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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: 1067649-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh christine.cavanaugh@state.mn.us 651-431-3444 Suspected Maltreatment Reported: It was alleged that a staff person (SP) drank alcohol while working at the facility and drove a vulnerable adult (VA) while under the influence. Date of Incident(s): November 24, 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 December 10, 2025; from documentation at the facility; and through nine interviews conducted with three facility staff persons (P1-P3), two supervisory staff persons (P4-P5), a resident who lived at the facility (R1), another resident’s (R2’s) case manager (CM), the VA’s guardian (G), and the SP. This investigator met the VA, but the VA did not provide information for this report due to his/her diagnoses. This investigator met R2, but s/he declined to interview. The VA’s file stated that the VA had a good sense of humor and liked to laugh. The VA enjoyed listening to music, being outside, going for rides, watching movies, and being in the community. The VA was diagnosed with a traumatic brain injury and was nonverbal but was able to express his/her likes and dislikes to others. The VA lived at the facility since 2011 and attended a day program four days a week. (Note: The VA’s day program was approximately four miles from the facility). The facility was divided into two units/levels—an upper and lower, each with a kitchen/dining/living area, bedrooms, and bathrooms with a connecting door between the units. The VA and R1 lived in the upper level of the home, and R2 lived in the lower level. During daytime hours, there were separate staff persons for each level of the home, and during overnight hours, there was one awake staff person for both levels. The Internal Review and P4 provided the following information: · On Monday, November 24, 2025, at approximately 7:55 a.m., P1 arrived at the facility upstairs unit and saw the SP asleep on the couch. There was a “little over half full” vodka bottle on the end table. The VA was asleep in his/her room. The SP awoke and went to wake up the VA. The VA missed his/her bus ride for work/day program, so the SP was “in a hurry” to get the VA ready. P1 thought that the SP transported the VA in his/her own vehicle to the VA’s day program, but “wasn’t sure.” · At approximately 8:25 a.m., P1 called P4, and told P4 about what s/he saw. P4 contacted the non-emergency police department to report the SP was possibly under the influence of alcohol. P4 then called the day program and learned that the VA was dropped off at 8:26 a.m. · After calling the VA’s workplace and the non-emergency number, P4 called the SP and left a voice message for the SP to come to the office to talk about what happened. At 9:09 a.m., the SP called P4 back and left a voice message that sounded like s/he was “slurring [his/her] words.” P4 called the SP back and set up an in-person meeting later that day. · At 2 p.m., the SP met with P4 and another supervisory person. The SP stated s/he was “overly tired” from the past weekend and being “out of town.” The SP acknowledged sleeping, but stated that it was “not long” and that s/he was awake at 6 a.m. and “must have leaned [his/her] head back and nodded off” and “before [s/he] knew it,” P1 “was there” and “it was 8 a.m.” The SP stayed at a family member’s house the past weekend and was “cleaning up” before s/he left the home. During that time, the SP put the “full” vodka bottle, that belonged to his/her family member, in his/her bag. The SP denied drinking alcohol while at the facility and stated that s/he had not had “alcohol in three months” due to “current health issues.” · According to the facility, the SP was not authorized to drive residents due to not submitting a driver’s record or insurance. However, the SP stated that s/he “didn’t know that [s/he] couldn’t drive” and that s/he drove the VA to work about four years ago when an unknown person asked him/her to. P1-P3, P5, R1, and facility timesheets provided the following information: · According to facility timesheets, on November 23, 2025, the SP clocked in at 10:11 p.m. and worked until November 24, 2025, at 9 a.m. On November 24, 2025, P1 clocked in at 7:55 a.m. and P2 at 7:25 a.m. (Note: P2 worked in the lower unit). P2 did not remember what staff person was working in the upstairs unit and had no information about any staff persons being under the influence of alcohol while working.
· On November 23, 2025, P3 worked until about 10 p.m. and talked to the SP for approximately “three to five minutes” in the facility driveway. P3 did not “notice anything” that would indicate the SP was under the influence of alcohol nor did P3 smell any alcohol on the SP. · P1 provided information that was consistent with the Internal Review and also stated that when s/he arrived at the facility the morning of the incident, the residents were still in bed. P1’s entrance “startled” the SP, who was “very out of it.” P1 and the SP helped the VA get ready to go to work and around that time, P1 saw a Diet Coke and a “less than half” empty vodka bottle on an end table next to the couch. P1 “wasn’t sure what to do,” was “uncomfortable,” and in a “panic situation” trying to get the VA ready for work. Then at some point, P1 noticed the bottle was no longer on the end table. During P1’s and the SP’s interactions, P1 did not get “close enough” to the SP to smell whether there was an alcohol scent. However, P1 said the SP “was kinda groggy” and the SP’s lips were “sticking” to his/her “face.” The VA’s bus usually came at 8 a.m. but was sometimes late. The SP did not tell P1 that s/he was going to drive the VA. · R1 said s/he “never” saw any staff persons drink alcohol while working at the facility. · P5 heard about the incident from P4. P5 had “suspicions” that the SP was drinking alcohol while at the facility in the past, but “never smelled” alcohol on the SP or saw anything that made P5 think the SP was intoxicated or had been drinking. The G had no prior concerns with the facility and said that it was a “great place” for the VA to live. The CM had no concerns with the facility. The SP stated that around 5 a.m. on the date of the incident s/he was “pulling stuff” out of his/her personal bag looking for a medication and set an alcohol bottle, that was from the weekend prior, on the side table. Around 6 a.m., the SP “put” his/her “head back” and “nodded off.” Around 8 a.m., P1 walked into the facility, which “woke [the SP] up.” The SP looked at the clock, “got frazzled,” and was in a “hurry” to get the VA ready, who was usually to be awake by 6:45 a.m. The SP got the VA dressed and gave the VA a cereal bar. The VA missed his/her bus ride to work, so the SP drove the VA. The SP denied drinking alcohol while working and stated s/he had not “drank” since Saturday (Note: Which would have been November 22, 2025). The SP stated that s/he had a valid driver’s license and stated that s/he would provide a copy of it for this investigation. [Note: At the time of this report, the SP had not provided a copy of his/her driver’s license.] Law enforcement was notified of the report, but did not investigate it. The Drug and Alcohol Use policy stated that no employee may be under the influence of alcohol while in the workplace, while on duty, or while operating a vehicle or equipment owned/leased by the company. Possessing or being under the influence of alcoholic beverages while on the company’s property, while on duty, or while operating a vehicle or machine leased/owned by the company may lead to disciplinary action. P1-P5 and the SP were trained on the Drug and Alcohol Use policy, the Reporting of Maltreatment of Vulnerable Adult’s Act, and the VA’s plans. Conclusion: On November 24, 2025, at 7:55 a.m., P1 arrived at the facility and saw the SP asleep on the couch. P1 saw a vodka bottle, which was approximately three-quarters full, and a Diet Coke on the side table next to the couch where the SP was sleeping. P1 went about his/her job duties and then at some point saw the alcohol bottle was no longer on the side table. P1 did not say anything to the SP about what s/he saw and did not get “close enough” to the SP to smell whether the SP smelled of alcohol. However, P1 stated the SP “was kinda groggy” and that the SP’s lips were “sticking” to his/her “face.” The VA missed his/her bus ride, so the SP drove the VA to his/her day program without communicating it to P1. At 9:09 a.m., the SP left P4 a voice message that sounded like s/he was “slurring [his/her] words.” The SP provided inconsistent information in the Internal Review and to this investigator regarding when s/he last drank alcohol and told P4 that the alcohol bottle was full, but P1 stated the bottle was “less than half” empty. The SP denied drinking alcohol while working. Although there was concern that the SP drove the VA while under the influence of alcohol and that the SP had reason to minimize his/her actions for fear of repercussions, given that no persons saw the SP drink alcohol and/or smelled alcohol on the SP prior to driving the VA, that the VA arrived safely at his/her day program at 8:26 a.m., that it was not able to be determined whether the SP had a valid license, and that the SP denied being under the influence of alcohol, there was not a preponderance of the evidence that there was a failure to provide the VA with care and services that were reasonable and necessary to maintain the VA’s physical or mental health and 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 stated that their policies and procedures were adequate but not followed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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