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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: 1070041-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman/Beth Virden Minnesota Department of Human Services 651-431-6567 Suspected Maltreatment Reported: It was reported that staff left a vulnerable adult (VA) in his/her wheelchair for 20 hours and during that time, staff did not administer the VA’s medical treatment, empty the VA’s catheter bag, or reposition the VA causing skin breakdown around his/her preexisting wound. Date of Incident(s): Ongoing between March 2 and 3, 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 19, 2025; from documentation at the facility; and through seven interviews conducted with the VA, the VA’s case manager (CM), facility staff persons (P1 and P2), and supervisory staff persons (P3, P4, and P5). The VA’s Support Plan and Self-Management Assessment provided the following information: · In October 2024, the VA moved into the facility seeking support and services relating to his/her diagnoses, which included paraplegia (paralysis) of his/her lower extremities. · The VA was “intelligent, social, [and] resourceful,” and wanted to be as independent as possible with all tasks and live independently someday. The VA told staff when s/he needed assistance. The VA had shared (1:4) staffing during overnight hours. The VA was not subject to guardianship. · The VA had upper body mobility and strength and used a manual wheelchair to get around. The VA repositioned him/herself independently but needed help transferring into and out of his/her bed, wheelchair, etc. Staff used a mechanical lift to transfer the VA. [Note: There was no information regarding the number of staff required to be present when using the mechanical lift for the VA.] · The VA had an electric bed that s/he could independently change the positioning and elevation. “[The VA] does not like to get into bed due to [his/her] current bed being smaller than expected. [S/he] is afraid that once in bed [s/he] will not be able to get up and maneuver [in his/her] environment.” The VA’s legs retained liquid if they were not elevated “often.” · Staff helped with the VA’s medical treatments, including catheter care and maintenance, and administered a suppository at midnight each night, which typically produced a bowel movement for the VA around 2 to 3 a.m. [Note: According to webmd.com, a suppository is a dosage form used to deliver medication by insertion into a body orifice, such as the rectum.] · The VA preferred to “fall asleep” around 4 a.m. and be “transferred out of bed” around 11 a.m. or noon. [Note: The Support Plan and Self-Management Assessment did not state what time(s) the VA preferred to be transferred into bed at night.] The facility occupied one side of a duplex with the other side being another program operated by the same license holder. The license holder provided staff on each side of the duplex. The facility’s Program Abuse Prevention Plan stated that the facility provided a 2:4 staffing ratio (two staff per four clients). A staff schedule showed that at least two staff were scheduled at the facility 24-hours a day. The VA provided the following information: · On March 2, 2025, around 11 a.m., staff transferred the VA from bed into his/her wheelchair. The VA then remained in his/her wheelchair that day. The VA preferred to be transferred back into bed around midnight, “sometimes earlier.” However, on March 2, P1 and P4 asked if the VA was okay being transferred into bed before 10 p.m. The facility was short-staffed that night and P1 would be the sole staff working at the facility between 10 p.m. and 7 a.m. the next morning. · The VA “was told” s/he required two staff to use the mechanical lift and be transferred into bed at night. If after 10 p.m., P1 was the sole staff working, the VA would be “stuck” in bed until staff arrived the next morning. The VA’s “biggest fear” was being left in bed and losing his/her freedom of movement. · There was one staff person (P8) working on the other side of the duplex (commonly referred to as, “next door”). However, the VA did not know P1, P4, or P8; they were “strangers” to the VA. The VA said, “I’m uncomfortable with staff I don’t know.” The VA was “uncomfortable [being] naked” in front of unfamiliar staff and having them insert his/her suppository and then clean him/her after a bowel movement. The VA wanted there to be “regular” staff on each shift but with short staffing, this did not always happen. [Note: P1 provided information to the DHS investigator that the VA told him/her that s/he was uncomfortable with P1, P4, and/or P8 using the mechanical lift since the VA was unfamiliar with them.] · So, on March 2, 2025, when P1 and P4 asked to transfer the VA into bed before 10 p.m., the VA said, “No,” and spent the entire night sitting in his/her wheelchair. P1 did not check on the VA at any point that night, and since the VA was in his/her wheelchair, P1 did not administer the VA’s suppository or clean the VA’s preexisting wound, which was supposed to be done “at night.” P1 also did not ask to empty the VA’s catheter bag. · On March 3, 2025, around 7:30 or 8 a.m., two staff arrived for the morning shift. At that point, the VA had been sitting in his/her wheelchair for around 20 hours and his/her catheter bag was full. The morning staff transferred the VA into his/her bed for a few hours to reposition him/her, complete wound cares, and empty his/her catheter bag. · The VA said that March 2-3, 2025, was “super stressful” and “disheartening.” Facility documentation and P1-P5 provided the following information: · P3 said that the day of, or just prior to, March 2, 2025, more than one staff abruptly ended their employment, most worked the overnight shift, for reasons relating to the VA’s “behaviors.” “No one was willing” to work the overnight shifts with the VA. P3 called five staff to come in and they all “refused to work.” P1 was the sole staff, who agreed to work March 2-3, 2025. P4 also agreed to work for a few hours that evening to help P1 transfer the VA into bed. · P1 and P4 each said that at or around 10 p.m., they arrived at the facility. · P4 said that s/he “explained the situation” to the VA. The facility was short-staffed and while P1 would be working the entire night, P4 was only there for about an hour to help P1 transfer the VA into bed. P4 told the VA that s/he understood it was “a bit early” for the VA to go to bed. · P1-P4 each said that the mechanical lift needed two staff when used for the VA. P5 said that it could be used with one staff. The VA was not able to transfer him/herself into or out of bed. · P4 said that the VA declined to be transferred into his/her bed and told P1 and P4 to leave his/her bedroom. About 15 to 20 minutes later, P1 and P4 approached the VA again with the same request to be transferred into bed around 10:30 or 11 p.m. The VA again declined and said that s/he did not trust P1 and P4. P4 waited at the facility about an hour to see if the VA changed his/her mind. At 11:30 p.m. before leaving, P4 told P8 to leave the connecting door between the duplex sides open in case of emergency. · P1 said that after P4 left, s/he checked on the VA every two hours while the VA sat in his/her wheelchair in his/her bedroom. “I thought it best to give [the VA] space.” The VA “got mad” each time P1 checked on him/her. P1 added, “I tried to do the best I can. [The VA] was safe ... No matter what I do, I was not going to make [the VA] happy.” P1 told the VA, “If you need help, there’s [P8] next door that can help me … [The VA] was told … that we, we would have helped [him/her].” P1 said, “If we had to get [the VA] into bed, we could’ve done it. We’ve done this type of work for a while so we could have got [him/her] into bed safely.” · P1 said that s/he had worked with the VA three times prior to March 2-3, 2025, but never as the sole staff and was “not trained to work” at the facility. P1 did not know if the VA had a catheter, but said, “I think [s/he] does.” · P5 said that s/he told P1, “We will use [P8] in case anybody needs cares. You know, the offices (between the duplex sides) are connected. [P8] could assist [P1] if there was somebody who needed care that [P1] couldn’t do by [him/herself].” [Note: It was not stated when P5 told this to P1, whether before March 2-3, 2025, or after.] · P2 said that on March 3, 2025, around 7:30 a.m., s/he arrived at work and saw the VA awake and sitting in his/her wheelchair in the living room. P2 was late to work and so did not meet with the staff person from the shift before. P2’s coworkers for the day (P6 and P7) were already present and looked “upset,” which P2 did not immediately understand until s/he talked to the VA. The VA told P2 that s/he had been in his/her wheelchair since around 11 a.m. or noon the previous day, March 2, 2025, and that s/he “refused” to be transferred into his/her bed because there was not enough staff to transfer him/her out of bed if needed. “[The VA’s] biggest fear is getting stuck in bed.” · P2 said that around 7:45 a.m., P2 and P6 transferred the VA into bed and noticed the VA’s legs were “very swollen” and the VA’s suprapubic catheter bag was “super full to where urine was flowing back into [the VA’s] bladder.” The catheter site had “an open sore/wound and [was] bleeding.” The VA’s preexisting wound on his/her buttock was “irritated and red.” P2 had not seen the VA in over a week and so did not know what his/her catheter site or wound looked like the day prior. · P2 administered the VA’s “scheduled suppository that should have been given overnight [March 2-3].” P2 cleaned the VA’s catheter site and wound and asked if the VA wanted to go to the emergency room, but the VA declined. P2 was not aware of the VA sustaining an infection or needing increased wound care following the incident. [Note: A schedule showed P2 worked with the VA between 7 a.m. to 3 p.m., March 3, 4, 5, and 7, 2025.] The CM said that the VA experienced “a lot of trauma” after his/her “life-changing” accident that left him/her in a wheelchair and, at times, was “a difficult person to serve.” The VA did not always provide accurate information; “Things can get skewed.” The CM did not have concerns with the facility’s overall care and supervision of the VA. Facility documentation stated that P1-P5 received training on the Reporting of Maltreatment of Vulnerable Adults Act. P2-P5 received training on the VA’s Support Plan and Intensive Support Self-Management Assessment and P1 received unspecified training on “[The VA’s initials].” Relevant Minnesota Statutes and Rules: Minnesota Statutes 245A.65, subdivision 2, states, in part, the license holder shall establish and enforce ongoing written program abuse prevention plans. Minnesota Statutes 245D.07, subdivision 1a, paragraph (a) states, in part, the license holder must provide services in response to the person's identified needs, interests, preferences, and desired outcomes as specified in the support plan and the support plan addendum. Conclusion: Information was consistent that between March 2 and 3, 2025, the VA sat in his/her wheelchair for 20 hours straight, which the VA described as “super stressful” and “disheartening.” On March 3, 2025, at approximately 7:45 a.m. P2 and P6 transferred the VA into his/her bed, administered the VA’s suppository, cleaned the VA’s wound, and emptied the VA’s catheter bag. The VA did not sustain an infection or need additional medical- or wound-care following the incident. The facility’s Program Abuse Prevention Plan stated that the facility provided a 2:4 staffing ratio, which was not provided March 2-3, 2025, and was a violation of Minnesota Statutes 245A.65, subdivision 2. In addition, the VA’s catheter- and suppository-cares were not completed during the overnight of March 2-3, 2025, which was a violation of Minnesota Statutes 245D.07, subdivision 1a, paragraph (a). Although the VA described the incidents as “super stressful” and “disheartening,” the VA chose to decline P1’s and P4’s help to transfer into bed between 10 and 11 p.m. The VA said that s/he did not trust or feel comfortable with P1, P4, and/or P8 completing his/her cares because they were “strangers” to the VA and not the facility’s “regular” staff. After P4 left, P1 said that s/he told the VA that P8, next door, was available to assist if needed, but the VA continued to “refuse.” The VA was not subject to guardianship. Although P1 did not complete all the VA’s cares, the VA did not sustain an infection or need additional medical- or wound-care following the incident. Given this and that the VA having options to transfer into bed during the 20 hours but declined to do so, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services, which reasonable and necessary to maintain the VA's health or safety. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. “At no time will the team consider staff on duty [next door] as part of their solution to meet staff ratio needs.” On March 2, 29, and 31, 2025, the facility did not have two staff on duty as required in the Program Abuse Prevention Plan. On March 2 and 29, staff “resigned effectively immediately,” which led to “last minute concern” to find staffing to cover the shift. To ensure services were provided, a second staff was at the facility between 10 and 11 p.m. to help the VA into bed, but the VA declined help and chose to remain in his/her wheelchair. The facility provided additional training on the VA’s plan of care, made changes to ensure “adequate staffing,” and hired additional staff. Action Taken by Department of Human Services, Office of Inspector General: On October 13, 2025, the facility was issued a Correction Order for the violations outlined in this this report.
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