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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: 1071657-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) was impaired and appeared to be under the influence of a substance while working at the facility. The SP was sent home and it was discovered that a vulnerable adult’s (VA’s) liquid medication was missing. Date of Incident(s): August 27, 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 9, paragraph (b), clause (1): In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. Summary of Findings: Pertinent information was obtained during a site visit conducted on September 17, 2025; from documentation at the facility, law enforcement records, and medical records; and through six interviews conducted with facility staff persons (SP, P3, and P4), facility supervisory staff persons (P1 and P2), and the VA’s guardian (G). The VA was not able to provide information for this investigation. The VA’s diagnoses included catatonia, epilepsy, severe-profound developmental cognitive disability, and hypotonia. The VA enjoyed van rides, music, being outside, books, and going for walks. The VA was prescribed lorazepam in liquid form. The VA received a total of 4.5 milliliters (mL) per day between five doses (0.75 mL at 8 and 11 a.m. and 1 mL at 2, 5, and 8 p.m.). One bottle of lorazepam contained 30 mL. The facility was a single-family, one-story residence in a residential neighborhood. The main level consisted of two bedrooms, an office/bedroom, two bathrooms, a living room, a dining room, a kitchen. The basement consisted of an office/living room area, a bedroom, bathroom, and laundry room. Information from law enforcement (LE) showed that on August 27, 2025, at 1:53 p.m., LE received a call to the facility for a theft report of missing lorazepam. P1 informed LE that 30 mL of lorazepam went missing during the SP’s shift. The SP started acting “sick” and thought s/he was having a “stroke.” The SP was picked up by his/her significant other. At 1:54 p.m., LE received a call to the SP’s residence for the SP possibly having a stroke. LE arrived and the SP said s/he took prescription medicine that was not the SP’s. The SP’s symptoms were “severe,” and the SP was transported to the hospital. The SP was not questioned about the theft as “getting to the hospital soon was crucial.” On September 11, 2025, LE spoke with the SP regarding the theft of lorazepam. The SP stated s/he gave the VA liquid medication and threw the bottle away after the VA’s medication was administered. The SP denied consuming any of the medication and did not remember much about the time the SP was at work because the SP had a “medical emergency.” The VA’s two most recent deliveries of Lorazepam were on July 30 and August 14, 2025, in which three 30 mL bottles were delivered in each shipment. The VA got a total of 4.5 mL of Lorazepam per day. P4 confirmed there was at least a full bottle and a half full bottle of Lorazepam on the morning of August 26, 2025. The facility did not have a set schedule of when medications were refilled. Medical records showed the SP was examined at a local hospital in the Emergency Department on August 27, 2025, at 2:17 p.m. and presented with an “altered mental status and concern for a potential overdose of lorazepam.” The SP’s diagnosis was “toxic encephalopathy, unspecified toxin.” Records stated the SP had a “change in mental status,” it was “suspected that it was a combination of the weed/THC that [the SP] used in conjunction with extra benzodiazepines that were taken.” A rapid drug screen urinalysis was completed and showed “non-negative” results for THC metabolites and benzodiazepines. The SP was “sleepy”, had “somewhat slurred” speech, and had an “unsteady” gait. The SP told hospital staff that s/he took his/her usual medications at 8 a.m. and “did not take any additional doses.” The SP was discharged after 8:31 p.m. on August 27, 2025. P2 provided the following information: · On the date of the incident, P2 was training the SP in at the facility. P2 and the SP went outside around 9 to 10 a.m. and smoked vapes. P2 took a “hit” off the SP’s vape. P2 stated his/her vape only contained nicotine and denied that the SP took a hit off of his/her vape. P2 did not state what was in the SP’s vape. · At 11 a.m., lorazepam was administered to the VA. P3 also observed for training. P2 did not know how much liquid lorazepam was left after it was administered to the VA’s G tube (Note: P2 and P3 each stated the SP administered it but the SP said P3 did). · P2 and P3 took the VA outside for approximately one hour and the SP chose to stay inside. P2 saw inside the facility and it looked like the SP was “stumbling around.” · When P2 went back inside, the SP told P2 they needed to order more lorazepam. P2 thought there was another bottle of the lorazepam but did not think about it at the time. The SP should not have been touching the medications, as s/he was not medication “trained.” · The SP brought P2 to the VA’s room, where the lorazepam was kept, and “kept running into walls and was getting worse to the point [the SP] could not even talk or form a sentence.” The SP showed P2 an empty bottle and a half full bottle of lorazepam. P2 told the SP to use a black marker to cover up information on the medication label and had the SP throw the empty bottle away. The SP got “worse over time” and fell backwards every time s/he tried to stand. P2 had the SP sit down and the SP stared at the floor for “20 minutes straight.” P2 called P1 and asked for advice. · The lorazepam was kept in a lock box in a fridge in the VA’s bedroom. The key for the lock box was kept in the office. · P1 and additional supervisors arrived and spoke to the SP. The SP said that s/he had taken a new nighttime medication earlier in the day. · On the morning of August 27, 2025, P4 told P2 when they were getting low on lorazepam and there was a full bottle and a half full bottle left. P3 provided the following information: · P3 started his/her shift at 7 a.m. P3 and the SP were both in training. P3 and the SP both told P2 they wanted to learn to pass medication. P2 let the SP draw the VA’s lorazepam solution into a syringe. P3 was unsure who administered the lorazepam to the VA. At the time the lorazepam was administered, the bottle was almost empty. The bottle was not transparent and P3 did not know how much medication was left. · P3 and P2 went outside with the VA and the SP stayed inside the facility. The SP came out and told P2 that s/he needed to order more lorazepam. P2 told the SP s/he would do it and the SP went back inside the facility. P3 estimated s/he and P2 were outside for ten minutes. The SP came out of the medication room and was “wobbling” and was “not walking properly.” The SP told P2 that s/he was on a nighttime medication that makes the SP “wobbly.” P2 observed the SP for a while and observed the SP fall down. P2 then called a supervisor. The SP kept saying that s/he was okay. The SP appeared “drunk,” spilled a drink and kept falling down. P1 and another supervisor arrived at the facility and the SP’s family member arrived to take the SP home. · P3 talked to P2 and mentioned they should check the medication due to the SP wanting to reorder the lorazepam. P2 noticed a new bottle of lorazepam was about half full and the empty bottle of lorazepam had been “scratched out.” An empty box for lorazepam was in the trash. P1 provided the following information: · P1 stopped by the facility at 11 a.m. on August 27, 2025, and the SP was “fine.” The SP worked at another facility location and was cross training at the facility to get additional hours. It was the SP’s second shift at the facility. At approximately 1 p.m., P2 called P1 and informed him/her that something was wrong with the SP. The SP was stumbling around and bumping into furniture and walls. P1 and two other supervisors went to the facility. · Any time the SP tried to stand up, s/he “was about to fall over.” The SP was escorted to a vehicle by two supervisors, one on each side. The SP was picked up by a family member and P1 went back to the main office. · P2 called and informed P1 that some of the VA’s lorazepam was missing. On August 26, 2025, P4 informed P1 that there was a bottle and a half left, which would have been approximately 45 mL. It was estimated that approximately 25 mL was missing. The SP’s family member was called and notified that the SP may have consumed the lorazepam and that the SP should be evaluated at a hospital. The family member stated the SP had fallen and 9-1-1 had been called. · A police report was made for the missing lorazepam. The officer that responded to the theft report had previously responded to the 9-1-1 call for the SP. · The SP was interviewed by the facility investigator the next day and resigned on September 1, 2025. P4 provided the following information: · P4 worked the overnight shift on August 26, 2025, and was at the facility when the SP arrived for the morning shift on August 27, 2025. That was the first time P4 had met the SP. P4 counted a medication and had the SP “buddy check” and sign off on the medication count. P4 only spent about 15 minutes with the SP. · There was not a way to know how much liquid medication was left. P4 thought there was two and a half bottles in the locked box in the refrigerator in the VA’s room, prior to the incident. · P4 found out about the incident when s/he asked P2 why the medication needed to be locked in the medication room now and P2 told P4 that lorazepam was missing. The G was notified by the facility via email and was told there should have been a bottle and a half of lorazepam left. There was only half a bottle left. A police report had been made for theft and the facility ordered a replacement bottle and was covering the cost. The VA did not miss any doses of the lorazepam. The SP provided the following information: · On the date of the incident, the SP grabbed anxiety medication from his/her house and put the medication in his/her bag and went to work. · The SP started his/her shift at the facility at 8 a.m. It was the SP’s second day training at the facility. · Around 9 a.m., the SP took his/her anxiety medication. The SP went outside to vape with P2. The SP said P2 asked for a hit of off his/her vape. P2 told the SP to try his/her vape and the SP took a hit off of P2’s vape. The SP stated the contents of the vape had a “little weird taste.” The SP stated P2 mentioned s/he smoked “weed” daily “on the job.” · At 11 a.m., the SP drew the VA’s liquid lorazepam into the syringe, asked P2 if it was done correctly, and P3 administered the medication to the VA. The SP told P2 the bottle of Lorazepam was empty and then it was thrown in the garbage. The SP did not get a new bottle of Lorazepam. · Around 12 to 12:30 p.m., the SP started to feel “weird.” The SP did not remember anything after that time. The SP later learned s/he had texted a family member starting at 11:45 a.m. and the texts “didn’t make sense.” The SP did not remember sending the text messages. The SP did not remember P2 and P3 went outside, while the SP stayed in the facility. · The SP was picked up by a family member around 1:30 p.m. The SP did not remember anything after being picked up. The SP was taken to an area hospital around 2 p.m. after the SP fell and hit his/her head at home. Blood and urine tests were done at the hospital, which showed the presence of THC. The SP stated s/he did not “smoke weed.” The SP was released from the hospital around 9 p.m. · The SP’s family member found the medication the SP took in his/her bag. The medication was mirtazapine, a “nighttime” medication. The SP stated s/he had grabbed the wrong medication of his/her kitchen counter when s/he left for work. · The SP denied taking the VA’s lorazepam, anyone else’s medication, or taking medication out of the medication cabinet. The facility’s Internal Review stated the SP worked with P2 and P3 on August 27, 2025. The VA was given lorazepam at 11 a.m. and there was half a bottle left of the opened bottle. The SP drew the medication and did not say anything about the lorazepam being empty. There was also a full unopened bottle. P2 and P3 took the VA outside and the SP remained inside. P3 saw the SP go into where the “medication was kept.” The SP went outside one time to tell P2 that the lorazepam was empty and asked how to order more. The SP stated s/he accidentally took a nighttime medication and did not remember anything after that. The SP did not recall P2 and P3 going outside or what s/he was doing during that time. When the SP was messaging with a family member to be picked up, the SP tried to send the address of the facility via text message and instead entered the address in the search bar on the Walmart app. The SP slurred words and had trouble standing. The SP was picked up by a family member. An empty box and empty bottle of lorazepam were found in the trash. It was discovered that there was approximately half a bottle left of the VA’s lorazepam and approximately a full bottle was missing. P3 completed a Maltreatment Refresher, P2 completed Review of Job Description Acknowledgement, the door to the medication room and the medication cabinet remained locked when not in use, unopened lorazepam was kept in the medication cabinet, and the lorazepam was moved to the medication room and was kept in the locked box in the refrigerator once opened. Facility training records showed all staff persons interviewed had training on The Reporting of Maltreatment of Vulnerable Adults Act. P3 completed training on the Reporting of Maltreatment of Vulnerable Adults Act; however, it was completed eight months after it was due. P1 and P4 had been trained on the VA’s plans. The SP and P3 were in the process of being trained on the VA’s plans at the time of the incident. The facility stated P2 was trained on the client’s plans but was unable to provide supporting documentation. Conclusion: A. Maltreatment: Information showed that on August 26, 2025, there was a full bottle and a half full bottle of lorazepam. The VA received a total of 4.5 mL of lorazepam daily. On August 27, 2025, the SP worked at the facility with P2 and P3. At 9 a.m. the SP stated s/he took what s/he thought was a daytime medication but accidentally took his/her nighttime medication. The VA was given a dose of lorazepam around 11 a.m. The SP drew up the medication in the syringe and information varied on who administered the medication to the VA but was consistent that P2 was training the SP and P3 on medication administration so they were present at that time. Then, P2 and P3 took the VA outside and the SP remained inside the facility. After about an hour, P2 and P3 went inside the facility and the SP was stumbling and slurring words. The SP stated they needed to reorder lorazepam. P2 called P1, who went to the facility with two other supervisors. A family member was called and picked up the SP. The SP fell at home and was taken to the hospital to be evaluated. An empty box and empty bottle of lorazepam were found in the trash and a half full bottle was found in the VA’s lock box in the fridge in his/her room. It was discovered that approximately 25-30 mL of lorazepam were missing. The SP told LE that s/he took prescription medication that did not belong to the SP. Medical records showed the SP was examined at a local hospital and presented with an “altered mental status and concern for a potential overdose of lorazepam.” The SP had blood and urine tests performed at the hospital, which showed the presence of THC metabolites and benzodiazepines. Records stated the SP had a “change in mental status,” it was “suspected that it was a combination of the weed/THC that [the SP] used in conjunction with extra benzodiazepines that were taken.” The SP told medical personnel that s/he took his/her “normal” medications and did not take any additional doses. Later, the SP denied to LE consuming medication that was not his/hers. Although the SP provided conflicting information first stating that s/he took someone’s medication and then denying it, given that the day prior there were one and a half bottles of lorazepam, then after the SP had symptoms, there was only a half bottle and an empty in the trash, that the SP tested positive for benzodiazepines, that medical records stated the SP was examined the hospital and presented with an “altered mental status and concern for a potential overdose of lorazepam,” there was a preponderance of the evidence that the SP used and consumed some of the VA’s lorazepam in the absence of legal authority. It was determined that financial exploitation occurred (in absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). 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. The SP was trained on 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 financial exploitation for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious. The financial exploitation was a single incident and did not cause any harm to the VA as a result. Action Taken by Facility: The facility conducted an internal review and determined that policies and procedures were adequate and were not implemented as applicable, there was a need for additional staff training, the incident was not similar to past events, and there was a need for corrective action by the license holder to protect the health and safety of the VA. The fridge that contained the VA’s medication was moved to the office. The office was locked when new hires were at the facility and new hires did not have access to the office keys. 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. On January 5, 2026, the facility was issued a Correction Order for not having documentation that a staff person was trained on the VA’s plans and for a staff person completed the Reporting of Maltreatment of Vulnerable Adults Act training eight months after it was due.
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