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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: 1101020-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman/Alice Percy Minnesota Department of Human Services 641-431-6567 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA), who had a history of “cheeking” his/her medications, obtained and swallowed approximately 30 pills. The VA was transported to a hospital, where s/he was treated with activated charcoal. On the following day, the VA showed that s/he had an additional 145 pills. Date of Incident(s): Ongoing, prior to November 11-12, 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 November 26, 2025; from documentation at the facility and medical records; and through nine interviews conducted with the VA, two facility staff persons (P1andP2), three supervisory staff persons (P3–P5), a school health care professional (HCP), the VA’s public health case manager (CM), and the VA’s guardian (G). The VA enjoyed riding his/her bicycle, playing his/her guitar, doing puzzles, doing arts and crafts projects, shopping, playing sports, swimming, going to a park, going on community outings, and spending time with friends and family members. The VA’s diagnoses included post-traumatic stress disorder, disruptive mood dysregulation disorder, and anxiety. The VA attended high school each weekday. The VA’s Self-Management Assessment (SMA) stated that the VA understood his/her need for medications, the names of the medications, and the reason for taking them. The VA was “very cooperative” with his/her medications. The VA’s Support Plan Addendum stated that the staff persons were to set up and administer the VA’s medications to the VA. [Note: There was no information in the VA’s plans that provided information that the VA had a history of cheeking his/her medications or that staff persons were to take any additional actions regarding administering the VA his/her medications.] The VA’s interdisciplinary team (IDT) Discussion Notes, dated May 19, 2025, stated, “[The VA] has not been taking [his/her] medications and refuses to do them at the kitchen table and takes them to [his/her] room and then staff end up finding them at a later date. [The VA’s family member (FM)] is telling [the VA] that [s/he] doesn’t need the medications and [the medications] make it so [the FM] can’t understand [the VA] when [s/he] talks. This is causing [the VA] to not want to take [his/her] medications.” The VA stated that s/he “had [his/her] ways” of getting the medications but s/he did not want to talk about the incident or about how or where s/he got the medications. P1–P5 provided the following information: · P1 stated that on November 11, 2025, s/he worked at the facility with a staff person (P6). After the VA returned to the facility from school, staff persons, the VA, and another client (C) went shopping. At approximately 5:55 p.m., they returned to the facility and P1 asked the VA if s/he wanted to take his/her medications because s/he needed to take them by 6 p.m. The VA said, “No,” began to cry, and went to his/her bedroom, where s/he began to “dismantle things.” The VA then came to staff persons and showed them a note s/he had written on his/her cell phone that said that s/he was bullied at school and felt suicidal. P1 and P6 took the VA outside and away from the C where the VA told them that s/he had ingested 20 to 30 medications. P1 immediately texted P5 and told him/her what the VA said. P5 called P1 and told him/her to call an ambulance and P1 did so. · P1 then made calls to P3 and P4 respectively and told each what the VA said including that students at his/her school told the VA to “go home and kill [him/herself].” At that time, the VA was escalating, becoming agitated, and saying s/he took medications s/he had “hoarded.” P3 then went to the facility as did P4 and P5. · P3, P4, and P5 arrived at the facility while the paramedics and a police officer were there. P4 stated that the VA denied taking any medications to the police officer and became upset flipping over the kitchen table so the police officer placed the VA in handcuffs and took him/her to the ambulance. P5 then accompanied the VA to the hospital in the ambulance. P4 and P5 each stated that while at the hospital, the VA was given charcoal and then vomited. · After the VA left to the hospital, P1 checked the VA’s bedroom to see if there was more medications in the VA’s room and found five pills that were all “stained with saliva,” so P1 believed the VA put them in his/her mouth when they were administered, but did not swallow them which indicated that the VA had cheeked his/her medications when they were administered. · P5 stated that at approximately 2:45 a.m., the VA was released from the hospital and P5 took the VA back to the facility and assisted him/her with going to bed. P3 stated that after the VA returned, s/he talked to the VA about the incident. The VA told P3 that s/he did not always take his/her medications when s/he was at school and instead brought them to the facility and hid them. · P4 stated that after the VA returned from the hospital, the VA gave P4 over 100 pills that the VA had in his/her room that were mainly laxatives and mood stabilizers, which were medications that were administered to the VA at 12 p.m. each day at his/her school or at the facility on weekends. P4 and P5 each stated that the VA told P5 that s/he cheeked the medications when they were administered at school because the HCP did not ensure the VA swallowed the pills. P1 believed that the VA cheeked the medications at his/her school because in the past when P1 observed the HCP administer medications to the VA, the HCP did not watch the VA to ensure that the VA swallowed the medications. · P1 and P2 each stated that when the staff persons administered medications to the VA, they typically watched the VA take a drink of water after putting a pill in his/her mouth and then talked with the VA to ensure that s/he swallowed the medications. · P1, P2, and P5 each stated that prior to the incident they were not aware the VA had a history of cheeking his/her medications. P3 believed that the VA had a history of cheeking his/her medications. P4 stated that in the past, the VA had cheeked his/her medications and later gave them back to a staff person. The HCP stated that s/he administered prescribed medications to the students at the school. When s/he administered the medications, s/he placed the medication in the student’s hand and then watched him/her put it in his/her mouth and take a drink of water. The HCP did not check a student’s mouth to ensure the student swallowed the medication unless there was a concern that they might cheek the medication. No student was given any medication to take outside of the nurse’s office. The CM stated that if the VA did not take all of his/her medications, s/he might have “significant” behaviors, became very angry and violent, and destroy property. In the past, the VA sometimes refused to take his/her medications, but the CM was unaware of the VA cheeking his/her medications. In the past, the FM told the VA that s/he did not want the VA to take his/her medications. The VA also did not like the side effects s/he experienced with his/her medications. The G stated that when the VA had anxiety, s/he became depressed and then exhibited suicidal ideation. The G did not believe the VA had a history of overdosing on medications. The VA told the G that s/he was bullied at school and s/he was upset because of the lack of contact with the FM. In the past, the VA sometimes refused to take his/her medications, but the VA had not cheeked his/her medications since May or June 2025 when the G became his/her guardian. A total of 144 pills were in the VA’s room that s/he gave to the staff persons. The pills did not appear to have saliva on them. Twenty-one pills were only administered at the facility; 114 pills were administered at both the facility and school; and nine pills were as needed medications. The After Visit Summary stated that on November 11, 2025, the VA was seen at the ER for “ingestion.” The VA was prescribed activated charcoal and an odansetron ODT disintegrating tablet. The facility’s Policy and Procedure Pertaining to Medication Assistance and Administration stated that the staff persons were to chart the medication administered to each client on their medication sheet, Medication Administration Record, or their health T-Logs or progress notes only after a medication was administered and swallowed by the client. Facility documentation showed that P1 – P5 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Conclusion: Information obtained showed that during unknown dates the VA obtained 170-180 pills and on November 11, 2025, the VA ingested between 20 and 30 pills and was taken to the hospital where s/he was administered charcoal, which caused the VA to vomit. Although the VA did not provide information during his/her interview regarding where/when s/he obtained the pills, the VA provided consistent information to P3 and P5 that s/he obtained the medications from school. While this was a possible explanation for 123 of the pills, 21 of the pills were only administered at the facility and therefore, the VA would not have been able to obtain them at school and most likely obtained them at the facility. However, given that there was no information provided in the VA’s plans that required staff persons to take any additional actions when administering the VA his/her medications and that it was not known if s/he somehow accessed his/his medications at the facility in any other way, there was not a preponderance of the evidence as to whether there was a failure to supply the VA with care or services which were reasonable and necessary to maintain the VA’s physical or mental health or safety. It was not determined whether 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). Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate, but were not followed by the staff persons. After the incident, all staff persons were retrained on the facility’s medication administration policies. P3 stated that after the incident, the staff persons were trained to administer medications to the VA, watch him/her place the pills in his/her mouth and drink water, check the VA’s mouth, and observe the VA for 15 minutes to ensure s/he did not cheek the medications. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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