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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: 1095901-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: Allegation One: It was reported that on two dates, November 5 and 11, 2024, a vulnerable adult (VA) left the facility without supervision and that a staff person (SP1) did not provide supervision and follow the VA according to the VA’s plans. Allegation Two: During the investigation, it was reported that on the VA left the facility without supervision while another staff person (SP2) was to be supervising the VA. Date of Incident(s): Prior to November 28, 2024 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 18, 2024; from documentation at the facility and law enforcement records; and through eight interviews conducted with the VA, SP1, SP2, the VA’s guardian (G), a facility management staff person (P1), and three facility staff persons (P2-P4). The facility was in somewhat of a rural area with homes nearby, but also farmland and large groves of mature trees. The facility had an alarm system that sounded when doors were opened. P1 stated that the facility had an enclosed backyard. The VA was diagnosed with alcohol use disorder, traumatic brain injury (TBI), and had a seizure disorder. The VA’s Functional Support Strategies stated that s/he was an “amazing storyteller and loves to have the full attention of others” and that staff persons were to “make time to sit with [the VA] and listen to [his/her] stories, asking questions to show that you are interested and listening.” The document stated that “clear boundaries” worked well with the VA and that staff persons were to “tell [the VA] the behaviors you expect from [him/her] during your interactions.” The VA had instances of leaving without supervision that were primarily caused by “denied or delayed requests,” “lack of attention,” and “redirection of interfering behaviors.” When the VA left without staff person supervision, staff persons were to follow the VA in a vehicle to “maintain visual supervision.” Staff persons were to not “engage” with the VA until the VA returned “unless an imminent risk of harm is present, and staff are safe to intervene.” If “there is an immediate concern, staff will exit the vehicle and utilize physical safety strategies attempting to keep [the VA] and staff safe.” Staff persons were to call 9-1-1 if the VA walked toward a nearby highway. The VA’s Outcomes-Supports and Methods, implemented on October 14, 2024, provided the following information: · The “rationale” for the document was because, “It is important for [the VA] to gain the ability to take a walk independently in the community, as walking serves as a vital coping mechanism for [him/her] when [s/he] feels frustrated with staff.” · When the VA wanted to leave the facility on a walk, it was a “successful” walk if the VA “requested a walkie talkie” (the facility maintained two walkie talkies, one for the VA and another for a staff person to carry as they maintained visual supervision of the VA) and when the VA requested staff persons to accompany him/her on the walk. The walk was considered “unsuccessful” if the VA “refused” to take the walkie talkie, refused to allow staff persons to accompany the VA on the walk, or “walked outside the designated area.” (The facility had a designated area that the VA could walk to, and staff persons were expected to continue communicating with the VA on the walkie talkie and maintain visual supervision of the VA while the VA was on a walk in this area. P1 stated that the use of the walkie talkie was not required.) · If the VA left the facility to go on a walk and refused to use the walkie talkie or allow staff persons to accompany him/her on the walk, staff persons were expected to follow the VA with a vehicle. The VA’s Supervision Needs-Residential and Vocational dated September 11, 2024, provided the following information: · When at the facility, the VA’s supervision level was one staff person to two clients. When the VA was in the back yard, the VA did not need to have staff person supervision, but if the VA was in the front yard, staff persons “will be physically present with [him/her] for the entire duration.” · In the community, the VA required one to one staff person supervision. When the VA left the facility on foot, staff persons were to offer to go with the VA on his/her walk. If the VA agreed, staff persons walked with the VA. If the VA declined, staff persons were to offer the VA the walkie talkies. If the VA declined those, staff persons were to follow the VA in a vehicle if one was available, maintaining visual supervision. · If the VA passed a certain landmark, walking toward a highway, staff persons were to call 9-1-1. The VA’s Self-Management Assessment showed that the VA engaged in making sexually inappropriate comments and gestures, sexual and physical aggression toward others, as well as “making threats to harm and homicidal ideation.” As a result, staff persons were trained to offer de-escalation techniques to the VA. The plan stated that the VA needed one to one supervision “at all times in the community.” The VA’s Individual Abuse Prevention Plan stated that the VA was susceptible to sexual abuse and the specific measure to minimize the risk was “with minimum of 1:1 staffing, supervision will be provided during interactions with housemates and other staff.” Staff persons were to verbally redirect the VA when s/he engaged in behaviors such as making sexual or suggestive comments. The VA did not recall how many times s/he left the facility or how long s/he was gone but knew that staff persons were supposed to “look around for me” when s/he left the facility and that SP1 did “nothing” when the VA left. The facility’s training records showed that all staff interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to November 5, 2024. Allegation One: It was reported that on two dates, November 5 and 11, 2024, the VA left the facility without supervision and that SP1 did not provide supervision and follow the VA according to the VA’s plans. Regarding November 5, 2024: Law enforcement records showed that on November 5, 2024, at 1:43 p.m., SP1 called law enforcement because the VA left without supervision “7 minutes ago.” At 2:23 p.m., law enforcement found the VA, who was walking back to the facility. The facility’s Internal Review Conclusion and Evaluation stated that at an unspecified time on November 5, 2024, the VA “was walking on the road down toward the dead-end zone, no outlet (private property). Tried talking with [him/her] over the walkie no response.” At some point, the VA “ignored” SP1 and walked out of SP1’s sight. SP1 went back to the facility at an unspecified time, called 9-1-1, and then continued looking for the VA. The VA was located at 2:25 p.m. by law enforcement. The review did not provide information in terms of what SP1 and the VA were doing prior to the VA leaving the facility or the time, but stated that SP1 used the facility’s vehicle to look for the VA. The facility’s staffing schedule for November 5, 2024, provided the following information: · P3, SP1, and SP2 worked from 7 a.m. until 3:30 p.m. · P2 and another staff person (P5) worked from 2:30 to 10:30 p.m. P1 provided the following information: · Prior to November 5, 2024, the VA had a “huge history” of leaving the facility without supervision. The facility tried to allow the VA unsupervised time in the fenced in backyard. · On the morning of November 5, 2024, P1 went to the facility and SP1 was assigned supervision of the VA, but SP2 and P3 were also working that day. P1 saw the VA standing outside. When P1 went inside the facility, P1 saw SP1 sitting at the dining room table, which was not within view of the VA in the front yard. P1 “had to remind” SP1 that s/he “needed to keep an eye” on the VA. When P1 said that to SP1, SP1 said, “Oh,” and then went outside to be with the VA. P1 went to the lower level of the facility. · At later unknown date, P1 was told by an unknown person about one occasion on November 5, 2024, in which the VA left the facility without supervision at about 1:45 p.m., that SP1 did not follow the VA, and that the VA was returned to the facility by law enforcement at 2:25 p.m. but P1 did not remember specific information. P1 was not present when the incident occurred. P1 also stated that use of the walkie talkies was optional but was encouraged. P3 recalled a recent incident in which the VA left without supervision, but P3 did not recall the date. When that happened, P3 told SP1 “five times,” over a ten-minute period, that s/he needed to follow the VA. SP1 did not recall the VA leaving without supervision on November 5, 2024, and said that when the VA left without supervision, SP1 followed the VA. When SP1 was asked to provide information about a time when P1 arrived at the facility and found the VA unsupervised outside (November 5, 2024), SP1 stated that s/he did not “recall that.” When SP2 was asked about staff persons not following the VA’s plans when the VA left, SP2 said that P4 and SP1 did not follow the plans, but SP2 did not remember specific information or when that occurred. SP2 did not recall an incident on November 5, 2024, in which the VA left without supervision. P2 provided the following information: · When the VA left without supervision, in general, staff persons asked the VA to take the walkie talkie and if the VA did that, staff persons were expected to stand in the driveway to observe the VA and communicate with the VA on the walkie talkie, but if the VA walked out of the staff person’s visual supervision, staff persons were expected to follow the VA. · When P2 was asked to provide dates, times, and number of instances of when the VA left without staff supervision, P2 was unable to do so because there were “so many incidents.” P2 did not remember if there was an incident on November 5, 2024, in which the VA left the facility without supervision. P4 did not remember specific dates or the number of incidents, but stated that there were times that s/he told SP1 that the VA had left without supervision, but SP1 did not immediately follow the VA and P4 did not remember how long it took for SP1 to begin looking for the VA. Other staff persons, including P4, had to follow and locate the VA, but P4 did not remember specific details. P1-P4 said that the VA typically wore weather appropriate clothing when the VA left without supervision. A review of facility documentation showed a written document, dated November 5, 2024, which stated, “Met with [SP1] in the morning on [November 5, 2024] and the afternoon regarding following supervision expectation. It was reviewed that staff should be outside at all times when [the VA] was outside.” The author of the document was not noted, but P1 told this investigator that s/he was the author of the document. The G did not have concerns related to the facility. P4 denied that there were times that s/he did not follow the VA’s plans when the VA left without supervision. Regarding November 11, 2024: On November 11, 2024, P2, P3, and SP1 worked from 7 a.m. until 3:30 p.m. and other staff were scheduled to work the evening shift that day. According to P1, SP1 had supervision responsibility for the VA during his/her shift that day. A review of law enforcement records for November 11, 2024, provided the following information: · At 9:23 a.m., the VA left the facility without supervision and was located by law enforcement, and returned to the facility, at 10 a.m. · At 11:21 a.m., the VA left again and was located by law enforcement, and returned to the facility, at 12:16 p.m. · At 1:46 p.m., law enforcement was informed that the VA left again. The VA was found, by an unnamed facility staff person, at 4:24 p.m. The VA was taken to a hospital for evaluation. The VA’s medical records, dated November 11, 2024, showed that the VA was seen in the emergency room for a “crisis evaluation.” The VA had a “mental health evaluation” and it was determined that the VA would be discharged, to the facility, that day. There was no documentation to show that the VA was injured or that treatments were provided to the VA. An Incident Report Form dated November 11, 2024, and completed by SP1 stated that at 8:42 a.m. the VA “walked off didn’t want to take walkie nor did [s/he] want to engage in conversation or work with assigned staff” and that SP1 used the facility’s vehicle to locate the VA but was unable to do so. As a result, law enforcement was called and the VA was brought back to the facility, but times were not identified. The report did not document what was happening prior to the VA leaving the facility without supervision. P2 provided the following information:
· P2 recalled an incident on November 11, 2024, in which P3 told SP1 that it was likely that the VA would leave without supervision because P2 and P3 were getting ready to go on a community outing at about 8:30 a.m. with other clients and the VA was not going. P3 told P2 that the VA might become upset and leave the facility. As P2, P3, and clients left the facility at about 8:30 a.m., SP1 sat at the dining room table and the VA was in the living room, which was in visual sight of SP1. At the time, SP1 and the VA were the only people at the facility. When P2, P3, and the clients were driving back to the facility, about two hours later, P2 saw the VA, who was carrying a walkie talkie, walking a few blocks from the facility. P2 stopped and told the VA to return to the facility and while P2 drove back to the facility, s/he maintained visual supervision of the VA. When P2 got to the facility, SP1 was standing in the driveway.
· Shortly after the VA returned to the facility, the VA took his/her medications and then left again without supervision at about 10:35 a.m. When P2 “kept telling” SP1 that s/he needed to follow the VA, who left without a walkie talkie, SP1 did not do so until P2 told SP1 to “go,” at which time SP1 left to go look for the VA with a vehicle. When the VA left that day, law enforcement returned the VA to the facility at least two times, but P2 did not remember exact times. SP1 told P2 that s/he was “depending on the cops to look” for the VA. · On another occasion that day, the VA left without supervision and SP1 did not follow the VA, but P2 did not remember specific information in terms of when the VA left. When the VA was returned to the facility, by law enforcement, the VA told P2 that s/he “hitchhiked” to a gas station. P3 provided the following information: · On November 11, 2024, SP1, who was responsible for the VA’s supervision, sat at the dining room table on his/her phone. Around 8 a.m., the VA asked P3 for coffee and when P3 told the VA that s/he was busy and that s/he could ask SP1, the VA “just left” through the front door without saying anything. P3 heard P2 tell SP1, “You know, [the VA] left, right?” SP1 responded, “Am I supposed to follow [him/her]?” After a minute or two, SP1 got up and used the bathroom. While SP1 used the bathroom, for about 15 minutes, P2 and P3 looked out the front window and saw the VA in the front yard and SP1 returned to the table after using the bathroom. At some point, P3 stepped away from the window, while SP1 was in the bathroom, and P2 went outside and stood in the driveway. P3 returned to the window and noticed that the VA was walking back to the facility with P2. During that incident, the VA was not “out of supervision.” · A short time later, P2 and P3 made plans to take another client on a community outing and P2 “consistently” told SP1 that s/he needed to “be outside” when the VA was outside. At one point, P3 heard SP1 say that it was “cold” outside. At about 8:30 a.m., the VA left again and SP1, who was sitting at the dining room table, did not look for the VA and both P2 and P3 told SP1 that s/he needed to follow the VA. P3 went outside to look for the VA, but could not see him/her, so P3 returned inside and told SP1, “You need to get the car” and look for the VA. P3 gave the vehicle keys to SP1 and after about five minutes, SP1 went to look for the VA. After being gone for about one hour, the VA returned on his/her own. Once the VA was back inside, P2 and P3 left the facility with other clients and returned around 10:30 a.m. Later, the VA left again and when P3 told SP1 that the VA left, SP1 said, “Okay,” but did not look for the VA until P3 told SP1 to go look for the VA. Even though P3’s shift was over at 3:30 p.m., P3 used his/her personal vehicle to look for the VA, who was found at about 4 p.m., by law enforcement and was transported to the hospital. P4 did not remember specific dates or the number of incidents, but stated that there were times that SP1 was made aware of the VA leaving without supervision and SP1 did not follow the VA. Other staff persons, including P4, followed and located the VA. On November 13, 2024, P1 sent the following email to SP1: “Hello, Thanks for taking the time to meet with me today. I have included a review of key points that we discussed and the expectations going forward. There is a concern of you not following [the VA’s] unsupervised time leading to incidents, [the VA leaving without supervision] and 9-1-1 calls. It has been reported that you have been sitting at the dining room table/not providing supervision when [the VA] is outside or [leaving without supervision] when you are assigned to supervise. I have observed at least [one] such incident when I arrived to [the facility] on [November 5, 2024], you were sitting at the dining room table and [the VA] was outside by [him/herself] unsupervised…It is an expectation that you follow the supervision plan as outlined, reviewed 1:1 with you today as well as trained within our staff meeting this morning [November 13, 2024]. It is imperative that this is followed to ensure safety of [the VA] and reduce unnecessary 9-1-1 calls for missing persons. Let me know if there are any questions.” SP1 provided the following information: · When SP1 was asked to provide information in terms of the supervision that was supposed to be provided to the VA, who had a history of leaving without supervision, SP1 stated, “Eyes on [the VA] at all times.” Staff persons were trained to follow the VA, on foot or in the vehicle, and if staff persons lost visual supervision of the VA for more than 15 minutes, staff persons were trained to call 9-1-1. Staff persons were encouraged to ensure that the VA carried a walkie talkie when the VA went for a walk and SP1 did that “initially,” but did not continue to do that on November 11, 2024, because the VA refused to carry the walkie talkie. · SP1 recalled working on November 11, 2024, and when the VA stated that s/he was going to go on a walk, SP1 told the VA to take the walkie talkie or allow SP1 to walk with the VA, the VA “refused” and left the facility. When that happened, the VA left, but remained on the property so SP1 could see the VA. At some point, the VA left the facility and when that happened, SP1 got the vehicle keys and a cell phone and followed the VA. SP1 maintained visual supervision of the VA until the VA went on private property and into a grove of trees. SP1 continued to drive around looking for the VA and after 15 minutes, SP1 called law enforcement. Shortly after making the call to law enforcement, SP1 continued to look for the VA. Law enforcement found the VA, but SP1 did not remember how long the VA was gone. · On November 11, 2024, the VA left a total of three times and SP1 followed the VA, with the vehicle, when the VA left each time. SP1 thought that law enforcement located the VA at least two times that day, but SP1 was not certain of that. SP1 was not aware of anything that could have been done differently. There was no information that the VA was harmed because of the times that s/he left the facility without supervision. Conclusion for Allegation One: The VA’s Self-Management Assessment showed that the VA needed one to one supervision “at all times in the community.” The VA could be in the backyard at the facility without supervision. If the VA wanted to go on a walk, staff persons would accompany the VA or the VA would take a walkie talkie with. If the VA refused and left without staff persons, staff persons would follow the VA in a vehicle. Regarding November 5, 2024: Law enforcement records showed that on November 5, 2024, at 1:43 p.m., SP1 called law enforcement because the VA left without supervision “7 minutes ago.” At 2:23 p.m., law enforcement found the VA, who was walking back to the facility. The facility’s Internal Review Conclusion and Evaluation stated that at an unspecified time on November 5, 2024, the VA “was walking on the road down toward the dead-end zone, no outlet (private property). Tried talking with [him/her] over the walkie no response.” At some point, the VA “ignored” SP1 and walked out of SP1’s sight. SP1 went back to the facility at an unspecified time, called 9-1-1, and then continued looking for the VA. The VA was located at 2:25 p.m. by law enforcement. SP1, SP2, and P3 were working on November 5, 2024, but no one remembered details regarding what happened prior to the VA leaving that day. SP1 was assigned to supervise the VA at that time. Although the VA left without supervision and it was reported that SP1 did not follow the VA’s plans, given that the VA took the walkie talkie from SP1 who communicated with the VA until the VA refused at which point SP1 called 9-1-1, and that the VA was able to go on a walk if s/he took the walkie talkie, there was not a preponderance of the evidence whether SP1 failed to provide the VA with reasonable and necessary care and services. Regarding November 11, 2024: Information from the investigation showed that the VA left the facility three or four times while SP1 was assigned the VA’s supervision. Law enforcement information showed that on November 11, 2024, at 9:23 a.m., the VA left the facility without supervision and was located by law enforcement, and returned to the facility, at 10 a.m. At 11:21 a.m., the VA left again and was located by law enforcement, and returned to the facility, at 12:16 p.m. At 1:46 p.m., law enforcement was informed that the VA left again. The VA was found, by an unnamed facility staff person, at 4:24 p.m. The VA was taken to a hospital for evaluation due to the number of times that s/he left without supervision, but the hospital discharged the VA that day after completing a mental health evaluation. P2, P3, and SP1 each provided conflicting information regarding when and how many times the VA left on November 11, 2024. P2 and P3 stated that SP1 did not follow the VA each time the VA left until they told him/her to do so but did not provide details regarding how long after the VA left they did so or what SP1 was doing when the VA left. SP1 stated that s/he followed the VA each time. Some information showed that some of the times the VA left s/he had the walkie talkie and other times s/he did not. One occasion, P2 and P3 maintained visual contact with the VA. One occasion, P3 returned to the facility in the facility van and saw the VA but the VA had a walkie talkie with him/her. Although the VA left without supervision while SP1 was assigned to supervise the VA and that P2 and P3 each stated SP1 did not follow the VA until they prompted him/her to do so, given that information was conflicting regarding the details of each occurrence, that even if not SP1 a staff person saw the VA leave and then action was taken soon after, that law enforcement was called, that some occasions the VA had the walkie talkie so was able to be out without supervision, and that there was no information that the VA was harmed while unsupervised, 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). Allegation Two: During the investigation, it was reported that the VA left without supervision and that SP2 did not provide supervision according to the VA’s plans. P1 stated that there was an incident on an unspecified date when the VA left without supervision while SP2 supervised the VA and when P1 reviewed the incident, P1 determined that SP2 followed the VA with the facility’s vehicle and when SP2 lost sight of the VA, SP2 called law enforcement. P1 determined that SP2 followed the VA’s plans as outlined and that s/he did not have concerns related to how SP2 addressed the incident. SP2 told this investigator that s/he followed the VA’s plans when the VA left without supervision. Conclusion for Allegation Two: Given that P1 did not have concerns related to SP2’s supervision of the VA and that P1 and SP2 each stated that SP2 followed the VA’s plans, there was a preponderance of the evidence that there was not a failure to provide the VA with reasonable and necessary care and 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 although policies and procedures were adequate, SP1 did not follow the polices related to supervision. Additional training was provided to SP1 on November 14, 2024. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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