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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: 1124734-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Heidi Murphy Heidi.Murphy@state.mn.us 651-431-6544 Suspected Maltreatment Reported: It was reported that a staff person (SP) did not inspect a package that was delivered to a vulnerable adult (VA). The VA ordered razors and was able to self-harm by cutting his/her arm. Date of Incident(s): September 24, 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 October 16, 2025; from documentation at the facility and medical records; and through four interviews conducted with three facility staff persons (the SP, P1, and P2) and the VA. The VA was not subject to guardianship. The VA’s diagnoses included major depressive disorder, persistent mood disorders, anxiety disorder, borderline personality disorder, other specific personality disorders, impulse disorders, unspecified intellectual disabilities, autistic disorder, attention deficit hyperactivity disorder, and suicidal ideations. The VA enjoyed video games and spending time with family. The VA’s plans stated room checks were to be done “frequently” and sharp objects that the VA could use for self-harm were to be removed. The VA had a “history of attempted suicide or thoughts of suicide; [the VA] will act on the thoughts and will self-harm [him/herself] by cutting.” Staff checked on the VA every 15 minutes. The VA handled his/her own money and got assistance from family members. The VA’s plans did not prohibit internet purchases or require staff to open the VA’s packages. The facility was a single family three level split residence in a residential neighborhood. The main level consisted of a kitchen and a dining room. The upper level consisted of three bedrooms and a bathroom. The lower level consisted of one bedroom, a bathroom, a living room, a laundry/utility room, and an office. The VA provided the following information: · On the day of the incident, the VA ordered razor blades from Amazon in the morning. They were delivered the same day and the SP brought the package to the VA and left the package in the VA’s bedroom. The SP did not open the package before it was given to the VA. · The VA waited until nighttime and then cut his/her arm with the razor blades because s/he was depressed. The VA then went and told P1 that s/he had cut him/herself. · The VA was taken to the hospital within approximately 20 minutes and received treatment. · Some staff persons asked to check the VA’s packages and others did not. There was nothing “concrete” regarding checking packages at the time of the incident. · The VA did not think staff persons were supposed to check packages before they were given to the VA. The VA was not subject to guardianship and was able to order whatever items s/he wanted. There were no restrictions on what the VA purchased. · Staff persons were now required to check the VA’s packages. The VA felt comfortable telling staff persons when s/he felt like self-harming. The SP provided the following information: · On September 24, 2025, the SP was at the facility and saw an envelope style package, approximately eight inches by eight inches, in the entryway addressed to the VA. The SP brought the package to the VA’s room and asked if the package contained Pokémon cards and the VA did not respond. The SP left the package on a chair in the VA’s bedroom and left. · The VA had previously ordered Pokémon cards off the internet. The SP stated the box inside the package “felt” like the previously ordered boxes of Pokémon cards. · The VA did not have restrictions on using the internet or making purchases. There was no policy that required staff persons to open or inspect the VA’s mail. · At 9:59 p.m., P1 called and notified the SP that the VA had cut him/herself and was bleeding. The VA used razor blades to cut his/her arm. The VA refused to let P1 clean the wounds or see how deep the cuts were. The VA gave P1 two razor blades. · The SP called P2, who just finished a shift at the facility working with another client, and asked P2 to go to another facility to get a van and bring the VA to the hospital. · P2 transported the VA to the hospital and the cuts were cleaned and sutured. The SP looked on Amazon and discovered razor blades came in packs with more than two. The VA waited to see a mental health professional and the SP requested that P2 returned to the facility to look for additional razor blades. · P2 left the hospital and looked through the VA’s room and found an additional 48 razor blades from a box of 50. · The VA was discharged from the hospital on the morning on September 25, 2025. The VA agreed to have staff persons open packages in the VA’s presence in the future, to ensure the package do not contained items the VA can self-harm with. The VA’s team was working on putting rights restrictions in place to include the inspection of packages. P1 provided the following information: · On September 24, 2025, P1 started work at the facility at 2 p.m. The VA spent time in his/her bedroom and P1 checked on the VA every 15 minutes during the shift. · P1 checked on the VA at 9:45 p.m. and started documenting shift activities. Around 9:55 p.m., the VA approached P1 and stated s/he had cut him/herself. P1 asked what the VA used and the VA stated “blades” and gave P1 two razor blades. The VA told P1, “I can’t give you the rest.” P1 could not see how deep the cuts on the VA’s arm were and the VA refused to let P1 clean the wounds. · P1 called and notified the SP that the VA had cut him/herself. The SP asked P2, who just got off of work, to take the VA to the hospital. The VA left with P2, while P1 and an overnight staff person looked for the additional razor blades for approximately one hour. No additional razor blades were found. P1 left for the night and the overnight shift continued to look for the razor blades. · P1 did not think the VA had any rights restrictions. At the time of the incident, P1 did not know of any policies or plans that required staff persons to open the VA’s packages. P2 provided the following information: · P2 was working with a client in the lower level of the facility on the night of September 24, 2025. P2 was leaving the facility a few minutes prior to 10 p.m., when the SP called and asked P2 to go to another facility, get a van, and come back to the facility to drive the VA to the hospital. · P2 went and got the van and drove the VA to the hospital. The VA was seen right away and was asked how s/he harmed him/herself. The VA told hospital staff that s/he ordered the razor blades through Amazon and cut him/herself. The VA received stitches and waited for a “psych doctor” to meet with the VA. · The SP called and asked P2 to go back to the facility and look for additional razor blades. P2 went back to the facility, searched the VA’s room, and recovered “more than 20” razor blades in the closet. P2 sent the SP a photo and secured the razor blades in the office. · P2 mostly worked the night shift and did not often deal with mail or packages. Packages that were received were given to clients. At another facility location, staff persons opened packages in front of the clients. P2 was not aware of the facility’s procedure for giving clients packages. P2 was not sure if there was a company policy that addressed opening client’s mail or packages. · The VA did not like staff persons sitting with him/her and safety checks were conducted every 10-15 minutes prior to the incident. Facility records showed the SP, P1, and P2 had training on The Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans. Conclusion: Information showed that on September 24, 2025, the VA ordered a box of razor blades from Amazon and had them delivered to the facility that morning. The SP manipulated the package and believed the package contained Pokémon cards. The SP did not open the package and gave it to the VA. There were no policies or plans in place that required the VA’s packages to be opened prior to giving them to the VA. P1 conducted safety checks on the VA every 15 minutes during his/her shift from 2 p.m. to 9:45 p.m. At approximately 9:55 p.m., the VA approached P1 and stated s/he had cut his/her arm with a razor blade. P1 contacted the SP and P2 drove the VA to the hospital for evaluation and treatment. P1 searched the VA’s room and was unable to locate any additional razor blades. P2 left the hospital and returned to the facility to look for additional razors blades and located “more than 20” in the VA’s closet. The razor blades were confiscated. The VA received treatment at the hospital and was released back to the facility. Although the VA had a history of self-harm with sharp objects, given that there were no plans or policies that required the VA’s packages be opened or inspected before they were given to the VA, that the SP manipulated the package and would not have reason to believe there was anything dangerous in the package, and that P1 conducted safety checks every 15 minutes during the shift, 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 was 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’s Internal Review stated policies and procedures were adequate and were followed. Staff persons were trained on supervision protocols and asked the VA’s team for additional support with package protocol. Staff persons started to open packages in front of the VA. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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