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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: 1110149-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070370-HCBS (Home and Community-Based Services) Investigator(s): Samantha Wueste 651-431-2278 Suspected Maltreatment Reported: It was reported that there were ongoing concerns regarding short staffing at the facility that resulted in multiple incidents in which staff persons could not provide a vulnerable adult (VA) with adequate supervision and care that was required by the VA’s support plans including: · The VA accessing and ingesting cleaning products that contained bleach. · The VA leaving the facility without the knowledge of staff persons and trying to get into neighboring homes. · The VA fell and hit his/her head after being left unsupervised in the bathroom which then resulted in the VA receiving medical care that was not consistent with the VA’s support plans. Date of Incident(s): Ongoing prior to February 13, 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 March 3, 2025; from documentation at the facility, emergency services records that included law enforcement records, and medical records; and through nine interviews conducted with a facility staff person (SP2), a supervisory staff person (SP1), three administrative staff persons (P2, P3, and P4), the VA’s guardian (G1) who was also the VA’s family member, a guardian (G2) of a client (C) who received services from the facility, the VA’s case manager (CM1), and the C’s case manager (CM2). Multiple attempts were made via phone to contact and interview five additional staff persons (P1, P5, P6, P7, and P8), but the attempts were not successful. P1 initially responded to this investigator about scheduling an interview but then did not respond further or by the completion of this investigation. Additionally, this investigator met with the VA but due to his/her diagnoses and limited communication, the VA was unable to provide information for this investigation. The facility was a split-level home in a residential area, where the VA lived with one housemate (the C). The facility’s main door opened into an entryway that provided access to both levels of the facility, with a front hallway that led to the main level of the facility and a staircase that led to the lower level of the facility where the C’s bedroom and a laundry room were located. On the main level to the left of the front hallway was a dining room, a kitchen, and a living room. Through the dining room was access to an attached garage. To the right of the front hallway towards the rear of the facility was a back hallway that led to a staff office, the VA’s bedroom, a bathroom, and a storage room. The storage room was to be kept locked when not in use and contained items that were only to be accessed by staff persons including cleaning products. The VA’s plans completed by P4 including the VA’s Coordinated Service and Support Plan (CSSP) dated November 1, 2024; the VA’s Individual Abuse Prevention Plan (IAPP) updated April 4, 2024; the VA’s Coordinated Service and Support Plan Addendum (CSSPA) and Intensive Support Self-Management Assessment (ISSMA) updated July 19, 2024; and the VA’s Individual Resident Placement Agreement (IRPA) dated February 10, 2023, provided the following information: · The VA’s diagnoses included severe intellectual disabilities, autism spectrum disorder, seizure disorder, and sensory disabilities. The VA had a history of self-injurious behaviors, leaving the facility without staff persons knowledge/supervision, and was “prone” to choking that resulted from consuming food items “too quickly.” Additionally, the VA was at risk of becoming injured from incidents related to tripping and/or falling due to the VA’s “unsteady gate.” The VA was susceptible to abuse due to a lack of community orientation and self-preservation skills, an inability to identify potentially dangerous situations, and would not be able to defend him/herself against verbally/physically aggressive persons. · The VA did not communicate verbally with words but was “good” at accepting assistance from his/her care team. The VA enjoyed outdoor activities, zoo and farm animals, coloring, and spending time with family. · On February 24, 2023, the VA moved into the facility seeking supports and services relating to his/her diagnoses that included health and behavior management, community integration, transportation, and supervision and physical assistance from staff persons to complete “all” activities of daily living including eating, bathing, dressing, personal hygiene/grooming, and toilet use/continence support. The VA had 2:1 staffing during awake hours (6 a.m. to 10 p.m.) and no unsupervised time within the facility or community. According to an email dated February 28, 2023, from P4 to the VA’s case manager at that time, the “first few days” of working with the VA at his/her “new home” were “very challenging” for facility staff persons due to the VA’s care needs and behaviors. P4 then stated that s/he would update the VA’s RMS Service Agreement (RMS) to request that the facility would provide the VA with 2:1 staffing. The VA’s RMS and Lead Agency Provider Tool for DWRS Exceptions (Residential) completed by P4 dated November 1, 2024, provided the following information: · Due to the “complex needs” of the VA, the facility needed to hire staff who had “extensive experience” working with clients who had similar diagnoses and care needs of the VA. Additionally, the VA required 2:1 staffing due to the VA’s “complex behaviors” that included “running” into the kitchen to consume items that were a “danger” to the VA’s health; “excessive” incontinence; “smearing” and “throwing” excrement; and a history of falling, seizures, and elopement. Incidents regarding these behaviors from the VA “usually” required assistance from two staff persons when responding to and/or resolving these situations. · Due to the VA’s “day-to-day” mental and physical health needs, the license holder had to change the management supervision staffing pattern to the house manager having oversight of one home (the facility) instead of two homes to provide the VA and the staff persons working at the facility adequate support. · The VA received 40 daytime hours of individual direct care staff per day and eight overnight hours of an awake shared staff per day. The C’s CSSP and RMS dated November 30, 2024, and the C’s CSSPA and IAPP updated January 25, 2024, provided the following information: · The C enjoyed spending time with family, going to the barbershop, and participating in Special Olympics. The C did not communicate verbally with words and was diagnosed with mild intellectual disabilities, autism spectrum disorder, bipolar disorder, and seizure disorder. Additionally, the C had a history of physical aggression and property destruction during situations when the C was feeling “angry” or “frustrated.” · On November 19, 2023, the C moved into the facility seeking supports and services relating to his/her diagnoses that included supervision, health and behavior management, community integration, and verbal prompts and/or physical assistance with “most” activities of daily living. Staff persons provided the C with routines, visual prompts that included a calendar of the C’s schedule, and verbal reminders that helped the C understand what activities were planned or coming next. The C had 1:1 staffing during awake hours and no unsupervised time within the community. Staff were to remain on site and available to assist the C at “all times” when s/he was present within the facility. · From 8:30 a.m. to 3 p.m. on the weekdays during the school year (September 3, 2024, to June 5, 2025), the C attended an educational program located in the community that was operated by the local intermediate school district’s Special Education program. The C’s plans noted that the C preferred “set” routines and “struggled” on days when the C did not have school. The district’s school year calendar was provided to the facility that showed the days when there was “no school” scheduled (on days which normally provided programming to the C) so the facility could plan accordingly. G1, G2, CM1, and CM2 provided the following information: · Due to the diagnoses, behaviors, and needs of the VA and the C, both clients had a 24-hour plan of care that required a “constant” and “high level” of “monitoring” from staff persons, a “calm” but “stimulant” environment, “structured” programming and routine schedules, and adequate staffing as outlined by each of their support plans. Additionally, three staff persons were required to be working during all awake shifts when both clients were present at the facility. During overnight hours, the VA and the C shared one overnight awake staff from 10 p.m. to 6 a.m. · Consistent information was provided regarding multiple and ongoing concerns regarding the care that the VA and the C received from the facility that included adequate supervision and staffing, training of staff persons, a lack of community integration, cleanliness and maintenance of the facility, the VA’s and the C’s access to personal belongings, the condition and quantity of furniture and items within the home, and providing a level of support and services that were consistent with meeting the daily needs and goals listed in the VA’s and the C’s plans. · Consistent information was provided by G1, G2, and CM2 that staff persons did not typically take the clients outside of the home for physical activities or community activities as required by each of their plans. Additionally, staff persons told G1 and G2 that they could not take the VA and the C for activities outside of the facility because they lost the keys to the facility van and therefore, did not have the ability to transport them. The facility’s documentation of staffing time sheets from November and December 2024, and June 2025, showed that on an ongoing and consistent basis, the facility was not providing the VA and the C with the staffing that was required. The facility consistently provided two staff persons to work at the facility during times when three staff persons were required. This was a violation of Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a) which states that the license holder must ensure services were provided in response to a person's identified needs, interests, preferences, and desired outcomes as specified in the coordinated service and support plan and the coordinated service and support plan addendum, and in compliance with the requirements of this chapter. License holders providing intensive support services must also provide outcome-based services according to the requirements in section 245D.071. According to the facility's Program Abuse Prevention Plan, the facility was currently serving two clients, including the VA, who each received a 24-hour plan of care and supervision from the facility. Furthermore, the clients were vulnerable to incidents of abuse and/or neglect if staff did not provide adequate supervision, assistance and “advocacy” to “help prevent” maltreatment from occurring. Additionally, the lower level of the facility was “difficult to supervise” and staff persons were to complete visual health and safety checks on the C every hour. The facility’s policy on the Rights of Person Served stated that clients had a right to be free from maltreatment and to live without the fear of abuse and neglect. Additionally, clients were to have services and supports provided to them that were identified in their plans in a manner that respected clients as individuals and took into consideration the person’s preferences. Facility documentation showed that all staff persons who provided information for this investigation received training on the client care plans, including the VA’s plans; the facility’s policies and procedures, including the Rights of Person Served and the Program Abuse Prevention Plan; and the Reporting of Maltreatment of Vulnerable Adults Act. Regarding the VA accessing and ingesting cleaning products that contained bleach. SP1 provided the following information: · On November 8, 2024, SP1 and SP2 were working at the facility during the dayshift with the VA and the C. The C did not have school scheduled for this day and remained at the facility. At unknown times throughout the morning, the C was “angry” because s/he was not able to go to school and wanted to leave the facility. During this time, the C was “not acting like [him/herself] and had “physically aggressive” behaviors that included hitting the wall and breaking a DVD. SP1 then asked the C if s/he wanted to go for a “van ride” to go get a haircut since these were activities that the C enjoyed. · At an unknown time later that morning, SP2 left the facility to take his/her lunch break and returned to the facility shortly thereafter. After this, SP1 left the facility with the C while SP2 stayed at the facility with the VA. SP1 drove the C to a local hair salon but the salon was not available to service the C at that time so SP1 scheduled an appointment for the C’s haircut the following week. SP1 then drove the C to a nearby fast-food restaurant for lunch before returning to the facility. During this outing, SP1 and the C were gone from the facility for approximately one hour. · After returning to the facility with the C, SP1 walked into the facility and saw that “the whole house was destructed.” SP1 saw SP2 sitting with the VA attempting to assist the VA with personal care activities. The VA was coughing and the facility “smelled like bleach.” SP1 asked SP2 what happened and SP2 told SP1 that s/he was “trying to take care of [the VA].” SP2 also said that when s/he was assisting the VA with using the toilet and changing the VA’s absorbent undergarments, SP2 needed the VA’s personal care items that were located in the supply room next to the bathroom. SP2 left the VA in the bathroom to go get the items but the VA ran out of the bathroom. SP2 was not able to “redirect” the VA’s behavior without the help of a second staff person. SP1 then walked down the back hallway and saw that the supply room door was open and not locked as required. Additionally, SP1 saw that there were two bottles of household cleaner (a bottle of bleach cleaning solution and a bottle of Lysol) that were empty in the VA’s bedroom which was “soaked” and smelled like “chemicals.” Although the VA was “acting normal,” SP1 immediately contacted P2 and told him/her about the situation including that the VA was coughing and “smelled like bleach.” Shortly thereafter, P2 arrived at the facility and called 9-1-1 since staff persons were not aware if the VA ingested the cleaning products or not. Emergency services then arrived at the facility and the VA was transported to a local hospital via ambulance. · Later, after evening staff persons arrived at the facility, SP1 drove the facility van to the hospital to see the VA. The hospital’s team of medical health professionals (MHP) “examined” the VA for “maybe seven hours” before discharging the VA back into the facility’s care later that evening. The MHP told SP1 that there was not a way to “actually know” if the VA ingested some of the cleaning products and that the VA could have been coughing due to “inhaling some of the chemicals” that were in the products. After the VA was discharged, SP1 transported the VA back to the facility. · SP1 was aware that the VA required 2:1 staffing, supervision “at all times.” The VA “was not a client you can leave” and SP1 told SP2 this when s/he arrived at the facility. The VA was “strong,” “fast”, and would “find a way” to do what s/he wanted, especially with staff persons who were “new” and not familiar with the VA’s behaviors and “challenges.” According to SP1, SP2 was attempting to supervise the VA at the time of the incident and “tried” to provide the care and assistance that the VA required but was not able to do so because “two people were needed.” Additionally, SP1 needed to provide adequate care and supervision to the C who was also present at the facility during this time and was having “some hard behaviors.” · On an ongoing basis within the past year, the facility’s programming did not provide the clients with adequate staffing during awake hours as required by their support plans. On multiple dates, SP1 worked alone at the facility during the daytime hours. Additionally, staff persons who came to work at the facility were often “incompetent” and not “properly” trained to work with clients like the VA and the C. Administrative staff persons, including P4, were made aware that the facility was understaffed and the result that this had on the staff’s ability to manage and respond to the “hard behaviors” of the clients and in completing the daily job responsibilities that were required of staff. If SP1 “complained too much” to P4 regarding the need for additional staff, “sometimes” a third staff person would come work at the facility for two or three days but then the facility would return to being understaffed again shortly thereafter. SP2 provided the following information: · On November 8, 2024, SP1 and SP2 were working at the facility during the dayshift with the VA and the C. SP2 stated that s/he had only worked at this facility once prior to this date and typically worked at another location where the license holder operated a similar licensed residential program. Upon arriving to the facility, SP1 told SP2 about the VA that included the VA’s behaviors and “basically […] lectures about everything [the VA] does.” SP2 was also aware that the VA “moved around” and staff persons were to “follow” the VA “everywhere.” · During this shift, the C was in the lower level of the facility and sleeping while the VA was on the main level with SP1 and SP2. The VA and the C did not have any appointments or other activities that required transportation to be provided by the staff persons during this time. Additionally, there was not a time when a staff person left the facility with either client during this time. · At an unknown time, SP1 told SP2 that s/he could take a “quick” 30-minute lunch break so SP2 left the facility while SP1 stayed at the facility with the VA and the C. SP1 was the only staff person present at the facility during this time. At some point when SP2 returned to the facility, s/he saw that the VA was taking a shower and that SP1 was “panicking” and telling SP2 that the VA “drank Clorox.” SP1 then contacted administrative staff persons and shortly thereafter, an unknown administrative staff person arrived at the facility and told staff to call “an ambulance.” SP1 then called 9-1-1 and emergency responders arrived at the facility soon after. SP2 could not recall any additional information related to the incident. · After the incident, the VA was “acting like [his/her] normal self” and SP2 was not aware of the VA receiving any injuries as a result of this incident. Emergency Service records and medical records provided the following information: · On November 8, 2024, at approximately 1:25 p.m., a facility staff person called 9-1-1 and told the dispatcher that the VA “drank a cup of bleach” at approximately 1 p.m. Facility staff persons did not observe this incident but it was “presumed” to have occurred because the VA “smelled like bleach.” · At approximately 1:35 p.m., emergency medical staff (EMS) arrived at the facility, completed a physical examination of the VA, and then transported the VA via ambulance to a nearby hospital. The VA arrived at the hospital’s Emergency Department (ED) at approximately 2:13 p.m. Between 2:13 to 3:40 p.m., medical health professionals (MHP) made multiple attempts to contact facility staff persons to obtain additional information regarding the incident, but the attempts were not successful. Although the VA was initially examined upon arrival to the ED, the MHP were “significantly limited” in diagnosing or treating the VA without the assistance of facility staff persons due to the VA’s diagnoses and limited communication abilities. · At approximately 4:03 p.m., a facility staff person (later to be determined as SP1) arrived at the hospital and went to the VA’s hospital room. SP1 told the MHP that the VA was able to access a bottle of household bleach that was being used by a staff person who was cleaning a bathroom and who had turned his/her back towards the VA during this time. The VA then “spilled” on him/herself and/or “possibly” ingested approximately ¼ of the bottle’s cleaning solution. Immediately after this, the VA started to cough “a lot.” At approximately 5:06 p.m., the VA was discharged from the hospital’s care and SP1 transported the VA back to the facility. The VA’s After Visit Summary from the ED showed that the VA was diagnosed with "ingestion of bleach, accidental or unintentional, initial encounter.”
· There were not any known injuries to the VA that resulted from this incident. P2, P3, P4, the facility’s General Event Report completed by P3 dated March 4, 2025, and facility documentation related to the incident that was completed by administrative staff persons provided the following information: · On November 8, 2024, SP1 worked at the facility from 6:09 a.m. to 6:37 p.m. and SP2 worked 9:34 a.m. to 3:28 p.m. According to P3 and P4, the VA was provided 2:1 staffing during this time because the C attended an offsite educational day program while the VA remained at the facility with SP1 and SP2. P3 later told this investigator that after reviewing the C’s yearly school calendar, the C was not scheduled to attend school on November 8, 2024, but was not aware of this information at the time of the incident. · At approximately 1 p.m., P2, P3, and P4 were working at the company’s main office building when P2 received a call from SP1 to inform him/her of the incident. During the call, P2 used “speakerphone” so that P3 and P4 could also hear and talk to SP1 about what happened. SP1 said that after a staff person cleaned the bathroom, a bottle of “bleach cleaner” was left in the bathroom and accessible to the VA. SP1 saw that the bottle of cleaner was spilled and “suspected” that the VA took the bottle of cleaner and ingested some of its contents because the cleaner was on the VA’s clothing, the VA “smelled like bleach,” and the VA was coughing “a lot” after this. After speaking on the phone with SP1, P2 immediately left the office and went to the facility to check on the VA. Despite the VA acting “normal,” P2 called 9-1-1 to “err on the side of caution” since staff persons were not aware if the VA ingested any of the cleaning product. Shortly thereafter, the EMS arrived at the facility and then transported the VA via ambulance to a local hospital. SP1 “followed behind” the ambulance in the facility van and remained with the VA for “the entire time” that the VA was at the hospital. [Note: This was inconsistent with the VA’s medical records which stated that staff persons were not at the hospital with the VA and that hospital personnel wondered if staff persons were going to arrive or not.] · Staff persons provided the EMS with the VA’s medical binder that included the VA’s plans and emergency contacts prior to the VA leaving the facility that was to be given to the MHP after arriving to the hospital. After the EMS left the facility with the VA, P2 also left the facility and returned to the office. At 2:57 p.m., P2 sent an email to G1 with information about the incident that included how the facility responded to the incident and that the VA was transported to the hospital via ambulance to “make sure [the VA] was ok.” According to G2 and CM2, the C did not have school scheduled for November 8, 2024, which was information that was provided to the facility so that adequate staffing could be planned for and maintained during the daytime hours. Due to the C’s history and diagnoses, a staff person was to be actively monitoring, engaging with, and assisting the C when present at the facility. When the C was in his/her bedroom on the lower level of the facility without a staff person, staff persons were to provide the C with visual health and safety checks every 15 minutes to an hour. The C was known to have “high energy,” and it was “unlikely” that the C would be asleep during the morning and early afternoon hours. Additionally, G2 reviewed the C’s financial statements for this date and stated that at approximately 11 a.m., lunch was purchased for the C using his/her debit card at a local fast-food restaurant.
Regarding the VA leaving the facility without staff persons supervision: P2, P3, and P4; the facility’s Incident Report completed by P2 dated December 5, 2024; and facility documentation completed by administrative staff persons relating to the incident provided the following information: · On December 1, 2024, two staff persons (P6 and P7) were working at the facility during the evening shift with the VA and the C. At approximately 6:15 p.m., P7 was doing laundry on the lower level while P6 was in the kitchen on the main level with the VA. P6 then began to clean the dishes while the VA sat at the kitchen table. At approximately 6:20 p.m., P6 was still cleaning in the kitchen, the VA left the table unnoticed by P6 and used the patio door to exit the home without P6 knowing. At some point, P7 finished the laundry and walked up the stairs to the main level of the facility where s/he saw P6 cleaning the kitchen. P6 realized the VA was not at the table and looked for the VA but did not find the VA on the main level. P6 asked P7 if s/he knew where the VA was but P7 did not. At approximately 6:43 p.m., staff opened the front door to search for the VA, saw that the VA was in the facility’s driveway walking up the stairs to the front entrance, and “pulled [him/her] inside.” The current air temperature at that time was -20 degrees Fahrenheit and the only clothing that the VA was wearing while outside was a T-shirt, jeans, and a pair of plastic gloves. [Note: There was no information regarding whether the VA was wearing footwear including socks and/or shoes.] · At approximately 10 p.m., P6 and P7 left the facility when P8 arrived to work the overnight shift. Prior to leaving, P6 and P7 did not tell P8 about the incident and did not document that the VA left the facility unsupervised. At approximately 10:30 p.m., law enforcement officers (LEO) arrived at the facility to talk with the VA. P8 allowed the LEO to enter the facility but told the LEO that the VA was diagnosed with autism spectrum disorder and was non-verbal. The LEO then told P8 that the VA left the facility without a staff person earlier that evening, walked to a neighboring home, “banged” on the door trying to enter the home, and “destroyed” holiday decoration items that were outside on the property. The resident (R) inside the home contacted local law enforcement (LE) to report the incident. P8 then told the LEO that s/he was not aware this incident occurred and would notify supervisory staff persons. Shortly thereafter, the LEO left. · On December 2, 2024, at approximately 9:00 a.m., P8 called SP1 and told him/her about the incident and what the LEO said. SP1 then contacted and told P3. At approximately 9:15 a.m., P3 sent an email to G1 to notify him/her of the incident. After this, P3 also contacted P2 and P4 with this information. · According to P2, the VA “eloped a couple times around Christmas time” but at that time, a Ring Doorbell had been installed on the facility’s front door due to prior concerns of inadequate staffing and supervision of the VA. The Ring Doorbell camera footage was reviewed by administrative staff persons for December 1, 2024, and showed when the VA returned to the facility and was brought back inside by staff persons. Additionally, P2 stated that there were “many issues” with staffing which P2 and P3 “brought up all the time” to P4 that included the facility being understaffed. LE records provided information that was consistent with the information provided by P2, P3, P4, and facility documentation. LE records also showed that after the VA left the facility, the R went out to his/her garage and saw the VA sitting alone in the facility van that was parked in the facility’s driveway. After the R went back inside his/her home, the VA got out of the van and tried to enter the R’s home. The VA “got really aggressive” when trying to open the R’s door but the R remained inside his/her home and “waved [the VA] away.” The VA then picked up “lawn décor” that was on the R’s property and “smashed” it. After this, the VA left the R’s property. Additionally, the R told LE that this incident was similar to past incidents and that the VA has entered the R’s home three times prior to this. During one of these prior incidents, the VA was not wearing any clothing or undergarments. [Note: LE records showed that other residents in the neighborhood also called LE to report similar incidents and concerns of the VA’s elopement from the facility unsupervised prior to this.] Regarding the VA hitting his/her head after falling in the bathroom: SP1, P2, P3, and P4; the facility’s General Event Report completed by P3 dated December 5, 2024; and facility documentation relating to the incident that was completed by supervisory/administrative staff provided the following information: · On December 5, 2024, SP1 and P1 were working at the facility during the dayshift. On this date, the VA remained at the facility with two staff persons while the C attended school and was not present at the facility from approximately 7:30 a.m. to 3:30 p.m. At approximately 11 a.m., the VA was sitting on the couch in the living room with SP1 while P1 was in the kitchen preparing the VA’s lunch. At some point after this, the VA became “agitated” and ran out of the living room, to the back hallway, and into the bathroom. When the VA started to run out of the living room, SP1 stood up from the couch to follow the VA and walked towards the direction that the VA ran to. SP1 was in the back hallway “right outside” of the bathroom door when s/he heard a “loud noise” and then the VA started “yelling.” SP1 entered the bathroom and saw that the ceramic toilet tank lid had “cracked” and it “appeared” that the VA had fallen. SP1 then assisted the VA to walk to the living room so they could assess the VA for injuries but the VA did not have any physical injuries at this time. SP1 did not know how the toilet lid broke and was “worried” that the VA may have hit his/her head in an area where the VA’s hair was covering. · At approximately 12:29 p.m., SP1 sent a text message to P2, P3, and P4 about the incident but none were aware of the message until later in the afternoon. Inconsistent information was provided about what time administrative staff persons responded to the incident. According to P3, at approximately 2:47 p.m., P4 was “the first” to see SP1’s text message and then told SP1 to call 9-1-1 immediately. (Note: Documentation of an email between P2 and G1 showed that at 1:09 p.m., P2 contacted and notified G1 of the incident.) At 2:55 p.m., P2 called emergency services who arrived at the facility shortly thereafter. · According to P2, SP1 contacted and told P2 and P3 that the VA had a “taken a little fall.” At some point after this, P2 received additional information and called the facility. SP1 told P2 that s/he did not know how the toilet lid broke during this incident without leaving any “marks” on the VA but s/he did not see any injuries. P2 then told SP1 that if the VA fell “that hard” and there was “even a suspicion” that the VA hit his/her head, staff needed to call 9-1-1 so that the VA could be assessed for any internal injuries that may have occurred. Shortly thereafter, P2 arrived to check on the VA and talk with the staff. P2 also did not see any physical injuries to the VA but stated a “small bump” could be felt on the top of the VA’s head but staff did not know if it was a result of the incident. At approximately 3 p.m., P2 called 9-1-1 and told the dispatcher that the VA fell in the bathroom and it was “suspected” that the VA hit his/her head. Shortly thereafter, the EMS arrived at the facility and examined the VA but did not see any injuries. Due to the VA’s diagnoses and limited communication abilities, P2 told the EMS that the facility preferred to have the VA assessed by the MHP at the VA’s “preferred hospital” to ensure that the VA did not have a head or internal injury that staff were not able to see. P2 then provided the EMS with the VA’s medical binder and the VA was transported via ambulance to a local hospital. · At an unknown time between 4 to 5 p.m., P2 received a call from the MHP that were caring for the VA. During the call, P2 was made aware that the VA was transported to a different hospital than what was instructed to EMS by P2 and the VA’s plans. After speaking with the MHP, P2 contacted G1 to inform him/her that the VA was transported to a different hospital for evaluation. G1 was “upset” that the VA was taken to the “wrong” hospital because the VA had an extensive medical history and information that might not be available or known to the MHP who were currently caring for the VA. After the call with G1, P2 told a staff person to go to the hospital and stay with the VA until G1 arrived. · On December 6, 2024, at approximately 10 a.m., the VA was discharged from the hospital and SP1 transported the VA back to the facility. Emergency Service records and medical records provided information that was consistent with the information provided by P2, P3, P4, and facility documentation. Additionally, medical records showed that a staff person (who was not identified) arrived at the hospital on December 5, 2024, at approximately 5:39 p.m. and then left the hospital at approximately 6:09 p.m. On December 6, 2024, G1 arrived at the hospital at 8:27 a.m. and was “upset” after seeing that the VA was being provided a medication that s/he was allergic to and put on a medical hold for assessment that was not consistent with why the VA had been transported to the hospital. G1 then told the MHP that s/he wanted the VA to be released from the medical hold and discharged from care to which the MHP agreed upon. The MHP attempted to contact the facility at 9:07 a.m. and then again at 9:14 a.m., but the attempts were not successful. At approximately 10:05 a.m., a facility staff person arrived at the hospital and the VA was discharged from the hospital to the care of the facility. Conclusion: A. Maltreatment: Information from all sources showed that the VA had 2:1 staffing from 6 a.m. to 10 p.m. and that the C had 1:1 staffing during awake hours. When the VA and the C were home together three staff persons were required to be at the facility. However, on multiple dates in November and December 2024, including November 8 and December 1, 2024 (as outlined below); and June 2025, only one or two staff persons were working which was a violation of the VA’s and the C’s plans and a violation of Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a). [Note: The licensing violation related to the December 1, 2024, incident was previously cited in an Order of Conditional license dated April 25, 2025.] Regarding the VA accessing and ingesting cleaning products that contained bleach: The VA was diagnosed with severe intellectual disabilities, autism spectrum disorder, seizure disorder, and sensory disabilities. Additionally, the VA lacked self-preservation skills and had a history of “running” into the kitchen to consume items that were a “danger” to the VA’s health. Information was consistent from all sources that the VA and the C received a 24-hour plan of care and “high level” of monitoring from the facility due to their diagnoses, behaviors, and needs. The VA received 2:1 staffing during awake hours and had no unsupervised time in the community or at the facility. The C received 1:1 staffing during awake hours and was to have a staff person available to assist him/her at all times at the facility, with staff persons providing the C with visual health and safety checks at least every hour when the C was on the lower level of the facility without a staff person. On November 8, 2024, SP1 and SP2 worked at the facility during daytime hours with the VA and the C. Although SP1 told SP2 “everything” about the VA, SP2 had only worked at the facility once prior to this date and was not familiar with the VA or the C. Additionally, the C’s school was not scheduled for this date which caused the C to become “angry” and have aggressive behaviors throughout the morning. According to the C’s care plans, the C “struggled” on non-school days and had a history of physical aggression and property destruction during situations when the C was feeling “angry” or “frustrated.” Although there was some information provided by SP1 that was inconsistent with the information provided by SP2, each stated that at the time of the incident, there was only one staff person present at the facility with the VA. SP1 and SP2 also stated that at an unknown time, SP2 left the facility for a 30-minute lunch break. Additionally, at some point that day, SP1 and the C left the facility to try to get his/her hair cut and ate lunch at a nearby fast-food restaurant. Facility documentation, emergency services and medical records, and all staff persons who provided information for this investigation stated that around 1 p.m., the VA was left unsupervised for an unknown amount of time and able to access a bottle of cleaning product containing bleach that was not stored in a secure space as required. Since it was “suspected” that the VA had then ingested some of the cleaner, emergency services were contacted and the VA was transported via ambulance to a local hospital for evaluation. Information provided by SP1, P3, G1, G2, and the facility’s staff timesheets showed that there were ongoing concerns regarding adequate staffing and staff training that were provided by the facility to the VA and the C. During awake hours on November 8, 2024, two staff persons were working at the facility with the VA and the C when a third staff person was required. Information provided by SP1, P3, P4, the VA’s plans, and emails between P4 and the VA’s prior case manager showed that P4 was aware that the VA received 2:1 staffing from staff who had “extensive experience” working with clients who had similar diagnoses and care needs of the VA. In February of 2023, four days after the VA moved to the facility, P4 contacted the VA’s case manager to request this additional staffing and staff experience to be provided to the VA due to the VA’s “challenging” and “complex” needs and behaviors. Given the VA’s diagnoses and history; that the VA required 2:1 staffing and had no unsupervised time in the community or within the facility; that the VA was able to access and possibly ingest items that were known to be dangerous to the VA’s health and safety, such as household cleaners; and that staff persons were not aware that the VA accessed the cleaning product or observed if it was ingested by the VA or not, there was a preponderance of the evidence that there was a failure or omission to supply the VA with care or service including supervision which were reasonable and necessary to obtain or maintain the VA’s physical 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). Regarding the VA leaving the facility without staff persons supervision: P2, P3, P4, and facility documentation provided consistent information that on December 1, 2024, P6 and P7 worked the evening shift with the VA and the C. At approximately 6:20 p.m., P6 and P7 were both completing job related responsibilities when the VA was able to leave the facility without the knowledge and supervision of either. The VA was unsupervised and in the community for approximately 25 minutes before returning to the facility where staff persons then assisted the VA. Additionally, the VA was outdoors during this time in below freezing temperatures while wearing only a t-shirt, jeans, and plastic gloves. There was no information provided whether the VA was wearing any footwear including shoes and/or socks. LE records provided information that after the VA left the facility, s/he tried to “aggressively” enter a neighboring home and “smashed” the lawn décor that was outside of this residence. Furthermore, there were prior similar incidents that were reported to LE by other residents within the neighborhood. P4 provided information that the VA had a history of elopement that “usually” required the assistance and response of two staff persons to respond to and/or resolve the situation. Given the VA’s diagnoses and history of elopement; that the VA had no unsupervised time in the community or within the facility; that on December 1, 2024, the VA left the facility unsupervised and without staff persons knowledge for approximately 25 minutes which resulted in property damage and a police report; that the VA was exposed to freezing air temperatures without adequate clothing items for approximately 25 minutes; and that the VA left the facility unsupervised and without staff persons knowledge prior to this incident, there was a preponderance of the evidence that there was a failure or omission to supply the VA with care or service including supervision which were reasonable and necessary to obtain or maintain the VA’s physical 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). Regarding the VA hitting his/her head after falling in the bathroom: According to the VA’s plans, the VA was at risk of becoming injured from incidents related to tripping and/or falling due to the VA’s “unsteady gate. Information was consistent from all sources that on December 5, 2024, at approximately 11 a.m., there were two staff persons working at the facility with the VA when s/he ran out of the living room and towards the bathroom while SP1 immediately followed the VA. After the VA ran into the bathroom, s/he tripped and fell as SP1 was approaching the entrance to the bathroom. SP1 then assisted the VA in walking to the living room and checked to see if the VA had any physical injuries since the VA was “yelling” and the lid to the toilet tank was “cracked” after the VA fell. Although the VA did not receive any injuries from the incident that staff could see, SP1 contacted administrative staff persons to tell them about the incident. Later that day, P2 became aware of the incident and went to the facility to check on the VA but did not see any physical injuries. There was a “small bump” on the VA’s head but staff were not aware if this was an injury that resulted from the incident. Staff persons then contacted 9-1-1 to assess the VA for any internal injuries that the VA might have received that staff were not aware of or able to see. Shortly thereafter, the EMS arrived at the facility and transported the VA to a local hospital. Given that SP1 immediately followed the VA after the VA ran out of the living room, that SP1 provided immediate care and assistance to the VA after the VA fell by assessing the VA and notifying supervisory staff person, and that the VA was eventually taken to the hospital for evaluation, there was a preponderance of the evidence that there was not a failure to supply the VA with reasonable and necessary care. It was determined that neglect did not occur (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 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. At the time of each incident [November 8, 2024, when the VA accessed and ingested cleaning products and December 1, 2024, when the VA left the facility without staff persons supervision], SP1 and SP2, and P6 and P7 respectively were responsible for the care and supervision of the VA who received 2:1 staffing and the C who received 1:1 staffing during awake hours. Administrative staff persons were aware of the staffing requirements that were to be provided to the clients and that the facility had ongoing concerns of being understaffed. Given that the facility was responsible for maintaining compliance with Minnesota Statutes including hiring and training staff persons and ensuring required staffing that met the individuals’ needs was maintained, individual staff persons’ responsibilities were mitigated. The facility was responsible for the neglect of the VA. C. Recurring and/or 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 two incidents of substantiated neglect for which the facility was responsible did not meet statutory criteria to be determined as serious because there was no information that on either occasion the VA sustained a serious injury which reasonably required the care of a physician whether or not the care of a physician was sought. Action Taken by Facility: The facility completed an Internal Review and determined that policies and procedures were adequate, but not followed by staff persons. All staff persons were retrained on the VA’s plans and supervision requirements. P6 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On September 29, 2025, the license holder was ordered to forfeit a fine of $2000 as a result of the substantiated maltreatment for which facility was responsible and cited for the violations outlined in this report. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal.
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