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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: 1084092-H_CRS (Home and Community-Based Services-Community Residential Setting) 1072139-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a vulnerable adult (VA) had tooth pain and required a dental appointment, however a staff person (SP) refused to schedule the appointment. Date of Incident(s): Multiple incidents since July 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 24, 2025; from documentation at the facility; and through four interviews conducted with a facility supervisor (P), the VA, the VA’s guardian (G), and the SP. Facility documentation showed the VA enjoyed activities that provided physical exercise as well as a sense of well-being. The VA enjoyed playing board games, listening to music, and socializing with friends and family. The VA was diagnosed with a traumatic brain injury and had difficult with his/her memory. The VA had previously worked in the community and was seeking other employment. The VA moved into the facility in May 2024, had two hours of unsupervised time in the community and four hours of unsupervised time while at the facility. The VA’s Coordinated Service and Support Plant Addendum provided the following information: · The facility staff persons were to provide assistance with medical and dental appointments. The VA was able to manage some areas of his/her life independently, while needing ongoing support in other areas. Staff person would work with the VA to build competency in the areas that s/he is willing to improve upon. · The VA had an annual meeting in April 2025, and there was no known tooth pain or need for a dental appointment noted. The VA’s Self-Management Assessment provided the following information:
· The VA was aware of his/her physical and health needs, and was always willing to attend scheduled appointments. · The VA understood the benefit and need of his/her preventative appointments and attended them as needed. The VA attended appointments when scheduling, management, and transportation were provided by staff persons. The G said the VA told him/her about tooth pain in August or September of 2025, but was uncertain whether an appointment had been scheduled. The G added s/he had also talked to the VA in the spring of 2025 about getting “implants” as the VA had talked to the G about his/her teeth. The P said the SP was responsible for scheduling appointments for the VA, but failed to follow through on the VA’s requested appointment. The P said there were no previous concerns with the SP’s work performance. The P said the VA had not brought up the concern of tooth pain to him/her during their interactions. The VA provided the following information: · The VA said s/he had tried to get a dental appointment scheduled for the past six months as s/he had tooth pain prior to moving into the facility. The VA described the tooth pain as happening a couple times a week, and it hurt when s/he breathed, or consumed hot or cold items. · The VA was not able to provide an exact timeline of when s/he asked the SP to schedule an appointment as the VA said s/he had short-term memory loss. · The VA said the tooth pain caused issues with eating and drinking, but did not have any further medical issues. The VA said the SP had scheduled other medical appointments for him/her without any issues, and had no other concerns with the SP. The SP provided the following information: · The SP said on at least two occasions the VA said s/he had tooth pain and requested a dental appointment. The SP said the VA’s request occurred in August, or September 2025. The SP contacted a previous dental provider, but the VA was not a current patient at that dental facility. The VA would be considered a new patient; however, the dental facility was not accepting new patients, and therefore the VA was unable to be seen. Additionally, the SP said there were limited dental providers that took the VA’s insurance in the area. · The SP said s/he had not observed any additional health issues for the VA related to the tooth pain, and the VA had no other change in behavior since the SP had become aware of the tooth pain. · The SP acknowledged the VA had requested a dental appointment, but the SP did not schedule the appointment until after the maltreatment report was made. The SP explained s/he had previously intended to schedule the appointment, but the appointment “just slipped my mind,” and was just “a mistake.” The SP said the VA had an appointment scheduled for November 11, 2025. The facility completed an Internal Review, and the information obtained from the VA, the P, and the SP was consistent with that found above. Dental records provided the following information: · The VA was seen at a dental office on November 11, 2025, and it was noted the VA’s last cleaning/checkup was February 03, 2023. The treatment provided on November 11, 2025, was not considered a cleaning due to heavy build up throughout the VA’s mouth, but a dentist was able to develop a treatment plan for the VA. · The VA was diagnosed with decay and the VA was recommended to have fillings on eight teeth. There were no teeth considered “hopeless.” · The VA stated due to memory loss it was difficult for him/her to remember to brush teeth on a daily basis. · The VA had appointments scheduled on December 23, and 30, 2025, to completed treatment for cavities. The SP, and the P were trained on the VA’s client specific information, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: It was reported the VA had tooth pain and requested the SP make him/her an appointment to be seen by a dentist. The VA said s/he had requested the appointment within the last six months; however, the VA was unable to provide an exact timeframe. The VA said all other required appointments had been completed, and the VA did not have any other concerns with the SP. The SP and the G said the VA expressed concerns about his/her teeth around August or September 2025. The SP said s/he initially attempted to schedule a dental appointment for the VA, but was unable to schedule an appointment as the dental provider that accepted the VA’s insurance was not accepting new patients and there were limited providers in the area that would accept the VA’s insurance. The SP said s/he planned to follow-up to get the VA an appointment, but s/he did not schedule an appointment until this investigation was opened. The SP scheduled a dental appointment for the VA for November 11, 2025. A dental treatment plan was created for the VA’s dental needs, and appointments were scheduled for December 2025. There was no information obtained that showed the VA had any additional health issues related to the tooth pain. Minnesota Statutes, section 626.5572, subdivision 17, paragraph (c), clause (5), 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 that results in injury or harm, which reasonably requires the care of a physician; and: (i) the necessary care is provided in a timely fashion as dictated by the condition of the vulnerable adult; (ii) after receiving care, the health status of the vulnerable adult can be reasonably expected, as determined by the attending physician, to be restored to the vulnerable adult's preexisting condition; (iii) the error is not part of a pattern of errors by the individual; (iv) if in a facility, the error is immediately reported as required under section 626.557, and recorded internally in the facility; (v) if in a facility, the facility identifies and takes corrective action and implements measures designed to reduce the risk of further occurrence of this error and similar errors; and (vi) if in a facility, the actions required under items (iv) and (v) are sufficiently documented for review and evaluation by the facility and any applicable licensing, certification, and ombudsman agency. Given that the VA received necessary dental care in a timely fashion once the error was discovered; that the VA’s health was reasonably expected to be restored to the VA’s preexisting condition; that there was no pattern of similar errors by the SP; that the incident was reported immediately and recorded; that the facility identified and took corrective action and implemented measures to reduce the risk of further occurrence of the same or similar errors; and that the facility sufficiently documented the incident, therefore the SP’s actions were an error in the provision of therapeutic conduct. This error in the provision of therapeutic conduct to the VA by the SP 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 and determined that the policies and procedures were adequate but not followed. The report was not similar to any past events. The SP was retrained on the client specific information, and facility policies related to the alleged maltreatment. Action Taken by Department of Human Services, Office of Inspector General: The SP was not substantiated as a perpetrator of maltreatment of the VA because the Department of Human Services found that the incident for which the SP was responsible met the criteria to be determined an error. The SP was notified by the Office of Inspector General that any future incident of possible neglect of a vulnerable adult for which the SP is responsible might not be considered an error.
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