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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: 1093705-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Brittany Dolen 651-431-6701 Suspected Maltreatment Reported: It was reported that a staff person (SP) was under the influence of marijuana and drove a vulnerable adult (VA) in a facility vehicle. Date of Incident(s): October 19, 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 7, 2025, from documentation at the facility and through seven interviews conducted with the VA, the VA’s guardian (G), two supervisory staff persons (P1 and P2), two facility staff persons (P3 and P4), and the SP. The VA was diagnosed with sacral spina bifida without hydrocephalus, compression of brain, transient paralysis, epilepsy and spastic quadriplegic cerebral palsy. The VA required a G-tube for feeding, was ventilator dependent and had a cuff tracheostomy that provided humidified air to the VA. The VA was non-verbal but used a talking device or his/her cell phone to communicate. The VA’s Individual Abuse Prevention Plan said that the VA required staff person assistance with all activities of daily living and spent most of his/her time in his/her wheelchair or bed. The VA had a Hoyer lift in his/her bedroom for safe movement by staff persons, and a seatbelt and tray on his/her wheelchair. The facility’s Alcohol and Drug Use Policy said that it was “not permissible for LSS team members, subcontractors, and volunteers to be on duty, transporting a person(s) served, driving on organization business or accompanying a person served into the community when under the influence of alcohol or illegal drugs or impaired by any chemicals or prescription/legal drugs.” The facility’s Employee Information Guide said that driving under the influence of alcohol or drugs or transporting alcohol or drugs in company vehicles was “prohibited” and staff persons were required to follow the facility’s Driver Policy. The Facility’s Driver Policy said that “all wheelchairs must be securely fastened using the tie downs designed for that vehicle”, and that all persons in the vehicle “must maintain safe behavior.” The facility vehicle was a large conversion van, with a front driver and passenger seat. Behind the front driver and passenger seats was an open back area to accommodate two wheelchairs. There was no additional seating for persons who did not use a wheelchair. The van was approximately eight feet long from the back door to the back of the front seats, and wheelchairs could be secured in multiple locations. Wheelchairs were secured by four hooks, one on each wheel and could be placed directly behind the driver and passenger seats, or three feet behind that, in the middle of the van. The VA said that on an unknown date, the SP drove the VA and P4 to a sporting event and it “did not go how [the VA] hoped” because the SP was “high on drugs all day long.” The SP lost the tickets because s/he was “high” and the VA, P4, and the SP missed the first quarter of the sporting event. The VA thought the SP was high, because every time the SP stopped the van s/he went outside and when the SP returned, s/he smelled “like skunk” and it was “really strong.” The VA was “pretty scared” when the SP drove and “did not feel safe” because the SP “almost fell asleep” and “swerved twice.” The VA did not tell the SP or P4 that s/he felt unsafe during the drive, but when they returned to the facility, the VA texted the G, P1, and P2 and told them what happened, and that s/he did not feel safe. P4 provided the following information: · P4 said there were three different locations in the van where the VA’s wheelchair could be secured. Staff persons secured and tightened the wheelchair to the van and then the VA or the staff person moved the wheelchair back and forth to tighten it more. · On October 19, 2025, around 6:45 a.m., the SP drove P4 and the VA to a sporting event located in the Twin Cities, approximately 224 miles away. Before leaving the facility, the SP asked P4 if it was “OK” if the SP “smoked.” P4 told the SP that was “fine,” because P4 thought the SP was going to smoke a cigarette. P4 then secured the VA in the front wheelchair spot in the van and then P4 sat in the passenger seat. When the SP entered the van, s/he did not smell like marijuana and started the drive to the event. · The SP had a cooler in the vehicle, which s/he opened as s/he was driving. When the SP opened the cooler, P4 thought it smelled like marijuana because P4 knew the smell and “knew what it was.” P4 asked the SP if there was marijuana in the cooler, but the SP did not respond. An unknown amount of time later, the SP stopped the vehicle because the VA needed his/her medication. P4 gave the VA his/her medication, while the SP got out of the van to smoke. When the SP got back into the van s/he “smelled really bad” like marijuana so P4 thought the SP smoked marijuana while s/he was outside. · Around 11:45 a.m., when they reached the sporting event that was scheduled to begin at 12 p.m., the SP asked P4 if s/he could smoke again, and P4 told the SP, “No, because we needed to get inside.” The SP was “mad” that s/he could not smoke. · At approximately 3:30 p.m., on the way back to the facility, the SP stopped the vehicle because the VA again needed his/her medication. The SP walked to the back of the vehicle, and P4 saw the SP “smoking out of a bowl.” P4 saw the SP “hit it once, look up, hit it twice and then look around.” The SP got back in the vehicle and continued to drive. P4 offered to drive due to the SP’s “condition,” but the SP did not respond. · At an unknown time, the SP stopped the vehicle again because P4 needed to use the bathroom. At that time, P4 asked the SP to check on the VA’s wheelchair “strap” because the VA’s straps may have been loosened during the stop. When P4 returned to the vehicle, s/he asked the SP if the VA was secure, and the SP said the VA was. As the SP left the parking lot and stopped at a stop sign, the VA’s wheelchair “scooted all the way up” from the middle of the vehicle to behind the seats. P4 told the SP to stop the vehicle so s/he could resecure the VA’s wheelchair and asked the SP again if s/he was “okay” to drive and the SP said s/he was. P4 then tightened the VA’s wheelchair, and the SP continued to drive. On the way back to the facility, P4 “didn’t feel the safest” as the SP drove because the SP drove “pretty fast” and tried to pass multiple vehicles. · P4 was not able to drive facility vehicles so s/he told the SP that s/he could call P1 to ask if s/he could drive due to the SP’s “condition.” The SP did not respond to P4. P4 then text P3 and told him/her that s/he thought the SP was smoking marijuana. P4 also text P2 saying s/he needed to talk with P2 when they returned. · Around 8:30 p.m., when they returned to the facility, the VA told P4 that the SP “pissed [the VA] off” when s/he smoked. P4 told the VA that in the morning, s/he planned to tell P2 what happened. The next day, around 11:00 a.m., P2 called P4 and P4 told P2 about the SP’s smoking. · P4 knew the SP was “high” when s/he drove because his/her eyes were glossy, s/he smelled like weed, and s/he drove “careless.” The SP drove “really fast” and tried to pass cars while doing so. P4 “did not feel the safest” when the SP drove. The G provided the following information: · On October 19, 2025, the VA went to a sporting event with the SP and P4. The facility made plans for the VA to attend the event, and the VA looked forward to it “for months.” · The VA did not speak due to his/her diagnosis and communicated with the G through text message. When the VA went on outings, s/he usually sent the G multiple texts and photographs. On the day of the incident, the VA text the G when s/he left the facility and sent one photograph from the event which the G thought was “odd.” · On October 20, 2025, the VA text the G and P1 and said when the SP drove the VA to the event, the SP “reeked of weed” and was “high the whole time they were gone.” P1 “immediately” called the G and was “livid.” P1 told the G the SP no longer worked at the facility. · The VA text the G “for a couple of days” after the incident saying that when the SP drove, s/he “drove crazy” and that the VA missed the first quarter of the game because the SP “lost” the tickets. The VA also said the SP “almost fell asleep” a couple of times and “hit the brakes” which made the VA’s wheelchair move in the vehicle because s/he was not strapped correctly. The VA said s/he was “scared” when the SP drove. · The G did not have previous concerns with the facility. P2 provided the following information: · On October 19, 2025, the SP drove the VA and P4 to a sporting event. That evening, around 8 p.m., P4 text P2 saying s/he “needed to talk” to P2. · On October 20, 2025, P3 told P2 about P4’s concern. P2 then called P4 who said that the SP left the vehicle and smoked at every stop. P4 said s/he saw a bowl and marijuana in a bag, and that the SP drove “really fast.” · Around 11 a.m., the VA text P1, P2, and the G and said when the SP drove to the sporting event, the VA was “upset” because the SP “smelled like weed.” The VA also said the SP drove “recklessly” and that the VA felt “uncomfortable and not safe.” · At an unknown time later that day, P2 spoke with the VA, P4, and the SP each separately. The VA told P2 that the SP “drove fast” but did not provide additional details. · P4 told P2 that the SP “smelled like marijuana” and that P4 saw the SP “smoke at every stop.” P4 said s/he saw a “bowl and actual marijuana in a bag” in the vehicle, and that the SP “drove really fast.” P4 did not offer to drive the vehicle because s/he was not approved to drive for the facility. · The SP denied smoking marijuana and P2 did not speak with the SP again after that conversation. The SP provided the following information: · On October 19, 2025, at 7 a.m., the SP, P4, and the VA went to a sporting event. At 9 a.m., the SP, who was driving, stopped the vehicle to use the restroom. They then continued driving. · Around 11 a.m., the SP and P4 “spoke briefly” about “cannabis.” P4 asked the SP if s/he “smoked pot” and told the SP that if s/he ever “needed flower or disposable vapes” that the SP could contact him/her. The SP told P4 that s/he did not smoke cannabis that often because the SP had bad experiences from “sketchy” cannabis, and it made him/her “paranoid” about his/her “lung function and overall health.” The SP thought P4 “seemed offended” and “insisted” that his/her stuff “wasn’t sketchy.” · Around 11:30 a.m., SP, P4, and the VA arrived at the sporting event. The SP had been logged out of the application where the tickets were stored, so an individual at the event assisted the SP with getting the appropriate seats and they sat down around 12:10 p.m. · Around 2 p.m., the VA said s/he was “very fucking cold,” so the SP text P2 and asked him/her if they could leave the sporting event early which P2 approved. When the SP, the VA, and P4 arrived back to the vehicle they got the VA “situated.” The SP then stood near the side of the vehicle and “smoked [his/her] tobacco pipe,” then got into the vehicle and drove. · On the drive back to the facility, they stopped at 4:30 p.m. to get gas and food for P4, and again at 6:40 p.m. so the SP could use the restroom. When the SP used the restroom, P4 administered the VA’s medication. The SP did not know if P4 unbuckled the VA when the SP used the restroom. When the SP continued driving after the second stop, at no point did the VA’s wheelchair slide/move forward in the van. · At an unknown time, P4 asked the SP if s/he was tired and offered to drive. The SP told P4 s/he was fine and reminded P4 that s/he was not approved to drive the facility vehicle. The drive back to the facility was “uneventful” and the SP thought they returned to the facility around 8 p.m. The SP got the VA into the house and then went home, because P4 offered to complete necessary documentation. · On October 20, 2025, P2 called the SP and said there was an “accusation” that the SP “got high” at work and that P2 “would be investigating” the allegation. P2 told the SP they would “talk soon” but then never called the SP. The SP stated s/he did not speak with anyone at the facility after the call with P2. · During the outing, the SP had a cooler in the van with some snacks including energy drinks, frozen water bottles, two sandwiches, a jelly Danish, and some chips. When the SP smoked, s/he smoked from a pipe and the tobacco was flavored. The SP denied having marijuana in his/her cooler, that s/he smoked marijuana when s/he worked, and/or that s/he smoked marijuana at any point when s/he drove the VA. P1 provided information regarding the text message from the VA that was consistent with the information provided by P2. On an unknown date, P1 called the SP, but the SP did not respond to P1. Around October 21, 2025, P1 spoke with P4 and P4 said the SP drove “between 80-90 miles per hour” and P4 did not call anyone because s/he “did not feel comfortable” doing so with the SP next to him/her. P3 had prior concerns that the SP used marijuana when s/he worked because P3 “smelled it” on the SP “at least three times.” On October 20, 2025, P3 told P2 what P4 said about the incident and had no further involvement regarding the incident. The facility’s personnel files showed that P1-P4 and the SP were trained on the VA’s plans, the facility’s Alcohol and Drug Use Policy and Driver Policy, and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rules and/or Statutes: Minnesota Statutes, section 169A.20, subdivision 1, clauses (3) and (8) states in part that it is a crime for any person to drive, operate, or be in physical control of any motor vehicles when the person is under the influence of an intoxicating substance and the person knows or has reason to know that the substance has the capacity to cause impairment; and the person is under the influence of cannabis flower, a cannabis product, a lower-potency hemp edible, a hemp-derived consumer product, an artificially derived cannabinoid, or tetrahydrocannabinols. Conclusion: A. Maltreatment: The VA provided consistent information to P1, P2, and the G that on October 19, 2025, when the SP drove the VA and P4 to a sporting event, the VA smelled marijuana and believed the SP was “high.” The VA said the SP drove “crazy”, and the VA did not feel safe. Additionally, P4 said s/he smelled marijuana in the vehicle when the SP opened his/her cooler and saw the SP smoke from a “bowl” during the trip. P4 also said the SP drove “recklessly” and P4 believed the SP was high. The SP denied smoking marijuana when s/he worked or at any time when s/he drove the VA and that s/he smoked flavored tobacco from a pipe. Although the SP denied the allegations, given that the VA’s and P4’s accounts of the SP’s actions were consistent, that each smelled marijuana on the SP when s/he got back into the vehicle and drove, that each had concerns with the SP’s driving, and that driving after using intoxicating substances is illegal and placed the VA significant risk of harm, there was a preponderance of the evidence that there was a failure to supply the VA with care or services which were reasonably necessary to obtain or maintain the VA’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. At the time of the incident, the SP was responsible for the VA’s health, safety and wellbeing. The SP was trained on the VA’s plans, the facility’s Alcohol and Drug Use Policy and Driver Policy, and 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 it was a single incident, and the VA did not sustain an injury that required the care of a physician. Action Taken by Facility: The facility completed an internal review and determined policies and procedures were adequate but not followed. All staff persons were retrained on the Reporting of Maltreatment of Vulnerable Adults Act, and the facility’s Drug and Alcohol and Safe Transportation policies. 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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