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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: 1072043-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Alice Percy 651-431-3970 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was not seen by his/her mental health physician in a timely manner, resulting in the VA not receiving his/her medications for two weeks. This caused the VA to have increased behaviors including paranoia, aggression, and vandalism.
Date of Incident(s): Ongoing, prior to October 17, 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 November 5, 2025; from documentation at the facility; and through four interviews conducted with two facility supervisory staff persons (P1 and P2), the VA, and the VA’s mental health case manager (CM). The VA enjoyed watching television, going for walks, playing basketball, listening to music, watching movies, going shopping, and spending time with his/her family members. The VA’s diagnoses included diabetes, Asperger’s syndrome, paranoid schizophrenia, and anxiety. The VA was not subject to guardianship. The VA’s Individual Abuse Prevention Plan stated that the VA had a history of non-medication compliance and his/her paranoia “appeared to play a part when [the VA] chooses to become noncompliant with [his/her] medications.” The VA also had a history of physical aggression and property destruction. If the VA displayed physical aggression, the staff persons were to intervene and attempt to redirect the VA. The VA was not an accurate reporter of events. The VA’s Self-Management Assessment stated that the VA was unable to self-administer his/her medications and had a history of attempting to “cheek” medications. The staff persons were to administer the VA’s medications and transport the VA to scheduled medical appointments. The staff persons were also to ensure that the VA had an appointment with his/her psychiatrist at a minimum of every three months. The VA stated that s/he typically saw his/her mental health physician every three months. Recently, in order for him/her to have his/her medication prescription renewed s/he needed to see his/her mental health physician. A former supervisory staff person (P3, last date of employment was August 29, 2025) had scheduled an appointment for the VA to see his/her mental health physician, but did not tell another staff person about the appointment and the VA missed the appointment. If a patient missed two appointments, they “could not have services.” Because the VA did not see his/her physician, s/he did not have his/her clonidine medication for approximately ten days. When P2 attempted to get the VA’s prescription refilled, the mental health physician required that the VA be seen prior to the prescription being renewed. The VA then had a virtual appointment with the physician. The CM stated that P1 recently began working at the facility. Prior to that, P3 was typically responsible for scheduling the VA’s medical appointments. On October 7, 2025, the CM visited the VA and found out that s/he had not been administered his/her clonidine for two days. P2 told the CM that s/he was working with the physician to get the prescription refilled. However, the VA began to have behaviors and “keyed” a staff person’s car. On October 16, 2025, the CM learned that the VA did not get his/her medication for over two weeks. The facility had scheduled an appointment and the VA was seen by his/her physician the following day. P1 and P2 provided the following information: · P1 stated that in September 2025, P2 began working at the facility. One of P2’s responsibilities was to schedule all medical appointments.
· Every three months, the VA had a virtual appointment with his/her mental health physician. In July or August 2025, the VA refused to go to one of his/her appointments. P1 stated that the VA sometimes refused his/her appointments, even though the staff persons encouraged him/her to attend. On August 6, 2025, the VA was scheduled to see his/her physician, but the physician was not available, so it was rescheduled to August 14, 2025. Then on the day of the appointment, a staff person was sick so the VA was not able to attend the appointment and it was rescheduled for September 2025. P3 did not write the date of the appointment on the facility’s calendar, so the VA missed the appointment. · P2 stated that when s/he checked the VA’s health history that tracked medical appointments, s/he saw that the VA had not been seen by his/her mental health physician in the required three-month period. At approximately the same time, the pharmacy delivered the VA’s medications and there was no clonidine included. P2 called the pharmacy and was told they could not fill the prescription until the VA was seen by his/her physician. At that point, the VA only had two clonidine pills left. P2 then called the VA’s physician and was told that the VA needed to be seen by his/her physician before the prescription could be renewed, so P2 scheduled an appointment for October 16, 2025, which was the earliest appointment available. P2 asked the scheduler to call if any appointments opened up prior to that. P1 stated that P2 did not notify him/her when the VA ran out of his/her medication. · P2 stated that on October 14, 2025, the VA became more anxious than usual and while P2 was making dinner, the VA swore at P2. P2 called P1, who then talked to the VA. The VA told P1 that s/he believed they had the VA’s clonidine, but were mad at him/her and “were keeping it from [him/her].” P1 and P2 each told the VA that they would not keep the VA’s medications from him/her. That day, the VA “keyed” P2’s car and left a scratch along the side of the car. P2 filed a police report about the damage to his/her car. · P1 stated that when P2 realized that the VA missed the appointment, s/he called the physician and rescheduled the appointment “as soon as [s/he] could.” On October 16, 2025, the VA met with his/her physician. On October 17, 2025, the pharmacy delivered the VA’s clonidine. · After the incident, the staff persons developed a protocol to track all of the clients’ medications, so that it was clear when a client’s prescription would expire and when a staff person needed to call about it. A list of the VA’s medical appointments stated that a medical appointment for September 4, 2025, was cancelled and an appointment for September 18, 2025, was a “no show.” The VA was scheduled for another medical appointment on October 16, 2025. Facility documentation showed that P1 and P2 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Conclusion: In July or August 2025, the VA refused to go to one of his/her medical appointments. On August 6, 2025, the VA was scheduled to see his/her physician, but the physician was not available, so the appointment was rescheduled to August 14, 2025. Then, a staff person was sick that day so the appointment was rescheduled to September 18, 2025. P3 did not write the date of the appointment on the facility’s calendar, so the VA missed the appointment. When the pharmacy did not renew the VA’s prescription for clonidine, P2 immediately called the pharmacy and the VA’s physician and scheduled the earliest available appointment for the VA to be seen by his/her physician. Once the VA was seen by his/her physician, the clonidine was delivered to the facility the following day. Although the VA was not administered his/her clonidine medication for several days, given that appointments were scheduled and attempted but were rescheduled for various reasons, that P2 contacted the pharmacy and the VA’s physician as soon as s/he was made aware that the VA’s prescription for clonidine was running out but was not yet out but the earliest appointment was not until October 16, 2025, there was not a preponderance of the evidence as to whether there was a failure to provide care or services to the VA which were reasonable and necessary to maintain the VA’s physical 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 determined that the facility’s policies were adequate and were followed by the staff persons. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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