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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: 1073045-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jamie Randall 651-431-4121 Suspected Maltreatment Reported: It was reported that a staff person (SP) was arrested for driving while impaired (DWI) while a vulnerable adult (VA) was in the vehicle. Date of Incident(s): January 12, 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 26, 2026; from documentation at the facility and law enforcement records; and through seven interviews conducted with the VA, a client from the facility (C), two supervisory staff persons (P1 and P2), and three staff persons (P3, P4, and the SP). The VA enjoyed coffee, the restaurant Chipotle, computers, and music. The VA was “very spiritual” and attended church services. The VA’s diagnoses included traumatic brain injury, Hyponatremia, cerebellar ataxia, hypertension, and osteoporosis. The VA had unsupervised time in the community for up to three hours. Staff persons would assist the VA with filling a weekly medication set that the VA would use to self-administer medications. The facilities Drug and Alcohol Prohibition Policy said that “the consumption of alcohol is prohibited while being directly responsible for persons receiving services” including on the facilities property and vehicles. The facilities Safe Transportation Policy said that staff persons would “ensure safe transportation, handling and transfers of the person and any equipment used by the person when assisting a person who is being transported” and that staff persons were “responsible for the supervision and safety of persons while being transported.” The law enforcement report provided the following information: · On January 12, 2026, at 7 p.m., the facility vehicle entered onto a highway and the driver’s side tires crossed a fog line on the entrance ramp. The vehicle appeared to “sway in between lanes” and observed the vehicle “tap its brakes” as another vehicle, that was not near the facility vehicle, went in front of the facility vehicle. A traffic stop was initiated. · A law enforcement officer approached the vehicle and asked the SP “if there was a reason s/he kept crossing over the fog lines” to which the SP replied that s/he was “talking to other occupants in the vehicle.” The SP did not have his/her driver’s license in his/her possession. While the SP looked for the vehicle insurance information, the SP was “observed taking drinks of water” and the officer detected an odor of consumed alcohol. The SP completed a field sobriety test with a different officer that resulted in the SP being placed under arrest. P2 was contacted to pick up the VA and the facility vehicle. The SP told the officer who completed the field sobriety test that s/he consumed “three shots” (note: the law enforcement report did not include when the SP consumed “three shots”). The SP was asked if s/he would “submit a PBT [preliminary breath test] sample” to which the SP denied. The SP was placed under arrest and taken to a local police station. While at the police station, the SP agreed to take a breath test, and the results were 0.11 blood alcohol content (BAC). The SP was cited for and charged with 4th Degree Driving While Impaired and Operating a Motor Vehicle with an Alcohol Content of 0.08 BAC or Greater Within 2 Hours. The VA provided the following information to this investigator and for the facility’s internal review: · A “couple” weeks prior to January 26, 2026, the VA had a hair appointment. The SP took the VA in the facility vehicle to the hair appointment at a local salon. When the VA started his/her hair appointment, the SP left the salon, and the VA did not know where the SP went. The VA’s appointment took two and a half to three hours. The SP came back to the salon prior to the appointment ending, and a hair stylist told the SP that the VA would be done in fifteen to twenty minutes. The SP left the salon and returned when the VA’s appointment was done. · After the VA’s appointment ended, the SP and the VA got into the facility vehicle with the VA sitting in the front passenger seat. The SP asked the VA if s/he wanted to get food from a local restaurant and that the SP would pay for the VA’s meal to which the VA responded, “No.” The SP asked the VA if s/he could go and pickup his/her boy/girlfriend as it was one the way back to the facility. The VA told the SP, “No,” as s/he was expecting a phone call and wanted to get back to the facility. The SP told the VA that it would be on the way back to the facility and drove to pick up his/her boy/girlfriend. The VA did not know where the SP was going but it was not on the way to the facility. The SP’s boy/girlfriend got into the vehicle and sat in the back seat. The SP, who brought a bag with him/her, “threw” the bag to his/her girlfriend. The VA did not see what the SP’s boy/girlfriend did with the SP’s bag. · The SP entered onto a highway before the vehicle was pulled over by law enforcement. When the law enforcement vehicle lights flashed, the SP’s boy/girlfriend said, “[The SP], how are you going to get out of this one?” A law enforcement officer asked the SP for a driver’s license which the SP did not have. The SP collected facility information for the vehicle from a passenger side glovebox and gave that to the law enforcement officer. The SP got out of the vehicle and went with the law enforcement officer to the officer’s vehicle. The VA and the SP’s boy/girlfriend were each asked for their identity document by law enforcement. Law enforcement contacted the facility and P3, who was working at the facility, was alone and needed to get coverage for the facility to arrange for the VA to be picked up. P2 was called and came to pick up the VA “around two hours” after the SP was pulled over. The SP’s boy/girlfriend was picked up by an unknown person before the VA was picked up by P2. P2 drove the VA back to the facility in the facility vehicle. · The SP did not show signs of impairment, and the VA did not notice the facility vehicle “swerving” before law enforcement pulled the vehicle over. At an unknown time after the VA arrived back at the facility, the VA was told that the SP had a bottle of mouthwash in the SP’s bag. The VA did not remember who told him/her about the mouthwash. The VA did not see the SP drink anything during the drive or at the hair salon but thought that if the SP used mouthwash that was why s/he could not “smell anything.” · The SP never showed any signs of impairment on previous occasions while working at the facility. P2 provided the following information: · On January 12, 2026, the SP arrived for his/her shift at 3 p.m. P2 told the SP that s/he would be taking the VA to an appointment, and the VA had the address. The SP and the VA left in the facility vehicle between 3:15 and 3:20 p.m. The SP “looked normal” and did not act impaired. · At 8:30 p.m., P2 received a call from P3. P3 told P2 that there “was a problem” and someone needed to speak with P2. P3 provided P2 with a number and when P2 called that number, law enforcement answered. A law enforcement officer told P2 that the SP was unable to drive and that another person was needed to transport the VA and the facility vehicle. P2 told the officer that s/he would find coverage for the facility and would pick up the VA. P2 arranged for P4 to come to the facility while P3 and a staff person from another location assisted with bringing the VA back to the facility. P2 met P3 and the other staff person at a gas station and decided to have P3 drive P2’s vehicle back to the facility so P2 could pick the VA up. P2 drove to where the VA and the facility vehicle were and drove the vehicle and the VA back to the facility. · On the drive back to the facility, P2 asked the VA what happened. The VA was dropped off by the SP at the appointment and the SP left. After the appointment was over, the SP picked up the VA and drove to pick up the SP’s boy/girlfriend. The SP and the SP’s boy/girlfriend argued and passed the SP’s lunch bag back and forth. P2 asked the VA why s/he allowed the SP to pick up the SP’s boy/girlfriend and the VA said, “What would I do?” · The SP had issues with attendance but did not show any prior signs of impairment while working at the facility. P3 provided the following information: · On an unknown Monday in January 2026, P3 was working a shift at the facility with the SP. The SP arrived for his/her shift at 3 p.m. and left with the VA for a hair appointment shortly after. Around 7 p.m., P3 was assisting a housemate of the VA’s when the facility phone rang. An unknown person, that P3 thought might have been law enforcement, called the facility and asked questions to confirm that the VA resided at the facility. The person on the phone told P3 that the VA needed to be picked up and P3 got the address. P3 called P2 and told them that the VA needed to be picked up but P3 was working by him/herself and could not leave the VA’s housemate alone at the facility. P2 told P3 that s/he would call the person back and get more details and that they would also find coverage for the facility. · P2 had a staff person from another facility come to assist with coverage. P2 and the staff person from the other facility left and picked up the VA. The VA arrived back at the facility with P2 “around 9 or 10 p.m.” The VA requested dinner and “received care” before P3 left at 10 p.m. P3 asked the VA what happened and the VA told P3, “Ask [P2].” · P3 said that the SP just started to pick up shifts at the facility and did not have any prior concerns with the SP. P1 provided the following information: · On January 12, 2026, P1 had a missed call from P2 at 8:05 p.m. and called P1 back at 8:42 p.m. P2 told P1 that law enforcement called and told him/her that the SP was not “fit to drive” the VA back to the facility and that the VA and the vehicle needed a way to get back to the facility. P2 found coverage for the facility and drove to pick up the VA. When P2 arrived where the facility vehicle had been pulled over, a law enforcement officer told P2 that the SP had been arrested for a DWI and was taken to jail. The officer did not provide further details to P2 as the SP was an “adult.” The officer said that the SP’s boy/girlfriend was present in the vehicle when it was pulled over. · On the way back to the facility, the VA told P2 that the SP and the SP’s boy/girlfriend argued and s/he saw a tote bag being passed back and forth between the SP and the SP’s boy/girlfriend. The VA did not see what was in the bag. · The VA did not have any injuries from the incident and did not appear to be “emotionally” affected by it. · The SP had issues with attendance and phone use but no prior signs of alcohol use while working at the facility. The C provided the following information: · On January 12, 2026, the SP arrived for a shift at 3 p.m. and said, “Hi,” to the C. The SP was taking the VA to a hair appointment and both the SP and the VA left in the facility vehicle shortly after the SP arrived on shift. The SP seemed fine, but the C was not “100 percent sure.” The VA returned home after 6 p.m. and the SP was not with the VA. · On an unknown date, the C overheard a phone conversation between the VA and an unknown person that the SP drove the VA around “drunk.” The VA got picked up after his/her hair appointment ended by the SP in the facility vehicle. The SP asked the VA if s/he wanted to get food and that s/he would pay for the VA, but the VA declined. The SP told the VA that s/he had to go and pick up his/her boy/girlfriend. After picking up the SP’s boy/girlfriend, the SP was pulled over for swerving into different lanes without using “blinkers.” The VA had multiple phone conversations about the SP driving the VA while “drunk” and the C did not remember when s/he heard the first conversation. · The SP would pick things up in the community for the C, but the C had never been in a vehicle when the SP drove. The C had never seen the SP appear “drunk” and said that the SP was “good, by doing [his/her] job.” P4 provided the following information: · On what P4 thought was two weeks prior to January 26, 2026, P4 was called around 8 p.m. by P2. P2 told P4 that s/he got a call from law enforcement that said the SP was arrested and that the facility needed help with coverage as the VA needed a staff person to bring him/her back to the facility. The VA arrived back at the facility after 10 p.m. and had a snack before going to bed. The VA did not say much and did not provide details of what happened to P4. · P4 did not have any concerns with the SP and the SP always “acted normal.” The SP provided the following information to this investigator and for the facility’s internal review: · On January 11, 2026, the SP went to a party with friends that lasted until the morning of January 12, 2026. The SP said that he consumed six or seven alcoholic beverages during the party. The SP went home around 6 a.m. and went to bed at 10 a.m. · The SP had a scheduled shift at the facility at 3 p.m. on January 12, 2026. The SP no longer felt the effect of the alcohol s/he consumed the night and morning prior. The SP arrived for his/her shift at 3 p.m. and drove the VA in the facility vehicle to a 3:30 p.m. hair appointment. The VA’s appointment lasted for three hours, and the SP waited in the parking lot for the VA’s appointment to end. · After the appointment, the SP drove the facility vehicle and the VA to a friend’s house as the friend was locked out of his/her home. The SP started to drive toward the facility and turned to face the VA, who was in the passenger seat, to say something and the vehicle crossed over a “white line.” The vehicle was then pulled over by law enforcement. Law enforcement told the SP that s/he crossed a fog line and that was why the vehicle was pulled over. The SP exited the vehicle and tested for alcohol use. The SP took a breathalyzer and the result was 0.08 BAC. Law enforcement called P2 to arrange for the VA to be picked up. A family member of the SP came to pick up the SP’s friend and stayed with the VA until P2 arrived. The SP was charged with a DWI and taken to jail. · The SP said s/he would not have gone into work if s/he still felt the effect of drinking alcohol the night and morning prior to his/her scheduled shift. The SP denied consuming alcohol during his/her shift on January 12, 2026, and said that s/he had not used drugs or alcohol on previous occasions when s/he worked at the facility. The facilities policy for working under the influence of alcohol was automatic termination. Facility records showed that P1-P4 and the SP were trained on the VA’s plans, the facility’s Drug and Alcohol Prohibition Policy, the facility’s Safe Transportation Policy, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: On January 12, 2026, the SP transported the VA to a hair appointment that started at 3:30 p.m. and ended around three hours later. The SP drove the facility vehicle with the VA in the passenger seat to pick up his/her boy/girlfriend. At 7 p.m., on the drive back to the facility, the SP was pulled over by law enforcement as the vehicle swerved in between lanes and crossed fog lines. The SP completed a field sobriety test which resulted in the SP’s arrest. P2 was called and arranged for the VA and the facility vehicle to be transported back to the facility. The SP told this investigator that s/he consumed six or seven beverages that contained alcohol the night and morning prior to the afternoon of January 12, 2026, and told law enforcement that s/he consumed “three shots.” The SP completed a breath test while at a police station, and the result was 0.11 BAC. Given that the SP was cited for and charged with 4th Degree Driving While Impaired and Operating a Motor Vehicle with an Alcohol Content of 0.08 BAC or Greater Within 2 Hours while transporting the VA which posed a significant risk of harm to the VA, there was a preponderance of the evidence that there was a failure to supply the VA with care and services that were reasonable and 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. The SP was trained on the VA’s plans, the facility’s Drug and Alcohol Prohibition Policy, the facility’s Safe Transportation Policy, and the Reporting of Maltreatment of Vulnerable Adults Act. At the time of the incident, the SP was responsible for the VA’s health, safety, and wellbeing. The SP was responsible for the 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 a serious injury that reasonably required the care of a physician. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but were not followed when the SP was under the influence of alcohol while at work and drove a vehicle with the VA as a passenger. 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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