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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: 1072513-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Elisa Montgomery 651-431-6474 Elisa.Montgomery@state.mn.us Suspected Maltreatment Reported: A vulnerable adult’s (VA) medication was taken and replaced with another. The VA was administered the replaced medication on two occasions. Date of Incident(s): December 30, 2025, to January 1, 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 9, paragraph (b), clause (1); and subdivision 17, paragraph (a): In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. 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 January 15, 2026; from documentation at the facility; and through five interviews conducted with the VA, three facility staff persons (P1-P3), and a supervisory staff person (P4). The VA was diagnosed with schizoaffective disorder, hypertension, and kidney disease. The VA enjoyed watching television, listening to the radio, and going to the local library. The VA said s/he did not have many details related to the incident but was informed by P4 that his/her medication was switched with another medication. The VA was given the wrong medication on two occasions. The VA had decreased blood pressure due to receiving the wrong medication but did not feel concerning side effects due to his/her history of high blood pressure. The VA did not know of or have concerns with any staff person working at the facility and did not feel that anyone would purposefully switch out the VA’s medications to harm him/her. P1 provided the following information: · At each shift exchange the incoming staff person and the outgoing staff person completed medication counts for narcotic medications. Both staff persons counted the narcotic medications, documented the number of pills left, and initialed the medication count sheet. · On December 30, 2025, P1 worked at the facility in the afternoon until the evening. When P1 arrived in the afternoon, s/he and P3 counted the narcotic medications during shift exchange and P3 left the facility. All medications were accounted for at that time. · Sometime later P1 administered the VA’s medications and noticed that tape was covering the back of the bubble pack for the dose that s/he had administered and the last two doses of one of the VA’s medications (determined to be Ambien a medication used to treat insomnia) which would be administered on December 31, 2025, and January 1, 2026. The bubble pack appeared to be punched out and then taped back up so the medication did not fall out. · Approximately one hour later, P1 went back to the lockbox in the locked cabinet where the VA’s medication was kept and looked at the bubble pack again. P1 took a photo of the bubble pack because s/he “felt” like something was wrong with the medications in the bubbles that were taped shut. · P1 noticed that the medication shape, size, and color were identical to the medication in a new bubble pack but the numbers on the pill were different and thought that maybe the medication “RX number had changed.” P1 put the medication back in the lock box and back into the locked cabinet. · On January 1, 2026, P1 worked at the facility and noticed that the VA’s bubble pack was still taped for the January 1, 2026, dose and called P2. P1 “forgot” s/he took a photo of the bubble packs but remembered when telling P2 and sent P2 the photo of the taped bubble pack at that time. P2 instructed P1 to administer the medication from a new bubble pack of medications. P1 administered medication from the sealed bubble in a new bubble pack and not the taped bubble in the original bubble pack. P1 noticed that the letters and numbers on the pills that were taped did not match the other pills in the sealed bubbles of the bubble pack. The VA did not complain of side effects. · P1 denied switching the VA’s medication with another that looked similar in size, shape, and color, and/or taping the bubble pack shut. P1 worked at the facility on December 29, 2025, and said that the bubble packs were not taped at that time. P2 provided the following information: · On January 1, 2026, P1 called P2 and said that the back of the bubble pack on the VA’s narcotic medication (Ambien) was taped. P1 said that the medication that was taped in the bubble pack was the same shape and color as the Ambien. · P1 sent photos of the taped bubble pack and medication inside to P2 and the facility nurse via email. The facility nurse instructed P1 to set the medication aside and the facility nurse would come to the facility. P1 administered the VA’s Ambien from a new bubble pack. · P2 informed P1 that P2 also noticed that the bubble pack was taped on December 30, 2025, when P2 worked at the facility. P2 did not notice the bubble pack was taped on December 29, 2025, and thought that an unknown staff person might have switched out the medications with a different one and took the VA’s Ambien. · On January 2, 2026, P4 and the facility nurse went to the facility to look at the bubble pack. The facility nurse used a website to identify the medication that was replaced in the bubble pack and said the medication in the bubble pack (Ambien) was likely replaced with Entresto (a prescription heart medication that can lower blood pressure and treat heart failure). P2 then contacted the VA’s primary provider who did not have concerns if the VA was administered one to two doses of Entresto. · P2 asked the VA if s/he experienced concerning side effects. The VA said s/he did not have any concerning side effects and took his/her blood pressure. The VA’s blood pressure was lower than usual but was not concerningly low. P2 offered to make an appointment to see his/her primary physician, but the VA declined.
· The facility’s procedure for medications that were accidentally popped out of a bubble pack was to put the medication into a small white envelope and label the envelope with the medication name, date, administration time, staff initials, and document it in the VA’s Medication Administration Record. If the medication was a narcotic, the same steps applied, and the envelope was put into a Ziploc bag and stored in the lock box. · P2 denied switching the VA’s medication with another medication that looked similar in size, shape and color, and/or taping the bubble pack shut. P3 provided the following information: · On December 30 and 31, 2025, P3 worked awake overnight shifts at the facility. P3 did not administer medications but completed Ambien counts upon arrival and before leaving his/her shifts on both days. · P3 did not check the back of bubble packs when counting the medications and did not notice that the VA’s Ambien bubble pack was taped. · P3 did not have concerns that a staff person had taken the VA’s Ambien and replaced the medication with Entresto. P3 denied taking the VA’s medication and/or switching it with another medication that looked similar in size, shape, and color. The VA did not report concerning side effects to P3 and P3 did not observe the VA acting or appearing out of the ordinary. · On an unknown date in the past, when P3 worked at another facility within the company s/he had used tape to ensure medications did not fall out of a bubble pack. P3 was told by P4 that it was not facility policy and tape should not be used. P4 provided the following information: · On January 2, 2026, the facility nurse and P4 were informed that there was a concern regarding the VA’s Ambien and the bubble pack being taped on the backside of the bubble pack for the December 30 and 31, 2025, and January 1, 2026 doses. P4 and the facility nurse went to the facility on January 2, 2026, to look at the bubble pack and pills. · The staff office was locked with a keypad, and the VA and housemates did not have access to the staff office where the medications were stored. The medications were locked in a cabinet and the VA’s narcotic medication was locked in a lock box. Staff persons who had the key were the only ones able to access both locked areas. · The facility nurse and P4 looked at the medication that P1 left in a white envelope at the facility. It was observed that the medication was the same shape, size, and color as the VA’s Ambien but the numbers on the medication were different. After looking up the numbers, shape, and color of the pill it was determined that the medication was Entresto. · P4 and the facility nurse determined that the switched medication, Entresto, was administered to the VA on December 30 and 31, 2025 by looking at the VA’s Medication Administration Record. P4 contacted poison control and the VA’s primary physician who did not have concerns regarding the VA ingesting Entresto on two occasions. · Neither the VA or any of the VA’s housemates were prescribed Entresto, so it was not able to be determined where the medication came from, how it was switched, or who switched the VA’s Ambien with Entresto. · P3 used tape on a bubble pack of medications in the past at another facility. P4 had a verbal discussion at the time with P3 regarding facility policy not allowing tape to be used on bubble packs of medications. P4 did not recall when this occurred but it was prior to December 30, 2025. The Medication Count Sheets provided the following information: · On December 30, 2025, medication counts for the VA’s Ambien were completed by two staff persons at 12 a.m., 8 a.m., and 4 p.m. and counts were correct. The VA was administered Ambien at 7:14 p.m. · On December 31, 2025, medication counts for the VA’s Ambien were completed by two staff persons at 12 a.m., 8 a.m., and 4 p.m. and counts were correct. The VA was administered Ambien at 7 p.m. · On January 1, 2026, medication counts for the VA’s Ambien were completed by two staff persons at 12 a.m., 8 a.m., and 4 p.m. and counts were correct. The VA was administered at Ambien at 7:07 p.m. The Staff Schedule at the facility showed that staff persons worked the following: · Three staff persons who were not interviewed worked at the facility on December 28, 2025. · P2 worked December 29, 2025, from 8 a.m. to 4 p.m. P1 worked December 29, 2025, from 4 p.m. to 12 a.m. P3 worked December 29, 2025, overnight until 8:30 a.m., on December 30, 2025. · P2 worked December 30, 2025, from 8 a.m. to 4 p.m. There was another staff person who worked at the facility on December 30, 2025, from 9 a.m. until 5 p.m. who did not have access to medications. P1 worked December 30, 2025, from 4p.m. to 12 a.m. P3 worked December 30, 2025, starting at 11:45 p.m., through the overnight. · P2 worked December 31, 2026, from 8 a.m. to 4p.m. Another staff person worked December 31, 2025, from 4 p.m. to 12 a.m. P3 worked December 31, 2026, overnight until 8:30 a.m., on January 1, 2026 All staff persons interviewed received training regarding the VA’s plan of care, the facilities policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: On December 30, 2025, P1 noticed that the bubble pack for the VA’s Ambien medication had three days (December 30 and 31, 2025, and January 1, 2026) that appeared to be punched out and then taped closed but still contained pills. P1 administered the medication that was taped in the bubble pack on December 30, 2025. On January 1, 2026, P1 checked the bubble pack again noticing that the numbers on the pills did not match the pills in a new bubble pack and notified P2. On January 2, 2026, P4 and facility nurse looked at the medication and determined the pills were the same shape, size, and color as the Ambien but the numbers on the medication were different. It was determined from the numbers on the pill that the mediation in the taped bubbles was Entresto. Staff persons likely administered the medication (determined to be Entresto) to the VA on two occasions (December 30 and 31, 2025). Poison control and the VA’s primary physician were contacted regarding the VA ingesting the medication and poison control and the VA’s primary physician did not have concerns that the VA was harmed after taking two doses of Entresto. The VA verbalized that s/he did not experience concerning side effects and declined to go to the hospital. The medications were kept in a lock box, in a locked cabinet, in a locked office in the facility. Multiple staff persons who worked at the facility had access to the lockbox, cabinet, and office. The Staff Schedule showed that P1-P3 worked at the facility leading up to and during the days of the incident. There was also one other staff person who worked who did not have access to the medications. P1-P3 each denied taking the Ambien and/or switching the Ambien with another medication. Regarding neglect: Although the VA was given the incorrect medication in place of his/her regularly scheduled medication for sleep on two occasions, given that that the facility contacted medical professionals as soon as the error was discovered and that the VA did not experience any concerning side effects, there was not a preponderance of the evidence whether staff persons failed to provide health care which was reasonable and necessary to maintain the VA’s physical 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). Regarding financial exploitation: Given that the VA’s prescription narcotic medication, Ambien, was taken and replaced with another medication that was not the VA’s there was a preponderance of the evidence that the VA’s property was willfully used or disposed or withheld in the absence of legal authority. It was determined that financial exploitation occurred (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). 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. Multiple staff persons who worked at the facility had access to the locked medication box, cabinet, and staff office where the medications were stored. It could not be determined when the medications were switched and staff persons who worked each denied doing so, therefore responsibility for the maltreatment was inconclusive. Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were adequate but were not followed. Facility policy did not allow for tampering of medication packaging including the use of tape. P1-P3 completed additional training on medication administration. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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