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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: 1101706-HCBS (Home and Community-Based Services) Investigator(s): Scout Peterson (651) 431-6578 Suspected Maltreatment Reported: It was reported that at 12 p.m. a vulnerable adult (VA) was seen sleeping on a couch lying in urine and feces. The VA stated that his/her brief was last changed around 9 or 10 p.m. the night before. Date of Incident(s): October 29, 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 medical records; and through four interviews conducted with two of the VA’s case managers (CM1 and CM2), an administrative staff person (P1), and the SP. The VA did not respond to calls or letters requesting to speak to him/her. When this investigator attempted to meet with the VA at the hospital, s/he was asleep, so this investigator left his/her card with a nurse, requesting a call from the VA but the VA did not return the call. According to the VA’s service plan the VA received eight hours of night supervision services and lived in his/her family member’s (FM) home. The VA received support and assistance with activities of daily living. The facility hired the SP, who was also the VA’s family member (not FM), to provide night supervision services. The VA was not subject to guardianship. The VA and the SP determined the SP’s schedule together. The SP worked only overnight shifts and was not hired by the facility to provide the VA any services during the day. Because the SP was the VA’s family member, s/he often went to the VA’s home during the day when s/he was not scheduled. CM2 provided the following information: · On October 29, 2025, at 12 p.m., CM2 went to the VA’s home and saw that the VA was sitting on a couch and had a garbage bag taped down beneath him/her. The VA was “soiled in feces” and had feces half-way up his/her back and down to his/her knees. The VA was wearing a disposable brief, but it was soiled and leaking. The VA said his/her brief was last changed around 9 or 10 p.m. the night before. The FM was also home, in his/her bedroom, when CM2 visited. · After approximately 30 minutes, the SP arrived to visit the VA, though s/he was not scheduled to work. The SP did not “immediately” assist the VA in cleaning him/herself up but did so when the VA asked approximately 10 minutes later. [Note: the SP was not scheduled to work at this time and was not responsible for the VA’s cleanliness or assisting the VA in cleaning.] · CM2 stated that s/he only met the VA three or four times, but that the VA seemed oriented to time and place. CM2 did not have additional information on the VA’s ability to recall or provide accurate information. The VA was dependent on caregivers for “toileting assistance” and “properly caring for incontinence episodes.” The VA did not ambulate independently. P1 provided the following information: · The VA could not use the bathroom without assistance and wore a disposable brief. The main responsibility of the SP during the overnight was to assist the VA with toileting and changing his/her brief. P1 thought that the VA received day services from another facility in addition to the overnight supervision provided by the facility but did not realize that those services ended prior to this report. P1 thought that the VA needed a higher level of care (LOC) than home and community-based services and supports could provide, such as an assisted living facility, but the VA did not want to move to a higher LOC facility. · If the SP was unable to work a scheduled shift, s/he did not typically tell P1 or ask for someone to fill in because the VA did not want to work with any other staff persons. When the SP was not working, s/he spent most of his/her time with the VA because they were family members, however the SP was not responsible for the care of the VA during the day. · The SP’s schedule showed that on October 28, 2025, the SP started his/her shift at 11:05 p.m. and worked until the morning of October 29, 2025, at 9:32 a.m. On November 2, 2025, the VA was hospitalized for an unrelated urinary tract infection. CM1 said that s/he was contacted by CM2 who explained what CM2 observed on date of the incident. On November 12, 2025, CM1 met with P1 and the SP to discuss the VA. The SP was not always able to work the overnight shift 40 hours a week but tried to see the VA “as much as [s/he] could.” The SP said that the VA “hid” when s/he had a bowel movement using blankets to cover him/herself. The VA did not receive services during the day, and the SP only worked overnight shifts. CM1 told this investigator that the VA was “not coherent” and could not remember specific information, nor could s/he call this investigator over the phone. The SP provided the following consistent information in an interview with this investigator and for the facility’s Internal Review: · The SP worked for the company since 2019 but took breaks throughout his/her employment. In October 2025, the SP resumed his/her employment with the facility and began working overnights from 11 p.m. to 5 a.m. with the VA. At that time, the VA lived with the FM, who was also the SP’s family member. Towards the end of the month, the VA had episodes of “severe” diarrhea since a prior hospitalization, and the VA had a bowel movement “every 10 minutes” which made the VA’s buttocks “raw.” · The SP worked overnight from October 28 – 29, 2025, and changed the VA’s disposable brief before s/he left on the morning. The SP stated that s/he never laid out a garbage bag for the VA to sit or lie on and never saw the VA sitting or lying on a garbage bag. The SP purchased hospital pads and briefs for when the VA had episodes of incontinence. The VA was never left in his/her brief overnight. On nights the SP did not work, the FM assisted the VA with brief changes and toileting. · The SP lived next door to the VA and the FM and was often at their home when the SP was not scheduled to work. The SP administered the VA’s medications daily at 6 p.m. and assisted with the VA’s needs whenever s/he was with the VA, including outside of his/her working hours. The SP wanted to ensure the VA was “comfortable,” because they were family, but was ultimately not responsible for the VA when s/he was not working. According to the VA’s medical record, on November 2, 2025, the VA was admitted to the hospital for treatment of hypovolemic shock due to recurrent UTI and chronic diarrhea. A social work note dated November 3, 2025, showed the VA felt that things were “going well” at home, and that s/he had “a lot of support.” The VA told hospital staff that his/her family member, the SP, provided the VA with care overnight. On October 18, 2025, the VA was discharged from the hospital with additional home care services. Information provided by the facility showed that the SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans. Conclusion: On October 29, 2025, at 12:30 p.m. CM2 found the VA sitting in a soiled disposable brief that was leaking urine and feces onto a plastic bag that was taped to a couch. The VA told CM2 that his/her brief was last changed between 9-10 p.m., the night before. The VA required assistance with activities of daily living and received eight hours of night supervision. Days later while at the hospital, the VA told hospital staff persons that s/he had a lot of support and that things were “going well” at home. Consistent information provided by P1, the SP, and CM1 showed that the SP only worked overnight shifts with the VA. The VA lived with the FM and P1 thought that the VA received day services from another facility. Because the VA was the SP’s family member, the SP spent a lot of his/her time with the VA during times when the SP was not working. On October 29, 2025, the SP worked until 9:30 a.m. The SP said that on the morning of October 29, 2025, the VA experienced episodes of diarrhea, and the SP changed the VA’s brief before s/he left. The SP did not leave the VA sitting on a garbage bag taped to the couch. On nights the SP did not work, the FM assisted the VA with toileting and brief changes. Although the VA was found at 12:30 p.m., sitting in soiled briefs that s/he said had not been changed since the night before, given that the SP stated s/he changed the VA’s brief before s/he left and did not leave the VA sitting on a garbage bag taped to the couch, that the SP and facility were only responsible for the VA’s care overnight which ended that day at 9:30 a.m., that CM2 did not see the VA until approximately three hours after the SP left the VA’s residence, that the VA had been having episodes of diarrhea during the time period and could have soiled him/herself between the time the SP left and CM2 arrived, and that the VA said that things were “going well” at home and that s/he had “a lot of support,” there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services which were reasonable and necessary to maintain the VA’s health. 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 policies and procedures were adequate and followed. Action Taken by Department of Human Services, Office of Inspector General: No additional action taken.
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