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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: 1070043-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Beth Virden Suspected Maltreatment Reported: It was reported that a staff person (SP) did not close a gate at the top of a staircase and that a vulnerable adult (VA) went through the gate and fell down the stairs sustaining more than one broken bone. Date of Incident(s): February 12, 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 February 27, 2026; from documentation at the facility; and through three interviews conducted with the VA’s guardian (G) who was also the VA’s family member, a facility staff person (SP), and a supervisory staff person (P). The VA was not interviewed due to his/her limited communication skills. The DHS investigator requested the VA’s medical records, but the records were not received by the completion of this investigation. The VA’s support plans, including Individual Abuse Prevention Plan, provided the following information: · The VA was “very friendly” and enjoyed spending time with family, coloring, and listening to music. · In 2024, the VA moved into the facility seeking services and support relating to his/her diagnoses, which included quadriplegia, cerebral palsy, and intellectual disabilities. The facility provided the VA with at least one staff person 24 hours a day to help with the VA’s activities of daily living and safety awareness. “[The VA] relied on staff to stay safe in all environments.” Staff were to always be within earshot or eyesight of the VA. · The VA used a mechanical wheelchair and needed full staff support for all his/her transfers into or out of his/her wheelchair, bed, etc. “Staff provide consistent physical assistance and supervision during mobility-related tasks to prevent falls and promote a safe environment … [The VA] may not always recognize unsafe situations, so staff assist [him/her] with navigating [his/her] environment and driving [his/her] wheelchair to safe areas when needed.” · The VA was “partially verbal” and communicated using “limited words” but was able to initiate and respond to “basic conversations.” The facility was a single-family house where the VA lived with one housemate (H). The facility’s front exterior door was downstairs; and the facility’s common spaces, like kitchen and living room, were upstairs. The facility had a wooden (not carpeted) staircase between the floors with a wheelchair lift attached. There was a three- or four-foot gate at the top of the stairs separating it from the common living space. The facility’s incident report stated that on February 12, 2026, around 4 p.m., the SP went outside to help the H off his/her bus and into the facility. The VA was waiting upstairs in his/her wheelchair watching a movie on TV at that time. When the SP and the H entered the facility, the VA was yelling, and the SP discovered the VA and his/her wheelchair halfway down the stairs “wedged” upside-down. The SP called out to the H’s bus driver for help, and the bus driver called 9-1-1 and then helped the SP to lower the VA the rest of the way down the stairs to wait for an ambulance. The VA was diagnosed with a broken nose and fractured jaw, and s/he had multiple scrapes and bruises on his/her knees and legs. The VA was admitted to a hospital for pain management and discharged back to the facility on February 14. The G provided the following information: · On February 8, 2026, four days prior to the incident, the G visited the facility and saw the gate at the top of the stairs propped open and saw that the SP was the sole staff person working. The G did not mention anything about this to the SP at the time. · On February 12, 2026, immediately following the incident, the VA’s family member (FM) went to the facility and saw the SP sitting a room “noticeably shaken” about what happened. The FM saw the VA’s wheelchair at the bottom of the stairs, “snapped in half,” and there was a “small pool of blood” about three quarters of the way down the stairs. The FM saw the gate at the top of the staircase was propped open at that time. · The G said that s/he had no prior concerns relating to the VA’s safety at the facility. However, regarding what happened, the G said, “We are lucky [the VA] is alive.” The VA’s wheelchair model or serial number at the time of the incident was unknown to the DHS investigator; however, based on a picture of the wheelchair, it likely weighed between 90 and 150 pounds – per internet article, How Heavy are Power Wheelchairs? The SP provided the following information: · On February 12, 2026, the SP was the sole staff working. At 3:30 p.m., a bus dropped the VA off outside and the SP guided the VA into the facility and used the stair lift to transfer the VA and his/her wheelchair upstairs. The SP started cooking dinner while the VA watched from his/her wheelchair in the kitchen. · At 4 p.m., a bus arrived to drop the H off. The SP needed to go outside to get the H but before leaving, s/he tried to engage the VA in coloring, but the VA declined to do so. The VA remained in his/her wheelchair in the living room or kitchen area while the SP walked downstairs to get the H. The SP walked to the parked bus and guided the H in the H’s wheelchair into the facility. The SP immediately heard the VA yelling, and discovered the VA and his/her wheelchair, upside-down, about three quarters of the way down the stairs. The SP immediately checked on the VA and then called out for the H’s bus driver to call 9-1-1. The SP and the bus driver lowered the VA and his/her wheelchair down to the bottom of the stairs. · The SP said that the gate at the top of the stairs should always be closed; however, two days prior to the incident, the lock on the gate broke. Staff could try to force the gate closed but it would eventually pop open and did not stay closed. The SP was not aware of a way to keep the gate closed with the broken lock. [Note: The gate had a metal slider, which held it closed. The SP and the P each referred to this as a “lock.”] · The SP said that when something, like the gate lock, broke at the facility, staff were supposed to notify a supervisor. The SP did not tell anyone about the broken gate lock because “it didn’t cross [the SP’s] mind” to do so. The SP said that an unidentified facility maintenance worker had visited the facility a few days prior to the incident and was aware of the broken lock. · The VA had a history of hanging out around the top of the stairs in his/her wheelchair. The VA also had a history of driving his/her wheelchair into things, like a TV stand. When the gate was open or when it popped open due to the broken lock, it was “wide” enough for a wheelchair to go through. On February 12, the SP “didn’t take any precautions” to keep the gate closed when s/he went downstairs to get the H. · The SP never purposefully propped the gate open. The P said that staff should always close the gate at the top of the stairs. On February 11, 2026, one day prior to the incident, the P visited the facility, and the gate lock was not broken at that time. Following the incident, the P visited the facility and saw the lock broken off the gate and sitting on a table. The P asked unidentified staff about the lock, and no one saw it broken prior to the incident. The P believed that the VA’s wheelchair broke the lock off when s/he fell down the stairs. The P was not previously aware that staff might prop the gate open. If the gate was closed properly, the VA would not be able to open it independently. The VA sustained a broken nose, which required “glue” to be repaired, and a fractured jaw, which required a soft food diet for a period. Facility documentation stated that the SP and the P received training on the VA’s support plans, including Individual Abuse Prevention Plan, and on the Reporting of Maltreatment of Vulnerable Adults Act. The SP’s job description stated that his/her responsibilities included observing safety hazards and maintenance needs at the facility; addressing any situation that might arise; and ensuring a safe and secure environment. Conclusion: A. Maltreatment: Consistent information was provided that on February 12, 2026, while the SP was outside getting the H from his/her bus, the VA was in his/her wheelchair and fell down the facility’s interior staircase because the gate was not secured. The bus driver called 9-1-1 and helped the SP to lower the VA the rest of the way down the stairs. The VA sustained a broken nose, which required glue to be repaired; a fractured jaw, which required a soft food diet; and multiple scrapes and bruises. Although the SP said that the gate lock was broken and therefore did not close, there was also information that contradicted the SP’s account of the lock being broken and the G saw the gate propped open when the SP was working a few days prior to the incident. The SP stated that the gate should always be closed. Regardless, when the SP went downstairs to get the H, s/he “didn’t take any precautions” to block or close the gate, and the SP was aware of the VA’s history of hanging out around the top of the stairs. Therefore, there was a preponderance of the evidence that there was a failure to supply the VA with care or services, which was reasonable and necessary for the VA’s health or safety. 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. On February 12, 2026, the SP was responsible for the VA’s care and supervision. The SP’s received training on the VA’s support plans, including Individual Abuse Prevention Plan, and the Reporting of Maltreatment of Vulnerable Adults Act. The SP said that the gate should always be closed. The SP was responsible for 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” maltreatment because it was a single incident but was “serious” maltreatment because the VA sustained a broken nose that required the care of a physician (e.g., glue) to be repaired. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were inadequate and not followed. The facility updated the VA’s support plans to include information about the gate at the top of the stairs and provided additional training for all staff regarding the importance of securing the gate. 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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