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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: 1119782-PRTF (Psychiatric Residential Treatment Facility) Investigator(s): Carla Harvieux 651-431-6616 carla.harvieux@state.mn.us Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was unsupervised in a facility bathroom for about forty minutes. When staff persons located the VA, s/he had tied strips of cloth around his/her neck and was unconscious. The VA’s face was “blue.” Date of Incident(s): May 19, 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 26, 2025; from documentation at the facility; and through interviews conducted with facility staff persons (SP1, SP2, P1, P2, P3, and P4) and the VA. The VA was not subject to guardianship. The facility provided services to individuals aged 12 to 19 with significant mental and behavioral health issues in a program to support families throughout the treatment process. The facility had a video recording system that recorded common areas of the facility, but the video recordings did not have sound. On campus, individuals received education services, therapies personalized to their needs, and recreational opportunities. The VA was 18 years old when the incident occurred. Facility documentation showed that the VA was diagnosed with generalized anxiety disorder and post-traumatic stress disorder and might become upset when others made comments about his/her appearance or brought up past events being his/her fault. The VA found the gender of some staff persons “triggering” and might have flashbacks when they were present. Positive affirmations and encouragement calmed the VA when s/he was upset. Declining to eat or asking to be alone in a room or bathroom was an indication that the VA might be agitated. Staff persons were to check on the VA often when s/he was not in a group of individuals and were to have near constant verbal checks with him/her when s/he was using the bathroom or taking a shower because many of the VA’s prior self-harm incidents occurred in the bathroom. If the VA made sounds that seemed like something might be wrapped around his/her neck or his/her voice sounded muffled or different when s/he was out of staff persons’ sight, they were to immediately check on the VA. If staff persons thought that the VA might engage in self-injurious behavior, they were to use a Columbia Suicide Severity Rating Scale to assess the VA. The VA’s April 29, 2025, Individualized Treatment Plan (ITP) showed that the VA was on five-minute increased checks for suicidal ideation and no information showed that the frequency of checks decreased prior to the incident. The VA enjoyed listening to music and wanted to live unsupervised in an apartment. Interviews with this investigator, facility documentation, and the facility’s Internal Review, provided the following: · Information was consistent from the VA, SP1, SP2, P1, P2, and a facility Incident Report completed after the incident. P1, P2, and P4 were supervisory/administrative staff persons and SP1 was a milieu lead. On May 19, 2025, the VA was attending an education program at the facility. P1, P2, P4, SP1, and the VA each stated that the VA and SP1 knew each other prior to the VA’s admission to the facility because SP1 previously worked at a facility in which the VA resided. The VA’s team at the facility decided that it would be best for the VA and SP1 to have no contact with each other at the facility because the VA engaged in more self-injurious actions when SP1 was present. SP1 thought that the VA’s attempts to harm him/herself when SP1 was present increased because the VA wanted SP1 to save or rescue him/her. SP1 did not work on units within the facility in which the VA resided. · Just before 1:15 p.m. on the date of the incident, the VA was in a classroom and asked the teacher (who was not a facility staff person), to use the bathroom, and the teacher used a walkie talkie to ask staff persons to walk with “a student” from the classroom to the bathroom, but no information showed whether the teacher specified that the VA was the student who needed to use the bathroom. SP1 went to the classroom to assist the teacher and then learned that the VA was the student who needed to use the bathroom. · According to SP1 and a review of video recordings at the facility, SP1 walked with the VA from the classroom to a common area of the facility, where SP2 and P3 sat. The video recording showed that at 1:14:39 p.m., SP1 was in the common area and made a hand gesture in the direction of SP2. SP1 spoke and when s/he did, SP2 slightly nodded his/her head at 1:14:42 p.m. It was unclear what SP1 said or whether s/he transferred the supervision of the VA to SP2, but SP1, SP2, and P3 remained seated in the common area, and the VA walked away from the common area then entered the bathroom. The video recording showed that many staff persons walked by the bathroom while the VA was in the bathroom. At 1:54 p.m., a staff person (P5) walked near the bathroom and then entered it. A few seconds later, multiple staff persons including SP2, P3, and a facility health care professional (HCP) went to the bathroom. The HCP entered the bathroom, left it, and returned quickly with medical equipment. A couple minutes later, the VA and the HCP exited the bathroom. The recording showed that the VA was unsupervised in the bathroom for about 45 minutes. · SP1 stated that s/he did not know that the VA was the student who needed the bathroom, but as soon as s/he could, s/he handed off the supervision of the VA to SP2. SP1 said that s/he told SP2 that the VA needed to go to the bathroom, and asked SP2 to watch the VA. SP2 nodded, and at that point, SP1 thought that SP2 was responsible for supervising the VA. · SP2 said that when the VA and SP1 entered the common area, SP2 was writing shift notes on his/her laptop and talking with a new staff person who was working his/her first shift. SP1 made a general statement that a youth was in the bathroom and SP2 felt that SP1’s statement was not a direct clear transfer of the VA’s supervision to SP2. SP2 and P3 talked with the new staff person but did not hear any noises of distress from the bathroom, then SP2 suddenly heard gasping from the bathroom and P5 ran into the bathroom where s/he observed the VA lying on the floor and turning “blue.” SP2 called for assistance, and P5 used scissors to cut strips of cloth that were tied around the VA’s neck. SP2 thought the bathroom was about 20-25 feet from the common area. · P3 said that on the date of the incident s/he, SP1, and SP2 were in a common area of the facility working on documentation on their laptops. The teacher called for a staff person to take a student to the bathroom but did not use initials of the student. SP1 answered the call, went to the classroom, and returned to the common area with the VA. Staff persons were aware that the VA had reactive attachment disorder which meant that the VA was more likely to harm him/herself after having contact with SP1 and therefore, the VA and SP1 were not to have contact. According to P3, s/he did not fully recall the exchange, but s/he thought that SP1 told SP2 that the VA needed to use the bathroom, and said, “You need to watch” him/her. SP2, who was using his/her laptop, responded by saying, “Uh huh.” SP1 soon left the common area to respond to a crisis in another part of the facility. P3 continued working and SP2 forgot that the VA was in the bathroom and did not realize the VA was unsupervised until they all heard choking sounds coming from the bathroom. · P4, an administrative staff person, said that when s/he reviewed the video recording of the incident, s/he observed that after SP1 walked with the VA to the common area, SP1 remained in the common area for about two minutes, then left the common area to assist staff persons on another unit in the facility. SP1 returned to the common area about ten minutes later, and remained in the common area with other staff persons until the VA was located in the bathroom at about 1:55 p.m. · P5 provided information in the facility’s Internal Review which showed that s/he heard sounds when s/he walked by the bathroom and then entered the bathroom to determine the source of the sounds. P5 located the VA in a bathroom stall and used his/her hands and scissors to remove cloth items from the VA’s neck. One of the fanny packs worn by a staff person did not have scissors in it, and there was an extremely short delay before another staff person gave P5 scissors from his/her fanny pack. P5 was facing the VA, and his/her back was to the staff persons, so s/he was unsure which staff persons had scissors and which did not. SP2 called for assistance and the HCP responded then evaluated the VA, but the VA did not require medical care from a physician. The facility’s Program Abuse Prevention Plan (PAPP) documented in several places that staff persons were to check on all youths at a minimum of every 15 minutes to ensure ongoing safety. Checks might be increased to 5- or 10-minute intervals depending on an individual’s vulnerability and safety needs. Checks were to be reassessed as needed. The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procedures prior to the incident. Relevant Rule/s and Statute/s: Minnesota Rules, chapter 2960V.06, subpart 2, subitems (8) and (9) stated that each resident shall be prescribed an individualized program, that does the following: ensures all PRTF service staff in regular contact with the resident are aware and understand each resident’s needs, goals and services identified on the plan of care and ensures all PRTF staff engage residents in continuous and intentional interaction designed to meet the resident’s needs regardless of the setting or activity during all waking hours including day, evening, and weekends. Conclusion: The facility provided services to individuals aged 12-19 and the VA was 18 years old when the incident occurred. When the VA was agitated, s/he might try to isolate him/herself from others and when the VA was upset, staff persons were to check on the VA often. If staff persons thought that the VA might have self-injurious behavior or was in the bathroom, they were to have almost constant verbal contact with him/her. If the VA’s voice sounded muffled or different, staff persons were to immediately check on him/her. Information was consistent that SP1 was not to work with the VA when the incident occurred, and SP1 said s/he transferred supervision of the VA to SP2 as soon as they reached the common area. SP2 said that when the VA and SP1 entered the common area, SP2 was working on his/her laptop and talking with the new staff person. SP2 thought that SP1 did not clearly transfer the VA’s supervision to him/her. The video recording showed that SP1 and the VA walked into the common area, and that SP2 gave a slight nod toward SP1 and the VA after SP1 spoke. P3 did not fully recall the conversation between SP1 and SP2 on the date of the incident, and s/he and SP2 were using their laptops when SP1 and the VA entered the common area. P3 thought that SP1 told SP2 that the VA needed to use the bathroom, and that SP2 needed to “watch” the VA. SP2 responded by saying, “Uh huh,” and SP1 soon left the common area to respond to a crisis in another part of the facility. P3 continued working and thought that SP2 forgot that the VA was in the bathroom. SP2 and P3 did not realize the VA was unsupervised until they heard choking sounds coming from the bathroom. The VA was assessed by the HCP after the incident and did not require medical care. Minnesota Statutes, section 626.5572, subdivision 17, paragraph (c), clause (4), states, “A vulnerable adult is not neglected for the sole reason that an individual makes an error in the provision of therapeutic conduct to a vulnerable adult which does not result in injury or harm which reasonably requires medical or mental health care. SP1 realized that s/he should not supervise the VA and transferred supervision of the VA as soon as possible to SP2, therefore, his/her responsibility was mitigated. No information showed that P3 was responsible for the VA’s supervision during the incident. The VA was unsupervised in the bathroom for about 45 minutes which was a violation of Minnesota Rules, chapter 2960V.06, subpart 2, subitems (8) and (9), and the facility’s policies and procedures. The VA used the unsupervised time to wrap items around his/her neck, which caused his/her face to discolor. Information was consistent from SP1 and P3 that SP2 was responsible for the VA’s supervision when the incident occurred. However, it was determined that SP2’s actions were an error in the provision of therapeutic conduct given that SP2 stated that SP1 did not clearly transfer supervision of the VA to SP2 so was considered a miscommunication, that the VA was assessed after the incident and did not require the care of a physician, that the VA returned to his/her previous state, that there were no past incidents between the VA and SP2, and that the facility reported the incident timely and identified what corrective actions needed to be completed, retrained staff persons, and sufficiently documented their actions for review and evaluation. This error in the provision of therapeutic conduct to the VA by SP2 was not maltreatment. 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 which determined that their policies and procedures were adequate but were not followed. SP1 and SP2 were retrained on communication skills, teamwork, and the importance of appropriate supervision and were to re-read the facility’s PAPP. SP1 received coaching and corrective action, and the PAPP was revised to show that when a staff person was responsible for supervising a youth, they were responsible for the supervision of the youth until they handed off supervision of the youth to another staff person in person with a verbal statement that responsibility for supervision was being handed off. Change in supervision was not considered complete until the person taking accountability for the youth confirmed their understanding of the transfer. Action Taken by Department of Human Services, Office of Inspector General: SP2 was not substantiated as a perpetrator of maltreatment of the VA because the Department of Human Services found that the incident for which SP2 was responsible met the criteria to be determined an error. SP2 was notified by the Office of Inspector General that any future incident of possible neglect of a vulnerable adult for which SP2 is responsible might not be considered an error. On December 11, 2025, the facility was issued a $200 fine failing to ensure the VA was supervised for about 45 minutes which allowed the VA an opportunity to harm him/herself. The Order to Forfeit a Fine is subject to appeal.
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