the VA’s waist. The red area on the VA’s back was raised and warm to the touch with blisters on the middle of the VA’s back with scratches and blisters on the VA’s lower right back/hip area. The VA told P1 “that [woman/man] [the SP] push me down when me outside. Me outside in the snowbank last night.” · P1 read in the VA’s progress notes that after dinner on January 14, 2025, the VA became upset because s/he could not find a “chuck pad,” (a chuck pad was an absorbent cloth pad that could be placed on a bed, chair, or other piece of furniture to prevent the item from getting wet). At 8 p.m., the VA had an accidental bowel movement in the hallway and went outside to the driveway. The VA was “poorly dressed” for the weather conditions. The SP and P2 followed the VA, and the VA showed signs of anger and confusion saying, “You two staff.” The SP and P2 used motivational interviewing to try and redirect the VA inside. The VA sat in the driveway and pushed away from the SP using both feet and “scooted” while on his/her back for approximately ten feet. The VA sat up in the driveway, walked onto the ramp leading to the doorway and sat down again. The SP and P2 were going to use emergency services if the VA did not go back inside after 30 minutes but the VA chose to go inside before that. During the VA’s time outside, P2 offered the VA a blanket. Once inside, the VA sat in the entry way for 15 minutes and then went to his/her bedroom. While outside the VA was incontinent of urine and had a bowel movement. The SP and P2 verbally redirected the VA to take a shower to ensure cleanliness. P2 assisted the VA with a shower and applied antibiotic cream to the scratch and red area on the VA’s back. The VA then watched TV in his/her bedroom until 10:15 p.m. and then worked on a puzzle in the living room. · P1 stated that staff were to use an emergency use of manual restraint and/or use emergency services to assist the VA because of the cold weather and the VA not being dressed properly. The SP and/or P2 could have used a “one person escort” or “two-person escort” to get the VA back into the facility with imminent risk present. With the weather being -9 degrees Fahrenheit and the VA not wearing a winter coat, the SP and/or P2 should have called emergency services within “five minutes” of the VA refusing to go inside. · P1 said the VA could provide accurate information but was diagnosed with dementia and could be “confused.” If staff persons “upset” the VA, s/he would say “staff bugging me,” “not doing job,” or “lazy,” to describe the staff person(s). After the incident on January 14, 2025, the VA told multiple other staff persons that the SP pushed the VA in the snow. · On January 18, 2025, the VA left the facility property without supervision and was followed by a staff person. Law enforcement was called, and the VA returned to the facility. The VA said that the SP’s car was at the facility and that “fucker” was here, s/he “pushed me in the snow.” The VA provided the following information to the investigator and to P1: · The VA was interviewed by this investigator on Tuesday January 28, 2025, and when asked about when the incident occurred s/he stated, “This Wednesday.” The VA said that s/he went outside using his/her walker to check the mail. The VA said that the SP was behind him/her, and s/he was “scared” and fell to the ground. The VA was on the ground and his/her feet were held up “high.” The VA said staff were “inside” and s/he got up on his/her own. · The VA told P1, “Me just going to the mailbox and that [man/woman], asshole push me down in snowbank last night, [s/he] held my feet.” The VA repeated that s/he was going to the mailbox and that s/he was pushed into the snowbank by the SP and sat outside. P2 provided the following information: · On January 14, 2025, P2 was working with the SP, P3, and P4. The VA became upset as they were looking for a “chuck pad.” Staff persons attempted to help the VA find the “chuck pad” but were unsuccessful. · The VA came out of his/her room and had a bowel movement on the floor. P2 saw the VA heading toward the front door and asked if they could get something for the VA and s/he yelled, “No.” P2 told the SP that the VA was heading out the door and the SP followed the VA. The VA was “poorly dressed” for the weather and did not have a winter coat, hat, or gloves on. The SP told P2 that s/he offered a winter coat, but the VA threw it at him/her and was refusing to put it on. P2 assisted the other three individuals in the facility while the SP and the VA were outside but looked out a front window a “couple times” and observed the SP “verbalizing” in the direction of the VA but since P2 was in the house, P2 did not hear what was said by the SP. · At some point, the VA went back into the facility and sat in the entry way, P2 offered the VA a blanket. P2 offered the VA a warm drink but the VA refused. P2 assisted the VA with a shower to help the VA get clean from the bowel movement and urine. The VA’s back was “pink” and when P2 asked the VA if s/he was okay, the VA said, “Better.” The VA did not show any signs of pain. P2 estimated that the VA was outside for at least 20 minutes. P2 did not see the SP push the VA into a snowbank. The VA was in his/her room after his/her shower. The VA “eventually” came to the living room and worked on a puzzle. · The VA had a history of leaving without supervision and staff were to follow the VA when s/he left. If weather appropriate clothing was not worn, staff were to bring with items and offer them to the VA. Staff were to try and use verbal guidance to “talk [the VA] out of it.” · P2 said that if s/he was to “go back in time” that either s/he or the SP should have called emergency services. P3 and P4 provided the following information: · P3 and P4 worked from 12 p.m. until 8 p.m. on January 14, 2025. A little after 7 p.m., the VA became upset and was yelling at staff persons because s/he was looking for his/her chuck pad and could not find it. Staff persons attempted to look with the VA for the chuck pad but by the time P3 and P4 left, the chuck pad was not found. · The VA and P2 were in the VA’s room around 7:45 p.m., and P2 was talking with the VA and made the VA laugh. The SP went into the VA’s room and asked the VA to be quieter as a roommate was trying to sleep. P3 and P4 did not hear a response from the VA from this interaction. P3 and P4 left at 8 p.m. · P3 worked the following morning on January 15, 2025. The VA came into the living room where the SP and P3 were working and the VA greeted P3. The VA then started to tell P3 about his/her back and the SP said, “That’s what happens when you try to leave like that.” The VA responded, “Shut up fucker. You pushed me.” The SP continued to talk with the VA and the VA started to become upset and yelled at the SP. The VA showed P3 his/her back and the VA’s back looked red and almost “like a sunburn.” · P3 said that the VA had a more “easy going” relationship with P2 and would talk to P2 more compared to the SP. P4 said that the SP and the VA had a professional relationship, and that the SP would “joke around” with the VA. P3 and P4 provided similar information that due to the VA’s diagnoses of dementia, s/he may not always provide accurate information. P4 said for “two days” after the incident, the VA talked about being pushed into the snow by the SP and then the relationship between the SP and the VA was “fine” like the incident never happened. P5 provided the following information: · On an unknown date, later determined to be January 15, 2025, P5 was working the morning shift with the VA. P5 administered the VA’s medications when the VA asked P5 to look at his/her back because a “[woman/man] pushed me.” P5 asked who pushed the VA and the VA responded with the SP’s first name (Note: There were two staff persons who used the same first name, one of which was the SP, and the VA did not specify which one). P5 asked the VA to show him/her the VA’s back and the VA lifted his/her shirt. P5 saw that the VA’s back was red like a “bad sunburn” from the VA’s waistline to VA’s neckline. One area of the VA’s back was starting to blister and was raised. P1 overheard the conversation between P5 and the VA and came over to look at the VA’s back. P1 told P5 that the VA’s back “doesn’t look good” and the VA should be seen by a doctor. · P5 took the VA to see his/her primary care doctor on January 15, 2025. On the way the VA told P5 that “[woman/man] pushed me. Bad [woman/man].” The doctor told the VA that the injury on his/her back was due to the frigid temperatures outside and explained that the VA should not be outside when it was so cold. When the doctor asked, the VA told the doctor that s/he did not know why s/he was outside. G1, G2, and the FM provided the following information: · The FM went to the facility with G1 on what s/he thought might have been Wednesday, January 15, 2025. A staff person told the FM and G1 that the VA got into an argument with staff persons and went outside without supervision. The staff persons said they were outside with the VA for “like 30 minutes” with the VA on the ground. · The FM said the VA would not be able to get up off the ground on his/her own and would require assistance from one or two staff persons. The staff person should have called the police or an ambulance to assist the VA since the VA was on the ground for so long with no jacket. · The VA told G2 “a day or two” after the incident happened that a staff person pushed him/her. G1 and G2 said that the VA told them that s/he did not like one of the staff persons at the facility. In both instances, the VA used a first name that two staff persons used, one of which was the SP, and did not specify which one pushed him/her or the staff person that s/he did not like. · The FM and G2 said that the VA would leave the facility without supervision and that staff persons were to follow the VA when s/he left. The SP provided the following information: · On what the SP believed was the date of January 16, 2025, later determined to be January 14, 2025, the VA had a bowel movement in the hallway just before 8:30 p.m. The VA then went outside in a t-shirt, pants, and slippers using his/her walker. The SP followed the VA and offered the VA a coat when s/he got to the middle of the driveway, but the VA refused and threw the coat. The SP waited for a “couple minutes,” and offered the coat again but the VA refused and then sat in the driveway with his/her back on the ground. The SP told the VA that s/he had to “get off the ground” and the VA started to kick at the SP with his/her feet. The VA then began to “scoot” about ten feet backward using his/her feet. The SP backed away from the VA as to not “hurt [him/her].” The SP positioned the VA’s walker facing the ramp that led to the facility. After about ten minutes the VA got up and used his/her walker and went toward the front door. When the VA got near the front door, P2 came out with a blanket and the VA sat down on the ramp. The SP went inside for about ten minutes with P2 and the VA on the ramp. After another ten minutes, the SP came out and told the VA that s/he was “going to have to call the cops” if the VA did not come inside as they did not want the VA to get “hurt.” The VA went inside the facility and sat in the entry way for 15 minutes. · P2 was able to get the VA to agree to a shower and assisted the VA. P2 asked the SP to look at the VA’s back as it had scratches on it. The SP saw “light abrasions” on the VA’s lower back. P2 applied “ointment” on the VA’s back. After the shower, the VA spent time in his/her room before coming out to the living room to work on a puzzle. · The SP said that the VA has a history of leaving without supervision and staff were to follow and provide encouragement to go back to the facility. If the VA or situation were to become unsafe, staff were to call 9-1-1. The SP said that s/he should have called 9-1-1 with the risk of frostbite. · The SP denied pushing the VA in a snowbank. The SP said that there was snow on the driveway and the VA sat and then “scoot[ed]” him/herself on the snow. The VA’s medical records showed that s/he was seen on January 15, 2025, and was diagnosed with first degree frostbite on his/her lower back. Treatment prescribed was to apply Silvadene cream on Telfa pads and cover when the blisters opened. Review of personnel records showed that the SP and P1-P5 were all trained on the Emergency Use of Manual Restraint policy, Inclement Weather policy, and the Maltreatment of Vulnerable Adults policy. Conclusion: Regarding the VA being outside and being diagnosed with frostbite: Information showed that on January 14, 2025, the VA became upset shortly after 7 p.m. as s/he could not find a “chuck pad.” Staff persons assisted the VA with looking for the “chuck pad” in various places throughout the house but could not find it. Around 7:45 p.m., P2 was discussing the missing “chuck pad” with the VA and got the VA to laugh. The SP went into the VA’s bedroom and asked if the VA and P2 could be quieter as another housemate was trying to sleep. The VA came out of his/her bedroom after 8 p.m. and had a bowel movement on the floor. The VA then went out of the front door using his/her walker. The VA was not wearing weather appropriate clothing as s/he was in a t-shirt, pants, and slippers. The SP followed the VA and at the midway point of the driveway attempted to verbally redirect the VA inside of the house. The SP offered the VA a coat, but the VA refused and threw it. The VA became upset and was saying “You two staff.” The SP waited for a “couple minutes,” and offered the coat again but the VA refused and then sat in the driveway with his/her back on the ground. The SP told the VA that s/he had to “get off the ground” and the VA started to kick at the SP with his/her feet. The VA then began to “scoot” about ten feet backward using his/her feet. The SP positioned the VA’s walker so it was pointed towards the ramp that lead to the front door. After about ten minutes the VA got up and used his/her walker and went toward the front door. When the VA got near the front door, the VA sat down on the ramp. After ten minutes, the VA got up from the ramp and went inside the facility, where s/he sat in the entry way. The SP and P2 both had information that the VA was offered a blanket but the SP and P2 differentiate as to if the blanket was offered while the VA was still outside on the ramp or after the VA went back into the facility. The VA was outside for approximately 20 to 30 minutes. After the VA sat in the entry way for 15 minutes, the VA went to his/her room. P2 was able to assist the VA with a shower as the VA had urinated and had a bowel movement outside. P2 noticed the VA had redness and scratches on his/her back and applied antibiotic cream. On January 15, 2025, around 8 a.m., P5 and P1 observed redness and blisters on the VA’s back. The VA was taken to his/her primary physician and was diagnosed with first degree frostbite. The treatment prescribed was to apply Silvadene cream on Telfa pads and cover when the blisters open. Although the VA was outside in cold weather without weather appropriate clothing for 20 to 30 minutes and was later diagnosed with first degree frostbite, given the VA’s plans stated that staff were to follow the VA outside and then call emergency services when a situation became “dangerous/unsafe” but did not specify a length of time or what this meant, that the SP followed the VA outside and offered the VA a winter coat which the VA refused, that the SP attempted to verbally redirect the VA, that the VA was on the ground in freezing weather which likely caused the frostbite, and that P2 also offered the VA a blanket, assisted the VA with a shower and applied cream to the VA’s back where redness and scratches were noticed but at the time did not indicate frostbite, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. 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 the SP pushing the VA in the snow: The VA told P1 that the SP pushed him/her into a snowbank. The SP denied pushing the VA in the snow and while the SP had reason to minimize his/her actions, the SP and the VA were alone at the time when the VA ended up on the ground so there were no other witnesses to confirm or dispute either account, therefore, there was not a preponderance of the evidence whether the SP engaged in conduct that was anything other than accidental. It was not determined whether physical abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The SP and P2 should have escorted the VA inside or used emergency services to keep the VA safe due to the extreme cold and the VA not being properly dressed. The VA’s individual plans were updated to reflect cold weather concerns. The facility placed thermometers outside all three exits and posted a National Weather Service Wind Chill chart on each door. Staff persons were required to review changes to the VA’s plans. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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