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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: 1072299-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Brittany Dolen 651-431-6701 Suspected Maltreatment Reported: Allegation one (202510484): It was reported that a staff person (SP) drove two vulnerable adults (VA1 and VA2) while under the influence of alcohol and marijuana which resulted in a car crash that injured VA1 and VA2. Allegation two (202510745): It was reported that the SP provided alcohol to VA1, VA2, and another vulnerable adult (VA3) who became so intoxicated s/he passed out in his/her bedroom. It was also reported that the SP previously provided VA1, VA2, and VA3 with alcohol and smoked marijuana with VA3. Date of Incident(s): Allegation one (202510484): November 6, 2025 Allegation two (202510745): November 6, 2025, and other unknown dates 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 November 17, 2025; from documentation at the facility, law enforcement records, and medical records; and through eleven interviews conducted with three supervisory staff persons (P1, P2, and P3), three facility staff persons (P4, P5, and P6), VA3’s guardian (G), VA1’s-VA3’s case managers (CM1, CM2, and CM3 respectively), and VA3’s probation officer (PO). Attempts were made via telephone and certified mail to contact and interview VA1 and the SP, however the attempts were unsuccessful. VA3 declined to provide information and VA2 was unable to provide information due to his/her diagnosis. The facility’s Drug and Alcohol Policy said that the facility “prohibits the use, sale, manufacture, distribution, dispensation, or possession of alcohol, illegal drugs, controlled substances or chemicals while you are on company business, providing serve to individuals, using company vehicles or on company property.” Staff persons were “prohibited” from consuming alcohol when responsible for persons who received services, on facility grounds or in a facility vehicle. The facility’s Safe Transportation Policy said that staff persons would “ensure safe transportation, handling and transfers of the person and any equipment used by the person when assisting a person who is being transported” and that staff persons were “responsible for the supervision and safety of persons while being transported.” Staff persons were required to “follow all traffic safety laws” when operating a facility vehicle, which included maintaining a valid drivers license and obeying traffic signs. The facility’s Employee Information Guide said that staff persons were “expected to follow the guidelines and policies of the company consistently when performing work responsibilities” and were “expected” to follow rules of conduct that protect the interests and safety of the individuals served. Saff persons were “responsible for safety” worked in a way that protected safety of other staff persons and individuals supported. Staff persons were not allowed to conduct personal business on work time, which included “shopping for food, clothing or other items,” and “stopping off” anywhere or “picking up” anything when on the way to or from a work location. Staff persons “must maintain a valid drivers license and an acceptable driving record” and driving under the influence of alcohol or drugs was “prohibited.” Facility records showed that P1-P6 and the SP were trained on VA1’s-VA3’s plans, the facility’s Drug and Alcohol Policy, Safe Transportation Policy, facility policies and procedures and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rules and/or statutes: Minnesota Statutes section 169A.20, subdivision 1, clauses (3 and 4) state in part that it is a crime for any person to drive, operate, or be in physical control of any motor vehicle within this state of any boundary water of this state when the person is under the influence of alcohol and/or a controlled substance. Allegation one (202510484): It was reported that the SP drove VA1 and VA2 while under the influence of alcohol and marijuana which resulted in a car crash that injured VA1 and VA2. VA1 was diagnosed with schizoaffective disorder, history of seizures, intellectual disability, history of polysubstance abuse and post-traumatic stress disorder. VA1 was primarily independent, but required staff person assistance with scheduling appointments, ensuring medication compliance and transportation. VA1 enjoyed being active, playing games, watching sports and talking with family. VA1 was not subject to guardianship. VA1’s Risk Assessment said that VA1 had a history of substance abuse that “historically had a significant impact” on VA1’s mental health, which led to behaviors that put VA1 and others “at risk.” Staff persons were available to “encourage sobriety” and provide supervision to VA1 to “discourage” substance use. VA2 was diagnosed with traumatic brain injury (TBI) and major neurocognitive disorder secondary to TBI without behavioral disturbance. VA2 enjoyed sleeping, listening to music, playing basketball, going for van rides and talking to family. VA2 was not subject to guardianship. VA2’s Risk Assessment stated that VA2 experienced “cognitive deficits” and “worsening dementia,” which caused VA2 to become “disoriented” and placed VA2 at risk to accurately recall and/or report events. VA2 had a history of substance use and would “likely use substances” if they were offered to him/her. Staff persons encouraged VA2 to maintain his/her sobriety and provided education on “risks” of substance use. VA2 required staff person assistance for transportation, budgeting, and the use of coping skills if VA2 was “frustrated or distressed.” A Record of Discussion, signed by P2 and the SP showed that on August 22, 2025, P2 spoke with the SP about a driving under the influence (DUI) citation the SP had received from law enforcement. At that time, the SP was told s/he was no longer able to drive residents. Law enforcement records provided the following information: · On November 6, 2025, multiple individuals saw the SP driving “erratically” at speeds of 75-100 miles per hour. At some point after, the SP was on a road with a speed limit of 55 miles per hour when the SP had a collision. · At approximately 6 p.m., law enforcement officers (LEO) arrived at the scene of the crash and found one vehicle that “appeared to have flipped” over and another vehicle (which was later determined to be the facility vehicle) that was on fire. Multiple individuals, including VA1 and VA2, were standing on the edge of the roadway. · VA1 told the LEO that the SP “drove recklessly” for two hours, including driving “over 100 miles per hour” and almost rear ending another vehicle. VA1 said the SP did not rear end the vehicle because the van had a safety feature that “automatically” applied the brakes when the van got too close to something. VA1 also said the SP drank alcohol before the crash. VA1 said that when the SP tried to pass a vehicle in front of them, the SP “veered” into oncoming traffic. As another vehicle drove towards them, the SP “turned the steering wheel to the right” and “crashed” into the vehicle that had been in front of them. · VA2 told the LEO that s/he was in the vehicle with the SP but was unable to provide additional information. · The LEO found the SP “walking away from the scene of the crash, leaving [his/her] burning vehicle on fire in the middle of the road.” When the LEO spoke to the SP, they noted the SP had “slurred speech, [an] odor of alcohol on [his/her] breath and delayed reactions.” The SP initially denied that s/he was driving but later told the LEO that s/he was employed by the facility, and s/he was not supposed to drive residents due to a revoked driver’s license. The SP said s/he drove VA1 and VA2 in the vehicle that caused the crash, and that s/he had VA1 and VA2 purchase him/her alcohol and was drinking alcohol and smoking marijuana before s/he drove and while s/he drove. · The SP completed a preliminary breath test at the scene and his/her blood alcohol content was 0.228. The SP was arrested and charged with Felony criminal vehicular operation, felony hit and run- failure to stop for an injury crash, gross misdemeanor reckless driving, misdemeanor liquor consumption by a person under 21, misdemeanor underage drinking and driving, and driving after revocation. · The SP had a revoked drivers license at the time of the crash. VA1’s and VA2’s medical records provided the following information: · On November 6, 2025, VA1 and VA2 were seen in the emergency room following a car crash. · At 7:17 p.m., VA1 arrived at the emergency room and told medical staff that s/he was a back seat passenger wearing his/her seatbelt. The SP drove “recklessly” around “100 miles per hour” and the airbags deployed when the car crashed. VA1 had chest and neck pain, pain in his/her right toe, and weakness in his/her legs. VA1 was diagnosed with whiplash and musculoskeletal injury due to the impact and was provided Tylenol, ibuprofen, and a lidocaine patch for pain. VA1 was discharged back to the facility at 9:25 p.m., advised to continue taking Tylenol for pain as needed and to follow up with his/her primary doctor. · On November 7, 2025, VA1 returned to the emergency room for continued chest pain because of the car crash. The VA did not receive a differing diagnosis and was advised to follow up with his/her primary doctor if his/her symptoms continued. The VA was prescribed ten lidocaine patches to place on his/her skin every twelve hours for pain. · On November 10, 2025, VA1 again returned to the emergency room with ongoing chest pain and concern for his/her safety at the facility. VA1 told medical staff that s/he believed staff persons at the facility were “threatening” him/her to “suppress” information and believed staff persons would “kill” VA1 if s/he shared additional information about the crash. Medical professionals believed VA1 had a psychiatric episode and diagnosed VA1 with chest wall pain and anxiety and placed VA1 on a mental health hold. On November 11, 2025, VA1 discharged to a family member and did not return to the facility. · At 7:44 p.m., VA2 arrived at the emergency room and told medical professionals s/he was wearing his/her seatbelt at the time of the crash and was “in pain” on the left side of his/her chest. VA2 received a computed tomography (CT) scan and was diagnosed with “closed fracture of multiple ribs of left side.” VA2 was prescribed oxycodone for pain, an incentive spirometer to use to keep his/her lungs inflated and was discharged at 11:40 p.m. VA2 was advised to return to the emergency room if s/he was unable to take deep breaths. · On November 10, 2025, VA2 returned to the emergency room for continued left side chest pain and was “unable to tolerate” the pain. VA2 was advised to use acetaminophen, ibuprofen and topical Bengay for pain, prescribed oxycodone, as well as directed to use an incentive spirometer by taking two deep breaths every hour while awake, for five days, to clear his/her lungs. VA2 was discharged back to the facility. P1, P2, P3, P4, P5, and P6; and the facility’s Internal Review provided the following consistent information: · On November 6, 2025, the SP, P3, and P6 were working at the facility. Around 4:45 p.m., P6 was cooking dinner when s/he realized that the SP left the facility with VA1 and VA2 in the facility vehicle. The SP did not tell P3 and P6 that they were leaving. Neither P3 nor P6 had a concern at that time that the SP was under the influence of alcohol or other substances. · At 5:39 p.m., P3 called the SP and asked the SP where s/he was. The SP told P3 that s/he “got pulled over” and received a “ticket for following to close.” The SP then said, “Dude, I don’t have my license.” P3 told the SP to stay where s/he was and P3 would come and get the SP, VA1, and VA2. The SP then said s/he was “just kidding” and they were on the way back to the facility. · At 6:04 p.m., P3 received a FaceTime call from the SP. The SP told P3 s/he “crashed” the facility’s vehicle and that it was “totaled.” P3 then saw the SP running from the crash towards the woods. · P3-P6 responded to the site of the crash to ensure VA1 and VA2 were safe, and their needs were met. P3-P6 each said VA1 and VA2 were transported to the hospital via ambulance to be evaluated for injuries. · The SP was not allowed to drive residents at the facility, however, approximately two weeks prior to the incident, the SP told P3-P6, on separate unknown occasions, that the “charges” against him/her were dropped and s/he was able to drive again. · VA1 and VA2 each received medical care for their injures. CM1 and CM2 were aware of the allegations and did not have previous concern with the facility. Conclusion for allegation one: A. Maltreatment: Information obtained showed that on November 6, 2025, the SP, who was not supposed to be driving due to a revoked drivers license, drove VA1 and VA2 while under the influence of alcohol and other substances. As a result of the SP’s actions, there was a car crash which injured VA1 and VA2. VA1 was diagnosed with whiplash and musculoskeletal injury and VA2 was diagnosed with “closed fracture of multiple ribs of left side.” Given that driving while under the influence of alcohol and/or other substances was illegal and not accidental or therapeutic conduct;, that as a result, the SP crashed the car while VA1 and VA2 were in the car and ran away from the scene leaving VA1 and VA2 near the burning vehicle, there was a preponderance of the evidence that there was a failure to supply VA1 and VA2 with care or services which were reasonable and necessary to obtain or maintain VA1’s and VA2’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. The SP was trained on VA1’s and VA2’s plans, facility policies and procedures and the reporting Maltreatment of Vulnerable Adults Act. At the time of the incident, the SP was responsible to ensure VA1’s and VA2’s health, safety, and wellbeing. The SP was responsible for the maltreatment of VA1 and VA2. C. Recurring and/or Serious Maltreatment: (See Conclusion for allegation two (202510745: Part C) Allegation two (202510745): It was reported that the SP provided alcohol to VA1, VA2, and VA3 who became so intoxicated s/he passed out in his/her bedroom at the facility. It was also reported that the SP previously provided VA1, VA2, and VA3 with alcohol and smoked marijuana with VA3. VA3 was diagnosed with a traumatic brain injury, schizophrenia, drug addiction and alcohol abuse, depression, generalized anxiety disorder, and a learning disability. VA3 required 24-hour supervision and assistance with eating and meal preparation, health interventions, transportation, memory and cognition, and self-preservation. VA3 enjoyed writing, spending time with his/her family, bowling, going for walks and attending church. VA3’s Risk Assessment said that VA3 had a history of substance use and displayed cognitive deficits which “may impact [his/her] reasoning and judgement” and impaired VA3’s ability to “identify potentially dangerous situations.” VA3’s Individual Service and Support Advocacy Plan (IAAP) said that VA3 had a history of “tonic clinic” seizures potentially related to previous substance overdose(s), required assistance with medication management, scheduling and maintaining medical appointments, and had an “extensive history of abusing alcohol and drugs.” VA3 was “likely” to use substances “if the opportunity presented itself” and “lacked insight” into his/her own personal safety which made VA3 “vulnerable to being taken advantage of.” Staff persons were responsible to ensure VA3 used his/her coping skills and encourage appropriate social skills and “without significant supports and supervision” it was likely that VA3 “wouldn’t have the ability to refrain from using drugs and quickly hospitalized or in jail.” VA1, VA2, and VA3 were each over the age of 21 and therefore, it was legal for each to drink alcohol and smoke marijuana. The G provided the following information: · On an unknown date, approximately two weeks before the incident in allegation one, VA3 told the G that s/he “drank” with the SP and that s/he passed out from drinking. The G thought the SP drank vodka or beer and told VA3 that the G “hoped” VA3 did not ride in a vehicle with the SP when s/he drove. At this time, the G did not tell anyone what VA3 had said. · On November 6, 2025, around 11 a.m., the G spoke with VA3 on the phone and VA3 “sounded slurry.” VA3 told the G that s/he was drinking. At some point during the call, the G heard P3 in the background of the call and at another point, the SP got on the phone and said, “Hi [mom/dad],” to the G. The G told the SP that VA3 should not get “really intoxicated” because VA3 would “get sick.” The SP “started laughing” and the G thought the SP “sounded a little messed up, a little goofy.” Later that evening the G talked to VA3 who told the G about the car crash and that VA3 was not in the vehicle because s/he was “passed out” in his/her bed from drinking. The G then text P3. · On an unknown date, after November 6, 2025, VA3 told the G that on more than one occasion s/he had ridden with the SP after the SP drank alcohol, and that while out driving, the SP had VA1 purchase the SP alcohol. · VA3 was a “severe addict” for “a lot of years” and was diagnosed with a traumatic brain injury due to his/her substance use. VA3 was “forgetful”, and the G did not believe VA3 could care for him/herself. · The G was concerned that other staff persons were not aware the SP drank when s/he worked, but did not have other concerns with the facility. P3 provided the following information: · On November 6, 2025, around 11 p.m., P3 received a text message from the G asking if VA3 would “be in trouble” for drinking with the SP at the facility. P3 told the G that VA3 was not in trouble, and did not have further conversation with the G. P3 documented the conversation and then left at the end of his/her shift. P3 thought VA3 told the G about drinking with the SP, but did not know when. · On November 7, 2025, VA3 told P3 that on the day prior, the SP brought a water bottle filled with alcohol to the facility and drank it with VA1, VA2, and VA3. VA3 told P3 that s/he did not get in the vehicle on the day of the incident because s/he was “too drunk” and stayed at the facility to sleep. · On an unknown date, after November 6, 2025, P3 found a marijuana grinder in the staff office at the facility and asked VA3 if it belonged to him/her. VA3 told P3 s/he thought it belonged to the SP. · P3 thought VA3 was an accurate provider of information but kept the drinking a secret due to his/her history of substance abuse. P1 said that on an unknown date, VA3 told P1 that VA1, VA2, VA3, and the SP drank alcohol together from a water bottle that the SP brought to the facility. VA3 also told P1 that the SP had VA1 purchase the SP alcohol when they were out driving in the van. VA3 also told P1 that the SP smoked marijuana with VA1, VA2, and VA3 but VA3 did not provide additional information to P1. P2 said that on November 7, 2025, VA1 told P2 that VA1, VA2, and VA3 all drank alcohol from a water bottle with the SP the day prior and that VA3 was “so drunk [s/he] passed out.” VA1 also said that s/he “occasionally” went outside with the SP and smoked marijuana, but did not provide dates or times this occurred. P2 did not have additional information about VA3 drinking with the SP. P5 said that on November 6, 2025, prior to the SP leaving with VA1 and VA2, the SP and VA3 went for a walk which was “very out of the ordinary.” After approximately twenty minutes the SP and VA3 returned and VA3 was “smiling and laughing at nothing” which was not normal behavior for VA3 because VA3 was “usually a down person.” VA3 had a history of substance abuse and P5 saw VA3 exhibit similar behaviors while under the influence prior to this. After the SP and VA3 returned, VA3 went to his/her bedroom to “nap” and P5’s shift ended shortly after. Before P5 left, s/he told P3 that “something was off” with VA3. P3 told P5 s/he would “watch VA3 and let [him/her] sleep it off.” P6 was not aware that the SP provided alcohol to VA3 until after the incident. On an unknown date, P6 helped VA3 with a project and VA3 wrote that s/he was “passed out” from drinking with the SP. P4 did not have information regarding the SP providing VA1, VA2, and/or VA3 alcohol. CM3 was aware of the allegations and did not have previous concern with the facility. The PO was not aware that VA3 had been provided alcohol and/or marijuana by the SP, but the facility was not required to notify the PO of every incident with VA3. The PO did not have previous concerns with the facility. The facility’s Internal Review said that on November 6, 2025, the SP shared a bottle of alcohol with VA1 and VA3 in the basement of the facility. The SP brought the alcohol from home, and it was not the first time the SP had done so. Conclusion for Allegation two: A. Maltreatment: VA1, VA2, and VA3 each had a history of alcohol and substance abuse. VA1 and VA2 required staff persons to “encourage sobriety,” “discourage” substance use, and/or provide education on the “risks” of substance use. VA3 was “likely” to use substances “if the opportunity presented itself” and “lacked insight” into his/her own personal safety which made VA3 “vulnerable to being taken advantage of.” Staff persons were responsible to ensure VA3 used his/her coping skills and encourage appropriate social skills and “without significant supports and supervision” it was likely that VA3 “wouldn’t have the ability to refrain from using drugs and quickly hospitalized or in jail.” The SP, VA1, and VA3 did not provide information for this report. However, information from the facility’s internal review, the G and P1-P6 showed that on November 6, 2025, the SP provided VA1, VA2, and/or VA3 alcohol which caused VA3 to become intoxicated and “pass out” at the facility. In addition, VA3 provided consistent information to the G, P1, and P3 that there was more than one occasion when the SP brought and drank alcohol with VA1, VA2, and/or VA3. P2 stated that VA1 told him/her that VA1, VA2, and VA3 all drank with the SP and that s/he “occasionally” went outside with the SP and smoked marijuana. VA3 also told P1 that the SP smoked marijuana with VA1, VA2, and/or VA3. Although VA1, VA2, and VA3 were each of legal age to drink alcohol and smoke marijuana, given that VA1, VA2, and VA3 each had a history of substance use that required staff person to encourage sobriety and/or discourage substance use, there was a preponderance of the evidence that the SP providing and consuming alcohol and marijuana with VA1, VA2, and VA3 was a failure to supply VA1, VA2, and VA3 with care or services which were reasonable and necessary to obtain or maintain their 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: (2) 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. (3) 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 (4) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on VA1’s-VA3’s plans, facility policies and procedures and the reporting Maltreatment of Vulnerable Adults Act. At the time of the incidents, the SP was responsible for the care and services of VA1VA3 to ensure their health, safety and wellbeing. The SP was responsible for the maltreatment of VA1, VA2, and VA3. 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 was “recurring” and “serious.” The SP was responsible for two separate incidents of maltreatment involving three vulnerable adults and VA2 was prescribed oxycodone and an incentive spirometer as a result of his/her rib fractures. Action Taken by Facility: The facility completed an internal review which determined that their policies and procedures were adequate but not followed. Staff persons were retrained on the facilities policies and procedures and the SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.
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