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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: 1101004-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lisa Shock/Lindsay Arth 651-431-6142 Suspected Maltreatment Reported: It was reported that staff persons did not follow supervision in the VA’s plan and accompany the VA to the hospital, and while at the hospital, the VA left unaccompanied and was sexually assaulted while in the community. Date of Incident(s): January 6, 2026 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 January 22, 2026; from documentation at the facility, medical records, and law enforcement records; and through seven interviews conducted with four facility staff persons (P1, P2, P3, and P4), two supervisory staff persons (P5 and the SP), and the VA’s guardian (G) who was also the VA’s family member. Additionally, this investigator met with the VA but the VA declined to answer any questions related to the investigation. The VA was diagnosed with bi-polar disorder, post-traumatic stress disorder, psychogenic nonepileptic seizures, borderline personality disorder, and mild intellectual disabilities. The VA also had a history of self-injurious behaviors. The VA was the only client in the facility and received 24-hour supervision, 2:1 staffing, with earned independent time. According to the VA’s Individual Abuse Prevention Plan, the VA was at risk for sexual abuse from other persons. The VA had a history of accepting money from strangers in exchange for sexual acts and a history of high-risk sexual behaviors where s/he believed that persons of the opposite gender were only interested in interacting with him/her when sex was the likely outcome. The VA experienced immediate attachment to strangers and the desire for attention and approval made him/her more likely to seek or cooperate in an abusive situation. Staff persons provided positive conversations with the VA about creating healthy relationships. The VA had an extensive history of leaving without the knowledge or supervision of staff persons, “mild to severe” self-injurious behaviors, and pseudo seizures. The VA was supported by staff persons while in the community or in his/her home at a ratio of 2:1. The VA’s Personal Safety Plan stated that the VA interpreted neutral interactions with community members as aggressive or sexual in nature and the VA gave out “personal information,” “followed strangers” to their cars or into bathrooms, “excessively touched” them, and made “sexually explicit” comments or gestures. The VA engaged in sexual conversations while on the telephone, had a history of sharing “nude photos” with people s/he met on the internet, and made plans to meet for sexual acts. Staff persons were to remain with the VA while s/he was in the community to provide support to make safe choices. The Progress Report and Recommendations stated that the VA had earned independent time while at home. The VA was practicing being safe while at home without having staff watching at all times. The SP provided the following information: · On January 6, 2026, around 4 p.m., P1 called the SP and said that s/he had called 9-1-1 and asked if P1 and P2 should go with the VA to the hospital. The SP told P1 that they did not need do so. The SP said that “a year and a half ago” an emergency room staff person told the SP that they did not want staff persons to come with the VA to the emergency room so the SP thought it was the “new norm” for all emergency room visits. · While on the phone with P1, the SP heard EMS tell P1 what hospital they were taking the VA to. [Note: This was not the same hospital/emergency room who told the SP staff should not accompany the VA.] · At 7:00 p.m., a hospital staff person called the SP asking if someone had picked the VA up. The SP called P1 and P2 to check if they had picked the VA up from the hospital and P1 and P2 told the SP that they had not. The SP then contacted law enforcement to file a missing persons report and was told that the VA had come to the law enforcement department and was then transported to a different emergency room. · The SP called P5 and told him/her about the VA so P5 went to the emergency room to be with the VA until s/he was admitted. The next day, January 7, 2026, when the VA was discharged, the SP picked up the VA. · Later that day, at some point after returning to the facility, the VA was on the phone with the G and asked to talk with the SP and P5. The VA then told them that s/he had been sexually assaulted by an unknown person while in the community. · The SP assisted the VA in filing a police report with the Anoka County Sheriff’s Office which is still being investigated. · The SP stated that the VA had 2:1 supervision while in the community and only one emergency room (not the emergency room the VA was taken to) was the only hospital that stated staff persons did not have to accompany the VA when s/he was sent in. The SP acknowledged that s/he had not followed the VA’s plans by telling P1 and P2 they did not have to go to the hospital with the VA. P1 and P2 provided the following information: · On January 6, 2026, P1 and P2 worked from 3 to 11 p.m. When each arrived to the facility, P3 and P4 told them that the VA had refused medications and spent the day sleeping which was unusual for the VA. · At 3:30 p.m., P1 administered the VA his/her medications and the VA ate and then went outside to smoke. P1 and P2 heard a loud noise and went outside to check on the VA. The VA told them s/he had fallen and hit his/her head but there was no blood or obvious signs of injury. · The VA wanted to lay down and went to his/her bedroom telling P1 and P2, “Don’t check on me.” P1 sat outside of the VA’s bedroom with the door open to “keep an eye on him/her.” The VA was on his/her tablet for an unknown amount of time and at some point, told P1 that s/he was “seeing stars.” The VA then began breathing heavy and “foaming” at the mouth. P1 asked P2 to come check on the VA and then at “4:50 p.m. or so,” P1 called 9-1-1. However, records from EMS showed that the EMS agency received a call for service at the facility at 4:30 p.m. and arrived at the facility at 4:40 p.m. · While waiting for EMS to arrive, P1 called the SP and asked if P1 and P2 should go with the VA to the hospital. P1 said that the SP told P1 that P1 and P2 did not have to go with the VA to the hospital and so the VA left via ambulance with EMS. In the past, when the VA went to the hospital, staff persons were expected to go with the VA until hospital staff informed them that the VA was admitted and they were no longer needed. P1 stated that “a year ago” the SP told staff persons that they did not need to go to the hospital with the VA and P1 has not been working when the VA has been sent to the hospital. · An unknown amount of time later, the SP called P1 and asked if either P1 or P2, who were still at the facility, had picked the VA up from the emergency room because the VA left without notifying hospital staff. P1 then left in his/her car to look for the VA while P2 stayed at the facility. At some point, the SP told P1 that the VA was located and was taken to a different emergency room and P5 was with the VA until admitted. · P1 and P2 stated that the VA had 2:1 supervision when in the community and the policy for going with the VA to the hospital had changed “a year ago” when the SP told staff persons that they no longer had to go with the VA. P5 provided the following information: · On January 6, 2026, the SP and P5 were in contact throughout the afternoon/evening regarding the VA. At an unknown time, the SP called P5 and said that the VA was taken to an emergency room by emergency medical services (EMS) after experiencing medical issues from a fall. The SP told P1 and P2, who were working with the VA at the time, that they did not need to go to the hospital with the VA. The SP said that personnel from another emergency room previously told the SP that staff members did not need to accompany the VA when s/he was sent to the emergency room. P5 informed the SP that the policy is for the VA to have 2:1 supervision and P5 began an internal investigation. · At 7:00 p.m., a nurse from the emergency room called the SP and asked if staff persons had picked up the VA because the VA was no longer in the waiting room. The SP then called law enforcement to file a missing persons report but was told that the VA had come to the law enforcement center and they transported the VA a different emergency room. The VA was discharged the next day at 12:30 p.m. and the SP picked up the VA. · On January 7, 2026, the VA provided consistent information to P5, the SP, and the G that after leaving the first emergency room and in the community unsupervised, the VA was sexually assaulted by an unknown person. P5 then filed a law enforcement report and the VA was taken to the emergency room for a sexual assault exam. · P5 stated that staff persons had been trained on the VA’s plans and that the VA required 2:1 supervision while in the community due to the VA’s history of self-injurious behaviors and risk of sexual abuse. P3 and P4 each stated that the VA had 2:1 supervision while in the community and the policy was to go with the VA when s/he went to a hospital/emergency room. The G provided the following information: · The G was not aware of the VA going to the hospital on January 6, 2026, until the following day although staff persons “usually” notified the G prior. The G stated that staff persons were to provide supervision for the VA at all times including emergency room visits. · On January 7, 2026, around 12:30 p.m. the VA was discharged from the hospital. At some point after returning to the facility, the VA called the G and while the SP and P5 were also on the call, and the VA told them that s/he had been sexually assaulted while in the community and the SP assisted the VA in filing a police report. At the time of this report, the law enforcement investigation was ongoing. Facility documentation showed that all staff persons interviewed were trained on the VA’s plans, including the expectation of 2:1 supervision and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a), states in part that the license holder must provide services as specified in the support plan and the support plan addendum. Conclusion: Consistent information was provided that the VA had 2:1 staffing at all times. On January 6, 2026, the VA fell and was transported to the emergency room via ambulance and staff persons did not accompany the VA which was a violation of the VA’s plans and a violation of Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a). P1, P2, and the SP each stated that the SP told P1 and P2 that they did not need to accompany the VA. The SP stated that s/he was previously told by emergency room staff persons that they did not want staff persons to accompany the VA to the emergency room. P5 stated that the policy was that the VA had 2:1 supervision and it did not matter what the emergency room previously told staff. The VA later left the emergency room without supervision and said that while s/he was in the community, s/he was sexually assaulted by an unknown person. Although the VA had a history of leaving without staff persons knowledge or supervision and required 2:1 staffing in the community, given that P1 and P2 were told by the SP that they did not have to accompany the VA, that the SP was previously told by emergency room personnel that they did not want staff persons to accompany the VA to the emergency room, and that once the VA was in the care of medical personnel it would be reasonable to expect that the VA was under the care and supervision of the medical personnel, there was not a preponderance of evidence whether there was a failure or omission to supply the VA with care or service including supervision which were reasonable and necessary to obtain or maintain the VA’s physical 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 followed by staff persons. All staff persons were retrained on the VA’s plans and supervision requirements. The facility implemented a new ED Protocol that staff persons must be with the VA at all times while at the emergency department until hospital admission or discharge. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate corrective action, a Correction Order was not issued for the violation outlined in this report. At the conclusion of the law enforcement investigation, the report will be assessed for any possible new information and additional action taken if needed.
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