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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: 1106251-HCBS (Home and Community-Based Services) Investigator(s): Gessner Rivas/Beth Virden Suspected Maltreatment Reported: It was reported that a staff person (SP) consumed alcohol with a vulnerable adult (VA) and then drove a vehicle with the VA as a passenger. Date of Incident(s): November 12, 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 for this investigation was obtained remotely, including documentation from the facility; and through four interviews conducted with the VA, a facility staff person (SP), and two administrative staff persons (P1 and P2). The VA’s support plans, including Support Plan Addendum, provided the following information: · The VA lived in his/her own apartment and enjoyed outdoor activities, like visiting dog parks. The VA was an “animal lover” and a “good friend” and wanted to improve his/her overall health and wellbeing by consistently attending medical appointments, taking his/her medications, and eating a healthy diet. “[The VA] wanted to work on quitting smoking.” · The facility supplied the VA with one staff person during certain hours of the day, who went to the VA’s apartment or brought the VA into the community and helped with the VA’s budgeting, scheduling and attending appointments, and shopping. The VA could use public transportation but said that it made him/her feel “sick.” Staff helped with transportation as needed and supplied the VA with companionship. · The VA’s diagnoses included attention deficit hyperactivity disorder, post-traumatic stress disorder, and depression. [Note: There was nothing stated in any of the VA’s support plans that the VA had a history of drug- or alcohol-addiction or related concerns.] The VA was of legal drinking age (21 years or older) and was not subject to guardianship. A facility incident report provided the following information: · On November 13, 2025, an anonymous community person called a facility administrator and told them that on November 12, 2025, around 1 p.m., the SP was working with the VA and drove him/her to the SP’s friend’s apartment where the SP and the VA each consumed an unknown amount of Fireball whiskey. An unstated time later, the SP and the VA left in the SP’s car with the SP driving and the VA a passenger. · When P1 contacted the SP about the allegations, the SP told P1 that s/he consumed alcohol with the VA and wanted to resign from his/her employment at the facility. The SP provided the following information: · One time, the SP and the SP’s friend picked the VA up and drove to a restaurant for lunch, which was unexpectedly closed. They then drove to a liquor store where the VA bought cigarettes and “something else.” The SP drove them back to the VA’s apartment where the SP and the VA each consumed alcohol. Later, the VA’s neighbor drove the SP to the SP’s house. The SP said that s/he did not drive with the VA as a passenger after consuming alcohol. · The day after this happened, the SP called P1 and said, “I drank with a client yesterday and I think I have to resign.” · The SP said that s/he drank alcohol with the VA the one time and it was a “big mistake.” P1 said that the SP called and said that s/he drank alcohol “on shift.” P1 could not recall the exact details of the SP’s account. The SP no longer worked at the facility following this incident. The VA said that one time, the SP brought the VA to the SP’s friend’s house. “The friend was acting strange the whole time we were there.” The SP “never” drank alcohol with the VA, including at the SP’s friend’s house, and “never” drove the VA in a vehicle after consuming alcohol. The SP once brought a pack of cigarettes for the VA. P2 said that s/he was not aware of prior concerns with the SP’s conduct. The facility’s drug and alcohol policies and procedures stated, “Employees … may not be on duty, transport persons served, drive on company business, or accompany persons served into the community while under the influence of alcohol ….” Facility documentation stated that the SP received training on the VA’s support plans, including Support Plan Addendum; the facility’s drug and alcohol policies and procedures; and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: The SP and P1 provided consistent information that at least once, the SP consumed alcohol while working with the VA. The SP’s conduct was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and with the facility’s drug and alcohol policies and procedures. However, the VA was of legal drinking age and there was no information that the VA was harmed by the SP’s consumption of alcohol or that the VA had a history of alcohol addiction or related concerns. In addition, although there was information that the SP drove the VA after consuming alcohol, the SP and the VA each denied this and there was no additional information to support whether the SP drove the VA after consuming alcohol. Therefore, there was not a preponderance of the evidence whether there was failure to supply the VA with reasonable and necessary care. 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 the 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 taken.
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