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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: 1126931-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lisa Shock 651-431-6142 Suspected Maltreatment Reported: It was reported that two staff persons did not supervise a vulnerable adult (VA) and allowed the VA to go into a gas station where s/he purchased alcohol, and then later consumed the alcohol in his/her bedroom. Date of Incident(s): Unknown 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 April 16, 2026; from documentation at the facility; and through six interviews conducted with one supervisory staff person (P1), four facility staff persons (SP1-SP4), and the VA’s guardian (G). This investigator met the VA but the VA declined to be interviewed for this investigation. The VA was diagnosed with neuro cognitive defects, anti-social personality disorder, schizoaffective disorder, bipolar disorder, and psychoactive substance dependence. The VA enjoyed spending time with family, going out to eat and going shopping. The facility was a split-level house in a residential neighborhood. The upstairs had a kitchen, living room, office, bedroom and a bathroom. The lower level had the VA’s bedroom and another bedroom, a bathroom and a living room.
The VA’s Supervision Needs updated on February 27, 2026, stated that the VA required 1:1 supervision in the home and the community and staff persons were to be on the same level as the VA. [Note: The previous Supervision Needs of the VA was 2:1 supervision in the home and the community.] The VA had a history of acting out of impulse and needing redirection, so when the VA was in the community, staff persons were to have “eyes on” the VA and be within 20 feet of the VA at all times. The VA had a history of substance abuse and would use if given the opportunity. Sobriety was important to the VA, and s/he often attended Alcoholic Anonymous meetings. The VA’s family had a history of drug abuse and when staff persons were with the VA for home visits, staff persons were to be aware of potential risk of family causing the VA to risk sobriety. The VA’s Individual Abuse Prevention Plan stated that the VA lacked self-preservation when s/he was “using” and did not make good decisions. The VA was over 21 years old and therefore was legal drinking age. P1 and in Incident Report dated March 18, 2026, written by P1 provided the following information: · On March 13, 2026, when the VA displayed signs of “being under the influence,” staff persons conducted a room search of the VA’s bedroom and an empty alcohol bottle was found. · P1 talked to the VA who said that s/he purchased the alcohol while on an outing with SP1 and SP2. The VA told P1 that on an unknown date, s/he was on an outing with SP1 and SP2 when they stopped at a gas station. The VA went into the store unaccompanied by either SP1 and/or SP2 and purchased alcohol which s/he brought back to the facility and consumed while alone in his/her bedroom. · On an unknown date, the VA told P1 that it was not SP1 and/or SP2 who allowed him/her to go into a store unsupervised but that s/he was with SP3 and SP4. · P1 stated that it was possible that the VA got the alcohol while on a home visit and believed the VA changed the story so s/he could continue going on home visits. SP1 and SP2 provided the following consistent information: · “Over a month ago,” SP1, SP2, and the VA were in the community when they stopped at a gas station. SP1 went inside and used the bathroom while the VA stood outside of the car smoking a cigarette and SP2 waited in the car. SP2 watched the VA the entire time s/he smoked and at no time did the VA enter the store. SP1 and SP2 each denied allowing the VA to go into a store unsupervised. · SP2 stated that s/he did not work the month of March 2026. · SP1 and SP2 stated that the VA required 2:1 supervision and needed to be in visual range while in the community. SP3 and SP4 provided the following consistent information: · The VA told SP3 that s/he “felt like crap” for getting SP1 and SP2 in trouble so s/he changed his/her “story” and said that it was SP3 and SP4 who took the VA out in the community and let the VA go into the store unsupervised. · SP3 and SP4 each stated that they did not remember bringing the VA into the community and/or stopping at a gas station. SP3 and SP4 each denied allowing the VA to go into a store unsupervised. · SP3 and SP4 stated that the VA required 2:1 supervision and needed to be in visual range while in the community. P1 and SP2-SP4 provided consistent information that the VA was not an accurate reporter of incidents. Personnel files showed that all staff person interviewed were trained on the VA’s plans and supervision requirements and on the Reporting of Maltreatment of Vulnerable Adults. Conclusion: Information was consistent that because of the VA’s history, the VA required 1:1 supervision at home and in the community and when in the community, staff persons were to have “eyes on” the VA and be within 20 feet of the VA at all times. Despite being legal drinking age, the VA was to maintain sobriety with the assistance of staff persons. On March 13, 2026, the VA appeared “under the influence” and an empty vodka bottle was found in his/her bedroom. The VA declined to provide information for this report but provided P1 inconsistent information. The VA initially told P1 that s/he obtained the alcohol while on a community outing with SP1 and SP2 who allowed the VA to go into a store alone and without supervision, but then later told P1 that it was SP3 and SP4 who allowed him/her to go into a store unsupervised. SP1-SP4 each denied allowing the VA to go into a store unsupervised at any time. Given the inconsistent information provided by the VA and that SP1-SP4 each denied the allegation, there was not a preponderance of the evidence whether there any staff person allowed the VA to be unsupervised in the community. 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 an updated plan for the VA and provided updated training to staff persons. Action Taken by Department of Human Services, Office of Inspector General: No further action taken
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