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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: 801558-RMI (Residential Treatment and Services for Adults with Mental Illness) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a vulnerable adult (VA) was exposed to another resident’s (R) urine as it was leaking into the VA’s bedroom. Thereafter, the VA was hospitalized due to a staphylococcus (staph) infection and pneumonia. Date of Incident(s): Mid-to late July 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 September 5, 2025; from documentation at the facility and medical records; and through nine interviews conducted with facility personnel including facility nurses and supervisors (P1-P8), and the VA. The VA’s diagnoses included neurodevelopmental/behavioral disorder associated with prenatal alcohol exposure, autism spectrum disorder, attention deficit hyperactivity disorder, posttraumatic stress disorder, borderline personality disorder, functional neurological symptom disorder (conversion disorder) with pseudo-seizures, and factitious disorder imposed on self (Munchausen syndrome). The VA had a history of self-injurious behavior, and physical aggression. The VA was able and willing to report abuse and/or neglect. The VA’s History and Physical dated July 18, 2025, showed the VA was morbidly obese and was described to have poor hygiene. The VA had an increased weight gain during the past year but had no noted acute physical distress symptoms. Additionally, the VA denied shortness of breath when lying down but had occasional shortness of breath due to activity. The VA denied any cold symptoms, coughing or wheezing. The VA’s Person-Centered Master Treatment Plan showed the VA struggled with poor hygiene at times, and also continued to struggle with his/her physical health such as weight, seizures, and sleep apnea. The VA resided in a single-person room within the Hickory Unit. The Hickory Unit had two floors of bedrooms, and the R’s room was directly above the VA’s room. Information was obtained during the investigation that a KaiVac machine was used bi-weekly to clean the R’s bedroom due to unsanitary conditions including urine on the R’s floor. An internet search showed a KaiVac machine was a cleaning system that used a no touch technology, which combined pressure washing, chemical injection, and powerful wet vacuuming on a portable platform to deeply clean and sanitize surfaces like restrooms, floors, and kitchens, removing soil and bacteria far better than traditional mopping. A KaiVac sprayed cleaning solution, blasted soil loose, then vacuumed the liquid and debris away, leaving surfaces dry, hygienic, and safe. The VA said s/he did not remember much prior to being hospitalized but believed s/he informed staff of a liquid leaking into his/her bedroom. The VA said s/he put a towel down to absorb the liquid, and thought the leaking had occurred for about a week. The VA was unsure what the liquid was, and said it was near the toilet, but did not leak onto the VA’s body or bed. During the site visit this investigator was informed that physical plant maintenance staff had completed repairs for the VA’s and R’s bedrooms. The repairs included re-caulking of an area where it was believed liquid had leaked from the R’s bedroom to the VA’s bedroom. The following information was consistent from the facility’s Internal Review, medical records, and an email chain between facility supervisors: · On August 1, 2025, P5 sent an email following up on a work order that was sent to physical plant maintenance by a facility staff person. The email stated there were concerns a liquid was leaking into the VA’s bedroom. The email stated that the liquid was leaking into the VA’s bedroom after a KaiVac was used to deep clean the R’s bedroom. (Later within the email chain there was information the R struggled with incontinence.) A response email from physical plant maintenance was sent on August 1, 2025, stating the concern would be addressed on August 4, 2025. · On August 1, 2025, the VA stated s/he did not feel well, and that his/her "lungs are sticking together." The VA was assessed by nursing and provided a warm pack and Tylenol. The VA was instructed to push fluids and had a temperature of 97.9 degrees Fahrenheit (F). The VA’s symptoms included headache, cough, and increase in his/her sleeping the previous three days. · On August 2, 2025, it was noted the VA had a “malodorous room” and complained of abdomen pain. Additionally, it was discovered the VA had couched up approximately two ounces of “clear slightly tinged yellow thin liquid.” · On August 3, 2025, the VA said s/he felt better, and nursing completed an assessment of the VA’s abdomen without remarkable findings. · On August 4, 2025, the leak in the VA’s bedroom was assessed and staff persons were instructed to assist the VA in cleaning his/her room in preparation for the work to be completed on August 7, 2025. It was noted that the VA’s bedroom continued to be malodorous and the VA had soiled linens on the floor. The VA declined assistance from staff person to assist with cleaning. · On August 6, 2025, staff persons cleaned the VA’s bedroom and washed all the VA’s laundry and bedding in preparation of the repairs assessed by physical plant maintenance. The VA was present; however, the VA was observed coughing and had not felt well. Nursing assessed the VA, and it was noted the VA appeared short of breath, and was coughing. The VA’s vitals were taken, and the VA’s primary medical provider was contacted due to on-going health concerns. · On August 7, 2025, physical plant maintenance completed repairs to the bedrooms. · On August 7, 2025, the VA’s met with his/her primary care provider, and provided recommendations related to the VA’s self-care including hygiene, physical activity, and getting fresh air, as well as medication orders to address lower back pain and an on-going cough. · On August 7, 2025, maintenance fixed a crack in the R’s bedroom using self-leveling caulk. It was believed the crack was allowing the liquid to leak from the R’s bedroom. · On August 8 to 10, 2025, the VA continued to have health complaints regarding his/her back pain and cough, however medical assessments showed the VA’s lungs sounded clear. · On August 11, 2025, the VA requested an inhaler, and nursing brought it to the VA. Due to ongoing medical concerns, the VA was assessed by nursing and primary medical provider. The VA had an x-ray completed and the results showed the VA had pneumonia. The VA was prescribed antibiotics, and the first dose of the antibiotic was administered to the VA on August 12, 2025. · On August 13, 14, and 15, 2025, the VA continued to have similar symptoms as stated above and on August 15, 2025, the VA was admitted to a medical facility. The VA was intubated due to (pleural effusion) an abnormal buildup of excess fluid surrounding his/her left lung. · On August 19, 2025, the abnormal fluid was removed, and the VA remained intubated. Testing for “bacterial and fungal cultures” were completed, and the results were pending. · On August 21, 2025, an email which included facility supervisors stated there was no information which showed “certainty of what may have” caused the VA’s pneumonia. · Medical records showed that on August 23, 2025, the cultures were positive for Streptococcus (anginous group) and a Methicillin-resistant Staphylococcus aureus (MRSA) which showed multiple organisms including anaerobes. · On September 11, 2025, the VA returned to the facility. The VA had been hospitalized due to pneumonia which led to respiratory failure that required intubation. While hospitalized the VA stated s/he had recent vomiting, which raised concern for medical providers that the vomiting incident may have led to the infection. · Medical records did not include information or statements which would have linked the liquid leaking into the VA’s room as a cause of the diagnoses. Interviews with P1-P8 provided the following consistent information: · The VA had difficulty maintaining his/her hygiene and bedroom conditions. P1-P8 were aware that the VA was exposed to a liquid that leaked into the VA’s bedroom, however there was minimal information related to any staff person observing the liquid leaking into the VA’s bedroom, the amount of liquid that leaked into the bedroom, or the exact time or length of time the liquid leaked into the bedroom. Based on the interviews, the liquid started to leak into the VA’s bedroom at some point in middle to late July 2025, and the physical plant maintenance resolved the issue in early August 2025. It was believed the liquid that was leaking into the VA’s bedroom was from the use of a KaiVac in the R’s bedroom above the VA’s bedroom. · P1 said there was a work order placed with physical plant maintenance; but did not attempt to move the VA to a different bedroom after learning of the liquid leakage. P1 said the R’s urine was seeping through the floor and into the VA’s bedroom. Although P1 did not observe urine in the VA’s bedroom, s/he said the R’s room smelled of urine. P1 also stated, “everyone,” and “a lot” of the staff were aware of the urine leaking into the VA’s bedroom and stated P4 had observed the urine leaking into the VA’s bedroom. · P3 said there were concerns with moving the VA to another bedroom due to his/her medical needs. P3 said the R had issues with missing the toilet while urinating, and there would occasionally be a small puddle of urine, but P3 believed any liquid that was leaked into the VA’s bedroom was from the room being cleaned by the KaiVac. · P4 said s/he was not sure what the liquid was that had leaked into the VA’s bedroom. P7 said there was no clear cause that was identified with the VA’s diagnosed pneumonia or staph infection. The facility trained staff persons on the facility’s policy and procedures, client specific programming, client rights, and Reporting of Maltreatment of Vulnerable Adults. Conclusion: Around middle to late July 2025, a liquid started leaking into the VA’s bedroom. The VA said s/he informed staff persons at the facility and used a towel to absorb the liquid leaking into his/her bedroom. A work order was made to physical plant maintenance, and on August 7, 2025, repairs were made to an area of the R’s and VA’s rooms. There were concerns the liquid was urine that was leaking from the R’s bedroom which was above the VA’s bedroom; however, based on the information provided, the liquid was more likely than not a mixture of substances including cleaning solution used from a KaiVac. Additionally, there was limited information related to the amount, duration, and timeframe of liquid leaking into the VA’s bedroom. During the investigation there was no information which showed the liquid was leaking onto the VA, VA’s bed, or that the liquid was amassed into any specific amount in the bedroom. The VA experienced a decline in his/her physical health during the timeframe in which the liquid leaked into his/her bedroom including a diagnosis of pneumonia, a staph infection, and a hospitalization with intubation required. However, there was no information to determine a causation between the VA’s illness and the liquid leaking into his/her bedroom. There was a malodorous smell in the VA’s room; however, the VA had soiled sheets on the floor that s/he initially refused assistance with cleaning, and the VA had issues with hygiene, so the odor did not assist in determining if the leaking liquid was urine, from the KaiVac, or a mixture of both. Given the facility took action to resolve the liquid leaking into the VA’s bedroom, and details regarding what the liquid was, how much there was, and how it affected the VA’s health was not determined, 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 maintain the VA's physical or mental 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 and determined that the policies and procedures were adequate and followed. The report was not similar to past allegations. The facility did not take corrective action or completed any additional training to protect the persons that received services. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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