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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: 1124188-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a vulnerable adult obtained a razor and cut him/herself. Staff persons took the VA to the emergency department of a hospital where s/he received stitches. The VA had a history of obtaining items which s/he used to harm him/herself. Date of Incident(s): February 5, 2026, and ongoing 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 26, 2026; from documentation at the facility; and through interviews conducted with facility staff persons (P1, SP1, SP2), the VA, and the VA’s case manager (CM). Facility documentation showed that the VA was diagnosed with post traumatic stress disorder (PTSD), borderline personality disorder, and depression. No information showed whether the VA had a history of providing inaccurate information. The VA had a history of engaging in self-injurious actions with the intention of dying by suicide but was not subject to guardianship. The VA resided at the facility with no other individuals and was supervised by two awake staff persons 24 hours a day. The Client Information sheet from the facility showed that the VA previously walked onto a highway to get hit by a car, that s/he had swallowed a razor blade, previously stabbed him/herself, sometimes ingested inedible items, and had attempted to jump from bridges. The VA might decline to take his/her prescribed medications. When the VA received food in takeout bags, staff persons were to look inside the bags to ensure that they were free of items that the VA might use to harm him/herself and remove any potentially dangerous items in the bags. The VA’s Individual Abuse Prevention Plan (IAPP) showed that the VA’s behaviors shifted quickly from regulated to unsafe. When the VA was upset, s/he might become impulsive, leave safe areas without supervision, or decline to follow staff persons’ instructions. The VA might hide sharp items and act quickly to harm him/herself with the items when staff persons were distracted. Staff persons were to actively supervise the VA during “service hours” and one staff person was to keep the VA in their line of sight if the second staff person needed to complete other tasks. In addition, staff persons were to complete and document environmental safety checks to look for sharp/unsafe objects or items that the VA should not have and were to ensure that items were not concealed in the VA’s bedding or personal items. Staff persons were to “review” items delivered to the VA for dangerous items because the VA had a history of buying prohibited items to be shipped to him/her. The IAPP and the VA’s Support Plan Addendum – Intensive Services showed that staff persons were to complete environmental safety checks “routinely” to ensure that hazardous items were secured and that the facility remained safe but did not specify the frequency of the checks. No schedule was given regarding checking the VA’s bedding/personal items, but staff persons were to be aware of behaviors that were unusual for the VA, including guarding/secrecy about personal items, declining to let staff persons enter his/her bedroom, or sudden panic when staff persons approached. The VA’s Self-Management Assessment (SMA) specified that staff persons were not to do “invasive” searches, but were to observe the VA, supervise him/her, and control his/her environment. According to the SMA, if the VA left the facility without supervision or separated him/herself from staff persons in the community, staff persons were to check the immediate area for the VA, and if a law enforcement agency was contacted, staff persons were to provide the agency with information needed to find the VA. If the VA’s absence was connected to an active suicide attempt risk, suspected ingestion, or other imminent dangers, staff persons were to “initiate 9-1-1” and were not to delay an emergency response when there were credible concerns of imminent self-harm or danger, including statements made by the VA, observed behaviors, or missing hazardous items that increased risk. Emergency calls might also be required if the VA engaged in self-harm actions including attempting to cut him/herself or attempting to leave supervision in a manner that created immediate danger, declining to stop during an active crisis, and situations when there was reason to think that the VA was at risk in the community, particularly if suicidal ideation was present or if recent behavior indicated imminent attempt risk. The VA was articulate and enjoyed completing puzzles. A Serious Injury Report completed by P1, who was a supervisory/administrative staff person, showed that at about 3:30 p.m., on February 2, 2026, the VA changed clothes, and it was observed that there was blood on his/her clothing from a wound the VA sustained on his/her abdomen from an earlier self-harm incident. The VA did not provide information to show how or when s/he sustained the wound initially, but staff persons cleaned the wound, gave the VA acetaminophen, and encouraged him/her to accept care from a health care professional for the wound, but the VA declined. Later that day, the VA agreed to be medically evaluated, and staff persons took the VA to an emergency department of a hospital where the wound was closed with stitches. The VA was evaluated then discharged back to the facility. Progress notes for the VA showed that on February 5, 2026, the VA “reopened” stitches on his/her abdomen from the previous injury and staff persons offered to take the VA to an urgent care clinic or a hospital, but the VA declined. The VA then placed his/her fingers into the wound and applied pressure, saying that s/he wanted his/her intestines to fall out. The VA was redirected and fell asleep, but staff persons documented that the VA should be evaluated by a health care professional. On February 6, 2026, the facility issued a Temporary Service Suspension Notice (TSSN) to the VA, which showed that the facility was immediately suspending services to the VA. The TSSN documented that the facility determined it was unable to serve the VA because the VA’s conduct posed an imminent risk of physical harm to self or others, because positive support strategies were not effective, and additional positive support strategies would not achieve and maintain safety, or less restrictive measures would not resolve the issues leading to the suspension. Due to the VA’s ongoing self-harm behaviors, escalation of suicidal risk, and a recent incident requiring law enforcement involvement and hospital transport, the facility determined that the VA posed an imminent risk of physical harm to her/himself. Despite multiple interventions, staff supervision, coordination with the support team, and crisis response efforts, Living Hope was unable to ensure the VA’s safety within the scope of licensed community residential services. The VA’s needs exceeded the level of care and clinical oversight that could be safely provided by the facility. In addition, the VA had emergent medical issues that exceeded the facility’s ability to meet the VA’s needs. Prior to issuing the TSSN, the facility consulted the VA’s support team to identify and resolve issues leading to the issuance of the TSSN. A TSSN was not equivalent to terminating services to the VA. During the temporary suspension period, license holders were to provide information requested by the person whose services were suspended or his/her case manager, work with the persons; support team to develop reasonable alternatives to protect the person and others to support the continuity of care, and maintain information about the service suspension including the written notice of temporary service suspension in the service recipient record. Interviews with this investigator, facility documentation, and the facility’s Internal Review, provided the following: · The VA said that when s/he initially began receiving services at the facility, staff persons supervised him/her more closely, but recently, several staff persons whose names the VA could not recall, slept during their shifts and did not supervise the VA. The staff persons were “fired” for sleeping on the shifts, but when the VA was not supervised s/he used items s/he obtained in the community to harm him/herself. On a date s/he could not recall, the VA ordered a set of five box cutter blades online that were delivered to the VA at the facility and according to the VA, the staff persons on shift when the blades arrived did not open the package the blades were in. The VA did not recall when the blades arrived or the names of the staff persons who were working when they arrived, but the VA took the package, opened it, and hid some of the blades in his/her clothing that s/he wore and in his/her personal hygiene items in the bathroom. Staff persons were not initially aware that the VA had the blades, but soon after the blades were delivered, the VA used one of them to cut his/her abdomen. P1 and other staff persons searched the facility for the blades but did not find them. · The VA stated that on February 6, 2026, s/he left the facility without supervision in a rideshare car because s/he learned that s/he was being discharged from the facility and was very upset. SP1 and SP2 were on shift when the VA left. After leaving the facility, the VA went to Minneapolis where s/he lived unhoused for a few days. While unhoused, the VA used one of the box cutter blades to cut his/her abdomen. The VA remained in contact with a community social worker (SW) who provided services to him/her at the facility and agreed to let the SW pick him/her up in the community to take him/her to the emergency department of a hospital on a date s/he could not recall in early February of 2026. The VA was then admitted to a unit of the hospital that provided mental health services to individuals and continued to receive inpatient mental health services there when this report was written. · In addition, the VA previously bought a pencil sharpener in a store in the community when s/he was with two staff persons whose identities s/he could not recall, and removed the blade from it, then used the blade to cut him/herself at the facility. The VA said that staff persons did not supervise him/her in the store, and s/he bought with pencil sharpener without the staff persons’ knowledge, and the staff persons did not check the bags for dangerous items. The VA’s team and mental health care professionals at the hospital were working together to find a facility to provide services to meet the VA’s needs upon discharge from the hospital. · P1 thought that the VA obtained razors or blades when s/he completed arts and crafts projects, broke the razors/blades into pieces, and hid them in his/her shoes. P1 interviewed staff persons who worked with the VA regarding the razors/blades, but staff persons did not know how the VA obtained them and had been retrained several times regarding the VA’s supervision needs. There was frequent staff turnover at the facility. The VA had no rights restrictions and was not subject to guardianship which were on going issues for the facility. The VA frequently declined medical care from first responders when staff persons called 9-1-1 and often declined transportation to hospitals or medical clinics. The facility wanted to place cameras in common areas of the facility, but the VA did not agree. When the VA was upset, the facility had three or four staff persons at the facility including a supervisory staff person and/or a program manager, who assisted staff persons to look for items the VA might use to harm him/herself. The VA ordered items that were delivered to the facility and community persons who were the VA’s friends/acquaintances visited him/her at the facility and might have brought dangerous items to the VA. In addition, the VA attended an educational program and went to family members’ residences where s/he was accompanied by staff persons. It was possible that the VA obtained dangerous items in those locations, but the facility and staff persons worked diligently to supervise the VA. · P1 said that the VA had a wound on his/her abdomen that s/he sustained when s/he previously used a blade to cut him/herself. The VA received medical care for the wound, and a health care professional closed the wound with stitches on the evening of February 2, 2026. On February 4, 2026, the VA, SP1, and SP2 went grocery shopping and then returned to the facility. The VA did not feel well and went to his/her bedroom to rest. Shortly after 5 p.m., the VA, SP1, and SP2, went on a brief community outing and stopped at a convenience store on the way back to the facility so the VA could buy a food item. The VA, SP1, and SP2 returned to the facility and the VA ate the food s/he bought, then went to his/her bedroom. Just before 6:30 p.m., SP1 and/or SP2 asked the VA to let them change the bandage on the wound and the VA initially declined, but the SPs redirected the VA, and s/he agreed to let them change the bandage. When the SPs saw the wound, they observed that the wound was “opened,” and the VA told them that the wound reopened that morning. The SPs cleaned the wound and bandaged it. The rest of the shift was uneventful. · On Friday February 6, 2026, the facility gave the TSSN to the VA and his/her team. The VA was upset prior to receiving the TSSN, but when s/he received it, s/he packed some of his/her personal items, threatened to kill him/herself, and left the facility. A law enforcement agency was contacted, and when the VA was located in the community, s/he was evaluated at a hospital. P1 was unsure when or where the VA was when s/he was found in the community because the facility had given the VA the TSSN and no longer provided services to him/her, but P1 thought that the VA was hospitalized somewhere in the metro area. · SP1 said that s/he often worked with the VA but did not know how or when the VA obtained an item with which s/he harmed him/herself. SP1 stated that SP2 told SP1 that the VA had a razor or razor blade and used it to cut his/her abdomen or reopen an old wound on his/her abdomen. Any sharp objects at the facility including knives were kept in a locked cabinet, which was not accessible to the VA, and the VA did not use razors or razor blades when s/he groomed him/herself. According to SP1, the VA was always closely supervised. When the VA used the bathroom, staff persons stood at the open door and waited for the VA, and when the VA slept, staff persons sat by the VA’s bed to watch him/her. SP1 denied sleeping on shift and was not on shift when the VA left the facility on February 6, 2026. · SP2 said that s/he worked with the VA for a couple of months and felt that some of the staff persons befriended the VA to decrease the number of behaviors the VA had. From the first day SP2 worked with the VA, the VA had high behaviors and frequently attempted to harm him/herself. Staff persons were to keep “eyes on” the VA at all times and when the VA slept, staff persons sat by the VA’s bed on a couch and observed him/her. In addition, staff persons retrieved the VA’s mail sent to the facility, opened packages delivered to the facility, supervised the VA three to one at stores in the community, and looked into bags when the VA made purchases in the community. Staff persons regularly cleaned the VA’s bedroom and looked for sharp or dangerous items in the bedroom. SP2 had no idea how the VA might have obtained anything with which to harm him/herself. SP2 was not on shift when the VA received the TSSN and left the facility and no longer worked at the facility for reasons unrelated to the allegations in this report. Records from a law enforcement agency showed that at 5:06 p.m., on February 6, 2026, the agency was aware that the VA left the facility without supervision. The agency contacted the VA at 7:12 p.m., on February 6, 2026, and located the VA in the community. Law enforcement officers picked up the VA in the community later that day and took him/her to the emergency department of a hospital where s/he was evaluated. The information provided in the records was inconsistent with information provided the VA regarding the length of time s/he was unsupervised in the community. The VA’s medical records were requested but were not received when this report was written. The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procedures prior to the incident. Conclusion: Information was consistent that the VA had a history of obtaining items that s/he might use to harm him/herself. The VA’s staffing ratio at the facility was two to one, and staff persons were to remain awake, with a staff person continuously keeping the VA in sight. The VA’s diagnoses included PTSD, borderline personality disorder, and depression, and his/her demeanor might shift quickly. No information showed whether the VA had a history of providing inaccurate information. Documentation showed that staff persons were to complete and document safety checks to look for items the VA might use to self-harm, but the checks were not to be invasive, instead focusing on observing and supervising the VA, and controlling his/her environment. There was no set schedule for the checks, but they were to occur routinely or when the VA’s behavior indicated the need for a check. If the VA left the facility without supervision or separated him/herself from staff persons in the community, staff persons were to check the area for the VA and contact a law enforcement agency by calling 9-1-1 if needed. The VA had an injury on his/her abdomen that reopened, and s/he stated that s/he bought a pencil sharpener in the community and ordered five box cutter blades that were delivered to the facility. The VA said that staff persons did not check his/her bag after s/he bought the pencil sharpener and did not open the box cutter blades when they were delivered. The VA hid the blades in his/her clothing and in his/her hygiene items. P1, SP1, and SP2 provided consistent information that the VA was closely supervised at the facility and in the community, and the SPs each said that staff persons kept the VA in their sight when the VA slept and SP1 said that staff persons stood outside the bathroom when the VA used the bathroom. It was unknown how the VA obtained items that s/he used to harm him/herself, but P1 said that the VA attended an educational program, visited his/her family members’ residences in the community, and that the VA’s friends/acquaintances from the community visited the VA at the facility, so it was possible that the VA might have obtained sharp or dangerous items at the program or from others. On February 6, 2026, the facility gave the VA and his/her team a TSSN letting them know that the facility was immediately suspending services to the VA because the services the facility provided to the VA were not sufficient to ensure the VA’s safety and well-being given the VA’s history of self-harm, his/her on-going behaviors, and the suicidal risk. The VA became upset, packed some of his/her things, and left the facility without supervision in a rideshare car. While absent from the facility, the VA used the blades s/he had with him/her to cut his/her abdomen. The VA remained in contact with the SW, and after a few days, the VA agreed to let the SW take him/her to the hospital where s/he received medical care for the injuries to his/her abdomen prior to being admitted to the part of the hospital that provided mental health services to individuals with mental illnesses. However, law enforcement records showed that on February 6, 2026, at 5:06 p.m., law enforcement was aware that the VA left the facility without supervision, contacted the VA at 7:12 p.m., and law enforcement officers picked up the VA in the community later that day. The VA provided information inconsistent with the law enforcement records about the length of time s/he was in the community after leaving the facility. Although the VA said that staff persons did not check his/her purchases in the community or examine packages that were delivered to the VA at the facility which might have permitted the VA to obtain a razor/sharp item that s/he used to cut him/herself, given that the VA could not identify the staff persons who worked when s/he bought the items or those on shift when the items were delivered; that although the VA did not have a prior history of providing inaccurate information, s/he provided information inconsistent with the law enforcement report so the credibility of the VA’s information regarding how s/he obtained the pencil sharpener and razors was not able to be determined; that the VA might have obtained sharp items from other people or programs s/he attended; and that staff persons stated that they supervised the VA as required, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services which were reasonable and necessary to obtain or maintain the VA’s 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 which determined that its policies and procedures were adequate and were followed. The incident was similar to previous incidents, and the facility indicated a need for additional staff person training related to monitoring and response to self-injurious behaviors, recognition of warning signs or wound manipulation, and appropriate escalation and documentation when an individual declines medical care, The training would also include increased reinforcement of supervision expectations during period of isolation or reduced activity which was to be completed within 30 days. Because of the February 6, 2026, incident, the facility issued the Temporary Service Suspension Notice to the VA and planned to coordinate services with the VA’s team and the CM to identify and facilitate transfer of the VA’s care to a facility that could meet the VA’s ongoing clinical and safety needs. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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