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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: 1070474-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: It was reported that a staff person (SP) “kidnapped” a vulnerable adult (VA). During the course of the investigation, additional concerns were reported that included: a staff person (P5) driving the VA on the same route that the SP drove during the incident; a supervisory staff person (P2) telling the VA to “get over the trauma of being kidnapped;” that the VA was not allowed to talk to his/her therapist alone; that the VA was denied water; that the VA’s cell phone use was “restricted;” and that staff persons, including P2, called the VA an “asshole.” Date of Incident(s): June 10, 2025, and 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 2, paragraph (b), clause (2); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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 23, 2025; from documentation at the facility and law enforcement records; and through eight interviews conducted with the VA, four facility staff persons (P1, P3, P4, and P5), two supervisory staff persons (P2 and P6), and the VA’s guardian (G). The SP initially agreed to an interview, but the SP then declined to provide information and ended the interview. Attempts were made via phone to contact the VA for follow up information, but the attempts were not successful. The VA enjoyed going out to eat, spending time with others, and going on car rides. The VA was diagnosed with Asperger syndrome and a mood disorder not specified. According to the VA’s plans, the VA was supervised by staff persons at all times, including while in the community. Staff persons were to “always” know the VA’s whereabouts. The VA did not have any restrictions in his/her plans, including regarding who s/he could spend time with. The facility was a split-level home and the upper level included the VA’s bedroom and a medication room. The facility was in a rural area and had a long driveway. The facility had cameras in various areas, including facing the driveway. The SP began working at the facility on August 5, 2024. On June 2, 2025, the SP took a “leave” and there was no date indicated as to when the SP would return. On the morning of June 10, 2025, P1 worked the overnight shift at the facility and was scheduled until 9 a.m. There were no other staff persons scheduled to work at this time, including the SP. Regarding the SP “kidnapping” the VA and P5 driving the VA on the same route that the SP drove during the incident: The VA provided the following information: · On June 10, 2025, around 6 a.m., the VA was asleep when the SP “barged” into his/her bedroom and asked the VA if s/he “trusted” the SP. The VA said that s/he did, and the SP told the VA that s/he had a “surprise” for the VA, which the VA thought was “cool,” and that s/he would meet the VA outside near the SP’s car. The VA then got dressed and went outside to the SP’s car. · The VA got into the SP’s car and the SP “peeled” out of the driveway and his/her car “fishtailed” which was “kind of fun.” During the drive, the SP also “blew” through a stop sign, was “yielding” but not stopping at other stop signs, and drove 60 miles per hour past a school, where the speed limit was typically 30 miles per hour. The SP was “not [driving] very safe” and was not using his/her car turn signals. · The SP drove to a nearby car dealership and the SP and the VA got out of the car. The SP said “crazy stuff,” including that his/her “fucking car” was there. No one was at the car dealership so the SP and the VA got back into the SP’s car. The SP then asked the VA if s/he wanted to meet the SP’s family member and the VA said, “Hell ya.” The SP then began driving again and at some point, the VA saw law enforcement behind the SP’s car with their sirens on. The SP did not initially stop his/her car and the VA became “very scared, was “shaking,” and was “terrified.” However, at some point, the SP stopped his/her car and law enforcement began talking to the SP. The SP told law enforcement that the VA was his/her child. (Note: The VA was not the SP’s child or related to the SP.) Law enforcement then arrested the SP and drove the VA back to the facility. · During the drive, the SP did not say anything threatening or concerning and the VA said s/he was “fine” and did not have any concerns until the VA saw law enforcement driving behind the SP which “scared” the VA. · Approximately three or four days after the incident, P5 took the VA on a van ride, which staff persons typically did with the VA, using the facility van. The VA asked P5 if s/he wanted to see where the SP drove the VA during the incident and P5 said, “Sure.” P5 then drove the VA on the same route that the SP drove during the incident. At that time, the VA was in “shock” so did not think “anything” about P5 driving him/her on the same route. · The VA and the SP typically had a “good” relationship but at times, the SP was “blunt” and “straight up.” The VA said that if someone would have asked him/her prior if the incident would have happened, the VA would have said, “Not a chance in hell.” The G provided the following information: · On the morning of the incident, around 6 a.m., P2 called the G and said that the SP came into the facility and “took” or “abducted” the VA and that 9-1-1 was called. The G said that was “all [P2] said.” The G then drove to the facility and when s/he arrived around 7:30 a.m., the VA had been returned home by law enforcement. The VA told the G that s/he was “scared” and “pretty shaken up.” · The VA was “easily influenced” and the G had concerns that the VA was able to be “abducted” from the facility. Law enforcement told the G that at the time of the incident, the facility front door was unlocked which allowed the SP to “walk” inside the facility. · When the G was at the facility on the date of the incident, P2 was watching video footage of the incident and showed the G. The video footage showed that at the time of the incident, the SP “walked right past” P1 who did not “interact” or “move towards” the SP as the SP walked to the VA’s bedroom. P1 only “watched from the window” as the VA went outside to the SP’s car. However, the video did not have sound so the G did not know if P1 said anything to the SP. · The G did not know why the SP took the VA but s/he heard from the “news” following the incident that the SP had told his/her family members that they “needed to do what [the SP] said” or “someone would die.” · The G also had concerns that two days following the incident, the VA told the G that P5 was “obsessed” about the incident and asked the VA to show him/her where the SP drove him/her. P5 then drove the VA on the same route the SP drove the VA during the incident, which the G thought was “pretty fresh” after the incident to be “revisiting that trauma.” P1, P2, P3, P4, the Pine County Sheriff’s Office police report, the facility Investigative Summary, and video footage from the facility provided the following information: · On June 10, 2025, at approximately 5:30 a.m., P4 was working at another home operated by the same license holder when s/he received a phone call from an unknown person, later determined to be the SP, asking if the VA was there. P4 told the SP “several times” that the VA was not there but the SP “insisted” so. P4 then told the SP that the VA lived at another facility and the SP became “really mad” and told P4 that s/he was the VA’s family member and that s/he was calling 9-1-1. The SP then hung up. · P4 thought the phone call was “weird” so P4 called P2, but P2 did not answer. P4 then called the facility and spoke to P1 to let him/her know about the call. P1 said, “Okay,” and then P4 did not hear anything further at that time. · P1 said that at 5:43 a.m., P4 called him/her stating that the VA’s family member (later determined to be the SP), called the home P4 worked at and wanted to talk to the VA. P4 told P1 that s/he told the SP that the VA did not live at that home and the SP became “mad,” including “swearing” and “screaming,” and then the SP told P4 that s/he was going to call law enforcement. P4 told P1 that s/he wanted P1 to be “aware” of this and P1 “thanked” P4 and then they hung up. · Shortly after P1 spoke to P4, law enforcement “dispatch” called the facility to ask if the VA was “okay.” P1 told them the VA was okay and that the VA was asleep in bed. The “dispatch” then told P1 that s/he would “call off the deputy” who was planning to “come out” to check on the VA. The law enforcement dispatch did not provide any additional information and then P1 and “dispatch” hung up. · P1 said that at 6:08 a.m., s/he was in a medication room near the top of the stairs getting morning medications ready when the SP opened the facility front door, “rushed” inside, and ran up the stairs. P1 was not expecting to see the SP because the SP was on leave and not scheduled to work but was still able to “be on the property.” P1 had “no notification” by anyone that the SP was “not allowed on the property.” P1 then came out of the medication room, stood at the top of the stairs, and asked the SP how she was “feeling” due to the SP being on leave. The SP said, “Thank you for asking,” but did not say anything further about him/herself. However, the SP told P1 that s/he had a “wonderful surprise” for the VA and then the SP went into the VA’s bedroom and woke the VA. P1 thought it was “wonderful” that the SP had a surprise for the VA and P1 did not have any concerns with the SP at that time. · P1 remained near the medication room and the top of the stairs and then the SP left the VA’s bedroom and went outside to his/her car while the VA got up, got dressed, and went outside to the SP’s car. P1 then went to the living room window and watched them from the window, when s/he saw the SP leave with the VA in his/her car at a “high rate of speed.” P1’s “heart sank” and s/he “could not believe [the SP] took [the VA].” P1 then called P3 and law enforcement. · Multiple law enforcement officers (LEO) arrived at the facility and they eventually learned that the SP and the VA were at a nearby car dealership where the SP was “banging” on the door and the VA and the SP appeared to be “arguing.” The LEOs then left and drove to the car dealership. During that time, the LEOs were notified that the SP and the VA had gotten back in the SP’s car and “fled the [car dealership] at a high rate of speed.” At some point after, the LEOs located the SP who was driving at a “high rate of speed.” The LEOs drove behind the SP with their emergency lights “activated” but the SP continued driving and did not stop. The LEOs then “activated” their siren and the SP eventually stopped. The SP got out of his/her car and “yelled” that s/he was going to his/her home, that s/he was the VA’s family member, and that s/he “owned the road.” The SP did not listen to the LEOs “commands” and began to walk away from them. However, the SP was eventually handcuffed and the SP was arrested for kidnapping or “removing any person-no consent.” The SP was also charged with obstructing the legal process and fleeing a peace officer in a motor vehicle. [Note: At the time of this report, the legal action was still pending.] · During this time, the VA was standing outside the SP’s car and his/her hands were “shaking.” The VA told the LEOs that s/he did not know why the SP was “acting this way” and that s/he was “scared.” The VA said s/he had been “abruptly” awoken by the SP with the SP telling him/her that s/he “had to go with” the SP because the SP had something to show the VA. Because the SP was a staff person, the VA thought that the SP had “permission” to take the VA so the VA got into the SP’s vehicle and the SP began driving “recklessly.” The SP then drove to the car dealership to “switch cars” but the car dealership was not open. The VA told the LEOs that the SP then continued driving and that during this time, P2 was trying to call the SP “repeatedly” to return the VA to the facility but the SP threw his/her phone out the window. The VA said that the SP spoke “weird” during the drive and asked “weird” questions such as asking about the VA’s favorite movie. The VA also told the SP to stop his/her car “several times” but the SP “refused to stop” and told the VA that s/he “owned the road.” · Law enforcement drove the VA back to the facility. The VA was “medically okay and uninjured” but, the VA began crying once s/he returned to the facility. · P2 showed law enforcement facility video footage from the incident which showed the SP arriving to the facility, going inside and upstairs to where the VA’s bedroom was, and the SP and the VA leaving via the SP’s car. The SP was driving “recklessly” while leaving with the VA. (Note: This investigator also viewed the video footage which was consistent to what law enforcement described and was consistent with what P1 described.) · At some point, the LEOs spoke to the SP’s family member who said that the prior evening, the SP had been texting another family member “all night long” with “non sensical communication.” The SP’s family member was “worried” that the SP was going to “hurt” him/herself or someone else, including one of the SP’s family members, so the family member called in a “welfare check” on the SP. (Note: When the family member notified law enforcement for the welfare check, the SP was already in custody regarding the incident with the VA.) The SP also sent his/her family member a video telling the family member to do what s/he said or “someone will die.” The family member said that in the background of the video was a list of the facility houses. · P1, P2, and P3 said that there was no indication that the SP would take the VA prior to the incident but P2 said that the SP was “upset” that s/he was on a leave and unable to work. P2 and P3 said that the SP was not supposed to be at the facility because s/he was on leave. P3 also said that the SP was not “banned” but did not have a “reason” to be at the facility because s/he was not working. P1 and P2 said that the SP did not notify any staff person prior to taking the VA and the SP did not tell anyone that s/he wanted to harm the VA. · P1, P2, and P3 each said that at the time of the incident, staff persons did not typically lock the facility exterior doors and could choose whether to lock them or not. · P2 and P3 also said that at some point after the incident, P5 drove the VA on the same route the SP took the VA during the incident. However, when P2 and P3 spoke to the VA and P5, each provided different information regarding this. The VA told P2 that P5 asked him/her if s/he wanted to drive the route. P3 said that P5 told him/her that the VA asked to drive the route and P3 “believed” P5 because the VA tended to “embellish” things.” P2 and P3 each said that the VA enjoyed van rides. P5 provided the following information: · P5 worked at the facility on the date of the incident, after the VA returned. Throughout the day, the VA’s “emotions” were “up and down” including that the VA was “confused” as to why the incident occurred. · Prior to the incident, the SP “always complained” about the VA so P5 thought it was “odd” that the SP “took” the VA. However, P5 did not have any indications that the incident would have occurred. · Approximately one week after the incident, the VA asked P5 to take him/her on a van ride to drive the same route the SP drove the VA. P2 told P5 that staff persons were supposed to “work through” “trauma” from the incident so P5 thought it would “help” the VA. P5 did not know the area where the SP took the VA and the VA “did not know either” so P5 “turned around.” However, during the drive, the VA said that s/he had “fear” that the SP would “come get [him/her].” The VA also expressed “excitement” and thought it was “cool” that s/he had been “kidnapped.” The VA typically “enjoyed” going on van rides. · At the time of the incident, the facility doors were typically unlocked during the overnight and it was “up to” staff persons if they wanted to lock the doors or not. However, following the incident, the doors were locked “every night.” Regarding additional concerns that included: P2 telling the VA to “get over the trauma of being kidnapped;” that the VA was not allowed to talk to his/her therapist alone; that the VA was denied water; that the VA’s cell phone use was “restricted;” and that staff persons, including P2, called the VA an “asshole”: The G, the VA, P1, P2, P3, P5, and P6 provided the following additional information: · The G stated that following the incident, the VA told the G that P2 and another supervisory staff person (P7) told the VA that the “kidnapping” incident happened a “month” ago and that the VA needed to “get over the trauma of being kidnapped.” The G felt that there was “retaliation against” the VA from P2 because of the incident. The VA said that staff persons, including P2, told him/her to move on from the incident with the SP which made him/her “upset,” because staff persons and others, including the VA’s therapist, told the VA “different” things regarding how s/he should process the incident. P2, P3, and P5 said that at some point, P7 spoke to the VA about helping the VA to move past the incident with the SP. P2 and P3 each said that no staff person, including P7, told the VA to “get over it.” However, P2, P3, and P5 said that the VA told staff persons that s/he wanted to “stop talking” about or “get over” the incident because it “upset” him/her and P5 said that P7 told the VA to then “get over it” but that P7’s words got “twisted” and “taken out of context” by the G. P1 was not aware of any staff person telling the VA to “get over” the incident. · The G stated that the VA told him/her that P2 “refused” to let the VA speak to his/her therapist or psychiatrist alone and that the VA “did not like” having staff persons with him/her during those appointments. However, the G also said that a couple years prior, the VA wanted to have staff persons attend those appointments with him/her. The VA said that s/he had virtual therapy appointments and that the only place to do them was in the staff office, due to the facility internet connection. Because there were things the VA could not have access to in the office, the VA needed to have staff persons with him/her. The VA did not have any concerns regarding this but said that the G wanted the VA to speak to his/her therapist alone. P3 said that the VA had virtual therapy appointments but that staff persons had “attempted” to have the VA seen in person but there was no availability that worked for the VA’s and the therapist’s schedule. P6 said that the VA had in person and virtual appointments but that the VA’s prior guardian and/or staff persons were typically present, which P2 said was the VA’s preference, and it was “never an issue.” P2, P3, P5, and P6 also said that the only way for the VA to do the virtual appointments was in the staff office on a desktop computer with a camera. However, there were things in the office that the VA could not have access to unsupervised, so staff persons remained in the office with the VA. P2, P5, and P6 also said that the G said that s/he would “work” on getting the VA a “device” for the VA’s bedroom or for other assistance regarding this, so that the VA could have the appointments in his/her bedroom or elsewhere, but that “hasn’t happened yet [Note: The G said that s/he “did not realize” that the facility was waiting on him/her to get the VA a device.”] P1 was not aware of the VA not being allowed to speak to his/her therapist alone. · The G said that on August 5, 2025, the VA was “denied water” which led to an “aggressive response” from the VA and the VA being “sent” to the hospital for an “overnight hold.” The G had concerns that the water was withheld due to “retaliation” to the VA because of the incident with the SP. P1, P2, P3, P5, and P6 said that no staff person withheld water from the VA and that there was a CulliganTM water system accessible to everyone, including the VA, in the kitchen of the facility. However, the VA had a history of urinary incontinence so staff persons assisted the VA with reminders not to drink a lot of water prior to bed. P1 also said that it was the VA’s “idea” to not drink “liquids” after 8 p.m. due to urinary incontinence. · The G stated that the VA told him/her that the facility “restricted” the VA’s cell phone access. The G said that at some point when the VA first got a phone, the G, the VA, and staff persons talked about using the phone as an “incentive plan” for the VA, including for the VA’s teeth brushing, because the VA had a history of “oral health problems.” The VA and the G “agreed” to this and the G thought that this was documented in the VA’s plans but later, the facility told the G that they could not “enforce” this because it was not in the VA’s plans. P2 and P3 said that at some point, the G told staff persons to remove the VA’s phone from him/her at 9 p.m. each night so that the VA was not using his/her cell phone “all night.” P5 also said that prior to the incident with the SP, the G and a prior guardian told staff persons that if the VA did not complete hygiene tasks such as brushing his/her teeth or showering, then the VA was not to have his/her phone. However, once P2 and P6 found out staff persons were doing so, which P6 “heard” was at the request of the G, P2 and P6 stopped removing the VA’s phone because there was no documentation or rights restriction for this in the VA’s plans. Additionally, P1 said that at some point, the VA asked to “turn in” his/her cell phone each night so that s/he would not “loose” it. However, the VA was able to access it any time and it was “never restricted.” · The G stated that the VA told him/her that P2 called the VA an “asshole” to the VA’s “face” and also when talking to the G. The G had not heard P2 call the VA an “asshole” to the VA’s face and the G did not have “specific” information such as dates of when this occurred. The VA said that no staff person called him/her an asshole or any similar names and the VA did not have any concerns with P2. P1, P3, P5, and P6 were not aware of any staff person calling the VA an “asshole” and never saw any staff person, including P2, call the VA that. P2 denied calling the VA an “asshole” and denied telling anyone the VA was an “asshole.” · P6 said that the VA was “playing” staff persons “against” the G because since the incident with the SP, the VA wanted to move out. The VA and P3 said that the VA wanted to move because the SP was in a nearby jail and the VA felt “unsafe.” P2 and P6 said that the VA did not always tell the “whole truth.” The VA had lived at the facility for approximately 15 years and P2, P5, and P6 were not aware of any issues the G had prior to the incident. P1, P3, and P5 also said that since the incident, the G did “not get along” with P2, which P3 said was because P2 was “very straight forward.” P1 did not know why the G did not like P2 but said that the G was “nasty and foul” to P2 and when that happened, P2 “kept [his/her] cool” with the G but was later “in tears” regarding the G’s “treatment” of him/her. P2 said that since the incident, the G had concerns with the facility, including with P2. The Employee Handbook and the Use of Equipment and Vehicles said that staff persons were to drive in a safe and courteous manner, including obeying the speed limit and obeying all state motor vehicle laws. Only “authorized” visitors were allowed at the facility. If unauthorized visitors were on the “premises,” staff persons were to immediately notify supervisory staff persons and if there was any perceived imminent danger, staff persons were to call 9-1-1. The SP, P1, P2, P3, P4, P5, and P6 were trained on the VA’s plans; the facility policies and procedures, including the Employee Handbook and the Use of Equipment and Vehicles; and on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Regarding the SP “kidnapping” the VA: On June 10, 2025, around 6 a.m., the SP came to the facility, woke the VA up and told the VA s/he had a “surprise” for him/her, and when the VA came outside s/he got into the SP’s car and the SP drove away with the VA. When the SP was driving with the VA, the SP was described by the VA and law enforcement as driving “recklessly,” including at a “high rate of speed,” not stopping at stop signs, and not initially stopping for the LEOs when they attempted to pull the SP’s car over. The SP was arrested and charged with kidnapping or “removing any person-no consent,” and fleeing a peace officer in a motor vehicle. The VA was uninjured but said that s/he felt “very scared,” was “shaking,” and “terrified.” Although the SP took the VA from the facility when s/he was not scheduled to work, the VA did not have any restrictions in his/her plans regarding who s/he could spend time with and without additional information, including from the SP, it was unknown what the SP planned to do with the VA. However, given that the SP failed to obey traffic laws by driving “recklessly,” including at a “high rate of speed,” not stopping at stop signs, and not initially stopping for the LEOs when they attempted to pull the SP’s car over and that failing to follow traffic laws was not therapeutic or accidental and placed the VA at risk of harm, there was a preponderance of the evidence that the SP failed to supply the VA with care or services which are 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). Regarding P5 driving the VA on the same route that the SP drove during the incident: Additionally, although there were concerns that days after the incident, P5 drove the VA on the same route that the SP drove the VA, which caused “trauma” for the VA, information showed that the VA enjoyed van rides and typically went on them, and the VA, P3, and P5 each said that the VA asked P5 to drive the route and that when they did, the VA said that s/he did not think “anything” about it. P5 also said that neither s/he nor the VA knew where they were going so P5 “turned around.” Therefore, there was a preponderance of the evidence that there was not a failure to supply the VA with care or services which are reasonable and necessary to maintain the VA’s physical or mental health or safety. 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). Regarding additional concerns that included: P2 telling the VA to “get over the trauma of being kidnapped;” that the VA was not allowed to talk to his/her therapist alone; that the VA was denied water; that the VA’s cell phone use was “restricted;” and that staff persons, including P2, called the VA an “asshole”: Although the G stated that P2 told the VA that the “kidnapping” incident happened a “month” ago and that the VA needed to “get over the trauma of being kidnapped;” that P2 “refused” to let the VA speak to his/her therapist or psychiatrist alone; that the facility restricted the VA’s access to water and the VA’s cell phone access; and that P2 called the VA an “asshole,” there was no information that supported that these things occurred. The VA said that staff persons, including P2, told him/her to move past the incident with the SP which made him/her “upset.” However, P2, P3, and P6 said that staff persons helped the VA move past the incident including because the VA told staff persons that s/he did not want to talk about it. The VA had virtual appointments with his/her psychiatrist/therapist provider and due to internet access, the only place for the virtual appointment was in the facility office, where there were things that the VA could not have access to alone. Therefore, it would be reasonable for staff persons to monitor the VA while the VA was in the office during his/her appointment. Attempts were also made to provide in person visits for the VA and for the G to get the VA another device to do his/her visits in his/her bedroom. The VA said s/he had access to water but staff persons reminded the VA not to drink a lot of water at night due to incontinence. At some point, staff persons restricted the VA’s cell phone access, which the G and staff persons said was in agreement with the G, but once supervisory staff persons became aware, they stopped doing so. The VA also said that no staff person called him/her an asshole and no staff person observed P2 or any staff person call the VA an “asshole.” Given the aforementioned, there was not a preponderance of the evidence whether staff persons actions could reasonably be expected to produce emotional distress to the VA or whether there was a failure to supply the VA with care or services which are reasonable and necessary to maintain the VA’s physical or mental health or safety. It was not determined whether emotional abuse or neglect occurred (Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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. Prior to the incident, the SP was trained on the VA’s plans, the Reporting of Maltreatment of Vulnerable Adults Act, and on the employee handbook and use of equipment and vehicles policy which stated that staff persons were to obey all traffic regulations. Although the SP was on leave at the time of the incident, the SP remained an employee of the facility. 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 because it was a single incident and was not serious because the VA did not sustain a serious injury which reasonable required the care of a physician. Action Taken by Facility: The facility completed an internal review and determined that the SP’s actions of taking the VA were a “serious violation” of the facility policies and a “breach of ethical and professional standards, specifically involving conduct that placed [the VA’s] safety at risk.” The SP did not follow facility policies and procedures. However, once staff persons became aware of the incident, they followed policies and procedures. Additionally, following the incident, the facility doors were to be locked “24 hours a day.” 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.
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