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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: 1068588-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt/Jamie Randall 651-431-4121 Suspected Maltreatment Reported: It was reported that a staff person (SP) let a vulnerable adult (VA), who had a history of substance use, use the SP’s vape pen that contained tetrahydrocannabinol (THC). Date of Incident(s): May 16, 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 June 11, 2025; from documentation at the facility, law enforcement records, and medical records; and through eight interviews conducted with three facility supervisory staff persons (P1, P2, and P4), three staff persons (P3, P5 and the SP), the VA, and the VA’s guardian (G). The VA’s diagnoses included posttraumatic stress disorder, major depressive disorder, anxiety disorder, and borderline personality disorder. The VA enjoyed playing video games, hunting and fishing. The VA had a goal to maintain his/her sobriety. The VA’s marijuana use may put him/her at risk for losing his/her housing, job, independence in the community, or cause a decline in his/her mental health. The VA was aware of the risks and consequences of using substances and not maintaining his/her sobriety. The VA had unsupervised time in the community and could go for walks to a local store and/or around the VA’s neighborhood. After 30 minutes, the VA was to have a “face-to-face” check in with staff. The facility was a split-level home with a basement. Outside a front door was a patio with a chair where the VA and his/her housemates would sit and smoke cigarettes. The front door entry was connected to a living room that had a window where the patio was visible. The facilities Drug and Alcohol Policy said that staff persons may not consume or possess THC products at any time while at the facility. The VA provided the following information to this investigator, and for the facility’s the internal review incident report: · On May 16, 2025, the SP worked the overnight shift. At the beginning of the shift, the VA saw the SP drop his/her THC vape pen from his/her pocket. The VA told the SP, “Don’t worry, I won’t say anything.” Throughout the night the VA would ask to SP smoke cigarettes with him/her outside. During one of the times when the VA and the SP smoked cigarettes, the VA asked the SP if s/he could “hit” the SP’s vape pen. The SP told the VA, “If you don’t say anything,” and let the VA use his/her vape pen. The VA used the vape pen and began to cough for “10 minutes.” The VA was so “intoxicated” that s/he could not walk after using the vape pen. · After the overnight on May 16, 2025, the VA would get “dropped off” at a mall and would then walk to a smoke shop to buy THC products. The VA did not specify which smoke shop s/he went to and did not say how many times this occurred. The VA felt “angry” and “sad” after using the THC products s/he purchased. The VA had been sober for “four or five months” prior to using the SP’s vape pen and had a goal to maintain sobriety. · On the night of June 2, 2025, the VA took “too many edibles” and became “suicidal.” At 5 a.m. on June 3, 2025, the VA walked to a local convenience store that was “five minutes” from the facility. The VA did not tell P3 that s/he was leaving as s/he did not want to wake up his/her housemates. While walking to the store, the VA called 9-1-1 and told them s/he was having suicidal ideations. Law enforcement met the VA at the convenience store and the VA was transported to a hospital. The VA was at the hospital for a “couple hours” before being released. The VA was transported back to the facility by P5. P1 provided the following information to this investigator, and for the facility’s incident report and internal review: · On June 3, 2025, around 5 a.m., P1 received a phone call from P3 that the VA had left the facility and was at a local convenience store with law enforcement. The VA told law enforcement that s/he wanted to hurt him/herself and the VA was being transported to a local hospital. · While at the hospital, the VA was “not suicidal” and was told that s/he had a “cold.” The VA was discharged and picked up around noon. At around 1 p.m., P1 had to “run errands” and the VA asked to go with P1. While driving around, the VA told P1 that on the “second” overnight shift the SP worked, the SP let the VA use the SP’s vape pen that contained THC. The VA was “so intoxicated” that s/he could not even walk after using the vape pen. After the overnight, the VA said, “everything snowballed” and the VA purchased “edibles” and drinks that contained THC during his/her unsupervised time in the community. The VA called P4, who was a family member of the SP that also worked at the facility, and told P4 about the SP letting the VA use the SP’s THC vape pen. · P4 called P1 to discuss the situation. P1 told P4 that they should “not talk about it” as things can get “misconstrued” with more people discussing the situation. P4 said that the SP admitted to P4 that s/he let the VA “smoke marijuana” on the night shift. · For four days prior to being hospitalized, the VA had a cold for which the VA was taking a nebulizer treatment and cold medicine. The VA had been “sleeping a lot” and staying up “all night” playing video games which was not atypical behavior of the VA. · The VA had a history of substance use and staff would support the VA in several different ways including taking the VA to sweat lodges where the VA would meet with his/her sponsor, going to native sobriety meetings, and encouraging the VA to see his/her therapist. When the VA used substances, the VA would get “down” and may become “aggressive.” The VA had a history of using behaviors to “get attention.” The VA would say that s/he wanted to “kill” him/herself or would tell staff that s/he had suicidal thoughts but that those thoughts were “gone now.” P3 provided the following information: · On June 2, 2025, P3 worked an overnight shift that started at 10 p.m. Between 10 p.m. and 11 p.m., P3 talked with the VA and one of the VA’s housemates. The VA went out to the front patio to smoke cigarettes every half hour and talked with the same housemate every hour until 5 a.m. At 5 a.m., the VA went outside and came back in and asked P3 to go outside. P3 told the VA that s/he was cleaning, and the VA could talk with P3 inside. The VA went outside and sat in the patio chair. P3 went outside to the patio and the VA told P3 that s/he wanted an ambulance as s/he had a “cold” and was “not feeling well.” P3 told the VA that was not a “necessary reason” to call an ambulance, and the VA could go get medical care at 7 a.m. when another staff was scheduled. P3 went inside to mop the floor. · P3 mopped the living room and could see that the VA was still smoking outside. P3 went upstairs to mop the bathroom and when finished looked out the living room window to see that the VA was no longer on the patio. P3 estimated that between seeing the VA out the living room window and mopping was five minutes. P3 looked in the garage and around the facility but did not see the VA. P3 called the VA’s cell phone but did not hear from the VA. About 20 minutes later, P3 received a call from a law enforcement officer that the VA was at a local convenience store. The VA had called law enforcement and told them that s/he was “suicidal.” The officer said that the VA was “suicidal earlier” but did not “have a plan” so they were not worried. The officer asked if the VA could go back to the facility and P3 said, “Yes.” The officer told P3 that they would talk with the VA. Between 15 and 20 minutes later, the officer called P3 and told him/her that the VA was being transported to a local hospital via ambulance. P3 called P1 and notified him/her of the situation. P4 provided the following information: · On June 3, 2025, P4 received a phone call from the VA while the VA was at the hospital. The VA told P4 that the SP, who was also a family member of P4, was working “one night” and let the VA “hit” the SP’s THC vape pen. · After the VA called P4, the SP called P4 as the SP was called into the office and was told that there was a situation being looked into but could not “talk about it much more than that.” The SP did not “go into details” and was “afraid” to tell P4 about “anything.” The SP asked P4 if s/he should “quit.” P4 told the SP that “quitting is not going to solve anything” and to meet with P2. · P4 worked the morning shifts on May 31, and June 1, 2025. The VA was “fine” during these shifts and slept for most of the time P4 was working. The VA had a history of substance use and while sleeping a lot was one of the signs of the VA using, the VA would also stay up on overnights and sleeping through the morning was normal for the VA. The VA would also show signs of being “moody” and “depressed” when using but P4 did not notice these behaviors prior to the VA being hospitalized.
P2 provided the following information to this investigator and for the facility’s internal review: · P2 spoke with the VA at the facility on June 3, 2025. The VA provided similar details that the VA provided P1 regarding the overnight on May 16, 2025, and the SP letting the VA use the SP’s THC vape pen. After the SP let the VA use the SP’s THC vape pen, the VA started purchasing and using THC products. The VA had been sober for four to five months prior to using the SP’s THC vape pen. The VA told P2 that s/he had “messed up” and P2 discussed “bumps” and “forward movement” with the VA. · The VA was always “honest after the fact” but was “loyal” to his/her “persons.” The SP was not one of the VA’s “persons” and therefore would provide accurate details of the May 16, 2025, overnight shift. P5 provided the following information: · In the “few weeks” Leading up to the VA being hospitalized on June 3, 2025, the VA had a “cough” and was “attention seeking” but that was not “really different” behavior for the VA. The VA would tell staff that s/he just wanted to “converse” but would not say much. · The VA struggled with substance use, specifically with marijuana. When the VA used in the past, the VA would become “anxious” and “aggressive.” The VA became “physically violent” with housemates and when asked afterwards, the VA would say that s/he “used.” The VA would talk with P5 or other staff person “once a month” about wanting to stay sober. Law enforcement records showed that on June 3, 2025, at 5:08 a.m., the VA called law enforcement and stated that s/he was up all-night drinking energy drinks and had “some” THC edibles. The VA told law enforcement that s/he had self-harm thoughts and wanted to go to the hospital. Law enforcement officers met the VA at a local convenience store. Law enforcement spoke with staff at the facility and the VA left the facility “around” 5 a.m. because the VA did not want to “alarm” his roommates and did not want to go back to the facility. The VA was transported to a local hospital. The G said that the VA had a goal to stay sober and was “doing well.” The VA tested positive for THC “awhile back” and at that time, the VA said that s/he got THC from a gas station. The SP provided the following information to this investigator and for the facility’s internal review: · On a Friday or Saturday in the middle of May, later determined to be May 16, 2025, the SP worked an overnight shift that started at 11 p.m. The SP opened the door to the staff office around 11:30 p.m. and a vape pen that contained Delta 8 THC fell out of the SP’s jacket pocket onto the floor. The VA saw the SP’s vape pen and asked the SP if s/he could “hit” the vape pen. The SP let the VA use his/her THC vape pen and afterwards, the SP and the VA watched movies and listened to music. The VA “usually” stayed up “all night” and went to bed around 6 a.m. · The SP stated that the VA had a history of substance use and should “stay away” from substances. The SP “knew” that s/he was not supposed to have any type of substance in the facility and received the “training.” The SP did not “mean” to bring the THC vape pen to the facility and should have “left it at home.” The SP and the VA were “really chill,” and the SP saw the VA as a “friend” and should have been more “professional.” The SP said, “I know what I did was really wrong.” Staff were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s Drug and Alcohol Policy. P1 and P3-P5 were trained on the VA’s plans. P2 was a supervisory staff person that did not work directly with the VA. The facility did not have documentation that the SP was trained on the VA’s plans. Conclusion: A. Maltreatment: On May 16, 2025, the SP worked an overnight shift. Near the beginning of the shift, the SP’s vape pen that contained THC fell on to the floor. The VA saw the SP’s vape pen and told the SP, “Don’t worry, I won’t say anything.” Throughout the night the VA would ask to SP smoke cigarettes with him/her outside. During one of the times when the VA and the SP smoked cigarettes, the VA asked the SP if s/he could “hit” the SP’s vape pen. The SP told the VA, “If you don’t say anything,” and let the VA use his/her vape pen. The VA described him/herself as being so “intoxicated” that s/he could not move. The VA had a history of substance use and in the following weeks, purchased THC products which using made the VA feel “sad” and “angry.” The mental health decline culminated with the VA using “too many edibles” during an overnight shift on June 2, 2025, and having suicidal thoughts. The VA left the facility and walked to a local convenience store around 5 a.m. on June 3, 2025, and called law enforcement. The VA ended up going to the hospital with suicidal ideations. Given the VA’s history of substance use and the goal to remain sober and that the SP let the VA use the SP’s THC vape pen, after which the VA purchased and used THC products which led to the VA having suicidal ideations, there was a preponderance of the evidence that there was a failure to supply the VA with care or services that were reasonable and necessary to maintain the VA’s physical or mental health. 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 was trained on facility’s Drug and Alcohol Policy and the Reporting of Maltreatment of Vulnerable Adults Act. While the facility did not have documentation stating that the SP was trained in on the VA’s plans, the SP told this investigator that s/he knew about the VA’s history of substance use and that the VA should “stay away” from substances. 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 because it was a single incident, and the VA did not sustain a serious injury that reasonably required the care of a physician. Action Taken by Facility: The facility completed an internal review and determined that it’s policies and procedures were adequate but not followed by the SP when the SP violated the facility’s Drug and Alcohol Policy. Facility supervisory staff persons were retrained that all staff persons “filling in” needed to be trained on all the individuals “they are providing direct care to.” 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 November 6, 2025, the facility was issued a Correction Order for not having documentation that the SP was trained on the VA’s plans.
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