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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: 1123033-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh/Beth Virden Christine.Cavanaugh@state.mn.us Suspected Maltreatment Reported: It was reported that: · The facility overcharged a vulnerable adult (VA) for rent and/or staff “stole” the VA’s money. · Staff “overmedicated” the VA and/or had frequent errors when administering the VA’s medications. · Staff did not help the VA when s/he fell to the floor and was unable to get up. Alleged Licensing Violations: It was reported that staff restricted the VA’s access to a telephone, food, and community activities. Date of Incident(s): Ongoing Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 9, paragraph (b), clause (1); and subdivision 17, paragraph (a): In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property 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 June 24, 2025; from documentation at the facility and medical records; and through ten interviews conducted with the VA, the VA’s case manager (CM), the VA’s mental health professional (MHP), facility staff persons (P1-P5), and supervisory staff persons (P6 and P7). The VA’s Individual Abuse Prevention Plan and Self-Management Assessment stated that in March 2024, the VA moved into the facility. His/her diagnoses included major depressive- and panic-disorder. The facility provided at least one staff person 24-hours a day to assist with the VA’s activities of daily living, including hygiene, meal preparation, transportation, and medication management. The VA was not subject to guardianship. The facility was a single-family house where the VA lived with two housemates. Facility documentation stated that P1-P7 received training on the VA’s “care plans” and the Reporting of Maltreatment of Vulnerable Adults Act. It was reported that the facility overcharged the VA for rent and/or that staff “stole” the VA’s money. The VA’s Self-Management Assessment stated that the VA “effectively” handled his/her own finances, and that the facility was not responsible for assisting with the VA’s financial management. The CM said that the VA was overdue in rent and the VA did not know what was happening to his/her money. The MHP said that one time, when on the phone with the VA, s/he overheard a staff person “corner” the VA and take cash out of the VA’s hand. The VA provided the following information: · When the VA moved into the facility, his/her rent was $800/month, which s/he “was having a hard time paying.” The VA paid rent directly to P7. “In the beginning,” P7 told the VA that s/he only had to pay $400 of the $800/month; however, then on an unspecified date, P7 “skipped over to” $500/month, which the VA “struggled” to afford. · More than once, the VA thought his/her “money was missing,” but then would find it misplaced or remembered personally spending it. “It was my own mistake.” The VA had no information staff stole his/her money. P6 and P7 each said that the VA’s rent payments were “an ongoing issue.” “[The VA] barely pays rent.” P7 involved a state ombudsman to develop a payment plan for the VA. There was also concern the MHP told the VA that s/he did not need to pay rent, which was inaccurate and caused confusion for the VA. P1-P7 provided consistent information that they had no concerns anyone was stealing the VA’s money. The VA had a history of not always providing accurate information. The VA might get “mad and angry” and “accuse [others] of stealing.” It was reported that staff “overmedicated” the VA and/or had frequent errors when administering medications. The VA’s Self-Management Assessment stated that the VA had a history of “medication non-compliance,” including taking the wrong dose at the wrong time. Staff administered the VA’s medications, documented the administration electronically, and notified nursing of concerns. The VA provided the following information: · When the VA moved into the facility, s/he “wasn’t on a bunch of meds,” but “now” was prescribed seven to eight pills of which s/he did not know the name or purpose. “I don’t know what the hell they are for.” The VA did not trust staff and wondered if they were “sneaking” or not administering his/her medications. · One night, about two years ago, a staff person administered “two small white pills” to the VA and the VA immediately fell asleep for 10-12 hours. The VA did not recognize the pills. · More than once, the VA woke up and realized s/he had fallen asleep at the dining room table. At least once, the VA believed s/he was asleep at the table for eight hours without any staff waking him/her. · One time, the MHP visited and called 9-1-1 because the VA was “very sleepy.” [Note: The VA’s medical records stated that on June 5, 2025, the MHP and the VA presented at an emergency room with concern facility staff were overmedicating the VA. The VA was “acting abnormal” and feeling “sluggish” and “dizzy and crappy.” The VA was diagnosed with a urinary tract infection and instructed to follow-up with his/her primary care physician to review his/her medications for potential polypharmacy (regular use of five or more medications).] · The VA said that s/he “smoked too much weed,” which caused “memory problems.” P1-P7 provided consistent information that they had no concerns the VA was overmedicated or that medication errors occurred. P1-P7 were not aware of times the VA slept at the dining room table for hours. It was reported that staff did not help the VA when s/he fell to the floor and was unable to get up. The VA’s Self-Management Assessment stated that the VA was “a high fall risk.” The VA used a wheelchair. Staff ensured the VA’s path was free of clutter and assisted the VA when needed. The VA provided the following information: · “Less than three weeks ago,” the VA called 9-1-1 because s/he fell out of bed and yelled for staff but, “They won’t help.” Unidentified staff stated the VA was falling out of bed “on purpose.” · The VA’s bedframe was “flimsy,” and s/he frequently fell out of bed. The MHP said that the VA “falls all the time.” P1-P7 provided consistent information that if two staff were working, they tried to lift the VA up; however, if they were unable or if there was one staff working, they called 9-1-1 for help. P1-P7 were not aware of times the VA fell and was injured or left unattended on the floor. Conclusion: It was reported that the facility overcharged the VA for rent and/or that staff “stole” the VA’s money. The VA and P1-P7 each had no information anyone stole the VA’s money. The VA was supposed to pay $800/month in rent but “struggled” to always pay. For these reasons, there was a preponderance of the evidence that a staff person did not use, withhold, or dispose of the VA’s money. It was determined that financial exploitation did not occur (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). It was reported that staff “overmedicated” the VA and/or had frequent errors when administering medications. The VA said that the s/he had concerns regarding the number of his/her prescriptions and the purpose of each. P1-P7 provided consistent information that they had no concerns regarding the VA’s medications. Given that the VA’s medications were prescribed by doctors, outside of the staffs’ control; that there were no specific dates or names of medications, which were “overmedicated” to the VA; that the VA said s/he smoked “weed” which impacted his/her memory; and that there was no additional information to support the VA’s account that staff were overmedicating him/her, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services, including health care.
It was reported that staff did not help the VA when s/he fell to the floor and was unable to get up. The VA said that when s/he fell, staff did not always help him/her up. P1-P7 provided information that staff called 9-1-1 if they were unable to lift the VA up from the floor and they were not aware of times the VA was injured or left unattended on the floor. For these reasons and without additional information to support the VA’s account, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services, including supervision and health care. 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). Alleged Licensing Violations: It was reported that staff restricted the VA’s access to a telephone, food, and community activities. Minnesota Statutes section 245D.04, subdivision 3, paragraphs (a) and (b) states, in part, a person's protection-related rights include the right to have daily, private access to and use of a non-coin-operated telephone; have freedom and support to access food and potable water at any time; and engage in chosen activities. The VA said that staff restricted his/her access to the facility’s cordless telephone, did not always prepare the VA’s meals or purchase the VA’s preferred groceries, and did not take the VA into the community. P1-P7 provided consistent information that the facility had two cordless phones, and that the VA typically kept one in his/her bedroom. P1-P7 were not aware of staff restricting the VA’s access to the telephone. Staff prepared the VA’s meals, but s/he frequently changed his/her mind on what s/he wanted to eat. P1-P7 were not aware of concerns regarding the amount of food at the facility. Staff routinely offered to bring, and brought, the VA to department stores, gas stations, and appointments. The VA had a history of “changing [his/her] mind” about leaving on an outing. P1-P7 were each not aware of staff declining to take the VA into the community. At the time of the site visit, the DHS investigator saw that the VA had the facility’s cordless phone with him/her. The DHS investigator also saw multiple food items in the pantry and refrigerator and saw food receipts from a range of dates with a variety of food items listed. Given this, and with a lack of information regarding specifics of staff declining to bring the VA into the community, a licensing violation was not determined. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed. The facility updated the VA’s support plans and trained staff on the changes. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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