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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: It was reported that a vulnerable adult (VA) left the facility, climbed over a fence on a bridge overpass, and made statements about jumping. Staff persons (SP1 and SP2) followed but stayed in their vehicle and did not engage with the VA until a passerby called 9-1-1. Date of Incident(s): July 1, 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 site visits conducted on July 16 and August 11, 2025; from documentation at the facility and law enforcement records; and through eight interviews conducted with the VA, the VA’s guardian (G), the VA’s case manager (CM), facility staff persons (SP1 and SP2), and supervisory staff persons (P1, P2, and P3). The VA’s Self-Management Assessment and Individual Abuse Prevention Plan provided the following information: · In January 2025, the VA moved into the facility. His/her diagnoses included bipolar disorder. · The VA liked dance, music, and arts and crafts. · At times, when the VA was “upset” or “overstimulated,” s/he might leave without telling anyone. “Staffing is provided at [the VA’s] home and in the community. Staff are present on site but may not be in the same room as [the VA] at all times. Staff remained within visual range when in the community.” When the VA was struggling, staff encouraged him/her to take a walk and talk with staff. · In the event the VA left without telling anyone, staff spent ten minutes searching the immediate area. If after ten minutes staff could not find the VA, they called 9-1-1 and reported the VA as missing. The facility was a single-family home with staffing to provide crisis respite (short-term) services to residents. The facility was located next to a four-lane highway and about 0.3 miles from a bridge crossing the highway. The bridge had fencing on either side and an electronic traffic sign hanging on the south side noting freeway times. The immediate area included a lake, woods, restaurants, gas stations, and several residences. The facility’s Program Policies, including Emergency Use of Manual Restraints and Responding to and Reporting Incidents, stated the following: · “It is the policy of this company that emergency use of manual restraint (EUMR) is not allowed at any time.” · Staff should attempt to deescalate a person’s behavior before it posed an imminent risk of physical harm to self or others. This might include a calm discussion, distractions, or time alone. · “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. · Staff will implement any crisis prevention plans specific to the person served to deescalate, minimize, or prevent a crisis from occurring. If a mental health crisis were to occur, staff will ensure the person’s safety and will not leave the person alone if possible. · Staff will contact 9-1-1, a mental health crisis intervention team, or a similar mental health response team or service when available and appropriate and explain the situation and that the person is having a mental health crisis. The facility’s Incident Report stated the following: · On July 1, 2025, at approximately 1 p.m., the VA was “getting worked up” about a financial check s/he was expecting in the mail. S/he “accused” staff of stealing the check. Staff brought the VA into the staff office to show him/her that the check was not there. · The VA stated to staff that s/he was leaving and ran out of the house through the garage door. Two staff followed the VA in their car. The VA ran to a bridge, which crossed the highway. Staff stopped the car and got out to approach the VA, but s/he climbed over the fence on the bridge and stood on a sign overhanging the highway. A passing bicyclist tried talking to the VA. “Staff were there monitoring and attempting to redirect [the VA] and reassure [him/her].” The bicyclist called 9-1-1 and staff called P2. · A police officer spoke with the VA and convinced him/her to climb back over the fence, onto the bridge. An ambulance transported the VA to an emergency room. A Minnesota State Patrol Report stated that on July 1, 2025, at 1:08 p.m., a community person (CP) called 9-1-1 for a person, later identified as the VA, standing on the outside of the bridge fence, a “possible jumper.” The CP observed the situation from below as s/he drove past on the highway. The CP was not on the bridge and did not provide information about what was happening on the bridge. At 1:11 p.m., two state trooper vehicles arrived. At 1:15 p.m., northbound lanes on the highway were shutdown. At 1:16 p.m., the VA climbed back over the fence onto the bridge and an ambulance transported him/her to an emergency room. [Note: The Minnesota State Patrol Report provided limited information, including the bicyclist’s identity, the troopers’ identities, and/or what the troopers observed upon arrival.] A law enforcement officer (LEO) provided the following: · On July 1, 2025, around 1:08 p.m., the LEO heard the incident unfolding on a police scanner. The LEO was familiar with the area, the facility, and the VA. The LEO later asked the troopers about it. According to the LEO, state troopers arrived and saw the VA standing on the outside of the bridge fence. There was a car stopped nearby. SP1 and SP2 got out of the car and told the troopers that they were the VA’s staff. A state trooper spoke with the VA and convinced him/her to climb back over the fence, out of danger. · Following this, the LEO went to the facility and spoke with SP1, SP2, and P1. SP1 told the LEO that the VA ran off and s/he asked P1 what they should do. P1 told SP1 and SP2 to find and follow the VA. SP1 told the LEO that they drove around and found the VA on the bridge. “[SP1] stated that [the VA] had climbed over the fence and was on an electric sign over the traffic … [SP1 and SP2] stayed in their vehicle and monitored [the VA] but did not get out and try to get [him/her] to come back over the bridge or away from traffic.” SP1 told the LEO that s/he called P2, who told them to stay in their car and watch the VA. They were giving the VA “space.” When state troopers arrived, SP1 and SP2 exited their car. The VA said that the morning of July 1, 2025, SP1 was “snappy” toward him/her, which triggered the VA to leave and run to the bridge. SP1 and SP2 followed in their car but stayed in the car “the whole time” and did not say anything to the VA. Instead, SP1 and SP2 were listening to music in the car and “laughing.” SP1 and SP2 only exited the car when the state troopers arrived. SP1 and SP2 provided the following information: · SP1 and SP2 each said that the VA had 2:1 staffing. SP1 said that this meant two staff persons always had “eyes on” the VA. SP2 said that if the VA was in his/her bedroom, one staff person sat outside his/her bedroom with the door open and could switch off with the other staff when they needed a break. SP1 and SP2 each said that when in the community, both staff stayed with the VA. · On July 1, 2025, SP1 and SP2 worked with the VA. That morning, the VA was “set on” finding a check and believed unidentified staff “stole” it. The VA was “yelling” at SP1 and SP2. SP1 and SP2 each helped the VA look in the mailbox and showed him/her a stack of mail in the staff office, which did not contain the VA’s check. SP1 and SP2 each told the VA to wait for the postal carrier to arrive later that day. · Between 10 a.m. and “12 something,” the VA “announced” s/he was leaving, put on his/her shoes, and walked out of the house. SP1 and SP2 were right there and followed the VA out the door. The VA headed north on a frontage road with SP1 and SP2 in a car behind the VA within “a couple of feet.” SP1 was driving and SP2 was in the front passenger seat. SP1 said that they had the car window rolled down and told the VA to return to the house and wait for the postal carrier; however, “[The VA] wasn’t receptive” and continued walking. The VA walked onto the bridge. · SP1 said that s/he parked about 10 to 15 feet away from the VA and did not want to block traffic by driving too far onto the bridge. SP1 said that more than once, prior to July 1, 2025, the VA walked to this same bridge and in the past when the VA did this, s/he repeatedly put a foot on the bridge fencing as though s/he was going to climb only to take his/her foot off and keep walking. SP1 believed the VA did this to get a reaction from staff. The VA never actually climbed the fence before. SP1 and SP2 stayed in the parked car watching the VA walking on the bridge. · SP2 said that the VA was pacing back and forth on the bridge and “cussing at” SP1 and SP2. The VA kept “putting a leg on the fence and acting like [s/he] was going to climb, but never fully climbed.” SP1 and SP2 called P1, who was at the facility and said s/he would join them at the bridge to help. SP1 and SP2 next called several supervisory and administrative staff persons “to see what we should do” but no one answered. Around this time, a bicyclist stopped and talked to the VA while s/he stood on the bridge. SP2 believed the VA and the bicyclist talked for six to seven minutes. · SP1 said that the VA was “actively” talking to the bicyclist and so SP1 and SP2 let the VA be and did not engage with him/her. SP1 and SP2 stayed in the parked car watching the VA talk to the bicyclist. The VA was standing on the bridge during this time. However, then the VA climbed over the fence at which point the VA was standing on a structure, which held the highway sign to the bridge. SP2 said that s/he immediately got out of the car and ran towards the VA. By that time, P1 had arrived and also ran towards the VA. SP1 stayed in the car and said that at one point, SP2 got out of the car and s/he and P1 walked over to the VA. · SP2 said that when s/he was running towards the VA, more than one law enforcement vehicle arrived. SP2 later learned the bicyclist had called 9-1-1. SP2 said that s/he did not immediately call 9-1-1 because s/he was running towards the VA. “I didn’t have a chance” to call 9-1-1. SP2 said that s/he stood back and let law enforcement officers engage with the VA. SP2 told the officers that the VA did not like certain genders and to give the VA space. A law enforcement officer talked to the VA and eventually the VA agreed to climb over the fence back onto the bridge. SP2 held the VA’s hand as s/he climbed over the fence onto the bridge. An ambulance transported the VA to an emergency room. The VA was not physically injured. · SP1 said that s/he did not immediately call 9-1-1 because s/he had previously been told by supervisors and administrators, including P2 and P3, that staff were calling 9-1-1 too frequently and that they should not call 9-1-1. SP1 said that s/he was “really confused” about when to call 9-1-1. SP1 said that the facility did not allow for the emergency use of manual restraints (EUMR) with residents unless the person was at a risk of harm. SP1 said that staff did not use an EUMR to stop the VA from leaving the house because there was no risk of harm at that point. They also could not use an EUMR on the bridge because the VA was already over the fence at that point. “We were walking a fine line with [the VA’s] safety” and SP1 believed that physically redirecting the VA “wouldn’t be the best move for us.” · SP1 said that the VA was over the fence on the sign structure, for about three to four minutes before law enforcement officers arrived and SP2 said it was about two to three minutes. [Note: SP1 said that s/he was sitting in the car while the VA was outside the fence awaiting law enforcement officers, and SP2 said that s/he was actively running towards the VA. The bridge was approximately 100 feet spanning the highway. SP1 said that his/her car was parked about 10 to 15 feet from the VA.] P1 said that SP1 or SP2 called him/her and said that the VA climbed over the fence on the bridge and was sitting on a structure that held the highway sign to the bridge. P1 then ran to the bridge and upon arriving, saw SP1 and SP2 sitting in the parked car and the VA sitting on the highway sign, outside of the fence, talking to the bicyclist. SP1 or SP2 told P1 that they were “scared to approach” the VA and that law enforcement officers were enroute. SP2 then got out of the car and walked with P1 up to the VA. P1 spoke to the VA. The VA told P1 that s/he left the house because SP2 made an earlier comment about an unrelated incident from the previous weekend. Law enforcement officers then arrived and talked to the VA. P1 did not know if staff should have approached the VA sooner or if the VA had a history of being provoked by staff proximity. P1 said that during previous incidents when the VA left the house, P1 followed him/her and “nothing happened.” P1 said that law enforcement officers had previously told staff to stop calling 9-1-1. P2 said that at an unspecified time, SP2 called him/her and said that the VA had climbed over the fence and SP1 and SP2 did not know what to do. The VA was “just sitting there” on the outside of the fence and a bicyclist had already called 9-1-1. P2 told SP2 to “wait for the cops to come.” P2 explained that if the VA was “actively trying to jump off” the bridge, P2 would have instructed SP1 and SP2 to pull him/her over the fence. The VA was not threatening to jump off the bridge at that point. P2 did not have concerns with SP1’s and/or SP2’s handling of the incident. Regarding 9-1-1, P2 said, “The cops had told us not to call (9-1-1)” because “the police were tired of coming [to the facility].” “They told us not to call anymore, which made it hard for staff to know what to do.” Following this incident, “The police were then upset that we didn’t call them.” P3 said that staff “are very confused” about when they can call 9-1-1. Law enforcement officers were “very upset with our use of 9-1-1.” P3 said that staff should call 9-1-1 when “things are imminent, there is a significant danger … significant injury or something that is an emergency.” P3 believed SP1 and SP2 would have called 9-1-1 when the VA climbed over the fence, but the bicyclist did instead. P3 did not have concerns with SP1’s and/or SP2’s handling of the incident. The facility’s Internal Review, which was completed by P3, stated that once the VA was on the bridge, “There was a bystander that attempted to intervene to provide comfort or assistance to [the VA]. [The VA] went back and forth a bit but ended up climbing on a roadway sign. A staff was watching and verbally attempting to redirect [the VA], another staff was calling Supervisor so they could maybe help or provide other solutions, and the bystander called 9-1-1.” “Staff kept visual distance, utilized positive supports, ensured supervisor and police were contacted.” “[The VA] has a history of elopement and different types of self-harm.” The G said that s/he did not have information about the specific incident on July 1, 2025. The VA was supposed to have 1:1 staffing. If the VA left the house and staff were not following or supervising, the staff were supposed to search for 30 minutes and then call 9-1-1. The CM said, “[The police] communicated to us that [the VA] should not be in the community with this many calls (to 9-1-1).” Following the incident on July 1, 2025, the VA no longer lived at the facility. Facility documentation stated that the staff persons interviewed for this investigation received training on the VA’s Self-Management Assessment and Individual Abuse Prevention Plan, the facility’s Program Policies, and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Minnesota Statutes and Rules: Minnesota Statutes 245A.04, subdivision 14, paragraph (b), clause (3), states the license holder shall monitor implementation of policies and procedures by program staff. Conclusion: A. Maltreatment: On July 1, 2025, the VA left the house and ran to a bridge spanning a highway, climbed over the bridge fencing and stood outside the fence overhanging the highway. SP1, SP2, and the VA each said that when the VA left the facility, staff followed the VA in their car. The VA said that staff did not say anything to him/her but SP1 said that they had the window rolled down and were trying to redirect the VA back to the house. Once on the bridge, SP1 and SP2 each said that they stayed in their car watching the VA. The VA said that SP1 and SP2 stayed in the car listening to music and “laughing.” A bicyclist stopped and talked to the VA. The facility’s Internal Review stated, “There was a bystander that attempted to intervene to provide comfort or assistance to [the VA] ….” P1 said that when s/he arrived, the VA was outside the fence, overhanging the highway, and SP1 and SP2 were in their car “afraid to approach.” The VA and the LEO each said that SP1 and SP2 exited the car when the state troopers arrived. SP1’s and SP2’s conduct of failing to ensure the VA’s safety and leaving the VA alone during a mental health crisis was inconsistent with the facility’s Program Policies and a violation of Minnesota Statutes 245A.04, subdivision 14, paragraph (b), clause (3). Although the facility policy stated, “It is the policy of this company that emergency use of manual restraint (EUMR) is not allowed at any time” and SP1’s statement about why they did not use an EUMR at the time of the incident was reasonable, the facility’s policy on Emergency Use of Manual Restraints also stated, “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.” The VA’s conduct of standing outside a fence, overhanging a highway, placed the VA at an imminent risk of harm, including death. Although there was confusion about when staff should call 9-1-1, a person standing outside a fence on a bridge overpass reasonably represented an immediate need for help and it was reasonably expected that someone would call 9-1-1 in that situation. That said, instead of calling 9-1-1, SP1 and SP2 called P2 and told P2 that the VA had climbed over the fence. P2 told them, “Wait for the cops to come.” Although SP2 said that s/he ran towards the VA immediately after s/he climbed the fence and the facility’s Internal Review stated, “A staff was watching and verbally attempting to redirect [the VA],” information was provided by P1, P2, the VA, and the LEO that SP1 and SP2 were in their car when the VA was over the fence or until state troopers arrived. The conduct of not intervening in any way when a vulnerable adult was at an imminent risk of harm, including death, was inconsistent with the standards of professional caregivers in a facility licensed by the Department of Human Services. Therefore, there was a preponderance of the evidence that there was a failure to supply the VA with care or services, which were reasonable and necessary to maintain the VA’s 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 responsible for the VA’s care and supervision and received training on the VA’s Self-Management Assessment and Individual Abuse Prevention Plan, the facility’s Program Policies, and the Reporting of Maltreatment of Vulnerable Adults Act. When the VA climbed over the fence, SP2 called P2, who said, “Wait for the cops to come.” Given that P2 was a supervisory staff person, SP1’s and SP2’s responsibilities were mitigated. P2 was a supervisory staff person and received training and/or trained staff on the VA’s Self-Management Assessment and Individual Abuse Prevention Plan, the facility’s Program Policies, and the Reporting of Maltreatment of Vulnerable Adults Act. P3 was also a supervisory staff person and determined through an Internal Review that policies and procedures were adequate and followed during the incident and that there was not a need for additional staff training or corrective action. P2 and P3 had significant supervisory authority at the facility, including training staff persons, and the failure to appropriately instruct staff during the immediate situation, or recognize or take any corrective action following an incident where there was no staff response for a person standing over the fence on a bridge overpass represented a systematic failure by the facility. The facility was responsible for maltreatment of the VA. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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 maltreatment for which the facility was responsible did not meet statutory criteria to be determined as serious. The VA did not sustain a serious injury. Action Taken by Facility: The facility (P3) completed an internal review and determined that policies and procedures were adequate and followed. There was not a need for additional staff training or corrective action. The VA no longer lived at the facility. Action Taken by Department of Human Services, Office of Inspector General: On September 22, 2025, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal.
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