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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: 1071628-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 staff person (SP) went into the basement and did not close or lock the gate on the basement stairs which resulted in a vulnerable adult (VA) falling down the stairs. The VA sustained broken ribs and a broken vertebra. Date of Incident(s): February 11, 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 March 2, 2026; from documentation at the facility and medical records; and through eight interviews conducted with two supervisory staff persons (P1 and P2), two staff persons (SP and P3), an administrative staff person who was also a health care professional (HCP), the VA’s case manager (CM), and the VA’s guardians (G1 and G2). The VA was not able to provide information regarding the allegations due to his/her diagnoses. The VA enjoyed going for walks both inside and outside, sitting outside on the deck, and spending time with G1 and G2. The VA’s diagnoses included profound intellectual disability, seizure disorder, right hemiparesis and gait abnormality. The VA was non-verbal. The VA’s Intensive Support Services Assessment stated that the VA was able to walk independently in the facility and wore a gait belt with standby assistance when walking in the community. The VA did not observe his/her surroundings while walking which could cause the VA to fall. Staff persons needed to keep the VA’s area clear of obstacles The VA’s Coordinated Services and Supports Plan stated that the VA was “very “mobile but had access to use assistive technology including a wheelchair, a fall detection mat next to his bed, a gait belt, and grab bars in the bathroom. The VA did not need any additional technology or supplies. [Note: There was no information in the VA’s plans or the facility policies and procedures, including the Program Abuse Prevention Plan, regarding the stairs, a gate, or the VA’s use of stairs.] The facility was a rambler style home with a basement. VA’s bedroom was located on the main floor and there was a staircase leading to the basement with a wooden gate and a slide lock at the top of the stairs. There were sixteen carpeted steps with railings on both sides and tile flooring at the base. G1 and G2 provided the following information: · On February 11, 2026, from 1:08 through 1:55 a.m., G1 missed several calls from P1 and P3. At 1:58 a.m., P2 reached G2 and said that the VA had fallen down the stairs. G2 then called G1 who then reached out to P1 and was told that the VA fell down the stairs, and that emergency medical services (EMS) was called. The EMS assessed the VA and found no immediate concerns and P1 told them they could leave. · At about 8:15 a.m., G1 and G2 arrived to the facility and were told by P2 that the VA had a bump on his/her head. G1 and G2 then took the VA to the emergency room where s/he was diagnosed with three broken ribs and a broken vertebra. · G1 and G2 each stated that if the gate to the basement was locked, the VA would not have been able to unlock it to open it because the VA did not have the dexterity to do so. The VA’s medical records stated that on February 11, 2026, the VA was admitted to the hospital and diagnosed with T-9 fracture (ninth bone in the thoracic spine) and three left rib fractures. The VA was “intermittently” grinding his/her teeth and “intermittently” moaning. On February 17, 2026, the VA was discharged back to the facility with a Thoracolumbar Sacral Orthosis Brace (TLSO). [Note: There was no information that the VA required surgery.] The SP provided the following information: · On February 11, 2026, the SP was scheduled to work the awake overnight shift from 10 p.m. to 7 a.m. the next morning. The SP said it was his/her first time working at the facility and s/he was filling in. The SP had been trained on working overnights and on the VA’s plans. · At 10:30 p.m., the SP arrived at the facility and at that time the VA was in a recliner in the living room. At 11 p.m., the VA was walking around the living room and at 1 a.m., the VA was sleeping in the recliner. Because the VA was sleeping, the SP went downstairs to use the bathroom in the basement. The SP stated s/he closed the gate but did not lock it. · The SP was in the bathroom for less than ten minutes, and when s/he came out of the bathroom, the VA was sitting on the bottom of the stairs. The SP stated that s/he did not hear any noises or hear the VA fall down the stairs. The VA stood up and started walking around the basement. The SP guided the VA to a couch and immediately called P1 who directed the SP to call 9-1-1. · About 1:20 a.m., the EMS and P3 arrived at the facility. The EMS assessed/evaluated the VA and did not observe or determine that the VA had any injuries. The EMS told the SP and P3 that the VA was “fine and there was no reason” to bring the VA to the emergency room but if needed, they would come back and do so. Around 1:30 a.m., the EMS left and around 2 a.m., P3 left. · The VA slept the rest of the evening upstairs in the recliner in the living room. At 7 a.m., P3 returned to the facility and the SP’s shift ended. · The SP stated that there was nothing noted in the VA’s plans that the gate on the stairs should be closed and/or locked. Emergency Medical Services (EMS) records provided the following information: · On February 11, 2026, at 1:10 a.m., the EMS was dispatched to the facility for a fall and arrived at the facility at 1:27 a.m. When EMS arrived, the VA was lying on the basement couch. The SP told the EMS that when s/he came out of the bathroom, s/he found the VA at the bottom of the stairs and had not heard any sounds to indicate that the VA had fallen down the stairs. P3 said that the VA did not use the stairs and had never seen the VA use stairs. P3 also told the EMS that the VA was acting “normal” and did not “appear” to be in pain because when the VA was in pain s/he made “noises” and would grind his/her teeth. The EMS noted that those signs were not present at that time. · The EMS noted that the VA did not have bruising, bleeding and/or marks and the VA’s vitals were “within acceptable marks.” The VA stood up from the couch and walked around without difficulty. The EMS carried the VA upstairs and sat the VA in a chair in the living room. Staff persons stated that they did not want the VA transported by the EMS to the emergency room and stated that another staff person would transport the VA instead. Staff persons were advised that if the VA had any changes such as pain or changes in his/her mental status, they should call 9-1-1. At 1:46 a.m., the EMS left the facility. P1, P2, P3, and the HCP provided the following information: · On February 11, 2026, around 1:00 a.m., (the SP’s first shift working at the facility and with the VA), P1 received a phone call from the SP stating that s/he had gone downstairs to use the bathroom and when s/he came out of the bathroom the VA was sitting at the bottom of the stairs trying to stand up. · P1 told the SP to not move the VA, to call 9-1-1 and that s/he was on the way to the facility. P1 then tried calling G1 several times. P1 also called P3 and asked P3 to go to the facility to assist the SP and the VA. · At 1:15 a.m., P3 and the EMS arrived at the facility and the SP and the VA were in the basement and the VA was lying on the couch. After completing an evaluation of the VA, the EMS asked the SP and P3 if they should transport the VA to the hospital. P3 then called G1 but G1 did not answer. P3 said that the EMS stated they were not going to bring the VA to the hospital but to call them if the VA began to “act weird”. · Around 1:30 a.m., P1 arrived at the facility and the SP and P3 were upstairs with the VA who was on the couch. The EMS were already gone. P1 completed a body check of the VA and did not see any bumps, bruises and/or marks on the VA. · P3 stated that at 1:35 a.m., s/he had called G1 three times but did not reach G1. At some point, G1 called P3 and asked to speak with P1. P3 and P1 each said that P1 asked G1 if the VA should be brought into the hospital and G1 stated, “No, I’ll be there in the morning.” · Later that morning, P3 was giving the VA a shower and saw a “half dime sized” scratch on the top of the VA’s head. Around 8 a.m., G1, G2, and the HCP arrived at the facility and were notified of the bump on the VA’s head. The HCP told G1 and G2 that the VA should go to the emergency room to be examined and at 8:30 a.m. G1 and G2 brought the VA to the emergency room. · P1-P3 and the HCP each stated that there was nothing in the VA’s plans or facility policies and procedures that the gate was required to be closed and locked. Facility documentation showed that all staff persons interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans prior to the incident. Conclusion: The SP provided consistent information during his/her interview, and to P1 and the EMS that on February 11, 2026, around 1 a.m., the SP left the VA sleeping in a recliner and went to the basement to use the bathroom. The SP stated that s/he had closed the gate at the top of the stairs but did not lock it. While in the bathroom, s/he did not hear any sounds/noises. Less than ten minutes later, when s/he came out of the bathroom, the VA was sitting on the bottom stairs. The SP immediately called P1 and then 9-1-1. The EMS arrived and evaluated the VA and determined that there were no obvious injuries to the VA and they left. Later that morning, during the VA’s shower, P3 saw a small scratch on the VA’s head. P1, the HCP, G1, and G2 were notified and it was determined that the VA should be taken to be evaluated at the emergency room. The VA was subsequently diagnosed with three left rib fractures and a vertebrae fracture. Although the VA fell down the stairs fracturing his/her ribs and vertebrae, there was no information in the VA’s plans or facility policies and procedures, including the Program Abuse Prevention Plan, that required a gate, locked or unlocked, at the top of the stairs. The VA was also able to walk independently around the facility and when the SP went downstairs the VA was sleeping in the recliner. While the VA was not immediately taken to the emergency room, the SP called 9-1-1; P3 said the VA was not demonstrating that s/he was in pain as s/he typically did; and when the EMS arrived, after assessing the VA they did not have any concerns and left. Later that morning, after a bump/scratch was noticed on the VA’s head, the HCP, P1, G1, and G2, were notified and the VA was taken to the hospital shortly after and the VA’s care likely did not change as a result of the approximately seven hour delay. Therefore, there was not a preponderance of the evidence whether there was a 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 stated that their policies and procedures were adequate and followed. The facility added a new self-closing gate latch with alarm to the gate as well as a bed and chair alarm for the VA. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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