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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: 1087705-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Beth Virden Suspected Maltreatment Reported: It was reported that staff persons (SP1 and SP2) did not seek medical attention or properly determine a need for medical attention when a vulnerable adult (VA) fell and fractured his/her cheek bone. Date of Incident(s): November 19, 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 December 10, 2025; from documentation at the facility; and through four interviews conducted with the VA’s guardian (G), facility staff persons (SP1 and SP2), a facility staff person who was also a nurse (P1), and a supervisory staff person (P2). The VA was not interviewed due to his/her limited communication skills. The VA’s support plans, including Self-Management Assessment, provided the following information: · In 2017, the VA moved into the facility seeking services and support relating to his/her diagnoses, which included intellectual disabilities and “ambulatory unsteadiness.” The VA was “non-verbal” and might repeatedly vocalize one or two words but struggled to understand time and was unable to reliably report events. The facility provided the VA with at least one staff person 24 hours a day to help with activities of daily living, transportation, and medical needs. The VA did not have a history of seizures. · Staff were to be present and aware of the VA’s whereabouts and to visually check on the VA every two hours when s/he was sleeping. · The VA relied on staff to ensure his/her health and safety. “[The VA] is not a reliable reporter. Staff are trained in signs and symptoms of illness … Staff will monitor [the VA] for any changes that may suggest that [s/he] is ill or injured. Staff will follow the standing orders and will consult the [facility’s] Flip Chart for step-by-step recommendations on how to respond to certain situations. Staff are also trained to call a pharmacist regarding medication side effects, the clinic/urgent care or hospital.” · The VA had a history of falling and getting tired “easily.” The VA always used a walker and might use his/her wheelchair for longer distances. · The VA was prescribed Ativan-as needed (PRN) for anxiety. “[The VA] gets a PRN for [his/her] dental visits as prescribed by [his/her] psychiatrist … [The VA] gets very unsteady after receiving [Ativan] … When using [the VA’s] PRN anxiety meds [s/he] will use the wheelchair.” [Note: The support plans did not provide a timeframe for when the VA should use his/her wheelchair when using his/her PRN.] According to drugs.com, common side effects for Ativan include dizziness and drowsiness, and feeling unsteady. At the outset of the investigation, information was provided that on November 19, 2025, the VA had an “unwitnessed fall” after receiving his/her PRN, in which case, the VA should not have been walking and should have been using his/her wheelchair to minimize the risk of falling. The VA sustained a head injury and medical attention was not sought until the next day. The facility’s incident report and internal review provided the following consistent information: · On November 19, 2025, during the morning hours (unspecified), the VA took a PRN Ativan and then attended a dental appointment without issue. At 3 p.m., SP1 and SP2 arrived for the start of their shifts. · Around 6:40 p.m., SP1 was in the kitchen and SP2 was in the staff office. The VA fell while walking to his/her recliner in the living room. SP1 and SP2 did not witness the fall but heard it and immediately ran to the VA’s side. The VA was lying “face down” on the floor next to his/her recliner with his/her walker leaning against the recliner. The VA did not lose consciousness and was breathing “normal.” “[SP1 and SP2] noticed swelling/bruising under [the VA’s] right eye” and called P1. · P1 advised SP1 and SP2 to follow the recommendations on the facility’s Flip Chart (emergency and medical triage flow chart) and stayed on the phone while they did this. SP1 applied a cold pack to the right side of the VA’s face and SP1 or SP2 checked the VA’s vital signs, which were within normal limits. The VA did not show signs of pain; and SP1, SP2, and P1 determined that, based on the facility’s Flip Chart, the VA did not require immediate medical attention at that time. Later that evening, P1 called the facility twice to check on the VA and received no information that the VA was in pain or that his/her condition changed. The overnight staff checked on the VA hourly. · The next morning, November 20, 2025, “[Staff] noticed [the VA’s] right eye was swollen, puffy, and black and blue.” Staff brought the VA to an emergency room where s/he was diagnosed with a fractured cheek. The fracture did not require surgery and was expected to heal with time. [Note: The DHS investigator requested the VA’s medical records, but they were not received by the completion of this investigation.] The facility’s Flip Chart included the following information: · Eye injuries might include an impact or blow to the eye. Staff were to gently apply a cold compress to reduce pain and swelling. If a black eye, pain, or visual disturbance occurred, staff were to immediately contact an eye doctor, urgent care, or emergency room. · Fall injuries range from minor (bruises or scratches) to serious (concussion, fractures, or death) and might occur immediately or develop slowly over time. Staff were to report all falls to P1 to complete a “fall assessment.” If the person lost consciousness, staff were to call 9-1-1 immediately. If the person sustained bruising, staff were to monitor for “signs of health” and notify P1 if the bruise did not heal. · Head injuries might be a serious problem, and signs and symptoms might occur immediately or develop slowly over time. Staff were to call 9-1-1 if they observed certain signs and symptoms, including a fracture or swelling at the site of the injury. SP1 and SP2 provided the following information: · SP1 and SP2 each said that when they arrived at the facility at 3 p.m., on November 19, 2025, staff told them that the VA took his/her PRN and attended a dental appointment that morning. Typically, the PRN helped the VA “relax” and sometimes made him/her “wobbly.” The VA’s supervision requirements and cares did not change when s/he took, or in response to him/her taking, his/her PRN. The VA could continue to use his/her walker and move about but typically relaxed and did not move around much. · SP2 said that the VA appeared “normal.” “Everything was normal at that point.” The VA was walking around “fine.” However, around 6:30 p.m., when the VA walked to his/her recliner from the bathroom, s/he fell. SP1 and SP2 did not see the fall but heard it and ran to the VA, called P1, and consulted the facility’s Flip Chart. · SP1 and SP2 each said that the VA did not show signs that s/he was hurt. The VA might “grunt” or “give signs” when s/he was hurt but did not do so after s/he fell. SP1 touched the VA’s face, head, and legs, and to each, the VA said, “Good,” indicating the area did not hurt. The VA did not immediately have bruises or marks on his/her face. SP2 said that the VA always had “bags” under his/her eyes and as the evening progressed, the bag under the VA’s right eye “filled with blood” and appeared “bigger.” SP1 and SP2 each said that the VA went to bed without incident and continued to not show signs of pain. · SP1 said that s/he took a picture of the VA’s face at an unspecified time on November 19, 2025, but did not send or share the picture with anyone, including P1. The picture was provided for this investigation and showed a large black “bag” under the VA’s right eye. P1 said that on November 19, 2025, at 6:37 p.m., SP1 called him/her and said that the VA fell and sustained an “abrasion,” and that the VA was not complaining of pain. Staff did not provide a description of the abrasion or send a picture. Staff checked the VA’s vital signs, which were “normal.” Staff provided care according to the Flip Chart and emergency medical attention was not sought at that time. P1 told the staff to call him/her if the VA’s condition changed. P1 called the facility twice that night to check on the VA and the overnight staff said that the VA was “fine.” No one called P1 with additional concerns. P2 said that SP1 and SP2 followed policies and procedures. After the incident, the VA’s plans were changed so that s/he was required to use his/her wheelchair after taking his/her PRN “as an abundance of caution.” This was not a requirement at the time of the incident. The G said that for the past year and a half, staff administered Ativan (PRN) to the VA prior to attending his/her dental appointments. The G “trusted” the staff’s overall care and supervision of the VA. Facility documentation stated that SP1 and SP2 received training on the VA’s support plans and on the Reporting of Maltreatment of Vulnerable Adults Act. P2 was listed in the VA’s support plans as being a primary facility contact person for the VA’s care, and P1 was not required to receive the same training as SP1 and SP2. Conclusion: Consistent information was provided that on November 19, 2025, the VA fell and SP1 and SP2 called P1, and after consulting the facility’s Flip Chart, SP1, SP2, and P1 determined that medical attention was not necessary at that time. Although the VA developed a bruise under his/her eye, the VA did not show his/her typical signs to indicate pain and did not lose consciousness, and his/her vital signs were within normal limits. The next morning, the VA’s eye was puffy and black and blue, and staff brought the VA to an emergency room where s/he was diagnosed with a fractured cheek. P2 and the G did not have concerns. Given that the staff response was consistent with the VA’s support plans and the facility’s Flip Chart and with P1’s instructions, there was not a preponderance of the evidence whether immediate medical attention was necessary at the time of the fall or might have changed the outcome and/or whether there was a failure to supply the VA with necessary care or services, which was reasonable and necessary for the VA’s physical or mental health. 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: Facility documentation completed an internal review and determined that policies and procedures were adequate and followed. The VA had a history of similar falls. The facility made changes to administer the VA’s PRN earlier in the day of an appointment and required the VA to use his/her wheelchair for a period after the appointment. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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