|
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: 1104769-HCBS (Home and Community-Based Services) Investigator(s): Deb Neubauer-Hoffman/Beth Virden Minnesota Department of Human Services 651-431-6567 Suspected Maltreatment Reported: It was reported that staff did not intervene with a vulnerable adult’s (VA) use of alcohol, marijuana, and/or vape pens; and that a staff person (SP) provided the VA with alcohol and/or vape pens. Date of Incident(s): October 16 and 19, 2024; and other dates unknown 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 November 21, 2024; from documentation at the facility and medical records; and through 16 interviews conducted with the VA, the VA’s family member (FM), the VA’s case manager (CM), facility staff persons (the SP and P1-P10), and supervisory staff persons (P11 and P12). The VA’s support plans, Support Plan Addendum and Individual Abuse Prevention Plan, included the following: · The VA enjoyed going out to eat, journaling, reading, and visiting family and the mall. The VA hoped to graduate high school and live independently someday. · The facility provided the VA with crisis respite (short-term) services, which included a place to stay and at least one staff person, who provided the VA with mental health supports and independence training. · At the time of this investigation, the VA was 18 years old, and his/her diagnoses included post-traumatic stress disorder and schizophrenia. The VA was not subject to guardianship. The facility occupied more than one hotel room, in a hotel-complex, providing crisis respite services to more than one client. Each client had their own hotel room, and the facility provided separate staff for each client. The facility’s website, www.livinghopeofmn.com, stated, “[Crisis respite] provides short-term care for individuals needing intensive supports to allow them to progress, stabilize, and transition. Our crisis respite care serves as a steppingstone back to the community, facilitating the individual’s return to a more integrated setting.” Facility documentation stated that the staff persons interviewed for this investigation received training on the VA’s support plans, and the Reporting of Maltreatment of Vulnerable Adults Act. [Note: The SP specifically received training on the VA’s Support Plan Addendum, which did not include the VA’s birthdate or age. The records provided for this investigation did not include whether the SP received training on any of the VA’s other support plans, including Individual Abuse Prevention Plan. The space on the orientation checklist for this training was blank. This was a violation of Minnesota Statutes 245D.09, subdivision 4a, paragraph (c) which states, in part, that before having unsupervised direct contact with a person served by the program, the staff person must review and receive instruction on each person's support plan or support plan addendum and individual abuse prevention plan, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans.] The SP’s position description stated that his/her responsibilities, included: ensuring the daily wellbeing and safety of the clients; demonstrating an understanding of the client as a unique individual and how to implement programs; and providing person-centered services demonstrated through practice, action, and language. Minnesota state laws, www.revisor.mn.gov, prohibits, and identifies as illegal, the following: · A person under the age of 21 from purchasing and consuming alcohol, marijuana, nicotine, and vape pens. [Note: “Vape pens,” “vapes,” and “vaping” relate to personal vaporizer devices for inhaling substances, such as marijuana or nicotine.] (Minnesota Statutes, section 340A.503; 342.09; 152.0264; and 609.685) · A person lending the person's driver's license or Minnesota identification card to any other person or knowingly permit the use thereof by another; and displaying or representing as one's own any driver's license or Minnesota identification card not issued to that person. (Minnesota Statutes, section 171.22) Regarding staff not intervening with the VA’s use of alcohol, marijuana, and/or vape pens: The CM said that the VA had a history of alcohol and drug use; however, this was not specified in the VA’s support plans and there were no specific or related requirements for staff. The facility provided 24/7 services and 1:1 supervision to the VA. Staff remained present and available to the VA when s/he was at the facility. The VA worked during the day at a restaurant. Facility staff dropped the VA off at work and picked him/her up after work but were not required to stay with him/her at work. The FM said that while at the facility, the VA had access to alcohol and vape pens containing marijuana. The VA mentioned marijuana when speaking about his/her vapes and so the FM believed the vapes contained marijuana. The VA did not tell the FM how s/he obtained the alcohol and/or vapes. The VA provided the following information: · At some point between October 1 and 19, 2024, P7 drove the VA to a “drug dealer” where the VA bought marijuana and P7 bought his/her own marijuana. P7 had rolling papers and parked his/her car behind the facility where s/he and the VA each smoked marijuana. P7 stood outside the car while smoking to lessen the odor on his/her clothing. This was the sole time P7 bought and smoked marijuana with the VA. Another time, P7 drove the VA to a gas station in New Hope, MN, where the VA bought a vape; the cashier did not ask for the VA’s identification card (ID) or verify the VA’s age for the purchase. · On October 20, 2024, the VA was “high” and gave an unknown staff person $40 cash to buy a “huge bottle of whiskey” for the VA. The staff person did so, and the VA poured a shot of whiskey for P3. That night, the VA “felt suicidal” and drank whiskey and took unidentified prescription pills, which s/he had obtained from a friend, and ibuprofen. · The VA said that s/he had “a lot of (marijuana) vape pens,” which s/he got from an unidentified coworker at the VA’s job. More than once, the VA smoked marijuana in the presence of unidentified staff. P1 and P8 were aware the VA smoked marijuana. · The VA said, “I used drugs a lot there (at the facility).” “I am trying to be sober, [but] I am not the best person all the time.” The VA’s Medical Records stated that on October 20, 2024, the VA told healthcare professionals (HCPs) that s/he vaped “every day,” including nicotine and marijuana, and that s/he smoked marijuana “7 times a week” or “on a regular basis.” The VA stated that s/he “snuck” alcohol and marijuana into the facility/his/her hotel room. “[The VA] also mentioned that [his/her staff] bought [him/her] the alcohol and the weed.” The VA told the HCPs that s/he needed help to stay sober. P1-P12 and photographs taken by staff provided the following information: · P2 said that one time, around September or October 2024, an unknown staff person told P2 that the VA “drank too much” and fell by his/her bed. P2 told P11 about this and that the VA was under 21 years old and should not be drinking alcohol. P11 told P2 that s/he did not know how the VA obtained the alcohol but “it would not happen again.” P2 then told “everyone” that the VA should not be drinking alcohol. However, about two or three weeks later, P2 smelled a beer in the VA’s bedroom and again told P11 but P11 did not do anything about it. · P1 and P8 each said that on October 16, 2024, P1 or P2 found a bottle of whiskey in the VA’s bedroom. P8 said that the bottle was empty and P1 could not recall if there was alcohol in the bottle. P1 photographed the bottle and threw it away. The VA did not say anything to P1 or P8 about how s/he obtained it. · P1 provided an undated photograph taken on a cellphone of a ¾ full bottle of Woodford Reserve Double Oaked Bourbon. · P6 said that on October 19, 2024, at 8:45 p.m., s/he saw the VA walking in the hallway while “hiding,” or concealing, a bottle of alcohol under his/her arm. P6 took the bottle and threw it away and told a supervisory staff person (P13), who said that staff should “closely monitor” the VA. · P5 said that around 9 or 10 p.m., the VA asked to go to the emergency room because s/he wanted to “self-harm.” P5 drove the VA but once they reached the parking lot, the VA “changed [his/her] mind” and did not want to go inside. P5 drove the VA back to the facility and the VA grabbed some food and went into his/her room. P5 sat outside the VA’s door and checked on him/her every hour. · P5 and P6 each said that on October 20, 2024, around 1:30 or 2 a.m., the VA vomited and P5 drove the VA back to the emergency room. The VA told the HCPs that s/he consumed alcohol and a “full bottle” of ibuprofen. P6 said that the VA also told the HCPs that s/he hid the bottle of alcohol in a bathroom garbage can. P6 checked the garbage and found an empty bottle of alcohol and a bottle of ibuprofen. [Note: It was unclear if this was the same bottle of alcohol P6 observed the VA “hiding” under his/her arm at 8:45 p.m. October 19, 2024.] · P12 provided undated photographs taken on a cellphone of a nearly empty bottle of Woodford Reserve Double Oaked Bourbon and a bottle of ibuprofen. · P1, P2, P4, P5, P8, and P9 provided information that the VA never asked them to buy anything, including alcohol or marijuana, for him/her. They never observed the VA to be under the influence of a substance and they did not know where the VA obtained alcohol or marijuana. The VA worked at a restaurant in the community and staff were not with him/her when at work but would pick him/her up after work. · P3 said that s/he never drank alcohol or smoked marijuana with the VA. P3 did not know why someone would say that s/he did so. One time, the VA asked P3 to drive him/her to a smoke shop but P3 said, “No,” because the VA was underage. One time, P3 smelled marijuana in or around the VA’s room. · P7 said that s/he never smoked marijuana with the VA and never drove the VA anywhere in the community. If the VA had asked P7 to drive him/her to a vape store, P7 would have said, “No,” because “it’s not allowed.” The VA was under 21 years old, which was the required age to buy a vape. P7 saw the VA with vape pens but did not know where or how s/he got the vapes. P7 never vaped with the VA. · P12 said that the VA had a history of marijuana and alcohol use, and self-harm.
Regarding the SP providing the VA with alcohol and/or vape pens: The VA provided the following information: · One time, the VA bought alcohol using the SP’s ID and the SP’s money. The VA had asked the SP to go to a liquor store and the SP drove him/her to a liquor store in Richfield, MN. The SP went into the store with the VA where the VA selected a medium-size clear bottle of alcohol and two “shot things” of Jack Daniels and pink whiskey. To pay, the SP showed the cashier the SP’s ID and used the SP’s money, $33. The SP then drove the VA back to the facility and the VA “quickly” walked to his/her room carrying the alcohol in a brown paper bag. The VA “got really drunk” in his/her room. · The VA reimbursed the SP using “cash app.” The VA had a screenshot on his/her cellphone of a receipt from September 22, 2024, at 4:57 p.m., where s/he electronically sent $33.62 to someone with the SP’s first and last name. [Note: The facility’s daily notes showed the SP worked with the VA on September 21 and 22, 2024; the SP did not record anything in the daily notes regarding this transaction.] · On an unspecified date, the SP drove the VA to a smoke shop in Brooklyn Park, MN, and used the SP’s ID to buy a vape for the VA. P12 provided the following information: · On October 21, 2024, P12 spoke on the phone with the VA, who was “hesitant” to talk and did not want to get staff in trouble. The VA stated that s/he went with “staff” to a “vape store” and the VA used the staff person’s money to buy a “brown bottle of alcohol” for the VA’s own use. The VA reimbursed the staff person by sending him/her money through “cash app.” When P12 asked for the staff person’s name, and the VA hung up the phone. About two hours later, P12 called the VA and asked for more information. The VA stated, “[The SP’s first name],” and then said something, like, “Your staff should have boundaries.” · On October 24, 2024, P12 met with the SP, who appeared “hesitant” to talk. The SP told P12 that the VA asked to “get a vape” and so the SP drove the VA to an unidentified store. However, the VA did not have his/her ID or money and so the SP gave the SP’s ID and cash to the VA and then went into the store with the VA. The SP watched the VA purchasing items and a cashier putting the items into a brown paper bag, but the SP could not see and never learned what was purchased. The SP then drove the VA back to the facility and the VA reimbursed the SP using “cash app.” P2, P4, P5, and P7 provided information that they saw the VA smoking from a vape but did not know how the VA obtained the vape. The SP provided the following information: · One time, “a long time ago,” the VA borrowed the SP’s credit card to purchase something online before going to the VA’s family member’s house. The SP did not know what the VA purchased. The VA reimbursed the SP, and the SP said that the VA’s screenshot of the cash app receipt for $33.62 was related to this purchase. · “About a month ago” (as of November 23, 2024), the SP drove the VA to a gas station and went inside with the VA where the VA purchased a vape. The VA used his/her own money, and the cashier did not ask for the VA’s ID or verify the VA’s age for the purchase. Prior to this outing, the SP asked an unidentified staff person if the VA was allowed to purchase a vape and the staff person told the SP, “[It’s] okay for [the VA] to get a vape.” The SP knew this staff person’s gender and position title but did not know the staff person’s name. · The SP said that s/he never gave his/her ID to the VA and never purchased alcohol for the VA. “This was a false accusation.” The SP believed the allegation was the result of unidentified staff persons wanting to “blame” the SP for the VA’s alcohol use because the SP was a new employee at the time. Conclusion: A. Maltreatment: Regarding staff not intervening with the VA’s use of alcohol, marijuana, and/or vape pens: The VA told the HCPs that unidentified staff brought him/her “alcohol and weed.” The VA told the DHS investigator that P7 smoked marijuana with him/her, and that P1 and P8 were aware the VA smoked marijuana. The VA also said that P3 drank of shot of the VA’s whiskey. Although more than once a bottle of alcohol was discovered in the VA’s possession, the VA worked independently in the community without staff supervision and provided information that s/he obtained substances from a friend and a coworker, and that the VA “snuck” alcohol and marijuana into his/her room. Consistent information was provided by staff persons that they did not know where the VA obtained the alcohol or marijuana, and without additional information to support any of the accounts, there was not a preponderance of the evidence whether a staff person supplied the VA with alcohol or marijuana, or whether the VA obtained the substances from other sources, and whether there was a failure or omission 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 not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Regarding the SP providing the VA with alcohol and/or vape pens: The VA stated that one time the SP drove the VA to a liquor store where s/he used the SP’s ID and money to purchase alcohol and one time the SP drove the VA to a smoke shop where s/he used the SP’s ID to buy a vape. The SP told P12 that s/he provided his/her ID and cash to the VA to purchase a vape pen and that the VA reimbursed the SP using cash app. The SP said that one time s/he was with the VA when the VA purchased a vape, but the VA was not asked for identification by the cashier. The SP denied giving the VA his/her ID and denied purchasing alcohol for the VA. The VA was underage and not legally allowed to purchase or consume nicotine, marijuana, or alcohol. The VA was also not legally allowed to use another person’s ID to make such purchases.
The VA and the SP provided conflicting information regarding the SP purchasing or allowing the VA to purchase alcohol. However, the VA and the SP were consistent that the SP allowed the VA to use his/her ID and cash to purchase a vape pen on one occasion. The SP’s conduct was illegal, enabled and encouraged the VA to engage in illegal activity, and was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. The VA was living at the facility to receive crisis respite services, including mental health supports and independence training. 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. The SP received training on the VA’s Support Plan Addendum and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for the VA’s care and supervision and for ensuring the daily wellbeing and safety of the VA; demonstrating an understanding of the VA as a unique individual and how to implement programs; and providing person-centered services to the VA demonstrated through practice, action, and language. The SP was responsible for maltreatment of the VA.
C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. 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 neglect for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious. The SP was responsible for a single incident of maltreatment for which the VA did not sustain a serious injury. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed when the SP gave his/her ID to the VA. The facility provided additional training to all staff. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. On October 13, 2025, the facility was issued a Correction Order for the violation outlined in this report.
|
