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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: 1119298-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jamie Randall 651-431-4121 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had a burn on his/her hand, but care was not sought for the burn until the following day. Date of Incident(s): June 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 July 28, 2025; from documentation at the facility and medical records; and through seven interviews conducted with a supervisory staff person (P1) and six facility staff persons (P2-P5, SP1 and SP2). This investigator met the VA, but the VA was not interviewed due to his/her disability. Attempts were made to contact two additional staff persons (P6 and P7) for interviews, but neither responded. The VA was diagnosed with autistic disorder. The VA enjoyed car rides, music, riding elevators, going out to eat, and going to community parks to walk and swing. The VA had a 2:1 staffing ratio during awake hours and an “available” awake overnight staff (Note: The VA’s plans did not specify how staff were to implement 2:1 staffing for the VA but P1 told this investigator that 2:1 staff were to be “within hearing distance” of the VA but did not have to be “eyes on”). Staff were to regulate the VA’s water temperature for showers/baths and consumption. The facility was a two-level home with a basement. The main level had a kitchen and living room which was an open style. The kitchen included an over the range microwave. The VA enjoyed coffee and would ask for coffee throughout the day. Staff would prepare the VA’s coffee with milk. The amount of milk was not measured but SP2 said that the coffee prepared for the VA was “almost half milk” while SP1 also noted it was “a lot of milk” added to the VA’s coffee. The VA used a plastic cup for coffee without a lid which the VA would carry around the facility. P1 and P4 added that the VA would “spill” coffee on the floor while carrying the cup. There was conflicting information on whether the VA used the microwave. SP1 said that the VA would try to make coffee by putting a cup of water in the microwave and turning the microwave on. P1 said that staff were supposed to “redirect” the VA if s/he used the microwave and staff were to remove anything the VA put in the microwave in a “timely manner.” The facility’s incident report and internal review provided the following information: On June 15, 2025, at 5 p.m., P2 contacted P1 about a burn on the VA’s left hand. There was no documentation or direct communication regarding an injury to the VA’s left hand. The VA was taken to urgent care where the VA was diagnosed with a second degree burn that was “likely due to something hot spilling.” P1 contacted staff persons who had worked with the VA in the days prior. P3 said that at an unknown time “in the morning” on June 14, 2025, SP1 informed P3 that the VA had “burned [him/her]self” with coffee on the VA’s left hand. P3 saw the VA’s injury and described it as “slightly pink.” P3 told SP1 to “watch it” and if after 30 minutes the injury “looks worse,” to contact P1. No “follow up was made” and P1 was not notified of anything further until June 15, 2025, by P2. Medical records showed that the VA was seen on June 15, 2025, for a burn on the back of the VA’s left hand. The VA was diagnosed with a first-degree burn on the back of the VA’s left hand with a “small area of second-degree burn, about 1.5 cm diameter” on the VA’s left index finger. The area was cleaned with bacitracin and a band-aid applied with “no specific treatment for the discolored first-degree area.” The VA seemed to “not be having much pain” from the injury. There was a note that said, “Possibly from spilled coffee as [s/he] likes to drink coffee.” Regarding June 14, 2025: Progress notes for the overnight shift completed by P6 and dated on June 14, 2025, at 7:30 a.m., included that the VA slept all night and had not woken by the time P6 left. P3 worked from 8 a.m. until 3 p.m. on an unknown Saturday in June, later determined to be June 14, 2025, and was assigned to work with one of the VA’s housemates. SP1 and SP2 were the 2:1 staff working with the VA. At some point in the morning, P3 was helping one of the VA’s housemates clean his/her room when SP1 called out for P3. P3 went to the kitchen where SP1 told P3 that the VA “got burned.” P3 told SP1 to tell P1 and P3 went back to the VA’s housemate’s room. P3 did not see the burn and did not know “what happened” but assumed coffee or hot water caused the burn because the burn was on the VA’s hand. P3 also mentioned that the VA had been “red” in the past when out in the sun. SP1 worked from 8 a.m. until 3 p.m. on June 14, 2025, and was assigned as a 2:1 staff for the VA with SP2. SP1 was “watching” the VA the “whole time” and did not “see or notice” anything. SP1 did not see the VA use the microwave during the shift. SP1 helped the VA shower, gave the VA “medication” and “did all the work” before leaving his/her shift. SP1 denied speaking to P3 about an injury to the VA. SP2 worked from 8 a.m. until 3 p.m. on June 14, 2025, and was assigned as a 2:1 staff for the VA with SP1. SP1 and SP2 had “eyes on” the VA throughout the shift. SP1 and SP2 took the VA on an outing and the shift was “like a normal day.” The VA did not “complain” to SP2 and SP2 did not “see anything.” When the VA had coffee, it was prepared with “half milk” to make sure of “no hazards.” Progress notes for the morning shift completed by SP2 and dated on June 14, 2025, at 2:30 p.m., included that the VA had a shower and then breakfast and medications after waking up. The VA “relaxed for a bit” and then went for a “long” van ride and brought McDonalds home. When the VA returned home, s/he had a shower and then ate the food purchased from McDonalds. After eating, the VA took a nap. P5 worked from 3 p.m. until 10 p.m. on June 14, 2025, and was assigned as a 2:1 staff for the VA with P4. When P5 arrived for his/her shift, SP1 and SP2 told P5 that the VA was “okay.” The VA had a “normal” day and did not “show” any signs of pain. P4 worked from 3 p.m. until 10 p.m. on June 14, 2025, and was assigned as a 2:1 staff for the VA with P5. “Nothing happened” to the VA during P4’s shift. Progress notes for the evening shift completed by P4 and dated 9:30 p.m., included that the VA was on the couch when P4 arrived and got up to greet P4 before asking for coffee. The VA ate a burger and drank coffee before returning to the couch to take a nap. The VA took a shower, changed clothes, had his/her medications and then went to bed. Regarding June 15, 2025: Progress notes for the overnight shift completed by P6 and dated on June 15, 2025, at 7:30 a.m., included that the VA slept all night and had not woken by the time P6 left. Progress notes for the morning shift completed by SP2 and dated for June 15, 2025, at 2:30 p.m., included that the VA “woke up a little later” and then took a shower before breakfast and medications. The VA “relaxed” in the living room. The VA was “hitting staff” and requested a second coffee “immediately after finishing the first one.” Staff attempted to “redirect,” but the VA “spent most of the afternoon requesting coffee.” The VA “eventually calmed down and relaxed.” SP2 worked from 8 a.m. until 3 p.m. on June 15, 2025, and was assigned as a 2:1 staff for the VA with P7 (Note: SP2 did not recall if s/he worked on June 15, 2025, when interviewed by this investigator but did include information for this shift for the internal review). The VA was supervised throughout the shift with a 2:1 ratio. SP2 did not witness any incidents involving the VA and was “unaware of any opportunity” where an injury could have occurred. SP2 noted that the VA had a history of self-injurious behaviors that included “head banging” and “hitting” him/herself but nothing involving burns. SP1 worked from 8 a.m. until 10 p.m. on June 15, 2025, and was assigned to work with one of the VA’s housemates. Between 3 and 5 p.m., SP1 was told by a staff person that “something” happened with the VA and the VA was going to urgent care. SP1 saw the VA’s hand and it was “red” (note: SP1 did not remember which staff person told him/her about the VA). SP1 received a call between 7 and 8 p.m. from P1. P1 told SP1 that the VA had a burn on his/her hand and asked SP1 if s/he noticed anything with the VA. SP1 told P1 that s/he did not “see or notice” anything. SP1 told P1 that the VA enjoyed coffee and speculated that the VA may have spilled coffee on his/her hand as the VA did “shake” his/her hand when holding a cup of coffee. SP1 “emphasized” that this was only an assumption and not something that SP1 observed. P2 worked from 3 p.m. until 10 p.m. on June 15, 2025, and was assigned to work with one of the VA’s housemates. The VA was on an outing when P2 started his/her shift and returned to the facility around 5 p.m. The VA approached P2 and P2 saw a “bruise” on the VA’s hand (Note: P2 did not remember which hand but the left hand was indicated on the incident report). The VA’s hand had a “bruise” on top and an open blister on the thumb that was about the size of a quarter. The other staff working had not seen an injury on the VA and there was no documentation of an injury, so P2 called P1 and informed him/her of the injury. P2 took pictures of the VA’s hand and sent them to P1 which P1 reviewed and told staff to take the VA to urgent care. The VA was taken to urgent care between 5 and 6 p.m. and returned to the facility “two hours later.” P2 did not work directly with the VA after the VA returned from urgent care but heard staff mention that antibiotic ointment was to be put on the VA’s injury. P1 received a text message from P2 “just after 5 p.m.” on June 15, 2025, with a picture of the VA’s hand asking if s/he had been notified of an injury. The photo looked like a “bee sting” and P1 could tell that the injury to the VA’s hand was a burn. P2 and the other staff working were unaware of the injury or how it occurred. P1 instructed staff to take the VA to urgent care. P1 contacted staff who had been working in the days prior to see if one of them knew how the injury occurred. P3 said that on the morning of June 14, 2025, SP1 told P3 that the VA “burned” his/her hand. P3 told SP1 that if the VA’s hand was still “red” after twenty minutes to call P1. P1 contacted SP1, who told P1 that s/he “had no idea” about a burn on the VA’s hand. SP2, who was assigned to be a 2:1 staff for the VA with SP1 during the morning of June 14, 2025, told P1 that s/he did not know what happened to the VA. P3 received a phone call from P1 asking if P3 was aware of a “burn” on the VA. P3 told P1 that SP1 had told P3 about a burn on the VA’s hand the day before. SP1 noted that the VA needed a lot of help when s/he became “mad” and had made a “hole in the wall” in the past. When the VA wanted coffee, the VA may show frustration by saying a “bad word” and would “hit” staff persons. P1-P7, SP1 and SP2 were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act Conclusion: Information showed that on June 15, 2025, at around 5 p.m., P2 noticed that the VA had a “bruise” on the back of his/her hand. P2 texted P1 pictures of the VA’s hand which P1 thought may be a burn. The VA was taken to urgent care where the VA was diagnosed with a first-degree burn on the back of the VA’s left hand with a “small area of second-degree burn, about 1.5 cm diameter” on the VA’s left index finger. P1 called staff persons that were working with the VA in the days prior and all staff persons denied seeing an injury. All staff persons besides P3 stated they did not know what caused the injury but P3 said that SP1 noticed an injury on June 14, 2025, and asked P3 what to do about the injury. SP1 denied telling P3 about a burn on June 14, 2025, and was not aware of the burn until after it was noticed on June 15, 2025. SP2, who was assigned to be one of the VA’s 2:1 staff with SP1 on June 14, 2025, denied seeing a burn on the VA and was not aware of the burn until P1 called him/her on June 15, 2025. The staff persons interviewed, and a review of health notes did not provide details of an injury or any event that may have caused an injury to the VA’s hand. Although the VA did sustain a burn on the back his/her left hand and index finger, there was conflicting information as to whether there was an injury seen on the VA’s left hand on June 14, 2025, with P3 saying that SP1 told him/her about an injury to the VA’s left hand and with SP1 and SP2 denying that there was an injury present on June 14, 2025. While SP1 and SP2 had reason to minimize their actions, all other staff persons that worked with the VA did not see an injury until after 5 p.m. on June 15, 2025, so it was not able to be determined how or when the VA sustained the injury. Once the injury was noticed, the VA received immediate medical care. Therefore, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed when staff did not follow the facility’s policy regarding “the timely response to and reporting of incidents” and when a serious injury report was not completed “promptly” after the injury to the VA was identified. All staff persons working with the VA were to be retrained on incident reporting including internal and external reporting requirements. SP1 and SP2 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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