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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: 1071075-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Neubauer-Hoffman, Deb Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was in bed sleeping when a staff person (SP1) checked on the VA and believed the VA had died; however, SP1 did not contact a supervisory staff person (SP2) until an hour later and never called 9-1-1. SP2 drove to the facility and did not call 9-1-1 until directed to do so by his/her supervisor (P1). Date of Incident(s): November 9, 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 for this investigation was obtained remotely, including documentation from the facility and/or law enforcement records; and through five interviews conducted with P1, SP1, SP2, and two guardians (G1 and G2). The VA liked music, watching game shows and cartoons, and spending time with his/her housemates and family members. The VA enjoyed multiple vacations on cruise ships, attended several proms, and was described as a “social butterfly.” The VA’s diagnoses included myotonic dystrophy. The VA had vision and hearing limitations and received nutrition via a continuous feeding machine. According to various internet searches, myotonic dystrophy was a genetic disorder that caused progressive muscle weakness and was characterized by an inability to relax muscles after a contracture. Symptoms varied but included muscle stiffness, weakness in the face, neck and limbs, difficulty swallowing, and cardiac conduction problems. Information also showed that respiratory problems were a common cause of death, and a high percentage of deaths were linked to pneumonia due to loss of lung function. The VA’s plans showed the following information: · The VA’s Support Plan stated that the facility was responsible for monitoring the VA’s emergency health care needs and if care was needed, the plan was to “call 9-1-1” and transport to a preferred hospital. · A Coordinated Service and Support Plan Addendum (CSSPA) dated October 13, 2025, stated that the VA’s “overall physical health is declining and at some point, we may have to determine if this setting continues to give the care and supports [s/he] needs.” The VA received nutrition via a continuous feeding tube. · A Provider Orders for Life-Sustaining Treatment (POLST) signed by G1 and a physician (MD) on September 30, 2025, showed that if the VA had no pulse and was not breathing, the course of action was “Do not attempt resuscitation/DNR.” If the VA had a pulse and/or was breathing, the course of action was to focus on “comfort” that included pain relief, positioning, wound care, and/or the use of oxygen or suction for airway obstruction. It also indicated that the VA “prefers no transfer to hospital for life-sustaining treatments.” (Information obtained during the investigation showed that the facility did not have a copy of the VA’s POLST at the facility on November 9, 2025.) A General Loggings note for the VA dated November 8, 2025, written by a staff person (P2) stated that the VA “had a good day.” The VA was “talkative” although his/her speech was “jibberish [sic].” The VA’s breathing was “kind of rough” and “sounded like lots of thick mucus in [his/her] throat/chest” resulting in the VA receiving three nebulizer treatments that day. P1 provided the following information: · In early September 2025, the VA fell and was admitted to a hospital where s/he was diagnosed with stroke. According to P1, unidentified hospital personnel could not determine if the fall resulted in stroke, or if the stroke resulted in the VA falling. The VA was not supposed to receive food or drink by mouth (NPO); however, hospital staff persons inadvertently gave the VA juice, and s/he was subsequently diagnosed with aspiration pneumonia that “never fully went away.” Following the fall and hospitalization, the VA’s “health went downhill,” s/he was “hospitalized a lot,” and did not communicate or speak as much. · On November 8, 2025, SP1 arrived at approximately 10 p.m. for his/her overnight shift. · From statements written by SP1 and SP2 and/or conversations with them, P1 determined that SP1 checked on the VA throughout the night and on November 9, 2025, at 6:45 a.m., the VA looked like s/he was “possibly dead but (SP1) did not know.” SP1 looked for a pulse oximeter “for an hour” and then called SP2, a supervisory staff person. SP2 did not advise SP1 to call 9-1-1; however, SP2 immediately drove to the facility, checked the VA and “immediately knew [the VA] had passed.” · On November 9, 2025, at 8:21 a.m., SP2 called P1 and told him/her that the VA passed away. P1 asked SP2 if s/he called 9-1-1 and when SP2 said s/he had not, P1 directed SP2 to make that call. P1 said the facility policy stated to immediately call 9-1-1 in the event of a medical emergency including death. SP1 worked at the facility for approximately a month at the time of the VA’s death and provided the following information via documentation and/or during an interview with this investigator: · When SP1 was hired, s/he was told by an unidentified person at the main office who hired him/her that two of the three clients at the facility were “on hospice” and that one of them was currently in the hospital. Due to that conversation, SP1 believed the VA was on hospice because the VA was in the hospital when SP1 began his/her employment. · SP1 read the VA’s program plans when s/he was first hired in early October 2025, but did not meet the VA for the first time until Friday, November 7, 2025. SP2 came to the facility that night and showed SP1 how to use the VA’s feeding machine. SP1 was trained to complete “safety” checks on the clients during overnight hours approximately every two hours. During those checks, SP1 was supposed to check the VA’s adult absorbent undergarment and change him/her if necessary. · On November 8, 2025, SP1 checked on the VA when s/he first arrived at approximately 10 p.m. and saw a staff person (P2) in the VA’s bedroom changing the VA’s adult absorbent undergarment. P2 told SP1 that the VA did not feel well that day. After P2 left the facility, SP1 checked on the VA before going downstairs to complete required tasks. · At midnight SP1 checked the VA’s adult absorbent undergarment and feeding machine and the VA was watching TV. · On November 9, 2025, at 2 a.m., SP1 checked on the VA and changed his/her adult absorbent undergarment. The VA was checked again at 4 a.m. and s/he was “dry and sleeping.” · “Around 6:45 a.m.,” SP1 checked on the VA and saw that “something was wrong.” The VA was “really pale and was not breathing.” SP1 put two fingers to the VA’s wrist to check for a pulse and put his/her hand under the VA’s nose to feel if s/he was breathing; however, s/he was not breathing, and no pulse was found. Because the VA was unresponsive, SP1 left the room to find equipment to check the VA’s vitals. SP1 checked throughout the facility and no equipment to check vitals was located. “Around 7 [a.m.] something,” SP1 called SP2 and said s/he believed something was wrong with the VA and s/he wanted to check the VA’s vital signs but was not able to find any equipment. SP2 directed SP1 to the office where SP1 found “a little one that goes on a hand.” SP1 checked the VA with that equipment while SP2 remained on the phone and the equipment showed “no numbers” and said “error.” SP2 said s/he was on his/her way to the facility and arrived 12-15 minutes later. · When SP2 arrived, s/he went into the VA’s room and told SP1 that the VA passed away. SP2 made calls to 9-1-1 and the VA’s family (G1 and/or G2). Approximately 10-15 minutes later, law enforcement and an ambulance arrived at the facility and SP2 told SP1 that s/he could leave the facility. · When SP1 was asked why s/he did not call 9-1-1, s/he said because s/he was told by an unidentified person at the office who “hired” SP1, that the VA was on hospice. SP1 said that s/he worked at other organizations where if clients were on hospice, hospice was called instead of 9-1-1. Two days after the VA’s death, SP1 was told the VA was not on hospice. SP2 provided the following information via documentation and/or during an interview with this investigator: · SP1 recounted multiple hospitalizations for the VA between September and November 2025 that resulted in the VA being diagnosed with stroke, blood pressure issues, and/or pneumonia. The most recent hospitalization had the VA discharged back to the facility on November 6, 2025. (Information showed that shortly before the VA’s November 6, 2025, discharge to the facility, the POLST was in place that specified DNR.) On November 6-8, 2025, the VA was “fine.” The overnight of Friday, November 7, 2025, was the “first time” that SP1 worked with the VA. · On Sunday, November 9, 2025, at 7:57 a.m., SP2 received a call from SP1. SP1 said that the VA “was not breathing.” At that time, SP2 did not think about calling 9-1-1 because s/he believed SP1 was “mistaken” because the VA sometimes “breaths shallow” and “looks like [s/he] is not breathing but [s/he] really is.” SP2 told SP1 to get the “pulse cuff” and check the VA’s oxygen. SP2 remained on the phone while SP1 checked and said the VA’s oxygen “was not registering.” SP2 told SP1 that s/he was on his/her way to the facility. · SP2 arrived at the facility and “knew [the VA] passed just by looking at [him/her].” SP2 said that s/he was “in shock” and took a minute to gather him/herself, then called his/her supervisor, P1, and told P1 that the VA died. P1 told SP2 to call 9-1-1 and SP2 did so, then called the VA’s family members. Law enforcement officers and paramedics arrived and completed their reports. SP2 told SP1 that s/he could leave. · SP2 said the VA had a DNR order. When asked if SP1 was trained regarding the facility’s policies and procedures, specifically regarding when to call 9-1-1, SP2 said, “No, I would assume it would be common knowledge.” SP2 said, “I know I should have called 9-1-1,” but s/he was “shocked” because the VA was “fine” that weekend prior to the call from SP1. SP2 said it was possible that the VA would have had a different outcome if SP1 called 9-1-1 immediately upon finding the VA unresponsive; however, SP2 did not believe calling 9-1-1 after SP1 called SP2 would have changed the outcome since SP2 was not notified until an hour later. · When asked about the VA’s DNR orders, SP2 said that when the VA went to the hospital prior to his/her death, “we sent the only paper we had with them. I did not make a copy of it.” SP2 was aware the VA was not to be resuscitated and “no excessive treatment.” (Note: SP2 was referring to the POLST order that specified do not resuscitate.) G1 and G2 provided information together to this investigator: · The VA resided at the facility for 25 years and s/he was treated with respect and love. · G1 and G2 provided information that was consistent with P1 regarding the VA’s multiple hospitalizations within the two months prior to his/her death. · On Sunday, November 9, 2025, they received a call at 8:25 a.m. telling them that the VA passed away at the facility in his/her sleep. · G1 and G2 said that after the VA’s death, the facility asked for a copy of the VA’s POLST/DNR orders. However, G1 and G2 did not have a copy so they had to request copies from the hospital/transitional care where the VA resided three days prior to his/her death. A law enforcement Incident report stated on November 9, 2025, at 8:23 a.m., officers were dispatched to the facility and arrived at 8:28 a.m. The officers arrived prior to emergency medical technicians and observed the VA was “very pale” and was “under several blankets and was still warm to the touch.” The VA had no pulse and was not breathing, and the officers confirmed the VA was deceased. No autopsy was performed on the VA and his/her death certificate stated, “Natural cause of death after recent episode of pneumonia and fall due to weakness.” In addition, other contributing conditions were “myotonic muscular dystrophy and dysphagia.” The facility’s Incident Response, Reporting and Review Policy defined an “incident” as various serious injuries, death, or “any medical emergency.” The response procedure for each of those categories included immediately calling 9-1-1. The facility’s Death of Client Policy and Procedure stated to “immediately begin CPR” and then direct someone to call 9-1-1 if available or call 9-1-1 themselves as soon as possible. (Note: The policy did not specify what to do regarding CPR when a POLST order was in place.) SP2’s Job Description stated that s/he was responsible to assure staff persons completed orientation and annual training as required and to provide “effective oversight in emergency situations.” Facility documentation showed that SP1 and SP2 were each trained regarding the VA’s program plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: On November 8, 2025, SP1 arrived at the facility around 10 p.m. and worked the overnight shift. SP1 checked on the VA throughout the night and early morning, with the last check on November 9, 2025, around 6:45 a.m. At that time, SP1 observed “something was wrong” with the VA because s/he was unresponsive, had no pulse, and was not breathing. SP1 left the VA’s room to find equipment to check the VA’s vitals. SP1 believed around “7 [a.m.] something” (Note: Information showed it was 7:57 a.m.) s/he telephoned SP2 to tell him/her about the VA and asked about equipment to check the VA’s vital signs. SP2 told SP1 where to find the equipment; however, when used on the VA, no numbers registered, and it said “error.” SP2 immediately drove to the facility, arriving approximately 12-15 minutes later. SP1 said that s/he did not call 9-1-1 because s/he believed the VA was on hospice. SP2 said that when SP1 called him/her at 7:57 a.m., s/he did not tell SP1 to call 9-1-1 because SP2 believed SP1 was mistaken, and that the VA was just breathing shallow. When SP2 arrived at the facility and saw the VA, SP2 “knew” the VA passed away “just by looking at” the VA. At 8:21 a.m., SP2 called P1 who told P1 to call 9-1-1. Although SP2 knew that the VA had a DNR order, SP2 also said s/he knew s/he should have called 9-1-1 instead of first calling P1. The facility’s policy stated that for specific incidents, including death or “any medical emergency,” staff persons were supposed to “immediately call 9-1-1” and follow directives given by the emergency responder. However, given that SP1 spent an hour looking for a way to test the VA’s vitals prior to calling SP2, that SP2 did not advise SP1 to call 9-1-1 and drove to the facility where s/he determined the VA had died “just by looking at [the VA],” and that 9-1-1 was not called until approximately 98 minutes after SP1 first suspected “something was wrong” with the VA when s/he found the VA not breathing and without a pulse, there was a preponderance of the evidence that there was failure to provide the VA with reasonable and necessary care and services. 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. SP1 and SP2 were each trained regarding the VA’s program plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. SP1 was responsible for the VA’s care at the time of the incident, therefore, SP1 was responsible for maltreatment. In addition, SP2 was a supervisory person and was responsible for “effective oversight in emergency situations” and was also responsible to direct SP1 to call 9-1-1 when SP2 was informed the VA “was not breathing,” therefore, SP2 was also responsible for maltreatment. 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 SP1 and SP2 were each responsible for did not meet the statutory criteria to be determined as recurring because the incident was a single event and was not serious because it was not determined if the delay in calling 9-1-1 had any effect on the VA’s death. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but were not followed. The facility provided additional training regarding emergency response and notifications. SP1 and SP2 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 and SP2 were each 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. The determination that SP1 and SP2 were responsible for maltreatment is subject to appeal.
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