MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

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:

1071709-H_CRS (Home and Community-Based Services-Community Residential Setting)
1071691-HCBS (Home and Community-Based Services)

Investigator(s):

Heidi Murphy
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
Heidi.Murphy@state.mn.us

651-431-6544

Suspected Maltreatment Reported:

It was reported that a vulnerable adult (VA) was observed laying in “urine from head to toe” for several days. The VA was wearing an adult absorbent undergarment soiled with urine and feces and sores were noted on the VA’s coccyx area.

Date of Incident(s): November 22, 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 15, 2025; from documentation at the facility and medical records; and through nine interviews conducted with a the VA’s two guardians (G1 and G2), two facility staff persons (P3 and P5), three facility supervisory staff persons (P1, P2, and P4), the VA’s case manager (CM), and a health care professional not associated with the facility (HP). Due to the VA’s abilities, the VA was not able to provide information for this investigation.

The VA’s diagnoses included Lennox-Gastaut syndrome, epilepsy with uncontrolled seizures, severe intellectual disabilities, generalized anxiety disorder, and mixed incontinence. The VA enjoyed trains, tractors, music, walks, coloring, dogs, and playing ball. The VA had limited expressive communication skills.

The VA’s plans stated the VA had a history of verbal and physical aggression and displayed self-injurious behaviors. The VA also had a history of refusing to eat, drink, take medications, and complete hygiene and personal care for extended periods of time. The VA “often times will refuse to use the restroom which will result in [him/her] staying in wet urine-soaked clothes for an extended period of time.” The VA required staff persons to bathe him/her daily. The VA’s plans did not address what assistance the VA needed with changing his/her absorbent undergarments, clothes, or bedding and did not state what staff persons should do if the VA refused to be changed.

Medical records showed the VA was evaluated on November 22, 2025. A “small area of erythema, pressure injury associated with laying in moist environment” was observed on the VA’s buttock. The area was cleaned and the VA was dressed in clean clothing and dressing and was discharged with “normal wound care.”

The HP provided the following information:

· On November 22, 2025, the HP observed the VA “head to toe in urine, new and old.” Staff persons told the HP that the VA refused “everything” and had not eaten or drank all day. The VA’s bedroom windows were open because it “smelled so bad” and the bed was “completely wet.” The VA was shivering, and the HP closed the windows.

· The VA allowed the HP to change his/her adult absorbent undergarment. The VA was wearing two absorbent undergarment and both were full of fecal matter, which had run down the VA’s legs. The VA’s buttocks were red and appeared to be developing a sore from “being in that situation.”

· Staff persons stated the VA had not cooperated for a “couple days.” The HP was concerned staff persons waited so long before getting assistance.

P5 provided the following information:

· On November 20, 2025, the VA started having increased seizures and behaviors. The VA urinated and declined to let staff persons change him/her, declined to take medications, and declined to eat. The VA became aggressive whenever staff persons got close to the VA.

· On November 22, 2025, the VA was incontinent of bowel and continued to decline to let staff persons change him/her. G1 was called to assist with the VA. When G1 arrived, the VA “got overwhelmed” and the VA’s seizures increased so G1 called 9-1-1. The VA allowed EMTs to change him/her and the VA was transported to the hospital. P5 stated when the EMTs were at the facility, “it looked like we were neglecting [the VA], we didn’t want to change [the VA], but that was not the case.” The VA got “really aggressive,” and staff persons could not force the VA to be changed. There was only “so much” staff persons were allowed to do.

· P5 stated it had been “a day or two” since the VA was changed and it was “getting really bad,” which prompted a call to G1 for assistance. P1 and P2 were aware the VA had been declining to be changed. P5 was not aware of any protocol that addressed what to do if the VA declined to be changed for extended periods of time.

· The longest the VA had gone without being changed was “probably three to four” days. When the VA declined to be changed, P5 continued to ask the VA several times throughout the shift.

· Staff persons documented in the VA’s shift notes if the VA was changed or if the VA declined to be changed. P5 only documented when the VA declined in the shift notes. P5 offered to change the VA three times during a shift, in the morning, during lunch, and before P5’s shift ended. The VA was also encouraged to sit in the bathroom often, as the VA was not able to tell staff persons when s/he had to use the bathroom.

P1 provided the following information:

· On November 22, 2025, P5 was working directly with the VA. The VA was having increased seizures and declined to let staff persons change him/her. The VA “typically” declined to be changed. G1 was contacted and asked to come to the facility to assist with getting the VA changed. The VA continued to decline to be changed and had an increase in seizures. G1 called 9-1-1 for assistance with seizure control.

· P1 was not aware when the VA started declining to be changed. Shift notes showed staff persons were able to get the VA “up and ready” in the morning on November 20, 2025, but did not specify if the VA was changed. “Typically,” when the VA got “up and ready,” s/he was changed. On November 20, 2025, during the 3-10 p.m. shift, the VA declined to be changed. On November 21, 2025, during all three shifts, the VA declined to be changed. On November 22, 2025, the VA declined to be changed until the paramedics arrived.

· The VA was “embarrassed” by being changed and it was “uncomfortable” for him/her. The VA responded better to some staff persons versus others. The VA’s behaviors and cooperation level changed in a “split second.”

· When the VA refused to be changed, staff persons gave the VA time before they suggested changing him/her again. If the VA was pushed or pressured, the VA became agitated. Staff persons were expected to continue to try to get the VA changed throughout a shift and gave the VA time to “cool down” between attempts.

P2 provided the following information:

· P2’s first day working in the facility was November 20, 2025. The VA had “quite a few behaviors” and may have been “set off” by having a new staff person at the facility. On November 21, 2025, P2 learned that the VA had a bowel movement and was refusing to get up. P2 heard the VA had previously gone as long as a week declining medication, food, and adult absorbent undergarment changes. On November 22, 2025, P2 called and asked G1 to come to the facility and talk with the VA about getting changed. Around 3 p.m., P2 left and G1 arrived after. The VA had several seizures and G1 opted to call 9-1-1.

· P2 believed as of November 22, 2025, the VA had not been changed for a “day or a day and a half.”

· The VA got physically aggressive with staff and preferred certain staff persons over others. The VA declined to complete cares for some staff persons and cooperated with others. The VA hid in bed and yelled at staff persons when declining to be changed. If staff persons tried to uncover the VA’s head, the VA swung at staff persons and “somedays [the VA] was physically coming after [staff persons].” Recently, the VA “lunged” from the bed, grabbed a staff person, and “tried to pull [the staff person] down.” On one occasion, P2 helped the staff person get away from the VA and the VA “swung” and hit P2 in the nose. The VA got past P2 and pushed through a door and tried to get to the staff person. The staff person locked him/herself in the basement until the VA calmed.

· P2 told staff persons to document what times they attempted to change the VA and if the VA declined to or allowed staff persons to change him/her.

· The VA declined to be changed a “good chunk of the day” but was usually changed once or twice per day.

· The VA’s bed was stripped and changed whenever the VA left the bedroom and staff persons noticed it was dirty or wet.

P4 provided the following information:

· P5 told P4 that the VA declined medications, to eat, and to be changed on the morning of November 22, 2025. The VA had a history of physical aggression and P5 was fearful the VA would get physically aggressive as vocal behaviors occurred when P5 attempted to complete personal cares. P5 tried multiple times and attempts were unsuccessful.

· The VA had been in a soiled adult absorbent undergarment all day and P5 called G1 for assistance. When G1 arrived, the VA experienced more seizures, which prompted G1 to call 9-1-1.

· The VA was transported to the hospital and a sore was discovered on the VA’s buttocks. The sore was still present but was currently in the “healing process.”

· The VA was moved to the facility after an increase of self-injurious behaviors increased at his/her previous placement. The VA did not like new staff persons and personal care refusals increased when the VA moved to the facility four years ago. The VA declined cares “almost every day” including medication, toileting, food, and drink. When the VA did not take his/her medications, it led to increased seizures, which led to the VA’s declining personal cares. Personal cares were the most common thing the VA declined. The VA responded to familiar staff persons and staff persons of the same gender the best.

· P5 told P4 that when P5 started at the facility one to two years ago, the VA went up to a week without being changed. P4 advised medical attention should be sought for the VA after two to three days of declining to be changed for fear of “skin breakdown.”

· When the VA declined to be changed for an entire day, staff persons should have notified P2 and P2 should have notified P1.

· Staff persons put in shift notes if the VA was changed or if s/he declined to be changed. If it was not noted that the VA declined, P4 assumed the VA had been changed.

· P4 had not been made aware the VA declined to be changed days prior to the VA going to the hospital.

P3 provided the following information:

· P3 was off from work from November 1-16, 2025. P3 returned to work at the facility and worked with the VA on the morning of November 17, 2025. P3 heard the VA had not been changed in four to five days. P3 attempted to change the VA but the VA declined. The following day (date unknown,) P3 and another staff person showered and changed the VA.

· After the VA returned to the facility from the hospital, the VA had sores on his/her legs and buttocks.

· P3 only worked 1:1 with the VA when P3 picked up shifts. When P3 worked with the VA and the VA declined to be changed, P3 continued to ask the VA “every five minutes” throughout the shift until the VA agreed to be changed. There were some shifts in which the VA declined to be changed the entire shift.

· The VA preferred one gender of staff over the other. P3 often helped change the VA when opposite gendered staff persons were working with the VA. The VA “attacked” opposite gendered staff persons.

· Staff persons documented in shift notes and a communication log if the VA was changed or if s/he declined cares. The number of times the VA was asked to be changed was not specifically documented. The VA was usually only changed once per shift. P3 usually documented if the VA was changed, but sometimes P3 did not document it.

· The VA had behaviors that lasted anywhere from an hour to the entirety of the shift. P3 was not aware of any procedure of when to contact G1 or G2 for assistance.

Shift notes provided the following information:

· November 19, 2025, 3-10 p.m. shift: P3 stated the VA refused all cares.

· November 19, 2025, 10 p.m. to November 20, 2025, 8 a.m.: A staff person noted the VA refused medication overnight but took medication, ate, and got dressed in the morning.

· November 20, 2025, 8 a.m. to 3 p.m. shift: There were no notes.

· November 20, 2025, 3-10 p.m. shift: A staff person noted the VA refused food and refused to be changed throughout the shift.

· November 20, 2025, 10 p.m. to November 21, 2025, 8 a.m.: A staff person noted the VA slept through the shift and refused medication and breakfast.

· November 21, 2025, 8 a.m. to 3 p.m.: A staff person noted the VA was verbally and physically aggressive towards staff. Staff tried to get the VA to eat, take medication, and get changed every hour and the VA refused.

· November 21, 2025, 3 p.m. to 10 p.m.: P5 noted the VA refused to eat, take medications, or be changed. The VA was given a PRN after each of two seizures.

· November 21, 2025, 10 p.m. to November 22, 2025, 8 a.m.: A staff person noted the VA had a “high behavior” and refused medication, food, and to be changed.

· November 22, 2025, 8 a.m. to 2 p.m.: A staff person noted the VA was lying in a bed “full of a [bowel movement] and wet.” The VA refused staff assistance and did not want to “get up.” The VA refused food and medications and remained “wet and full of a [bowel movement].”

· November 22, 2025, 3-10 p.m.: P5 noted the VA refused to “get up and do anything.” The VA refused food and medications but later took medication and a PRN. G1 visited and called 9-1-1 after the VA experienced multiple seizures. The ambulance crew was able to change the VA and transported the VA to the hospital. The VA was discharged and upon arrival back at the facility, refused to be changed.

G1 provided the following information:

· G1 was contacted by the facility to come over and assist because the VA was declining to change his/her adult absorbent undergarment. Staff persons had been having difficulty with the VA for “a couple of days.” The VA had multiple seizures and G1 called 9-1-1 for paramedics to assist with seizure control.

· The VA had difficulty getting to know new staff and the facility had a lot of turn over with staff persons. The VA had preferences with staff persons and when the VA declined care, at times, it became a battle “to figure out how long it’s going to take before [the VA] feels like [s/he’s] won.” G1 stated issues with the VA’s declining care have been going on for roughly five years.

· When the VA was incontinent, staff was supposed to keep approaching the VA to be changed and call G1 or G2 if assistance was needed. G1 stated the facility called him/her once or twice a month for assistance with the VA. G1 and G2 wanted staff persons to “do as much as they can” without assistance from G1 and G2.

G2 provided the following information:

· The VA had behaviors “all the time.” The VA had more behaviors when new staff persons started at the facility. A new facility supervisor started around the time of the related incident and the VA declined to be changed for approximately three days.

· The VA had communication difficulties, anxiety, toileting issues, and behavioral problems that had worsened in the last couple of years. The VA was a “difficult” individual and staff persons tried to do what they could to get the VA changed. Some staff persons were better than others with the VA.

· The VA declined medications and changing more frequently over the last year and only changed for certain staff persons. The VA went up to three days without being changed on multiple occasions. Staff persons called G1 or G2 for assistance when the VA had declined personal cares for multiple days. The VA got embarrassed if s/he had a bowel movement and declined to let staff persons change him/her.

The CM provided the following information:

· When the VA did not want to do something, s/he would not do it. If the VA was “pushed” or asked more than once, the VA had significant behaviors which included physically assaulting staff, chasing staff, and property damage.

· The facility went “above and beyond” for the VA and had the VA’s best interest in mind.

· It was not okay for the VA to be incontinent and not get cleaned up. However, staff persons were not allowed to physically restrain the VA to clean him/her up. If the VA continued to refuse personal cares, staff persons attempted to give the VA a “bed bath” with wipes. A referral was made to get help with behavioral supports for the VA.

P1, P2, P3, and P5 were trained on the Reporting of Vulnerable Adults Act. P1, P2, and P3 were trained on the VA’s plans.

Conclusion:

From November 19-22, 2025, the VA declined to be assisted, was not changed, and was in two adult absorbent undergarments that were both soiled with urine and feces. The VA’s bed was also soaked in “new and old” urine. The VA was transported to the hospital, and a sore was discovered on the VA’s coccyx area.

The VA had a known history of declining medication, food and drink, and adult absorbent undergarment changes for extended periods of time. The VA also had a history of physical and verbal aggression toward staff persons when they attempted to assist the VA with personal cares and changing including hitting staff persons, pulling staff persons to the ground, and chasing staff persons. Staff persons attempted multiple times per day to change the VA and the VA continued to decline. Staff persons became concerned on November 22, 2025, and G1 was contacted for assistance. The VA continued to decline to be changed and had an increase in seizure activity, which prompted a call to 9-1-1 and the VA was transported to the hospital.

Staff persons offered assistance to change the VA several times a day, but the VA declined. Staff persons changed bedding when the VA left his/her bedroom. The VA’s G was called for assistance to attempt to get the VA to agree to be changed.

Given the VA’s history of refusing personal cares, that staff persons made multiple attempts each day to change the VA, and that staff persons sought assistance from G1 when the VA continued to decline assistance, there was not a preponderance of the evidence whether staff persons failed to provide the VA with care and services that were reasonable and necessary to maintain the VA’s 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 policies and procedures were adequate but not implemented as applicable. The VA’s plans were revised to reflect a history of medication, food, drink, and brief change refusals. Bathroom/toileting and eating/drinking tracking was developed for the VA. A behavioral analyst developed a behavior support plan pertaining to refusals and hygiene for the VA. All staff persons that worked with the VA were trained on the VA’s revised plans.

Action Taken by Department of Human Services, Office of Inspector General:

No further action taken.

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