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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: 1089816-SUD (Substance Use Disorder) Investigator(s): Lindsay Arth Lindsay.arth@state.mn.us Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) used a razor to cut his/her throat and wrist attempting to end his/her life. There were concerns regarding how the VA obtained the razor. Additionally, during the course of the investigation, there were concerns regarding the VA’s mental health and that staff persons did not do enough to address it prior to the VA harming him/herself. Date of Incident(s): February 20, 2026, and prior 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 19, 2026; from documentation at the facility and law enforcement records; and through six interviews conducted with the VA, four facility staff persons (P1, P2, P3, and P4), and a supervisory staff person (P5). A phone interview was scheduled with a staff person (P6) but at the prearranged time, P6 did not answer this investigators phone call and did not respond to subsequent attempts. The Residential Contraband Policy said that clients could use razors, hair clippers, nail files, and other items at the facility. However, these items were stored in a designated area within the staff office. (Note: Information from staff persons showed that only staff persons had access to the office and the office was locked when not in use.) The aforementioned items were able to be checked out by clients and then returned to the storage area after use. (Note: There was no time frame listed for when these items needed to be returned or when staff persons would follow up with the client to return them.) Items found “unsecured” in clients rooms were taken away. The Patient Hygiene Check Out and In showed that when clients wanted these items, the date, clients name, room number, the time the item was checked out, and the time the item was checked back in were to be documented. The VA began receiving services at the facility on February 13, 2026, and was diagnosed with schizophrenia. The VA was not subject to guardianship. The Suicide Severity Rating Scale said that on February 13, 2026, the VA denied thoughts of self-harm and denied having a history of suicidal attempts. The VA said that on February 19, 2026, around 10 p.m., s/he asked an unknown staff person for a razor and was given one. At 11 p.m., the VA went into a facility bathroom and cut his/her wrist and throat using the razor. The VA then walked around the facility with a covering over his/her throat and the VA did not tell staff persons about the incident for a “couple hours.” On February 20, 2026, around 1 a.m., the VA could not sleep so s/he told unknown staff persons, who were different than the staff person who provided the razor, about the incident. The staff persons then called 9-1-1 and the VA was taken to the hospital. The VA “did not know” if s/he told staff persons that s/he planned to harm him/herself prior. The VA had the razor for approximately “two hours” but could have kept the razor until the next day and did not think that anyone “would have done anything.” The VA only used one razor during the incident. The VA declined to provide additional information because s/he wanted to return to the facility when s/he was discharged from the hospital. P1, P2, law enforcement records, and the Critical Incident Report completed by P1 provided the following information: · On February 2019, 2026, around 11:15 p.m., P1 arrived at the facility. At 11:30 p.m., P1 and P2 did rounds which typically happened every two hours. During the round, the VA was in the hallway wearing a scarf, holding a radio, and staring “blankly” at a bookshelf. P2 asked the VA about the radio but the VA did not respond which P1 said was “weird.” After that, the VA was in various places including his/her bedroom and hallway. P1 said that around 12:50 a.m., five minutes before the VA showed P1 and P2 his/her injuries, the VA asked P1 for a razor but P1 told him/her, “No,” due to the time of night. At that time, the VA did not appear injured. · On February 20, 2026, at approximately 12:55 a.m., the VA approached P1 and P2, who were in the staff office, and asked them if they were “good at following directions” and they said they were. The VA was wearing a scarf covering his/her neck and part of his/her face so the VA pulled the scarf down and showed P1 and P2 a “deep laceration” on his/her neck and the blood “not pouring out” but “coagulated.” The VA also had a one inch “laceration” on his/her left wrist. The VA had his/her right hand in his/her pocket and stated that s/he was holding a “weapon.” The VA asked P1 and P2 to call 9-1-1 but to remain in the office or the VA would “finish it real quick.” P1 then left the office and called 9-1-1 and P2 came out of the office and spoke to the VA to assist the VA to “calm.” · When law enforcement arrived, the VA told them that s/he did not want to be “committed” and then law enforcement “de-escalated” the VA. P1 and P2 saw the VA throw an unknown object into a bathroom garbage. The VA was taken to a hospital via ambulance and had surgery for the injuries s/he sustained.
· After the VA left, P1 and P2 found a broken handle of a disposable razor in the bathroom garbage but they did not find a blade. P1 said that it looked like the razor had been “ripped off” because there was “exposed sharp plastic” on the handle. Two plastic razor “caps” were also found in the bathroom. P1 and P2 called the hospital to let them know that the VA may still have the blade on his/her person. P1 and P2 also found a “large amount” of blood in the bathroom. · P1 and P2 each denied that the VA made any comments of self-harm, including on the night of the incident, and P2 said that the VA was “fine” on the night of the incident. · P1 said that after the incident, s/he looked at the VA’s “chart” and saw that there was a “lot” of concerns regarding the VA but that “not a lot” had been done to address the concerns. The VA’s “very first chart note” documented suicidal ideation. (Note: There was nothing in the VA’s chart notes about this.) Additionally, the VA had talked to people on the phone about drug dogs, that the Immigrations and Customs Enforcement (ICE) was “out to get” him/her, and that people were going to “slash” the VA’s throat. The VA’s behaviors were “more frequent” at night. · P2 also said that the VA was going “downhill” on the “days” prior to the incident and P2 documented daily regarding the VA. The VA said that s/he was not “safe” and that “everything” around him/her was a movie and staff persons were “paid actors.” The VA also spoke on the phone but did not dial a number so P2 thought that the VA spoke to him/herself. The VA said things such as “they are out to get me” and that s/he would “do it myself before they will get me.” Because of these concerns, staff persons at the facility including counselors met with the VA and the VA told them that s/he was “fine.” P2 did not feel that “enough” was done and said that staff persons should have taken a “deeper dive.” · On the morning after the incident, P1 spoke to P3, who was the VA’s counselor, and P3 told P1 that s/he “did not know how [s/he] missed it.” P3 told P1 that other staff persons had concerns regarding the VA so, P3 and a facility mental health professional (P7) “tried to address” the concerns with the VA, but the VA “denied everything.” · P1 and P2 said that the VA did not check a razor out during their shift but that after the incident, P2 looked at the sign in/out sheet and saw that the VA checked a razor out on the same date but prior to P1’s and P2’s shift. However, the sign in/out sheet also showed that the razor was signed back in as being returned so it was “not clear” how the VA obtained the razor used during the incident. (Note: The facility no longer had the sign in/out sheets from the time of the incident.) · P1 said that although the facility had a sign in/out sheet for “hygiene” items including razors, nail clippers, Q-tips, foot powder, laundry soap, and other items, “no one used it.” At times, supervisory staff persons reminded staff persons to use it and it would improve but then “stop.” P1 said that staff persons were trained to ensure the items were returned but “no one really kept track.” At times, P1 saw razors in garbage in the client bedrooms and bathrooms and s/he removed them from the garbage. P2 said that staff persons were “pretty good” about getting the items they checked out back but that there was no time frame for how long a client could have an item. P3 provided the following information: · The VA was “quiet” and “reserved” and while P3 did not have any concerns about the VA, overnight staff persons, including P1 and a staff person (P8), emailed P3 with concerns that included when the VA used the facility phone, s/he said that the Federal Bureau of Investigation (FBI) or ICE were coming to the facility. Because of the concerns, P3 met with the VA but the VA denied suicidal ideation and P3 did not observe any of the aforementioned concerns. The VA also took a suicidal screening during admission and there were no noted concerns. · P3 also asked P7 to talk with the VA and when P7 did, the VA denied any concerns. Because the VA was not making any “threats” to him/herself or others, and the suicidal screening did not indicate any concerns, staff persons did not implement any additional “checks,” for the VA. Typically 30-minute checks were implemented when clients made any “threats” or scored moderate or high on mental health screenings or assessments. · The VA also met with an outside provider who prescribed the VA medication for his/her prior diagnoses of schizophrenia but the VA “made it very clear” that s/he “would not” take the medications. The facility could not “force” a client to take a medication and nursing charted that the clients refused when that occurred. · P3 never saw the VA with a razor and was not aware of the VA requesting one. At times, staff persons found razors that were “left” in clients bathrooms so staff persons “disposed” of them. P3 thought that the VA could have gotten a razor that way. · P3 had concerns regarding how “quickly” the incident occurred and said that the concerns s/he was aware of were regarding the VA’s “paranoia” but there were no concerns regarding self-harm. P4 provided the following information: · P4 worked with the VA a “very short amount of time.” P4 described the VA as “quiet” and that s/he “paced” and “mumbled a lot.” The VA did not indicate any self-harm to P4. · The VA did not check out a razor with P4. The process when clients wanted to use a razor or any hygiene item was to come to the office and “check out” the item on a check out sheet. There was no set time for how long clients had items but staff persons often checked on the use after one hour. Additionally, staff persons “always” made sure the item was checked in before the next shift arrived. At times, staff persons would find a razor or shaving cream in a clients bedroom. P4 did not know how the VA got the razor and said that at times, clients checked out two razors if they had a “lot of hair.” The check out sheets did not list the quantity of the items checked out. P4 was not aware of the VA going off site prior to the incident. P5 provided the following information: · The VA did not indicate any self-harm to P5 and P5 was not aware of the VA indicating self-harm to anyone else. Had the VA said or display self-harm concerns, staff persons were trained to notify supervisory staff persons, health care professionals, and the client’s counselor(s) to implement a safety plan. The safety plan included “extra safety checks” every 15 or 30 minutes. · Clients could use razors or other “hygiene” products such as nail clippers and shaving cream by signing them in/out. Clients could typically have the items for one hour and did not need to be supervised while using them. Once a client returned a razor, staff persons threw them away. Staff persons used the sign in/out sheets as trained to do. Prior to the incident, P5 had seen the VA check out razors and return them. P5 did not know how the VA obtained the razor or if the VA checked out more than one at once because there was no “quantity” on the sign in/out sheets. At times, clients may check out more than one razor if needed. There were times the razors were not returned and staff persons found them when they did a weekly facility “sweep.” The VA’s Discharge Summary provided the following information: · On February 14, 2026, at some point in the morning, the VA asked staff persons for a phone number to reach a news reporter and said that s/he wanted to “report how bad the government was messing with [him/her].” Staff persons thought that the VA was “joking,” but the VA said that s/he was not so staff persons directed the VA to the client phone. · On February 15, 2026, the VA came to the staff office and told a staff person that if the facility had “dogs,” s/he wanted them to come to the VA’s room to search to “prove” that s/he had nothing in his/her room and if s/he did, it was “planted.” The staff person told the VA there were no dogs at the facility and offered to search the VA’s room if the VA wanted and the VA agreed. There was nothing found during the room search. However, the VA said that s/he did not “trust” staff persons. · On February 16, 2026, the VA “paced” the halls for approximately 45 minutes and said that s/he was concerned about “ICE” and knew their “plan.” · On February 17, 2026, because staff persons noticed behaviors “related” to “paranoia,” the VA completed a diagnostic assessment with an outside agency used by the facility. The VA felt s/he was in “danger,” said that there was black mold at the facility, and had concerns with law enforcement and ICE. During the diagnostic assessment, the VA denied any mental health concerns including auditory or visual hallucinations, paranoia, delusions, and said that s/he “felt good.” However, at that time due to his/her history of schizophrenia, the VA was prescribed two milligrams Risperdal but the VA “refused” to take the medications and did not appear “receptive” to discussion about his/her “mental health and symptoms.” The Internal Investigation Report said that upon the VA’s admission, the VA denied any “suicidality” or mental health concerns and scored a “zero” on a suicidal assessment. Additionally, on February 19, 2026, the VA scored “zero” on both a generalized anxiety assessment and a depression assessment. The Risk Screening and Assessment Practice Guide said that all clients admitting to the facility were to be screened for suicide risk at admission. A follow up assessment by a mental health professional was to occur when clinically indicated by risk screening results. If a client indicated moderate to high risk, a safety plan was to be completed. Staff persons were to re-screen when a client “reported” thoughts of harming themselves. Facility documentation showed that P1, P2, P3, P4, and P5 received training on facility policies and procedures and on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: The VA began receiving services from the facility on February 13, 2026, and on that date, the VA had a suicide assessment and the VA denied thoughts to harm him/herself and denied having a history of suicidal attempts. Between February 13 and 19, 2026, there were concerns that the VA made comments regarding ICE, the FBI, and that s/he did not “trust” staff persons. The VA met with his/her counselor, P3, and a mental health professional (P7) about the concerns but the VA “denied everything.” On February 17, 2026, the VA also met with an outside agency about the concerns but the VA denied any mental health concerns and said that s/he felt “good.” Because of the VA’s prior diagnoses of schizophrenia, the outside agency prescribed medication for this diagnoses but the VA refused to take it. The VA told this investigator that on February 19, 2026, around 10 p.m., s/he obtained a razor from an unknown staff person at the facility and used it to cut his/her wrist and throat. The VA “did not know” if s/he told staff persons that s/he planned to harm him/herself prior. Although there were concerns that the VA displayed some concerning behaviors prior to the incident, the VA did not indicate any self-harm and staff persons responded by having P3, P7, and an outside agency meet with the VA and the VA denied any concerns. Additionally, while it was concerning that the VA used a razor to harm him/herself, clients could check out items to use such as razors, shaving cream, nail clippers, etc., and the clients were to return them after use. Items found “unsecured” were to be taken away. Given that clients were able to use razors without supervision, that the VA did not indicate any self-harm while at the facility including the night of the incident, and that staff persons immediately called 9-1-1 when they became aware of the VA’s injuries, there was not a preponderance of the evidence whether there was a failure to provide the VA with care of services which were reasonable and necessary to protect his/her health or safety. It was not determined whether neglect occurred (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 policies and procedures were adequate and followed, including because the facility followed policies and procedures based on the information “disclosed” to them by the VA regarding suicidal ideation. There were no similar incidents. Staff persons were re-trained on the check-in/check-out procedures, the “importance” of person searches when “re-entering” the facility and were re-trained on de-escalation. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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