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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: 1076913-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Brittany Dolen 651-431-6701 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) failed to complete required fifteen-minute checks on a vulnerable adult (VA). The VA, who was to refrain from using drugs, left the facility, walked to a smoke shop, and purchased marijuana. Date of Incident(s): August 13 or 14, 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 September 5, 2025, from documentation at the facility and through eight interviews conducted with three supervisory staff persons (P1, P2 and P3), three facility staff persons (P4, SP1 and SP2), the VA’s case manager (CM), and the VA. The VA was diagnosed with schizoaffective disorder, bipolar type, and had a history of substance abuse and physical violence. The VA was on a civil commitment and required assistance with transportation, coordinating his/her schedule, and ensuring s/he attended scheduled appointments. The VA wished to live independently, enjoyed recording and writing music, being active, and spending time with staff persons and other residents at the facility. The VA’s Intensive Support Self-Management Assessment (ISSA) dated February 26, 2025, stated that the VA had two hours of unsupervised time in the community and at the facility, and that staff persons were to be present on the premise when the VA was home. The assessment did not specify whether the VA’s unsupervised time included the yard of the facility. The VA’s Risk Assessment (RA) dated August 21, 2025, stated that the VA was under a civil commitment and had a provisional discharge. The RA provided conflicting information to the ISSA and stated that the VA had two hours of unsupervised time at the facility and no unsupervised time in the community. There was no information provided regarding whether assessment did not specify whether the VA’s unsupervised time included the yard of the facility. The VA’s Civil Commitment/Provisional Discharge stated that the VA “shall abstain from the use of alcohol and other non-prescribed drugs.” Team Meeting Minutes dated February 24, 2025, stated that the VA “talked about wanting alone time in the community, at home, and with family. [S/he] stated [s/he] would like to go to the store by [him/herself] . . . . . The team did deliberate [sic] about this and approved two hours of alone time both at home and in the community.” [Note: On March 6, 2025, for reasons unrelated to this report, the VA no longer had unsupervised time in the community.] The VA1, the CM, P1-P4, SP1 and SP2 provided consistent information that the VA did not have unsupervised time in the community. Because the VA had left the facility unsupervised, on July 30, 2025, the CM and the facility agreed upon and implemented the Outside Tracker, which documented fifteen minutes checks of the VA. The VA’s Outside Tracker stated, “PLEASE CHECK ON [the VA] EVERY 3 MINS IF [S/HE] IS OUTSIDE [S/HE] NEEDS TO BE IN EYESIGHT WHILE [S/HE] IS OUTSIDE!!” (Emphasis in original) [Note: Information from all sources was consistent that the VA required 15 minutes checks. P2 stated to disregard the information on the Outside Tracker regarding three-minute checks and “in eyesight while outside.”] The VA provided the following information: · The VA often smoked cigarettes in the yard outside of the facility. When the VA smoked in the yard, s/he smoked in “different places,” so it was easier to leave the facility without staff persons knowing. · On an unknown date and time, the VA “made sure” staff persons were busy with other residents and then s/he left the facility. The VA “rushed” to a smoke shop that was four to five minutes away where s/he purchased marijuana. The VA then “rushed” back to the facility and was gone “maybe ten minutes.” · The VA said that “maybe ten times” prior to this incident, s/he left the facility unsupervised, “sometimes” leaving from the front and “sometimes” out the back. The VA walked to the smoke shop and purchased marijuana. The VA knew s/he was not supposed to leave the facility and did not think staff persons knew when s/he left. · The VA kept the marijuana in his/her pocket. When the VA smoked marijuana, s/he also smoked a cigarette so staff persons could not distinguish the smells. · After the incident, the VA gave his/her debit card to P1, so the VA did not have money available and then did not feel the need to leave the facility. www.googlemaps.com showed that the smoke shop was 0.2 miles from the facility and was approximately a five-minute walk from the facility. However, a direct path through yards would be approximately half that. The CM provided the following information: · Due to the VA’s diagnoses and commitment s/he was not to use alcohol, illegal substances, or marijuana because it put the VA at risk of “psychosis.” In the past when the VA used substances, s/he had “active psychosis” and “active delusions” which caused him/her to be physically violent. The VA did not believe his/her diagnoses and when the VA had delusions, s/he acted on them because they were “very, very real” to the VA. · Between February 24, and March 6, 2025, the VA had two hours of unsupervised time in the community. The CM “never saw” the VA’s plans, and did not know if they were updated after his/her unsupervised time was “revoked.” The CM believed the yard of the facility was considered “community” as it was not inside the residence. · On July 29, 2025, “informal” fifteen-minute checks started for the VA, but the Outside Tracker was not created or implemented until July 30, 2025. · On an unknown date, the VA called the CM and told him/her that on August 14, 2025, while SP1 and SP2 worked, the VA left the facility, walked to a smoke shop and purchased marijuana. The VA told the CM that SP1 and SP2 were “busy” with other residents so the VA “just left.” The VA thought s/he was gone for half-an-hour and did not think SP1 or SP2 knew the VA was and/or had been gone. After speaking with the VA, the CM emailed P1-P3 and told them what the VA said. P3 responded and told the CM that the VA leaving the facility was “very concerning” and that P1 and P2 would speak with SP1 and SP2. · On August 15, 2025, P1 called the CM and told him/her that P1 “caught” the VA smoking marijuana that morning. The CM was unable to go to the facility, so another professional went to the facility and gave the VA a drug test, which was positive for marijuana. · On August 29, 2025, the CM attended the VA’s annual meeting along with the VA, P1 and P2. During this meeting, the CM was asked to discontinue 15-minute checks on the VA while s/he was outside, because the VA had two hours of unsupervised time at the facility. The CM told P1 and P2 that the VA’s unsupervised time was only inside the facility, and not when s/he was outside. Following this meeting, the CM requested the VA’s Outside Tracker documents and received them dated August 15-18, 2025. · The smoke shop was 0.3 miles from the facility, and the CM thought the VA left the facility through the backyard and “snuck” through the neighbor’s property. The VA “made it clear” to the CM that if s/he could access marijuana, s/he would do so and use it. After this incident, the VA chose to have P1 hold his/her cash and debit card to avoid his/her ability to purchase marijuana in the future. · The CM did not have prior concerns with the facility. P1-P3 provided the following consistent information: · The VA often smoked cigarettes in the yard of the facility but was not supposed to use alcohol or other substances. · On August 14, 2025, at an unknown time while P1 worked, P1 told SP2 that s/he “suspected” that VA was “high” but could not prove it. SP2 told P1 that s/he did not know how or when the VA would have accessed marijuana because SP2 had his/her eyes on the VA “the whole time” the VA was outside. · On August 15, 2025, P1 found the VA outside at the facility smoking marijuana. The VA looked at P1 and said, “You wanna get high?” P1 told the VA s/he was not supposed to be using marijuana and the VA ignored P1. P1 then notified the CM who came to the facility and gave the VA a drug test, which was positive for marijuana. · On August 22, 2025, P1-P3 received an email from the CM stating that on August 14, 2025, at an unknown time while SP1 and SP2 worked, the VA left the facility and walked to a nearby smoke shop where s/he purchased marijuana. Neither SP1 nor SP2 were aware that the VA left the facility. Although the CM believed the incident occurred on August 14, 2025. · P3 thought the incident occurred on August 13, 2025, after a facility picnic, but could not recall the specific date the incident occurred. · P1 spoke with the VA who thought s/he left the facility between 8-9 p.m., while other residents were getting their medications. P1 then spoke with SP1 and SP2 and told them about the incident and neither were aware the VA had left. P1 said that SP1 and SP2 completed all necessary checks on the VA. P2 stated that P1 told him/her that on August 14, 2025, there was a space that was “blank” in the Outside Tracker. P2 did not know what time was left blank. [Note: At the time of the investigation, P3 told this investigator that the facility could not locate the 15-minute check documents from August 13 or 14, 2025.] · Due to the location of the smoke shop, P1-P3 thought that the VA could make it to and from the smoke shop within the timeframe of the 15-minute checks. SP1 provided the following information: · SP1 did not know the date or time of the incident and was not aware that the VA left the facility at any time until told by P2 after the incident. · The VA did not have alone time in the community, and staff persons were required to check on the VA every fifteen minutes when s/he was outside. · On an unknown date, P2 told SP1 that the VA left the facility “around the date of the company picnic,” walked to the smoke shop and purchased marijuana. SP1 “thought” s/he knew the day the incident occurred and stated that on that day, s/he checked on the VA while the VA was outside smoking and then went inside the facility to use the restroom. After SP1 was finished, another resident used the restroom and “made a mess” that SP1 then cleaned. When SP1 checked on the VA again, the VA was still outside. The VA was “very swift,” exercised a lot, and was “very energetic.” The smoke shop was “just a few blocks” from the facility, and SP1 thought the VA could get to and from in ten minutes. · SP1 stated the VA smoked and had a “routine” at the facility. The VA went outside to smoke and was outside between 20 to 60 minutes. When finished, s/he came inside and went to his/her bedroom where s/he listened to music. The VA then came to the living room and visited with staff persons and other residents, had a snack and went back outside to smoke. SP2 provided the following information: · SP2 did not know the date or time of the incident and was not aware that the VA used drugs or left the facility at any time until told by P1 after the incident. · On an unknown date, P1 told SP2 that on an unknown date, around 8:30-9 p.m., the VA went to the back yard to smoke, and when the VA realized staff persons were busy with other residents, the VA walked to the smoke shop and purchased marijuana. SP2 thought the VA could get to and from the smoke shop in five to ten minutes. · SP2 stated that the VA was usually in his/her bedroom or outside smoking. The VA did not interact with others and enjoyed writing and listening to music. P4 did not have additional relevant information regarding the incident. The facility’s personnel files showed that P1-P4 and SP1 and SP2 were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information was consistent on August 13 or 14, 2025, at an unknown time, the VA left the facility unsupervised, walked to a smoke shop where s/he purchased marijuana, and then returned to the facility without SP1 and/or SP2 knowing s/he left. The VA’s Civil Commitment/Provisional Discharge stated that the VA “shall abstain from the use of alcohol and other non-prescribed drugs.” The CM and P1-P4 provided consistent information that the VA had a history of leaving the facility and did so when s/he knew staff persons were busy with other residents, so they would not know that the VA left. Neither SP1 nor SP2 were aware that the VA left the facility until they were told about it after the incident occurred. The VA stated that on the day of the incident, s/he left the facility when SP1 and SP2 were busy, that the smoke shop was “four to five” minutes from the facility, and s/he was gone for “maybe ten minutes.” The VA’s plans/documentation provided conflicting information regarding the VA’s unsupervised time in the community and his/her 15-minute checks. The VA’s ISSA stated that the VA had two hours of unsupervised time in the community and at the facility. The RA stated that the VA had two hours of unsupervised time at the facility and no unsupervised time in the community. Information provided from interviews was consistent that the VA required 15-minute checks but the VA’s Outside Tracker stated, “PLEASE CHECK ON [the VA] EVERY 3 MINS IF [S/HE] IS OUTSIDE [S/HE] NEEDS TO BE IN EYESIGHT WHILE [S/HE] IS OUTSIDE!!” (Emphasis in original) Although the VA’s plans/documentation was conflicting, given that information provided during interviews was consistent that the VA had no unsupervised time outside and required 15-minute checks, the interview information was most likely accurate and the practice at the facility. Given that the VA acknowledged leaving the facility when s/he knew staff persons were busy; that staff persons were required to check on the VA every 15 minutes, which because the smoke shop was a five minute walk from the facility, the VA could likely walk to and from the smoke shop within fifteen minutes, there was a preponderance of evidence that there was not a failure to supply the VA with necessary care or services. 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) Action Taken by Facility: The facility completed an Internal Review and determined that facility policies and procedures were adequate but not followed because SP1 and SP2 did not complete the VA’s 15-minute checks. Staff persons were retrained on the VA’s plans and supervision requirements. Action Taken by Department of Human Services, Office of Inspector General: The facility was issued a Recommendation to review and update as necessary, the VA’s plans and documentation to ensure consistency regarding the VA’s unsupervised time at the facility and in the community and timeframe regarding how often staff persons were to check on the VA.
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