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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: 1072293-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Brittany Dolen 651-431-6701 Suspected Maltreatment Reported: It was reported that a staff person (SP) drove a vulnerable adult (VA) to a home, where the SP used illegal drugs. The SP then drove the VA back to the facility. Date of Incident(s): August 28, 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 7, 2025, from documentation at the facility and through eight interviews conducted with the VA, the VA’s guardian (G), the VA’s case manager (CM), a facility resident (R), two supervisory staff persons (P1 and P2), and two facility staff persons (P3 and P4.) Attempts were made via telephone and certified mail to contact and interview the SP; however, the SP did not respond to those attempts. The VA was diagnosed with cerebral palsy and type 2 diabetes and required staff person assistance to maintain his/her medical conditions. The VA had a history of not following medical recommendations related to his/her diagnosis which resulted in the VA requiring placement in multiple residential settings. The VA had 12 hours of unsupervised time in the community as well as at the facility and was primarily independent but required prompts and encouragement to complete daily tasks. The VA enjoyed writing, acting, cooking and spending time with friends and family. The facility’s Safe Transportation Policy said that staff persons were responsible for the safety and supervision of persons being transported and were required to follow all traffic safety laws while operating the program vehicle. The facility’s Drugs and Alcohol Policy said that employees were prohibited from being under the influence of a controlled substance or illegal drugs in any manner that impaired or could impair a staff person’s ability to provide care or services to persons receiving services. The facility’s Employee Information Guide stated the following: · Staff persons were prohibited from the unlawful manufacture, distribution, dispensation, possession, or use of alcohol, illegal narcotics, drugs or controlled substances while on company business, providing service to individuals, using company vehicles or on company property. · Staff persons were prohibited from conducting personal business on work time such as personal errands or stopping, dropping off or picking up anything on the way to or from a work location, and/or visiting family, friends or any location not related to job responsibilities. · Staff persons were prohibited from, under any circumstance, taking an individual served to their home, a friend or family’s home or to any other locations, events, outings or errands without authorization from a supervisory staff person. The VA provided the following consistent information at different times to this investigator and P1: · On an unknown date, between 12-1 p.m., the VA asked the SP for a ride to the gas station. The SP agreed and told the VA s/he also needed to go to his/her home to “pick up some papers.” The SP then drove the VA to a home, which the VA described by color. · When they arrived, the SP left the vehicle and went into the house. The VA sat in the car for “a good twenty-five minutes” and then got out of the vehicle to find the SP. The VA found the SP in the garage with an unknown individual and the SP was holding a tray with “tinfoil and white powder.” The SP and the unknown individual were smoking something “wrapped up like a joint.” The VA was in the garage for “two or three” minutes and heard the unknown individual ask the SP “is this fentanyl.” The VA smelled a “burning smell” before s/he left the garage and got back into the vehicle. · When the SP got back into the vehicle, the VA thought the SP was “high” because his/her eyes were “glassy.” The VA did not say anything to the SP, and “hoped to God” the SP did not get into an accident. The SP then drove the VA back to the facility and the VA did not feel safe when the SP drove. The VA stated that s/he was “surprised [the SP] stayed in one lane” as s/he drove. · The VA did not remember what time they arrived at the facility, but when they did, the SP went downstairs, and the VA told the R what happened. The R told the VA that the SP should not have taken the VA to his/her home and that the VA needed to tell P1. The VA then called and left a voicemail for P1. On or around September 5, 2025, the VA talk to P1 and provided information to P1 that was consistent with the information the VA provided during his/her interview. · When the SP worked, s/he made “constant” trips to the bathroom and then the VA “smelled something burning.” On one occasion, when the SP left the bathroom, there was “black residue” on the sink, toilet seat and floor, but the VA did not see this. The VA “suspected” the SP did something “illegal” in the bathroom. · The VA said that the burning smell in the garage was the same as the burning smell from the bathroom at the facility when the SP used the bathroom. The R said that on August 28, 2025, the SP asked the R if s/he wanted to go to the gas station, but the R said, “No,” because s/he wanted to nap. Around 5 p.m., the SP and the VA left the facility and the R fell asleep. Around 7 p.m., the R awoke and the SP and VA returned around 7:30 p.m. The SP “went directly to the bathroom and then to the garage” and then the VA told the R that the SP drove the VA to a house and the SP went into the house but later the VA found the SP in the garage with an unknown individual. The VA heard the individual ask the SP if something in tinfoil was fentanyl, but the VA did not say if the SP responded, and the R did not remember what else the VA told him/her. The R said staff persons were not supposed to bring residents to their homes because of “confidentiality and safety.” When the SP worked, the SP “frequently” went into the bathroom and then there would be a “burning rubber/plastic” smell. P1-P4 and the facility’s Internal Review provided the following consistent information: · P1 said that staff persons had concern with some of the SP’s behavior which included using the bathroom frequently and for extended periods of time, and the SP acting “off.” On September 9, 2025, the VA told P1 about this incident and provided information to P1 that was consistent with the information the VA provided during his/her interview. · P2 did not work the day of the incident, but when s/he worked with the SP, the SP used the bathroom “frequently” and when the SP did so, s/he brought his/her bag and cleaning supplies into the bathroom. P2 sometimes noticed a “funny” smell when the SP worked, but “did not think anything of it.” There were also times when P2 saw the SP “nod off” when s/he worked but P2 thought the SP was “very tired.” · P3 did not work the day of the incident, but when s/he worked with the SP, the SP displayed “odd” behavior. The SP went to the bathroom multiple times per hour and left the facility to get paperwork, or had individuals bring paperwork to the facility. P3 worked with the SP “maybe three times” and each time when the SP left the bathroom, P3 thought the SP had “pinpoint” eyes, a “very high” mood and “dozed off.” On an unknown date, after the second time P3 worked with the SP, P3 told P1 his/her concerns and the SP’s behavior was closely monitored after that. · P4 was not working on the day of the incident. On an unknown date, P4 took a photo when the SP left the bathroom of “black, tar-like substance” that was on the back of the toilet, and sent it to an unidentified staff person, who then sent it to P1. · The SP denied bringing the VA or any other resident to his/her home and denied use of any substances while at work, or in general. · P1-P4 each said they observed the SP use the bathroom frequently when s/he worked, and that when the SP did so, there was a burning rubber/plastic smell. The SP worked approximately five shifts at the facility. The G was not aware of the incident, and did not have previous concerns with the facility. The CM was aware of the incident, and did not have previous concerns with the facility. The facility’s personnel files showed that all staff persons interviewed, and the SP, were trained on the VA’s plans, facility policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: The VA provided consistent information that on August 28, 2025, the SP drove the VA to a home that the SP said was his/her home. The SP left the VA in the car alone for approximately 25 minutes and when the VA went to look for the SP, s/he saw the SP and an unknown individual in the garage with a tray with “tinfoil and white powder” and they were each smoking something “wrapped up like a joint.” The SP then drove the VA back to the facility, and the VA did not feel safe. Multiple staff persons said the SP had previously displayed concerning behaviors at the facility, consistent with substance use. Facility policies and procedures said that staff persons were not permitted to bring residents to their homes and were not to conduct personal business on company time. Although the SP did not provide information for this investigation, given that the VA’s accounts of the incident were consistent, that there were previous concerns with the SP’s actions at the facility which were similar with the VA’s account of the incident, it was more likely that after using an intoxicating substance the SP drove the VA. Although the VA was in the car unsupervised for approximately 25 minutes, the VA had 12 hours of unsupervised time in the community. However, driving after using intoxicating substances is illegal and placed the VA at significant risk of harm. Therefore, there was a preponderance of the evidence that there was a failure to supply the VA with care or services which were reasonably necessary to obtain or maintain the VA’s physical or mental health or safety. 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. At the time of the incident, the SP was responsible for providing necessary services to ensure the VA’s health, safety and wellbeing. The SP was trained on the VA’s plans, facility policies and procedures, and the reporting of Maltreatment of Vulnerable Adults Act. 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.” Although the SP likely used substances while working at the facility, at those times, there was no information the SP drove any residents at that time, and there was another staff person present in the event of an emergency. Therefore, the SP was responsible for a single incident of driving the VA while intoxicated and the VA did not sustain and injury that required the care of a physician. Action Taken by Facility: The facility completed an Internal Review and stated that their policies and procedures were adequate but not followed. 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.
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