|
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: 1124584-CFRS (Child Foster Residence Settings) 1103884-HCBS (Home and Community-Based Services) Minnesota Statutes section 245A.04, subdivision 11, allows for a residential program to serve persons who are over the age of 18 but under the age of 21 when the person is completing secondary education or a program leading to an equivalent credential. Minnesota Statutes section 626.5572, subdivision 13, paragraph (b) identifies the Department of Human Services as the lead investigative agency (of vulnerable adults) for . . . any other facility or service not listed in this subdivision that is licensed or required to be licensed by the Department of Human Services. Investigator(s): Emily Kearns 651-431-6513 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) left the facility during overnight hours and that two staff persons (SP1 and SP2) did not see the VA leave. The VA was gone for over an hour during cold weather and later located. Date of Incident(s): January 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 January 29, 2026; from documentation at the facility and law enforcement records; and through five interviews conducted with a supervisory staff person (P1), a facility staff person (P2), the VA’s case manager (CM), the VA’s guardian (G) who was also a family member, and SP2. This investigator met with the VA, but the VA stated that s/he did not recall much of the incident and did not wish to be interviewed. SP1 was contacted via phone, text, email, and US mail, but did not respond to requests to be interviewed. The VA was diagnosed with attention-deficit hyperactivity disorder, post-traumatic stress disorder, major depressive disorder, reactive attachment disorder, and fetal alcohol syndrome. The VA liked dogs, creating art, working on puzzles, and spending time with his/her family. The VA did not have unsupervised time in the community. The VA was the only client at the facility, which was a split-level home with the front door entering into the living room with an attached garage. Two stairways led from the living room to the lower and upper levels. The lower level consisted of a laundry room, a living room, a staff person bathroom, and two additional rooms. One of the rooms was a craft room and the other was primarily empty with a lounge chair where the VA could go to calm. The stairs to the upper level entered the kitchen which overlooked the living room area below. Opposite the kitchen was a hallway with the VA’s bedroom at the end. The hallway also had doors to the VA’s bathroom and an office across from one another. The VA’s bedroom windows, on the second floor of the facility, had two hinged windows that opened via a crank. Screens were installed on both windows but could be removed by moving levers on the screen frames. The VA and the facility had a prior technology agreement allowing the use of cameras throughout the facility’s interior and exterior; however, the agreement was required to be updated annually and had expired two months prior to the incident. Video camera mounts were present in the facility in various locations, however the cameras were not hard-wired and needed to be charged regularly. The cameras and batteries were on the office desk when this investigator conducted a site visit and were not in use during the incident. Additionally, alarms and sensors were placed throughout the facility on various doors and windows, but they were not functioning. The VA’s plans did not specify that the camera or sensors were to be used. According to the VA’s plans, the VA had a history of leaving the facility without supervision. The VA’s support plans stated, “Staff [persons] will also be trained on internal and external reporting to ensure follow up” if the VA attempted to or left without supervision. The VA’s Individual Abuse Prevention Plan (IAPP) stated that the VA had a history of “self-abuse” related to engaging in self-injurious behaviors and “dressing inappropriately.” When the VA left without supervision, s/he might not dress appropriately for the weather and could be at risk for frostbite and possible hypothermia in the wintertime. The VA’s Self-Management Assessment (SMA) stated that the VA was at risk of falling when attempting to leave or leaving the facility without supervision. The VA’s Support Plan stated that the VA required 24-hour in-person, awake staff persons to maintain his/her health and safety. It stated that the VA “utilized” a smart watch. (Investigator’s note: the VA currently did not use his/her smart watch or a cell phone). The VA’s IAPP stated that the VA was to have three to one staffing “at all times” while the VA’s SMA stated that staff persons were to monitor the VA “at all time[s]” with two to one staffing. (Investigator’s note: The three to one staffing listed in the IAPP was an error in that it was not updated to two to one when the VA’s plans changed from three to one to two to one staffing which was in effect on the day of the incident). The VA’s Support Plan stated that the VA was required to have two to one supervision with the VA’s Support Plan Addendum (SPA) stating that the VA had a three to one supervision ratio in the past but was changed to a two to one level of supervision which was in place at the time of the incident. The VA’s plans did not specify how often staff persons were to check on the VA or if staff persons needed to be in hearing or visual distance of the VA. The facility’s Program Abuse Prevention Plan stated that there was “security surveillance both inside and outside the perimeter” of the facility to ensure safety of residents and staff persons. Staff persons were to check on the VA “sporadically” to reduce risks. The VA’s bedroom might be “difficult to supervise” because the VA had a right to privacy. According to www.wunderground.com, the temperature for the zip code where the facility and the VA were located on January 11, 2026, was listed at about 18 degrees Fahrenheit at around 3 a.m. At about 5 a.m., the temperature dropped to approximately 11 degrees Fahrenheit. According to www.google.com/maps, the VA walked approximately one mile from the facility’s location to the location where s/he was found. Law enforcement records, written by three law enforcement officers (LEO1, LEO2, and LEO3) provided the following information: · SP1 called 9-1-1 at 4:51 a.m. to report the VA “missing” from the facility. SP1 told the 9-1-1 dispatcher that the VA was wearing shorts and a T-shirt, and had last been seen by SP1 at 3 a.m. LEO1 was familiar with the VA and based on prior history, was concerned that s/he may not be properly dressed for the weather, which was a “real feel” temperature of 1 degree Fahrenheit. · At 5:12 a.m., community persons reported finding the VA at a location approximately one mile from the facility. LEOs went to the VA and the VA was wearing a hooded sweatshirt and pajama pants, but that s/he was not dressed “appropriately” for the weather and declined medical treatment.
· LEO3 went to the facility to talk to SP1, who said that s/he had last seen the VA watching television (the television was in the living room) before s/he left at about 3 a.m. SP1 told LEO3 that s/he was supposed to check the VA every 30-60 minutes. LEO3 questioned SP1 as to how almost two hours had passed since the VA was last seen and SP1 called 9-1-1. SP1 told LEO3 that s/he was looking around the facility for approximately an hour before calling 9-1-1. SP1 said that SP2 had been in the lower level of the facility but was looking for the VA in the community. · The VA told LEO1 and LEO2 that s/he did not want to return to the facility and that staff persons did not “effectively monitor” the VA. The VA said that staff persons “constantly” fell asleep on the job and that the staff person in the office (later determined to be SP1) was asleep, which upset the VA so the VA left. The VA attempted to wake SP1 and could not, so s/he left. The VA said that s/he had been gone for around one hour. 9-1-1- dispatchers told the LEOs that the 9-1-1 caller, SP1, stated that the VA had only been gone for approximately fifteen minutes prior to calling, however, the 9-1-1 call was made at approximately 4:51 a.m. and this conflicted with what SP1 documented on the progress notes, and what SP1 told P1. · The VA agreed to return to the facility so long as the community persons drove the VA back. LEO1 and LEO2 followed them back to the facility. LEO2 spoke with SP1, who stated that SP2 was out looking for the VA, but the VA was “insistent” that only SP1 was working. LEO3 did not see SP2 but was told by SP1 there was another staff person working. SP2 provided the following information: · On the night of the incident, SP2 arrived at the facility at approximately 3 p.m., along with SP1. The evening had mostly been going well. At around 11 p.m., SP2 attempted to start his/her car because it had been very cold and SP2’s car battery was not working well. The car would not start and SP2 had classes in the morning, so SP2 called P1 to ask about using facility items to jump start SP2’s car. SP2 also asked P1 if s/he could put his/her car in the garage and work on a few things to make sure it would run in the morning. This was not a typical request, but P1 approved SP2 to be in the garage. · SP2 was in the garage for several hours but continued to check on the VA every 30 to 60 minutes. Between 2 and 2:30 a.m., SP2 went into the lower level to sit on the chair in the common area to “rest” because s/he was tired, his/her back ached, and SP2 needed to warm up for about fifteen minutes. SP2 sat on the chair, awake. SP1 entered the lower level to use the bathroom. After SP2 warmed, s/he went back to the garage. SP2 saw the VA in the living room when s/he walked into the attached garage. · When SP2 came back inside to do the next check on the VA, which SP2 estimated was at around 3:20 a.m., the VA was not in the living room. SP2 told SP1 that the VA was gone, and asked SP1 if the VA was in his/her bedroom and both went to look. The VA was not in his/her bedroom. The window screen was removed and the window was open. SP2 did not recall what the VA was wearing and said that sometimes s/he slept with three to four blankets. · At that point, SP1 and SP2 talked about how the VA may have left the facility, but they decided to look for four to ten minutes. SP2 “hoped for the best” and that the VA was “hiding.” SP2 then told SP1 to notify P1 and law enforcement. SP2 said SP1 sent a text to P1. SP2 told SP1 to stay at the facility and SP2 would go look for the VA in the community in nearby areas where the VA had previously gone after leaving without supervision. In the past, SP2 knew that the VA had left the facility after being “mad” at staff persons and “wanted to get staff [persons] in trouble.” SP2 was unsure what time it was at this point. SP2 drove his/her vehicle around the neighborhood and checked the places the VA had gone in the past. · At around 5 or 5:20 a.m., SP1 called SP2 to say that LEOs had located the VA. SP2 was told the VA was “right by” the facility. SP2 was in disbelief because they had searched around the facility. SP2 parked his/her car and sat in his vehicle for about five minutes thinking about why the VA would leave and was back at the facility within fifteen minutes. · When SP2 returned to the facility, SP1 and the VA were there. · Staff persons tried to give the VA a little bit of “space” when s/he was sleeping because the VA felt it was “creepy” when staff persons were watching him/her while s/he slept. SP2 thought that the facility had door and window alarms but had never heard any door or window alarms make sounds during the time that SP2 had worked at the facility. At times, the cameras worked and “talked” to staff persons to make sure staff persons were moving around. · SP1 and SP2 typically rotated the 30 to 60 minute checks with one staff person doing checks on the hour and the other staff person doing them on the half hour. If the VA was awake, they sometimes checked more frequently than every 30 minutes. Sometimes staff persons forgot to check and it might be 40 minutes, but on a typical night, when SP2 was not working on his/her car, s/he would see the VA many times during each hour. Staff persons documented by the hour if the VA slept and all documentation for the shift was done on the progress notes sheet. · SP2 denied sleeping on the night of the incident and SP2 did not see SP1 sleeping when the VA was unable to be located. SP1 was awake when SP2 told him/her the VA was gone. · The VA typically would do “anything” to get what s/he wanted even if it meant self-harm, or “lying” because the VA knew that “nothing” would happen if s/he were not telling the truth. The VA also sometimes forgot what s/he said to people and would other times give incorrect information. A progress note written by SP1 on January 10, 2026, stated that staff persons checked on the VA every 30 minutes and at 4 a.m. the VA “ran away” and that staff persons called law enforcement. SP1 wrote that the VA was gone approximately 20 to 30 minutes. According to LEOs, SP1 said that the VA had last been seen at 3 a.m. A progress note written by SP2 stated that it was noticed at 3:23 a.m. that the VA was gone.
P1 provided the following information: · SP1 and SP2 were working an overnight awake position January 10 to 11, 2026. At around 4 a.m., P1 was contacted by SP1 and later again at 4:43 a.m. When SP1 called at 4 a.m., s/he stated that the VA was not in his/her room and that SP1 and SP2 had searched the facility, but the VA was gone. The VA had hidden inside the facility from staff persons in the past. Prior to calling P1, SP1 told P1 that SP1 and SP2 conducted 30 minute checks on the VA. Both staff persons were supposed to do the 30 minute checks, splitting the checks up between staff persons. · SP1 was using the lower-level bathroom and when s/he came back to the upper level, SP1 realized the VA was gone. During overnights, one staff person was to be on the upper level and one on the lower level, but P1 had given SP2 prior permission to be in the garage working on his/her car battery. SP1 told P1 that s/he called law enforcement and the G prior to calling P1. · At 4:45 a.m., P1 thought that SP1 said that the VA was located and was on his/her way back to the facility. The facility’s Internal Review, completed by P1 and information from P1 stated that the VA was unsupervised for 20-30 minutes because that was how long the VA told P1 s/he was gone. However, when asked further by this investigator to compare the time of the last check documented by SP2 and timestamps provided by law enforcement, P1 agreed that the VA was gone longer than 20-30 minutes. · The VA told P1 that s/he was upset that s/he asked staff persons for his/her glasses and no one responded so s/he was “mad” at SP1 and SP2. · Staff persons were to write on their shift notes that they completed 30 minute checks, but there was not a document for which staff persons documented each 30 minute check. · The VA did not like sleeping in his/her bedroom alone, so s/he typically slept on the living room couch. The VA initially told P1 that s/he left through a lower-level window, but the VA’s upstairs bedroom had the screens off and windows open. The VA previously had left through a second-story bedroom window and told P1 how easy it was to get out of the bedroom windows. · At times, the VA got upset with staff persons when they were “stern” with the VA or when they did things that the VA did not like, such as eating certain foods, and the VA had made “physical threats” in the past toward staff persons, or had threatened to “run away” when upset with staff persons. · P1 did not make notifications about the incident on January 11, 2026. P1 stated that s/he made notification sometime after 7 a.m. on January 12, 2026, when s/he arrived for his/her shift. The VA told this investigator that s/he did not remember much about the incident, but that s/he left through a lower-level window. The CM provided the following information: · The CM had not spoken with the VA about the incident, but the facility provided a lot of “conflicting information” to the CM. The initial incident report was “vague,” but the LEOs’ reports had additional details. The LEOs’ reports implied that staff persons were sleeping prior to the VA leaving the facility, and that LEOs were not sure if two staff persons were working as SP1 was the only one in the facility when they arrived. · The CM questioned the timeframe provided by the facility because the incident report stated that SP1 and SP2 performed 30 minute checks on the VA, that the VA was observed to be gone at 3 a.m., that the VA returned at 5 a.m., and that the facility incident report stated the VA was gone for 30 minutes. The CM observed that there was a 9-1-1 call at 5:12 a.m. from community members stating that they were with the VA out in the community. · While the LEO reports stated that the VA declined medical treatment, the CM felt that that decision should have been made by the G, not the VA. · The CM was not getting notified of events sometimes at all, and other times not at the date or time that the facility documented the notification time. The incident report for this incident stated that the CM was notified on January 11, 2026, however, the CM was not notified that date and received an email from P1 on January 12, 2026, at 2:53 p.m. · In the past, the VA called facility supervisors to tell them that staff persons were sleeping while working, which at the time, was confirmed by viewing the cameras. The CM thought that the facility was supposed to have cameras working, and at one point the VA’s team had filled out paperwork authorizing the use of video technology at the facility, but that form had expired and had not been renewed annually, as would have been necessary. The G provided the following information: · On the day of the incident, at about 2 or 3 a.m., the VA called the G and said that s/he was sleeping then woke up and could not locate SP1 or SP2. The G later found out that between checking on the VA, one staff was in the garage and the other in the lower level. The VA told the G s/he called out for the staff persons and no one heard the VA. The VA then got frustrated, put on his/her coat, hat, and winter clothing and went out the door and was gone for approximately 20 minutes after walking to a local strip mall. The VA met some community persons who helped the VA get in touch with LEOs and the VA was brought back to the facility. · Staff persons were supposed to check on the VA every 15 minutes and the G was under the impression that this was occurring. The 15-minute checks had “always been that way.” The G had seen the “log” that the facility used for documenting overnight checks. · The VA had a “long history” of leaving the facility without supervision and the G was relieved that the VA wore appropriate clothing. After the incident, staff persons were required to be within eyesight of the VA. · SP2 had been “diligent” with being attentive and patient with the VA, and had to do a “quick, temporary” check on his/her vehicle in the garage during this time. · The facility used video cameras, had “extra security” on the windows, and was working on putting alarms in place throughout the facility. The G stated that there was “supposed to be” video of the incident, but s/he had not seen it. · There had been times in the past when the VA called the G, saying staff persons were asleep and the G drove straight over to the facility during the overnight shift to find staff persons “alert.” · The VA required additional supports in place and had been a high level of care. The VA knew how to “manipulate” systems and the VA was a “good person” but “impulsive.” The VA was sometimes “fuzzy” on recalling details. P2 provided the following information: · Overnight staff were scheduled in pairs and would sit in a location where they could have “eyes on” the VA. The VA often slept in the living room on the couch and both staff generally watched the VA from the living room or the kitchen above. · The VA had never left the facility without supervision while P2 was working, but if the VA left the facility or could not be located, staff persons were to notify 9-1-1 “immediately,” and notify a supervisor as well. Both staff persons were to leave to look for the VA if s/he left. (Investigator’s note: There was not a written policy that specifically stated staff persons were to call 9-1-1 immediately if a client left without supervision.) · The facility had cameras, but P2 was unsure if they always worked. P2 was not responsible for charging the cameras. P2 was unsure if there were working alarms in the facility. Shift notes, completed by SP2 stated that staff persons checked on the VA every 30-60 minutes the night of the incident. At around 3:23 a.m., it was time for another check on the VA, and staff persons noticed that the VA had left the facility. SP1 and SP2 both looked for the client until about 3:40 a.m., and then staff persons texted P1, then called law enforcement. Staff persons then decided one staff person would remain at the facility and the other one would drive in the community to look for the VA. SP1 then notified SP2 that the VA had been found and SP2 returned to the facility. All staff persons interviewed for this investigation were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information showed that on January 10, 2026, at 3 p.m., SP1 and SP2 arrived at the facility for the evening and then the overnight shift. SP2 had car problems and called P1 and was approved to work on his/her car in the facility garage. SP1 and SP2 stated they conducted checks on the VA every 30 minutes. Around 2 or 2:30 a.m., SP2 went inside to warm up. SP1 was in the lower level and SP2 went back to the garage. At 3:23 a.m., SP2 went to check on the VA and saw the VA was not in his/her bedroom and the window screen was removed. SP2 notified SP1 who was awake that the VA was gone. They searched the facility and then SP2 decided to leave and look for the VA in the community and told SP1 to call P1 and 9-1-1. Information from LEOs showed that SP1 called 9-1-1 at 4:51 a.m. and reported that the VA had last been seen by SP1 at 3 a.m. At 5:12 a.m., community persons located the VA approximately one mile from the facility and assisted with returning the VA to the facility. LEO1 stated that the VA was not dressed “appropriately” for the weather, but the VA declined medical evaluation. LEO3 went to the facility and asked SP1 how almost two hours passed from the time SP1 last saw the VA to when SP1 called law enforcement. SP1 stated that s/he was looking around the facility for approximately one hour prior to calling 9-1-1. The VA told LEO3 that s/he had been gone for around one hour. According to SP2, at around 5 or 5:20 a.m., SP1 called SP2 to say that LEOs had located the VA so SP2 went back to the facility. SP2 denied sleeping on the night of the incident and SP2 stated that s/he did not see SP1 sleeping when the VA was unable to be located. At the time of the incident, the VA’s supervision was a two to one staffing ratio and the VA had a history of leaving the facility without supervision. The VA’s plans did not specify how frequently staff persons were supposed to check on the VA or list requirements for how closely staff persons were to monitor the VA. Plans also did not provide information regarding the current use of technology, such as video cameras or window and door alarms and did not specify these things were to be used. While it was reported that SP1 and SP2 were sleeping, SP2 denied sleeping on the night of the incident and SP2 did not see SP1 sleeping. SP2 was in the garage working on his/her vehicle and doing checks on the VA, alternating with SP1. Although information was conflicting regarding the times and how long the VA was gone, it was likely that the VA left between 3 and 3:23 a.m. so was gone approximately two hours. However, given that SP1 and SP2 stated they checked on the VA every 30 to 60 minutes, that the VA’s plans did not specify how often the VA was to be checked on or if the VA was to remain in hearing or visual distance of staff persons, that SP1 and SP2 took action when they saw the VA was not at the facility, that it was reasonable that SP1 and SP2 attempted to look for the VA before calling 9-1-1, and that the VA was not harmed, there was not a preponderance of the evidence whether there was a failure to supply the VA with reasonable and necessary care and services. 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’s Internal Review stated that policies and procedures were not adequate but were followed. The VA’s checks overnight were increased. Staff persons were to complete 15 minutes rather than 30 minute checks on the VA. Staff persons were informed they were to be next to the VA at all times if the VA was not in his/her room sleeping. Action Taken by Department of Human Services, Office of Inspector General: On April 6, 2026, the facility was issued a Correction Order for four licensing violations; a staff person was not trained on maltreatment reporting requirements before having direct client contact, a staff person’s personnel record did not contain training documentation as required, the facility did not report the incident to MAARC within 24 hours as required, and the facility did not notify the CM of the incident within 24 hours as required.
|
