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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: 1070308-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070299-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported that a staff person (SP) provided a vulnerable adult (VA) with hot coffee while the VA was in bed. The SP left the bedroom, leaving the VA unsupervised, and the VA spilled the coffee on him/herself resulting in significant burns. Date of Incident(s): February 28, 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 visit at a medical facility on March 12, 2026, as well as a site visit of the facility on March 20, 2026; from documentation at the facility, fire department records, and medical records; and through five interviews conducted with the VA, a facility supervisor (P1), the VA’s case manager (CM), the VA’s guardian (G), and the SP. Facility documentation showed the VA’s relationships with friends and family were important to him/her, and the VA was “very social,” but also liked to spend free time in his/her bedroom. The VA “loved” to shop, and other community outings such as going to parks, fishing, bowling, and local festivals. The VA liked to know his/her schedule, and preferred services to be provided calmly and quietly. The VA enjoyed using a tablet and cell phone to talk with people, to send text messages, to play games, and to access social media. The VA’s diagnoses included cerebral palsy, developmental disabilities, and neurogenic bladder. The VA had limited use of his/her right arm, used an electronic power wheelchair for mobility, and needed assistance with re-positioning in his/her bed. The VA relied on staff persons to help him/her make appropriate decisions and respond in potentially dangerous situations. The VA was vulnerable to all forms of abuse or neglect including physical, sexual, verbal/emotional and financial exploitation. The VA’s plans stated s/he received 24-hour supervision to ensure the VA’s overall safety. At the time of the incident the VA’s Coordinated Service and Support Plan Addendum (CSSPA) and the VA’s Self-Management Assessment (SMA) showed that the VA required assistance with “virtually all activities of daily living.” Staff persons were to regulate water temperature for the VA and adjust as necessary. Multiple reports received by the Department of Human Services showed that on February 28, 2026, at approximately 9:10 a.m., the VA was drinking coffee in his/her bedroom and spilled the coffee onto him/herself. The coffee spilled on the VA’s body, and the VA yelled for staff persons. Staff persons responded and removed the VA’s clothing and placed cool rags on the affected areas. Staff persons called the facility nurse and 9-1-1. Emergency responders arrived at the facility, and the VA was taken to a hospital by ambulance. The VA remained hospitalized until March 3, 2026, and at that time was discharged into the care of the G. The VA remained with the G until March 11, 2026, before returning to the hospital for continued care. The VA was subsequentially discharged from the hospital and returned to the facility on March 13, 2026. Medical records showed that the VA was diagnosed with first degree burns on his/her arm, as well as second, and third degree burns on his/her torso, and chest. Recommendations included wound care and a follow-up appointment at a burn clinic. The VA provided the following information: · The VA said s/he was in bed when the SP gave him/her hot coffee in a his/her drink container. The VA tried to drink the coffee but burned his/her lip. The VA said the lid was not secured to the cup which led to the lid falling off, and the coffee spilled onto his/her body. The VA said the coffee caused burns to his/her chest and stomach. · The VA said s/he normally drank iced coffee, and the incident was the first-time s/he was given hot coffee. · The VA expressed concerns about the SP working with him/her in the future, and said s/he did not want to return to the facility. Facility documentation included a General Event Report (GER) which showed the SP documented the incident on February 28, 2026. According to the document the VA asked for an “ice coffee” in his/her bedroom. Staff persons heard the VA “scream,” and the SP immediately went to the VA and observed the “ice coffee” to be spilled on the VA. The lid to the drink container was off the container. Staff persons assisted the VA by removing the VA’s clothing, and then cool wash cloths were applied. The VA’s skin appeared red and was “peeling.” 9-1-1 was contacted and paramedics arrived at the facility. Fire Department records showed a unit was dispatched to the facility at 9:17 a.m., on February 28, 2026, due to a person being burned from coffee. The VA was conscious and breathing, and was observed to have “clear burns” on his/her abdomen and inner arm. The burns had started “peeling,” and a burn jelly/bandage was applied to the affected area. The transfer of care occurred once emergency personnel/ambulance arrived. The VA was then transported to a hospital by ambulance. The facility completed an Internal Review (IR) which provided the following information: · The information within the IR was consistent to that from the GER. · After returning to the facility from the hospital on March 13, 2026, when the VA was interviewed for the IR, the VA said that on the day of the incident, the lid to the drink container was not on all the way, and when the VA took a drink the top of the container came off and the coffee spilled on him/her. · The facility found there likely was not enough ice and creamer added to the coffee to completely cool down the coffee. The container that the coffee was poured into was metal, which insulated and kept liquids hot. The SP did not check the temperature of the coffee before giving it to the VA, and it appeared the cover of the drink container “may not have been properly secured.” · As part of the internal investigation the temperature of a brewed pot of coffee at the facility was checked. The temperature was 165 degrees Fahrenheit, and the temperature increased to 170 degrees Fahrenheit after being poured into the metal drink container. The G and the CM provided the following consistent information: · The G said s/he met the VA at a medical facility burn unit and the VA had a small burn on his/her upper right arm, and a larger burn on his/her torso and chest. The VA required daily wound care due to the diagnosed second and third degree burns. · The G said there were no other health and safety concerns related to the SP prior to the incident; however, the VA stated the SP did not listen to him/her. After the incident the VA expressed s/he was scared the SP would “hurt” the VA again. · The G said the facility had a “strict policy” that did not allow the VA to eat or drink in his/her bed. The G said s/he had previously attempted to provide the VA with food while the VA was in bed, and was told that it was not allowed at the facility. · The G said the VA returned to the facility on March 13, 2026, and the G had a discussion with the facility about a “gradual and supportive approach to reintroducing” the SP back into providing care for the VA. However, the SP worked both March 14 and 15, 2026. · After returning to the facility the VA told the G that the SP had told staff persons and residents that the drink container lid was on at the time of the incident. The VA responded to the SP and stated, "You’re lying," as the lid was not on the drink container. The G said the SP talking about the incident and contradicting the VA’s experience made the VA upset. P1 provided the following information: · P1 said s/he was not at the facility during the incident, but was notified that the VA was burned while drinking coffee. P1 said the facility did not have any policies against eating and drinking in bedrooms. The VA used drink containers, and staff persons were supposed to check the temperature of food and drinks before giving them to the VA. P1 added that the VA would be at risk of injury if s/he were provided with a hot coffee. · P1 said the VA did not drink hot coffee, and the VA’s iced coffee typically consisted of a “little bit of coffee,” “creamer,” but “mostly ice.” P1 said staff persons would make the iced coffee and the VA used a drink container that was metal with a straw built into the top of the cup. The top of the drink container screwed on, and there were no other incidents in which the top had come off. P1 said staff persons would tighten the top of the drink container before providing it to the VA. · P1 did not have concerns with the SP’s interactions with the VA prior to the incident, and after the VA returned on March 13, 2026, the SP was working at the facility, but was not providing direct care to the VA. P1 said no other staff persons or residents had expressed the SP had discussed the incident with them. P1 said s/he discussed the concern with the SP, and expressed the SP could discuss the incident with a supervisor. · P1 said there had never been an “accident” like this before at the facility and the SP was “shook[en]”and “sad” by the incident. P1 said there was no reason in his/her mind that the incident should have happened, but the SP did not intend to harm the VA. The SP provided the following information: · The SP said s/he prepared an iced coffee for the VA, and used coffee that was “warm” as the coffee had been brewed the morning of the incident. The SP estimated the coffee had been in the pot for over an hour. The SP used the VA’s drink container with a screw on top, and mixed coffee, ice, and creamer together and shook the drink before providing it to the VA. The SP left the VA’s bedroom after giving the VA the iced coffee. · The SP said the coffee felt warm, but did not check the temperature prior to giving it to the VA. The SP did not know how the coffee spilled on the VA, “unless [the lid] was kind of sideways on it.” · The SP returned to the VA’s room and found the coffee had spilled on the VA, and remembered seeing “one” piece of ice. The SP observed the drink container, which was empty, and the lid was a little bit off. The VA told the SP the lid “came loose.” The SP observed the VA’s skin which was pink, and other staff persons went into the bedroom to assist. · The SP said, “Maybe I did not let the drink sit long enough,” but added s/he did not mean to harm the VA, and expressed remorse for the incident as s/he “did not know what [s/he] did,” and was “sick to [his/her] stomach” after the incident. · The SP denied providing care immediately to the VA after the VA returned to the facility, but said s/he was working with other vulnerable adults at the facility. The SP added that during the first weekend the VA was back at the facility the VA said the SP had thrown coffee on the VA, which the SP responded to, and said s/he did not throw coffee on the VA, and that the SP said s/he did not do it “on purpose.” · The SP said s/he had not yet returned to providing daily care to the VA at the time of the interview. After the incident the facility updated the CSSPA to state that the VA used a drink container with a lid that included an internal straw. The lid of the drink container should be closed tightly when serving liquid to the VA. Per request from the G, the VA should not be provided with any type of coffee and should not have any type of hot beverage while in bed. The facility provided information that a training was completed with all staff persons on serving hot liquids in beds and added that the Office of the Ombudsman would assist in providing a serious injury prevention training at the facility. A document provided during the training showed a table of time required for a third degree burn to occur: · Water Temperature of 155 degrees Fahrenheit causes a third-degree burn in 1 second. · Water Temperature of 148 degrees Fahrenheit causes a third-degree burn in 2 seconds. · Water Temperature of 140 degrees Fahrenheit causes a third-degree burn in 5 seconds. · Water Temperature of 133 degrees Fahrenheit causes a third-degree burn in 15 second. · Water Temperature of 127 degrees Fahrenheit causes a third-degree burn in 1 minute. · Water Temperature of 124 degrees Fahrenheit causes a third-degree burn in 3 minutes. · Water Temperature of 120 degrees Fahrenheit causes a third-degree burn in 5 minutes. P1 and the SP were trained on Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, and the VA’s client specific programming. Conclusion: A. Maltreatment: Information showed that on February 28, 2026, the VA was burned after coffee was spilled on the VA’s arm, chest, and torso. The VA’s client specific documentation showed the VA required assistance with “virtually” all daily living tasks. The VA drank iced coffee prepared by staff persons as part of his/her routine. The VA drank the iced coffee in bed out of a metal drink container with a screw on lid and straw. Staff persons were to screw on and secure the lid of the drink container. On the day of the incident the SP prepared the iced coffee and stated s/he placed ice, creamer, and coffee into the VA drink container prior to giving it to the VA. The SP said after s/he gave the VA the coffee, s/he left the VA’s bedroom, and returned to the VA’s bedroom after coffee had spilled onto the VA. The VA said s/he tried to drink the coffee, but it burned his/lip and then spilled onto his/her body when the lid fell off. The SP and other staff persons responded to the VA and assisted the VA in removing clothing and placing cool wash clothes on the VA’s skin. 9-1-1 was called, and emergency personnel arrived at the facility, and provided care to the VA. Thereafter the VA was transported to the hospital by ambulance and was diagnosed with first degree burns on his/her arm, and second and third degree burns on his/her chest and torso. The SP did not know how the coffee spilled on the VA. The SP stated “unless [the lid] was kind of sideways on it.” Upon entering the VA’s bedroom, after the coffee had spilled, the SP observed a single piece of ice, and that the lid of the drink container was a little bit off of the container. The VA told the SP the lid “came loose.” The VA required staff person assistance with activities of daily living and with adjusting water temperature so it was reasonable that staff persons should assist the VA with preparing his/her coffee and ensuring a safe temperature. Additionally, the VA had physical limitations, which increased his/her risk of harm. Medical records showed the VA burns were significant as s/he was diagnosed with first, second, and third degree burns after the coffee spilt on his/her body so therefore, the temperature of the coffee was hot enough to cause burns. Although the SP stated that s/he prepared the coffee with ice and creamer, shook the drink container, and did not intend to harm the VA, given that the SP did not test the temperature of the coffee before allowing the VA, who was vulnerable in that area, to consume the coffee, and that the VA sustained first, second, and third degree burns from the temperature of the coffee, there was a preponderance of 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 SP was trained on the VA’s client specific documentation and on the Reporting of Maltreatment of Vulnerable Adults Act. Therefore, the SP was responsible for the maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the SP was responsible was not “recurring” because it was a single incident but was “serious” maltreatment as the neglect resulted in serious injury which reasonably required the care of a physician. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, and followed. The facility completed adjustments to procedures related to checking food and beverage temperatures prior to providing the items to vulnerable adults. The facility provided additional staff training related to burn injuries, and changes to the VA client specific care plans. The report was not similar to past events Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.
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