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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: 1116686-Intensive Residential Treatment Services/Residential Crisis Stabilization Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported that an unknown staff person provided a vulnerable adult (VA) with an eyebrow razor, and the razor was not returned for multiple days. The VA engaged in self-injurious behaviors (SIB) while in possession of the eyebrow razor. Date of Incident(s): September 9, 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 January 30, 2026; from documentation at the facility; and through seven interviews conducted with facility staff persons, including two facility supervisors, (P1-P7). The VA had moved out of the facility prior to the investigation, and attempts were made to contact the VA by phone call, and an interview request was sent by mail to his/her last known address, however the VA did not respond. The facility was a two-story building, and the VA’s bedroom was at an end of a hallway on the second level. The facility provided intensive residential treatment and crisis stabilization services to adults who were diagnosed with a serious mental illness. Length of stay in the crisis stabilization program ranged from one to ten days and in the intensive residential treatment program up to 90 days with reauthorization for individuals requiring longer lengths of stay. Facility documentation showed the VA lived with family prior to being at the facility. The VA was not currently employed, and was not subject to guardianship. The VA had a history of self-injurious behavior (SIB), including multiple suicide attempts in which s/he ingested pills. The VA’s SIB also included cutting his/her arms, legs, and stomach with razors. The VA’s diagnoses included borderline personality disorder, depression with severe psychotic symptoms, anxiety, posttraumatic stress disorder, and substance use. An internet search showed an eyebrow razor included a small sharp blade designed for facial hair grooming, and unlike larger razors used for legs or beards, eyebrow razors allow for precision shaping and trimming. It was also noted that eyebrow razors were gentle on the person’s skin. The facility’s Program Abuse Prevention Plan (PAPP) stated sharps were kept in a locked staff office and were available by client request for less than 30 minutes. The facility used a document to sign out the sharps that were kept in the locked staff office. Staff persons were trained to complete the sharps sign-out document when providing a client with a sharp. At the time of the alleged incident the sign-out document did not include a space for the name of initials of the staff person who provided the client with the sharp. There was no specific information on the sign-out document which started the staff person that provided the sharp was responsible for ensuring the sharp was returned. The VA’s Individual Abuse Prevention Plan (IAPP) showed the VA was provided 24/7 staffing, with 60 minutes safety checks completed by staff persons. It was also noted in the VA’s IAPP that s/he had last engaged in a cutting SIB in July 2025. Staff persons completed daily shift notes on the VA which showed the VA had not engaged in SIB or suicidal behaviors from September 1 to 15, 2025. Facility administration said there was facility documentation (a sharp sign-out document) that showed the VA signed out the eyebrow razor at 4:10 p.m., on September 9, 2025. The facility was unable to locate and provide the document during the investigation. On September 9, 2025, the day the VA signed out the razor, P1-P7 were at the facility for a staff team meeting which started at 2:30 p.m. The facility completed an Incident Report and Internal Review (IR) which provided the following information: · The VA obtained the eyebrow razor from staff persons on September 9, 2025, and the VA did not return the razor. · On September 16, 2025, at 3:05 a.m., the VA was observed crying in his/her bed, and immediately “handed over” an eyebrow razor. The VA was observed to have blood on his/her arm, and after further examination the VA had “numerous cuts on both arms.” It was noted the VA had approximately “100 small” cuts on his/her arms from the razor, and basic first aid was provided to the VA. The facility instituted 30-minute safety checks for the VA and updated the VA’s IAPP to reflect the details of the incident. · The facility nurse assessed the VA’s cuts on September 16, 2025, at 10 a.m., and noted “roughly 50 or so superficial cuts” to the VA’s arms. The cuts were “all” superficial and were about 2" in length running horizontally along the length of his/her forearms. It was noted there were two deeper cuts on the VA’s left arm. There was no bleeding observed by the nurse and most of the cuts were beginning to “scab over.” The VA was provided with additional basic first aid and had no other injuries. · The facility was unable to determine who provided the eyebrow razor to the VA on September 9, 2025. The facility noted the sharps sign-out document was “revamped” after the incident to include the initials of the staff person who signed out a sharp. The VA’s progress notes provided the following information: · On September 9, 2025, the VA’s progress notes did not include any indication the VA was provided an eyebrow razor, and there were no documented concerns for the VA. · The VA was observed multiple times a day from September 9 to September 16, 2025. It was documented that the VA engaged in some behaviors, such as not following facility rules regarding loud music, declining prescribed medications, and refusing programming offered by the facility, however there were no concerns of SIB documented until the incident on September 16, 2025. · The facility started additional safety checks on the VA after the VA was found to have engaged in SIB. The following information was consistent from interviews completed with P1-P7: · P1-P7 each denied providing the VA with the eyebrow razor on September 9, 2025. · P1-P7 stated the VA had a history of SIB, and each consistently explained the process related to providing clients with “sharps,” and that the facility made changes to the process after the incident. · The injuries to the VA did not require additional medical care beyond basic first aid, and the VA returned to his/her prior health condition. · P1, P2, P3, P6, and P7 each stated they did not know who provided the VA with the eyebrow razor. · P4 stated P5 told him/her that P5 had witnessed P7 provide the VA with the razor. · P5 said s/he witnessed P7 provide the VA with the eyebrow razor just before P5 left the facility as his/her shift had ended. P5 also stated the concerns about the facility's handling of the incident in relation to the information provided to DHS and the accuracy of the timeframe in which the incident occurred. · P7 completed a second interview with this investigator and denied providing the VA the eyebrow razor and said there were employee interpersonal issues due to corrective action and training that was being provided around the time of the incident. · Text messages between facility administration provided the following information: o The text messages started at 8:20 a.m., and stated the VA attempted to get the eyebrow razor during a staff meeting, but had to wait until after it was completed. o The eyebrow razor was signed out on September 9, 2025, at 4:10 p.m., and it was “hard to determine” who provided the VA with the eyebrow razor. There were 5 additional entries (for other clients) on the sharps document after the VA signed out the eyebrow razor. o It was noted “all staff are responsible” when a sharp was checked out.
Prior to the alleged incident P1-P7 each completed training on the facility’s policies and procedures, client specific programming, and Reporting of Maltreatment of Vulnerable Adults. After the incident the facility completed retraining for all staff persons on the VA’s client specific plans, and documenting signing out sharps. The sharps document was updated to include staff person initials at the time the sharp was signed out. Conclusion: A. Maltreatment: On September 9, 2025, an unknown staff person signed out an eyebrow razor to the VA. The VA remained in possession of the eyebrow razor until September 16, 2025, at which time s/he was found with 50 or 100 superficial cuts to his/her arms. The VA was immediately provided with basic first aid by staff persons, and additional first aid until the cuts were healed. The VA did not respond to an interview request, however the VA had a documented history SIB in his/her client specific information. Additionally, the facility’s PAPP showed sharp objects were kept in a locked area and were available upon request for less than 30 minutes. The facility had a document for sharp objects to be signed out, but at the time of the incident staff persons were not required to initial the document. Most of the information obtained during interviews was consistent as P1-P7 each denied providing the VA with the eyebrow razor, however P5 stated that as s/he was leaving the facility s/he observed P7 give the VA the eyebrow razor on September 9, 2025. P7 denied providing the razor and stated there were employee interpersonal issues due to corrective action and training that was being provided around the time of the incident. From September 1 to 15, 2025, the VA did not have any documented SIB cutting and it was documented that staff persons checked on the VA multiple times each day. It was not determined when the VA used the eyebrow razor to cut his/her arms which could have happened in between checks and without staff knowing. Although the VA’s cuts were superficial and the VA did not need medical care, given that the VA was in possession of the eyebrow razor for longer than the allowed 30 minutes and subsequently the VA cut his/her arms, and that the VA had a history of SIB cutting and suicide attempts to had a high risk of harm having the eyebrow razor in his/her possession for a week, there was a preponderance of the evidence that there was a failure to provide the VA with reasonable and necessary care and services. It was determined that 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). 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. The facility had an established process for signing out sharps and all staff persons involved were trained on the process, as well as Reporting of Maltreatment of Vulnerable Adults Act, and the VA’s individual client specific programming. P1-P7 were at the facility at the time the VA signed out the eyebrow razor; however, each denied signing it out. P5 stated that s/he saw P7 give the VA the razor but P7 denied doing so and stated there were interpersonal conflicts. Even if the staff who gave out the razor was identified, there was no system in place to ensure the razor was returned within the 30-minute time limit and it was not specified who would be responsible to follow up and get the razor back from the VA. Therefore, it was not determined who was responsible for signing out the razor or who was responsible for ensuring it was returned so the responsibility for the neglect of the VA was inconclusive. Action Taken by Facility: The facility completed an internal review and determined the facility’s policies and procedures were not adequate and the facility was changed to ensure a staff signed his/her initials on the document when a persons served checked out a sharp. The report was not similar to past events. The facility provided additional training to staff persons, and no other corrective action was completed. Action Taken by Department of Human Services, Office of Inspector General: On April 23, 2026, the facility was issued a $200 fine for not ensuring the facility’s PAPP, which stated sharps were available by client request for less than 30 minutes, was followed. There was not a procedure in place to ensure sharps were returned in less than 30 minutes resulting in the VA having an eyebrow razor for seven days and cutting him/herself with it. The Order to Forfeit a Fine is subject to appeal.
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