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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: 1070650-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Heidi Murphy 651-431-6544 Suspected Maltreatment Reported: It was reported that a staff person (SP) worked at the facility while intoxicated and drove a vulnerable adult (VA) around in a facility owned vehicle for almost two hours. Law enforcement responded to the facility after the SP and VA returned from the drive. The SP provided a breath sample that registered at 0.293 BAC (blood alcohol concentration). Date of Incident(s): May 30, 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 June 11, 2025, from documentation at the facility, law enforcement records; and through seven interviews conducted with the VA, the VA’s guardian (G), a facility supervisory staff person (P1), three facility staff persons (P2, P3, and P4), and the SP. The facility was a one-level house in a rural setting. The facility had four bedrooms, a living room, a dining room, a kitchen, a laundry room, a medication area, a staff office, and three bathrooms. The VA enjoyed playing cribbage, going for drives, collecting guitars, painting, and listening to music. The VA’s diagnoses included schizophrenia, memory loss, cognitive deficits, hyperlipidemia, seizure disorder, and impaired decision making. The VA’s Supervision Needs-Residential & Vocational plans stated, “Staff transport and accompany [the VA] while out in the community. [The VA] may be [unsupervised] in the vehicle for no more than 15 minutes.” Law enforcement records showed deputies were dispatched to the facility for a welfare check on the SP at 8:12 p.m. on May 30, 2025. Two deputies arrived at the facility at 8:27 p.m. The SP was “passed out or sleeping in the recliner.” The SP’s eyes were “bloodshot and watery,” and the SP’s speech was “heavily slurred,” and at points the deputy “struggled to understand [the SP].” The SP stated s/he had one mixed drink of vodka and juice at 4 p.m. The SP stated s/he had taken the VA for a drive. A preliminary breath test was administered, and the result was 0.293 BAC. The facility’s Internal Review stated the SP left the facility at 3:30 p.m., went home to get a garden tiller, and returned around 4:30 p.m. The SP had to be reminded to administer medications at 5 p.m. Around 6 p.m., the SP took the VA for a drive and returned to the facility around 7:45 p.m. The VA stated they went to the SP’s house and got a tackle box. The SP stated they parked on a road and listened to live music at a bar from the vehicle. When the SP talked to other staff persons, the SP smelled strongly of alcohol, slurred his/her words, lost balance, and stared at the wall. A staff person contacted P1 at 7:55 p.m. and informed him/her of the situation and asked for assistance. P1 contacted law enforcement at 8:11 p.m. Law enforcement arrived and administered a breath test to the SP, and the SP stated s/he had a beer at 4 p.m. The SP was transported home. The VA told this investigator that s/he went on regular drives on backroads with staff persons almost daily. On an unknown date around two weeks ago, the VA went on a drive with the SP. When they left, the VA did not know where they were going. They ended up at the SP’s house. The SP went in the house and the VA stayed in the vehicle. The VA stated the SP was drunk and when they got back to the facility, two policemen talked to the SP. P2 provided the following information: · P2 started work at 7 a.m. the day of the incident, and had accompanied a client to the hospital and returned to the facility at 3:30 p.m. P2 asked the SP for assistance filling out paperwork in the office. The SP “seemed kind of out of it” and did not know how to answer P2’s question. The SP’s face was droopy and eyes were bloodshot. P2 called to let P1 know the SP was suspected to be intoxicated, however, P2 was unable to reach P1. · Around 4:15 p.m., P2 overheard the SP say s/he was going to take the VA for a drive. P2 called P4 into the office and expressed concerns over the SP driving the VA. P2 told P4 that s/he believed the SP was intoxicated. P4 looked in the SP’s bag and smelled the water and coffee and did not smell any alcohol. P2 knew the SP generally drank vodka and stated vodka does not smell. · The SP went into the office around 4:30 p.m. and poured some water from a bottle in his/her personal bag into a cup. Keys for facility vehicles were kept in the office. P2 heard a vehicle start and asked P4 who was driving. P4 told P2 that the SP was going home to get a tiller. The SP did not return until after 5 p.m. P2 stated the SP lived about 10 minutes away from the facility. · P4 asked the SP to administer medication, as it was supposed to be done at 5 p.m. The SP said, “Oh shit. I suppose I’m on meds, huh?” and laughed. · At around 5:45 p.m., the SP stated s/he was taking the VA for a drive. P2 told the SP not to take the VA, as the SP had previously told P4 s/he was tired, and offered for P2 or P4 to take the VA. The SP stated, “I just got my driving privileges back. If they ask me for a ride, I’m gonna take them.” The SP left the facility with the VA. · P3 arrived at the facility at 7 p.m. and P2 told P3 that the SP was suspected to be intoxicated. P2 left the facility at 7:30 p.m. and the SP and the VA were still gone. P3 provided the following information: · Prior to going to work on the date of the incident, P3 got a text from P2. P2 believed the SP had been drinking and did not think the SP should be driving. · P3 started work at the facility at 7 p.m. the day of the incident. The SP and the VA were gone when P3 arrived at the facility. The SP and VA returned around 7:30-7:45 p.m. P3 was in the office and the SP went into the office and the two had a conversation. “It only took about 30 seconds for me to know” the SP was intoxicated. The SP stated s/he took the VA to the SP’s house. P3 suspected that’s where the SP had gone to drink or grab a bottle. P3 called P1 approximately 15 minutes later to report that the SP was “wasted.” · P3 smelled alcohol “as soon as [the SP] came in the door.” The SP was red in the face, talked constantly which was not typical, slurred his/her words, and stumbled. “We’ve been through this a few times. It’s just [the SP’s] typical behavior when [s/he’s] under the influence.” · P3 contacted P1 and told P1 that the SP was intoxicated. P1 called law enforcement. Law enforcement arrived at the facility and spoke to the SP. The SP “was completely plastered at that point.” Law enforcement asked the SP when his/her last drink was and the SP answered it was at 5 p.m. The SP started work at 3 p.m. and was scheduled to work until 11 p.m. The SP provided a breath sample and was driven home. P4 provided the following information: · P4 arrived at the facility for work at 3 p.m. P4 spoke to P2, who stated the SP had been drinking. P4 smelled the SP’s water and coffee and did not smell any alcohol. · The SP left the facility after 4 p.m. and went home to get gardening equipment. The SP returned to the facility before 5 p.m. · After dinner, the SP took the VA for a drive around 6 p.m. and returned to the facility at 7:48 p.m. The SP stated s/he took the VA to a local bar, sat in the vehicle and listened to live music. P4 noticed the SP stumbled and had a red face. The SP went into the office where P3 was at. P3 came out and told P4 that the SP was intoxicated. · The SP came out of the office, “stared at the wall,” sat in a recliner, and did the “head nodding thing.” P4 smelled alcohol on the SP and told the SP s/he (P4) would administer medication to the residents. · P3 called P1 and told P1 that s/he believed the SP was intoxicated. P1 called P4 and asked if P4 thought the SP was intoxicated and P4 said, “Yes.” P1 called law enforcement. Law enforcement arrived and gave the SP a preliminary breath test. The SP admitted to law enforcement that s/he had consumed a beer at 4 p.m. The SP was driven home. · The VA also told P4 that the SP took the VA to the SP’s house and the SP gave the VA a tacklebox that had belonged to a family member of the SP. · Later that evening, the VA told P4 s/he did not want to go on outings with the SP anymore “if [the VA] was in danger.” The SP provided the following information: · On May 30, 2025, the SP started work at the facility at 3 p.m. The SP took the VA for a drive on the back roads and looked for wildlife. The SP stopped at his/her house, which was 5.5 miles from the facility, to show the VA the garden. They also stopped and parked on the side of the road and listened to live music at a bar. They got back to the facility at approximately 7-7:30 p.m. · When the two arrived back at the facility, the SP went in the garage and drank a quarter to half of a pint of vodka and did not mix it with anything. The vodka was on a shelf in the garage. · The SP denied drinking alcohol on either trip to his/her house or before driving the VA around. The SP denied ever being under the influence of alcohol at the facility and did not feel the amount s/he drank affected his/her ability to do his/her job. · The SP “blew” 0.2 BAC on the breath test the deputy administered an hour after the alcohol was consumed. The SP “never felt intoxicated” and stated the alcohol “didn’t affect the way I was feeling or anything.” · The SP stated that was the first time in a “long time” since s/he had drunk at work. The SP stated s/he drank alcohol in his/her personal vehicle after leaving work and before driving home. P1 provided the following information: · P1 received a call from P3 that the SP was intoxicated. P1 called law enforcement and asked for a welfare check on the individuals at the facility and to determine if the SP was intoxicated or under the influence of something that would jeopardize the clients. · Law enforcement called P1 and stated the SP was slurring his/her words, had difficulty standing, and provided a breath sample that registered over 0.2 BAC. The SP was driven home and put on investigatory leave. · The SP sent P1 a text and said s/he was going to resign and retire instead of going through the internal investigation. · The VA did not have the cognitive ability to know if someone was intoxicated when [the VA] went with [the SP]. The G provided the following information: · P1 notified the G that the SP had been intoxicated at work and had taken the VA out for a drive. No incidents occurred during the drive. · The G did not have any other concerns with the staff persons or the facility. The VA got along with staff persons very well and had never voiced any concerns. · The G did not know if the VA would have been aware that the SP was intoxicated. The VA had cognitive impairment and was heavily medicated. Facility training records showed all staff interviewed were trained on The Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans. The SP signed the vehicle use agreement on May 16, 2025, which stated the SP agreed to “drive responsibly and adhere to all traffic laws.” Conclusion: A. Maltreatment: Information showed that on May 30, 2025, the SP started work at the facility at 3 p.m. At 3:30 p.m., P2 returned to the facility from the hospital and asked the SP for assistance with paperwork. The SP’s face was droopy and eyes were bloodshot. P2 attempted to call P1 to inform P1 that the SP was intoxicated, however, contact was not made with P1. Sometime between 4-4:30 p.m. the SP went home to get a tiller and returned to the facility around 5 p.m. The SP had to be reminded to administer the 5 p.m. medications. At approximately 6 p.m., the SP took the VA for a drive to the SP’s house and to listen to live music at a bar from the vehicle. The SP and the VA returned to the facility around 7:45 p.m. The SP stumbled, slurred his/her words, stared at the wall, and smelled strongly of alcohol. P3 contacted P1 and law enforcement was contacted. Law enforcement arrived at the facility at 8:27 p.m. and encountered the SP “passed out or sleeping” in a recliner. The SP’s speech was “heavily slurred,” and eyes were “bloodshot and watery.” The SP admitted that s/he consumed an alcoholic beverage that consisted of vodka and juice at 4 p.m. A preliminary breath test was administered to the SP and the result was .293 BAC. Although the SP told this investigator s/he did not consume any alcohol until the SP and the VA returned to the facility from the drive, given that P2 observed behavior that led him/her to believe the SP was under the influence of alcohol prior to leaving for the drive, that the SP told law enforcement that s/he consumed alcohol at 4 p.m. and that the SP provided a preliminary breath test within 45 minutes of returning to the facility from the drive, which resulted in a .293 BAC, there was a preponderance of the evidence that the SP consumed alcohol prior to driving a vehicle with the VA in it which was a 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. 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 neglect for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because the incident was a single occurrence and the VA did not sustain an injury. Action Taken by Facility: The facility completed an Internal Review and determined policies and procedures were adequate and were followed. 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.
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