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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: 1112469-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lisa Shock Lisa.shock@state.mn.us 651-431-6142 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) obtained an air duster can and used it to get high. It was alleged that a staff person (SP) did not follow the plans which stated that the VA was not allowed to have air duster cans. Date of Incident(s): January 26, 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 February 10, 2026; from documentation at the facility; and through five interviews conducted with the SP, two facility supervisory staff persons (P1 and P2), the VA’s guardian (G), and the VA. The VA was diagnosed with traumatic brain injury, cognitive disorder, psychotic disorder, and post-traumatic stress disorder. The VA had a history of chemical dependency addictions including inhalant use. The VA’s Individual Abuse Prevention Plan stated that the VA was susceptible to self injurious behaviors due to a history of chemical abuse. The VA would “compulsively huff or smoke any chemical [s/he] thinks would produce a euphoric effect.” All cleaning and aerosol products were to be locked in a cabinet and only accessible under staff person supervision. The VA’s Support Plan stated that the had “some relapses with huffing” and “hopes to continue with [his/her] sobriety journey. The VA’s Intensive Services Assessment stated that the VA has used “household items. . . to obtain a euphoric high.” “All potentially toxic supplies and dangerous items are locked up at the site for safety. Items can be used by [the VA] with supervision and returned to the locked cabinet by staff after use.” The VA, the SP, P1, and P2 provided the following information: · On the evening of January 26, 2026, (the SP’s first week working at the facility and with the VA) the VA and the SP went shopping and the VA purchased multiple items including a two-pack of air duster. The VA did not have any restrictions on purchasing inhalants. The VA and the SP returned to the facility and the VA asked the SP if s/he could use the air duster to clean his/her computer and blinds and the SP agreed. The VA then took the purchased products into his/her bedroom and closed the door. That night the SP did not watch the VA while the VA used the air duster nor did the SP take them from the VA and lock them up. · The following morning the SP noticed a scratch on the VA’s face. When asked, the VA stated s/he fell out of bed and refused any medical attention offered by the SP. The SP sent a text to P2 informing P2 of the VA’s injury and sent a photo of the scratch. P2 then asked the SP if the VA had purchased and used any air duster. The SP told P2 that in fact the VA purchased some the previous day and used it that night. P2 told the SP that the VA could not have the air duster cans and they should be taken away and locked in the cabinet so the SP took them from the VA and locked them in the cabinet. · The VA stated that s/he used the air duster to get high and knew the SP was a new employee so s/he “took advantage of that.” · The SP stated that due to his/her culture, s/he was not aware that air dusters could be used as an inhalant to get high. Facility documentation showed that the SP was trained on the VA’s plans on January 19, 2026, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: A. Maltreatment: The VA’s support plans provided consistent information that the VA had a history of chemical use including inhalants and s/he would “compulsively huff or smoke any chemical [s/he] thinks would produce a euphoric effect.” Due to this all cleaning and aerosol products were to be locked in a cabinet and only accessible to the VA under staff person supervision. Consistent information was provided that on January 26, 2026, the SP and the VA went to the store and the VA purchased multiple items including a two pack of air duster. The VA asked the SP to use the air duster cans to clean and the SP agreed. The SP did not supervise the VA while the VA used the air duster which allowed the VA to use the cans in his/her bedroom to get “high” without the SP’s knowledge. At some point that night, the VA fell out of bed and sustained a scratch on his/her face. Given the VA’s history of using aerosol products to get high and that the VA was allowed to use the air dusters unsupervised which allowed him/her to use them to get high and subsequently fall out of bed sustaining an injury, there was a preponderance of the evidence that there was a failure or omission to supply the VA with reasonable and necessary care and services. 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. Although it was the SP’s first week of working with the VA and that the VA stated that s/he “took advantage” of the SP’s newness to his/her position, the SP was trained on the VA’s plans and on the Reporting of Maltreatment of Vulnerable Adults Act prior to providing direct contact services to the VA. The SP was responsible for the care and supervision of the VA at the time of the incident. Therefore, 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 was not recurring or serious because it was a single incident and although the VA sustained an injury from falling of the bed, the VA did not require the care of a physician. 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 and photos of air duster cans were posted for all staff persons to see. 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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