|
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: 1071910-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jamie Randall 651-431-4121 Suspected Maltreatment Reported: It was reported that a staff person (SP) was verbally abusive toward a vulnerable adult (VA) and would make fun of the VA due to his/her disabilities, that the VA ran out of mental health medications and went to an emergency room due to staff persons not reordering the medications, and that the SP took and hid the VA’s personal items. Date of Incident(s): Multiple dates 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 2, paragraph (b), clause (2); and subdivision 9, paragraph (b), clause (1); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. 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 November 7, 2025; from documentation at the facility; and through seven interviews conducted with the VA, a facility supervisory staff person (P1), three facility staff persons (P2, P3, and the SP), a day services staff person (DS), and a hospital worker (HW). A family member of the VA did not respond to an interview request. The VA enjoyed playing video games, working on cars, and listening to music. The VA’s diagnoses included attention-deficit hyperactivity disorder, autistic disorder, depression, and generalized anxiety. The VA had a history of “challenges with [his/her] mental health” including suicidal ideation. The VA was able to identify when s/he was having mental health “challenges” and staff persons supported the VA by being available “at all times to assist [him/her] and encourage appropriate choices.” The VA had the “ability to distinguish between truths and falsehoods.” The VA had a history of saying things that were “false” to “get out of trouble or to get someone into trouble.” The VA was not subject to guardianship. The facility was two stories with a main level and basement. The VA’s room was on the main level. The facility used “remote support and monitoring technology” which included door alarms for entry doors to the facility from the hours of 10 p.m. until 6 a.m. If “on-site/in-person support” was needed during those hours, the facility would have a staff person come “on site within 30 minutes or less.” The VA provided the following information: · On an unknown date, the VA went to a fair with the SP and P2. While at the fair, the SP made “multiple” comments to the VA that included, “Go get your [boy/girlfriend],” and “Go by your [boy/girl]friend,” while the SP pointed to P2. The VA though that the comments were “weird” and made the VA feel uncomfortable. The SP had other occasions where s/he would “make fun” of the VA and his/her housemates and call them names. On an unknown date, the SP called the VA the name of a known serial killer. · The facility had days where the VA or one of his/her housemates would make dinner for all the individuals. If one of the VA’s housemates was gone on their day to cook dinner and the SP was working, the SP would make food for him/herself but not the VA or the housemate still at the facility. Due to a housemate having a “food eating issue,” “stuff” was locked which the VA did not think was fair. If the VA wanted something to eat or drink, s/he would ask staff persons, but the VA was “afraid” to ask the SP. When the SP worked, the VA did not know what s/he was “walking into” and whether s/he was going to get the “good side” or the “bad side” of the SP. · On an unknown date in early October 2025, the VA went to the emergency room because s/he was “suicidal.” The VA’s housemates were “super loud all the time” and the SP was “always loud and snippy” which made the VA feel “trapped.” The VA’s family lived in a different city and the VA felt like s/he had nowhere to go. On an unknown date in the middle of October 2025, the VA was seen in the emergency room because s/he ran out of medications. There was an issue with getting a medication order from the provider and the medication was not filled before the VA ran out. P1 provided the following information: · At the end of May 2025, the VA told concerns regarding the SP to supervisory staff persons including P1. The VA’s concerns included that the SP would not bring him/her to places s/he wanted to go, that “leftovers” were not available to the VA, that the SP was on his/her phone, and that the SP would watch what s/he wanted to watch on TV rather than what the VA and/or his/her housemates wanted to watch. The SP told P1 that s/he would take the VA and his/her housemates to places that they wanted to go, that the refrigerator and freezer were “open,” that s/he was on his/her phone “one time” for a personal matter, and that the individuals supported watched “what they want” when they were not in their rooms. · On October 3, 2025, the VA reached out to P1 and said s/he was not “feeling the greatest,” that s/he was “in his head,” and was having “suicidal thoughts.” P1 asked the VA if s/he wanted P1 to come to the facility or if s/he wanted to go to the hospital. The VA said, “I think I need to call 9-1-1,” and P1 told him/her to do so. The VA texted P1 when law enforcement arrived at the facility. The VA was transported to the hospital and returned the following day. P1 and another supervisory staff person helped the VA get “set up” with his/her new provider that handled the VA’s mental health needs. The VA had recently switched providers as it was “tough” for the facility to get the “services” needed for the VA. When the VA had a lot of “downtime,” the VA would “get into his head” and let negative thoughts “creep in.” Staff persons tried to keep the VA engaged with what the VA wanted to do such as community outings or playing games. · The VA was on multiple medications for the VA’s mental health and ran out of fluoxetine on October 18, 2025. On October 18, 2025, the VA had no more doses of fluoxetine left and was taken to an emergency room by the SP. While at the emergency room, the VA was able to get two weeks of fluoxetine filled. On October 29, 2025, the VA ran out of another mental health medication methylphenid. Prior to the medication running out, the SP, a supervisory staff person, and the facility nurse all made attempts to contact the VA’s pharmacy and the VA’s provider as the medication required a prior authorization, but an order was not completed prior to the VA running out of the medication. · A progress note written by P1 on October 27, 2025, said that P1 called the VA’s provider and spoke with a representative regarding a refill request for methylphenid that required a preauthorization. P1 told the representative that “messages” had been left for the VA’s provider by P1, the VA, and a facility nurse with no response from the VA’s provider. The facility nurse called the VA’s pharmacy the week prior and was told that the pharmacy had been “working on this for a month” and had also not received a response from the VA’s provider. The medication was filled on November 3, 2025. · On November 6, 2025, the VA told P1 that the interactions between the VA and the SP were “going great” and that it had “gotten better.” The VA added that s/he did not have any “complaints.” P2 provided the following information: · When P2 first started working at the facility with the VA in June 2025, the VA told P2 that the SP was suspended because the SP talked “badly” about the VA and his/her housemates. The VA said that the SP called the VA and his/her housemates “lazy” and that they “never do anything.” P2 said that “recently” (P2 was interviewed by this investigator in November 2025) the SP had started “mocking” the VA by speaking what the VA said back to the VA either as the VA was still speaking or directly after. · In late August 2025 on an unknown date after a trip to the fair, the VA was in a “bad mood” and the SP called the VA the name of a serial killer. The VA told the SP, “Seriously, don’t call me that,” and that the comment “really upsets me.” The SP stopped and apologized to the VA. · When the VA and/or his/her housemates would ask the SP a question, the SP would ignore them. One of the VA’s housemates made a comment to P2 that the SP could be “power hungry sometimes.” The SP could be “on or off” when s/he went to the facility. The SP may “ignore everybody” or give a “mean look.” On “multiple occasions” when the SP arrived at the facility for a shift, the VA and his/her housemates would leave the kitchen or living room on the main level and go to their rooms as to avoid the SP. P3 provided the following information: · The VA accused the SP of taking his/her personal items “lately” including a phone charger. The SP did not take the items because the items were found at the facility. The VA had a “habit” of losing where s/he put his/her personal items and that had been happening “as of late.” The VA had been in possession of the SP’s personal items that the VA “brought back.” · The SP could be “snippy” with the VA and his/her housemates. The SP may “clap back” with an “attitude” if the VA or one of his/her housemates asked a question. The SP would have a “facial expression” and sounded “irritated.” The VA and his/her housemates mentioned a “few times” that they do not get along “very well” with the SP. The HW provided care to the VA in the emergency room on October 18, 2025. The VA was in the emergency room due to running out of mental health medications as they were not refilled on time. The VA told the HW that the SP was verbally abusive and would laugh at the VA and his/her housemates due to their disabilities. The SP would take and hide the VA’s personal items (Investigator’s note: the VA did not provide more detail to the HW as to how the SP was verbally abusive or what items the SP had taken and/or hidden from the VA). The VA told a manager and supervisor at the facility, but “nothing” had been done. The VA said that the situation impacted his/her mental health and resulted in more frequent hospital visits. The VA was in the hospital for mental health related symptoms on October 2 and 3, 2025. The DS said that on November 5, 2025, around 1 to 1:30 p.m., the VA told the DS that s/he was having issues with the SP. The VA said that when s/he would talk, the SP would mock the VA by “mimicking” what the VA said. When the VA would ask the SP for help, the SP would not respond and when the VA asked again, the SP would “snap” at him/her. The VA said that this had occurred over multiple days and was ongoing. The VA told his concerns to the facility but “no one did anything” (Investigator note: the VA did not tell the DS who s/he told his/her concerns to at the facility). The SP provided the following information: · The VA ran out of a medication for the VA’s “mood” on October 18, 2025, and missed a dose. A progress note written by the SP on October 15, 2025, said that the SP called the VA’s pharmacy to request a refill for fluoxetine and was told that the pharmacy “had to wait on the doctor’s approval to refill the medication.” The SP took the VA to a hospital at 4:22 p.m. and got a refill of either “30 or 14” doses of the medication. The medication ran out again and the VA missed a “couple days” before the medication was refilled on what the SP thought was “two” days prior to November 7, 2025. (Investigators note: information provided by the facility was that the medication that ran out on October 18, 2025, was fluoxetine and the medication that ran out on October 29, 2025, was methylphenid.) The medication required a preauthorization which the VA’s provider had not completed. The VA, the SP, and a supervisory staff person tried to contact the VA’s provider but did not receive a response prior to the VA running out of the medication. · A progress note written by the SP on October 26, 2025, said that the SP called the VA’s pharmacy and was told that “one of [his/her] [medications]” was not covered by insurance and required preauthorization. · The SP and the VA had a “good” working relationship. The VA would get “mad” sometimes and want “all of the attention” on him/herself. When the SP would work with one of the VA’s housemates and the VA wanted the SP’s attention, s/he may get mad and tell the SP that s/he would get the SP “suspended” or s/he may text P1 something that “half the time” was not true. In June or July of 2025, the SP was suspended when the VA and one of his/her housemates told supervisory staff persons that the SP was not taking them “anywhere.” The SP was not approved to drive the facility’s vehicle until after his/her suspension. The SP would ask the VA if s/he wanted to go to “community ed” and dances but the VA would refuse by saying, “Those are for [developmentally disabled] people,” and that s/he did not want anyone to know that s/he lived in a “group home.” The SP never “made fun” of the VA and his/her disabilities. · On an unknown date “not too long” before November 7, 2025, the VA told a family member that there was not food at the facility. A supervisory staff person came out to the facility, saw that there was food at the facility and took photos. Food was kept where it was “supposed to be.” · The SP “never” had any of the VA’s belongings. The VA and his/her housemates did not have personal items in the “common areas” of the facility. Facility personnel and training records showed that P1-P3 and the SP were all trained on the Reporting of Maltreatment of Vulnerable Adults Act. P2, P3, and the SP were trained on the VA’s plans. P1 was a supervisory staff person that did not work directly with the VA. Relevant Minnesota Rules and Statutes: Minnesota Statutes, section245D.04, subdivision 3, paragraph (a), clause (6), stated that a person’s protection related rights include the right to be treated with courtesy and respect Conclusion: Regarding the SP being verbally abusive and making fun of the VA: The VA said that the SP was verbally abusive, would make fun of the VA due to his/her disabilities, and would “mimic” what the VA would say. The VA said that this was ongoing, and “nothing” had been done by the facility to stop the behavior of the SP. P2 said that s/he was present when the SP made a comment saying that the VA was like the name of a known serial killer. P2 said that the SP apologized to the VA when the VA said that s/he did not like the comment. The SP said that s/he “never made fun” of the VA and said that the VA would tell P1 things that “half the time” were not true. It was likely that the SP engaged in behavior that was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and was a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), including saying the VA was like a known serial killer. However, there was not a preponderance of the evidence whether the SP’s conduct rose to the level of emotional abuse, was repeated, and would be reasonably expected to produce emotional distress. It was not determined whether emotional abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening.) Regarding the VA’s mental health medication not being reordered: Although the VA ran out of fluoxetine on October 18, 2025, and methylphenid on October 29, 2025, there was consistent information provided that the order for the medications required a prior authorization and that there were multiple attempts made by multiple staff persons to fill the medications. The VA missed one dose of fluoxetine and was seen in the emergency room on October 18, 2025, where the emergency department was able to fill two weeks of the medication and deliver to the facility. The VA ran out of methylphenid on October 29, 2025, and the facility made multiple attempts to contact the provider before the medication ran out. The medication was refilled on November 3, 2025. Given that multiple attempts were made to fill the medications prior to them running out and that when the VA ran out of the medication, care was sought for the VA and follow up attempts were made to the provider, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. 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). Regarding the SP taking and hiding the VA’s personal items: Although the VA said that personal items were taken and hidden by the SP, the VA did not provide details as to what those personal items were. The VA told P3 that the SP was taking his/her personal items including a phone charger, but the VA’s personal items were found at the facility. The VA mentioned food items being locked up and/or hidden, but consistent information was provided that if the VA and/or one of his housemates wanted something to eat or drink, staff persons would get the requested item. Therefore, there was not a preponderance of the evidence whether the VA’s personal items were withheld in the absence of legal authority. It was not determined whether financial exploitation occurred (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed. The facility completed training with staff persons at the facility for medication passing that included “medication double checks,” reordering medications, and “medication errors.” Action Taken by Department of Human Services, Office of Inspector General: On May 28, 2026, the facility was issued a Correction Order for the violation outlined in this report.
|
