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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: 1110558-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh/Beth Virden Suspected Maltreatment Reported: It was reported that staff persons did not seek immediate medical attention when a vulnerable adult (VA) fell down a staircase and expressed pain. The VA was later diagnosed with a fractured ankle. Date of Incident(s): Ongoing between February 21 and 24, 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 March 19, 2026; from documentation at the facility and medical records; and through 12 interviews conducted with the VA’s guardian (G) who was also the VA’s family member, facility staff persons (P1-P7), supervisory staff persons (P8 and P9), an administrative staff person (P10), and a staff person (P11) who was also a nurse. The DHS investigator met the VA, but due to his/her diagnoses, the VA was not interviewed and did not provide information regarding the incident. The VA’s support plans, including Intensive Services Support Assessment, provided the following information: · In 2023, the VA moved into the facility seeking services and support relating to his/her diagnoses, which included intellectual disabilities and dementia. The facility provided the VA with at least one staff person 24 hours a day to help with his/her activities of daily living, meal preparations, and medications. · The VA was a social person, a “talented singer,” and an “enthusiastic Minnesota sports fan.” · “[The VA] might not be able to communicate [his/her] concerns to get the medical care [s/he] needs” and was unable to seek medical attention independently. Staff were to schedule, transport, and attend all medical appointments with the VA. Staff were to ensure all doctor’s orders were followed and assist the VA with expressing his/her needs if s/he was having difficulty doing so. · The VA had a history of “mobility issues” and falls. Staff were to be present when the VA was walking and provide reminders and help if needed. “If staff notice that [the VA] is having mobility issues outside of areas [s/he] typically may need support, they will contact [the VA’s] medical provider to determine if [s/he] needs an evaluation.” The facility was a single-family house where the VA lived with his/her housemates. The VA’s bedroom was upstairs one level from the main floor. At the outset of the investigation, information was provided that on February 21, 2026, the VA fell down stairs and on February 22 and 23, the VA declined to walk and expressed pain, but that staff did not seek medical attention until February 24, at which point the VA was diagnosed with a right ankle fracture. The G, P1-P11, the VA’s medical records, and facility documentation provided the following information: · P1 and P3 each said that on February 21, 2026, around 7:07 p.m., the VA was “twitching” and having “seizure-like activity” in his/her bedroom and at 7:08 p.m., P3 called 9-1-1. The responding paramedics assessed the VA and determined that s/he should be evaluated in an emergency room. The paramedics began walking with the VA down the facility’s interior staircase, but the VA fell while on the last two steps and landed with his/her right leg pinned behind him/her. The paramedics helped the VA up and onto a stretcher and then into an ambulance. P3 called the G and the G said that s/he would meet the VA at the emergency room while P1 and P3 stayed at the facility. · The G said that s/he offered to go with the VA to the emergency room and was aware that staff were not going with the VA. The G did not express concerns about this when speaking to the DHS investigator. The G stayed at the emergency room with the VA. · The VA’s medical records stated that around 7:36 p.m., the VA arrived at the emergency room with possible seizure activity and falling while being escorted by paramedics. The VA “grimaced” when the doctor moved the VA’s (unspecified) hip, which prompted an x-ray that showed no fractures of either of the VA’s hips or pelvis. The doctor did not determine whether the VA had a seizure. The VA was discharged back to the facility with no new prescriptions or additional orders. · P1 and P3 each said that around 10 p.m., the G arrived back at the facility with the VA and told them that the VA was “fine” and that his/her right leg was x-rayed and there were no fractures or concerns. The VA walked into the facility with assistance from the G. However, the VA then declined to walk upstairs to his/her bedroom, so P3 made a bed for him/her on the first-floor couch. The VA told P1 and P3 that s/he “hurt” and pointed to his/her right leg. P3 said that the VA’s right ankle looked “a little swollen,” and P1 did not notice any concerns. · The G and P1-P11 each said that the VA was inconsistent with reporting pain or injuries. The VA might state that s/he “hurt” and might point at an area of his/her body which might be the exact location of the pain but also might not be. The VA might grimace or say, “Ow,” when s/he was in pain but might not. The VA might limp when his/her legs “fell asleep” from sitting too long and/or might struggle to walk due to his/her progressing dementia. As of February 2026, the VA’s dementia was starting to impact his/her abilities, including coordination. · P2-P7 and the facility’s daily notes and staff schedule each said that on February 22 and 23, 2026, P2-P7 worked at various points. P2-P7 were each aware of the VA’s fall on February 21 and the subsequent emergency room visit and that the VA had his/her “leg” x-rayed with no concerns. At that time, P2-P7 were each not aware that the x-ray did not include the VA’s right ankle, but rather only included the VA’s hips and pelvis. P2-P7 provided consistent information that they “assumed” the VA’s “whole leg” was x-rayed or that the doctor at least considered the VA’s right ankle during the examination of the VA’s right leg. P2-P7 each noticed the VA’s right ankle was swollen on February 22 and 23 but it was not discolored or bruised. P2-P7 each believed that this was related to the VA’s fall or that the VA might have sprained his/her ankle during the fall. P2-P7 each applied ice and elevated the VA’s ankle and administered Tylenol (over the counter pain medication). The VA declined to step on his/her right foot and so staff wheeled him/her around using an office chair and/or provided cares to the VA while s/he lay in bed. More than one staff person heard the VA state, “Ow,” when his/her right leg or ankle was moved or touched or heard the VA state that his/her right leg or ankle “hurt.” P2-P7 each said that P3 or someone else notified the facility’s nurse (P11) of the VA’s swollen ankle. · Facility documentation provided the following additional information: o On February 21, 2026, after P3 called 9-1-1, s/he notified P11 about the incident, including the VA’s fall down the stairs. P11 texted the information to P8, P9, and another facility nurse. o At 10:53 p.m., P3 texted P11 stating the VA was discharged from the emergency room. “Everything checked out normal.” “[The VA] had x-ray done on [his/her] leg and no fracture or broken bones. [The VA] is in a lot of pain for [his/her] leg therefore I gave PRN (as needed) Tylenol.” P3 also left a voicemail for the facility’s on-call supervisor describing what happened and that the VA discharged from the emergency room and said, “Everything checked out and is normal.” o On February 22, 2026, at 10:10 a.m., the on-call supervisor emailed the G and the VA’s case manager notifying them that the VA’s right ankle was swollen. o At 11:08 a.m., the G responded via email, “I spoke with staff this morning and it sounds like [the VA] is doing ok - ER did extensive bloodwork, a CT scan and x-rays and cleared [him/her]. Everything checked out fine. But after talking to [P3] this morning it sounds like [the VA] may have sprained ankle ([P3] said it was swollen and [the VA] is unable to walk right now) due to [his/her] slip on the stairs with paramedics. I asked [P3] if staff could try icing [his/her] ankle to get the swelling down.” [Note: On February 23, the on-call supervisor forwarded the G’s email to P8, P9, and a facility nurse.] o At 6:18 and 6:23 p.m., P3 texted P11 and P8 stating that the VA’s right ankle was swollen and it looked like s/he sprained it. The VA was “not complaining of pain” except when s/he walked or stood up and staff were administering Tylenol. [Note: P11 did not respond to this text, and P8 responded, “Thank you for the update.”] · P8 said that on February 23, 2026, between 9 and 5 p.m., s/he worked at the facility and saw the VA’s right ankle was “a little swollen” but not discolored or bruised. At that time, P8 believed the VA’s swollen ankle was a lingering effect from his/her fall down the stairs and not a separate injury or something needing immediate medical attention. P8 also believed the VA’s “right leg” had already been x-rayed and cleared of injuries when s/he was at the emergency room on February 21 and so there was not an imminent need to have his/her right ankle examined at another emergency room. P8 told staff that if the swelling on the VA’s ankle did not show improvement by the next day, February 24, they would take him/her to an urgent care clinic. Staff continued to apply ice and elevate and administer Tylenol. The next day, the VA’s ankle was still swollen, so P5 and P8 took him/her to an urgent care clinic. · The VA’s medical records stated that on February 24, 2026, the VA was diagnosed with a right ankle fracture. The doctor ordered the VA to wear a “boot,” take over the counter pain medication, and apply ice. The VA did not require surgery. · The G and P1-P11 provided consistent information that they had no prior or ongoing concerns with any of the staff who worked between February 21 and 24, 2026. The staff were “a great team” and “the best.” The staff had a history of being “overly cautious” and always reporting concerns. Some staff believed there was “miscommunication” regarding the VA’s x-rays and/or that staff should have accompanied the VA to the emergency room to receive information firsthand. The facility’s policies and procedures stated that in the event of a medical emergency, serious injury, or accident, staff were to provide the client with emergency medical first aid. If the situation was not life-threatening, but the client required care by a physician, staff were to transport them to the nearest emergency room or urgent care clinic. Staff were to call the facility’s nurse when there was a change in a client’s status, an accident or injury, or a fall with injury. Staff might also call the client’s primary care clinic, a pharmacist, or 9-1-1 when needed. Facility documentation stated that P1-P11 received training on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procedures, and that P3-P9 received training on the VA’s support plans. P1 and P2 each said that they received training on the VA’s support plans; however, the facility did not maintain documentation of the training, which was a violation of Minnesota Statutes 245D.095, subdivision 5, which states in part that the license holder must maintain a personnel record of each employee to document orientation and training. Conclusion: On February 21, 2026, P3 called 9-1-1 because the VA was experiencing seizure-like activity and when paramedics escorted the VA down the facility’s stairs, the VA fell and landed with his/her right leg pinned behind his/her back. The G accompanied the VA to the emergency room where a doctor x-rayed the VA’s hips and pelvis and determined there were no fractures or concerns. On February 22 and 23, the VA’s right ankle was swollen, and s/he declined to walk. P3 notified the on-call supervisor, P8, and P11, and P9 and the G were also notified. At that time, everyone believed the swelling was likely the result of a sprained ankle from the VA’s fall and that the emergency room had cleared the VA of fractures and so as they waited for the swelling to decrease, they monitored the ankle, applied ice, elevated the ankle, and administered Tylenol. On February 24, the VA’s ankle remained swollen, and staff took him/her to an urgent care clinic where s/he was diagnosed with a fractured right ankle. Given that the VA had been assessed at the emergency room for the fall and received x-rays, it was reasonable for staff to believe the VA’s ankle was not seriously injured and that the emergency room doctor “cleared” the VA. In addition, once they noticed the ankle swelling was not improving, the VA was taken to urgent care which was consistent with the facility’s policies and procedures. Therefore, there was not a preponderance of the evidence whether the two-day delay in having the VA’s ankle evaluated was a failure to supply the VA with care or services, which were reasonable and necessary. 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 completed an internal review and determined that policies and procedures were adequate but not followed. The facility provided staff with additional training in medical referrals and the expected response to changes in a person’s condition and when to call a nurse. Action Taken by Department of Human Services, Office of Inspector General: On April 23, 2026, the facility was issued a Correction Order for the violation outlined in this report.
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