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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: 1099933-H_CRS (Home and Community-Based Services-Community Residential Setting) 1069732-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) did not provide the required supervision to two vulnerable adults (VA1 and VA2) during a community outing. Date of Incident(s): February 26, 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 18, 2026; from documentation at the facility, law enforcement records, medical records; and through nine interviews conducted with VA1, VA2, a facility supervisor (P), VA1’s case manager (CM1), VA2’s case manager (CM2), VA1’s guardian, VA2’s guardian, SP1, and SP2. The VAs’ guardians were contacted but did not provide information regarding the incident. Facility documentation showed VA1 enjoyed listening to music, watching TV, painting, and going shopping. VA1 maintained a close relationship with his/her parents, and liked spending time with family. While at the facility VA1 was working on coping skills and maintaining his/her sobriety. VA1 diagnoses included schizophrenia, and epilepsy. VA1 history showed there were time s/he left his/her homes without communicating with staff persons. VA1 wanted to be as independent as possible, but did not have any unsupervised time, however s/he had stated his/her desire to have unsupervised time. VA1’s Support Plan showed the facility was funded for 24-hour plan of care, including 1:1 staffing for VA1 during daytime hours, and staff persons were to be trained on VA1’s care plans. VA1’s Support Plan Addendum showed VA1 would complete community outings on a regular basis with the assistance of staff persons. VA1’s Individual Abuse Prevention Plan showed VA1 was “very impulsive,” and had previously left without supervision in the community and was arrested. VA1 also had a history with substance use and refusing his/her prescription medications while under the influence. VA1’s Self-Management Assessment stated VA1 “struggled” to maintain his/her sobriety and substance use had a negative impact on his/her mental health. Staff persons should follow VA1’s protocol if VA1 was out of a staff persons sight. VA1 had left without supervision in the past to seek substances, if VA attempted to be unsupervised in the community staff persons would follow VA1 and keep him/her in their sight. Facility documentation showed VA2 was described as a vibrant person who enjoyed spending time with family, and creating friendships. VA2 liked spending time listening to music, going to festivals, and going to the gym. VA2 had “significant mental health symptoms including psychosis and delusional thoughts.” VA2 also had a “significant history” of substance use and leaving without supervision. VA2 diagnoses included schizoaffective disorder, post-traumatic stress disorder, anxiety, and attention-deficit hyperactivity disorder. VA2’s Support Plan showed the facility was funded for 24-hour plan of care, including 1:1 staffing for VA2 during daytime hours, and staff persons were to be trained on VA2’s care plans. VA2’s Support Plan Addendum showed VA2 participated in community outings with staff persons, and did not have any unsupervised time in the community. VA2’s Individual Abuse Prevention Plan showed VA2 had a “significant history” of substance use and had previously been sexually assaulted and trafficked. Staff persons were required to keep VA2 in line of sight at all times while in the community. VA2’s Self-Management Assessment stated VA2 was not able to maintain his/her safety in the community as s/he was unable to “identify safe/unsafe situations.” VA2 had a history of leaving without supervision and may “walk away from staff,” while in the community. Based on VA2’s history s/he would seek substances if unsupervised. Staff persons should follow VA2’s protocol if VA2 was out of a staff persons sight. Initial information showed the incident occurred while SP1, SP2, VA1, and VA2 were on a community outing in Saint Paul, Minnesota. The outing included stopping at a retail store and restaurant, which shared a building, but did not have connecting entrances. An internet map showed the building was located near a street with frequent traffic, and at least two bus stops within 50 yards of the restaurant. The parking lot had two lanes for parking. VA1 and VA2 shared consistent information that SP1 and SP2 went into the restaurant, while VA1 and VA2 remained outside. VA1 and VA2 each said they both got on a bus, and hid from SP1 and SP2. Law Enforcement Records provided the following information: · On February 26, 2026, at 6:33 p.m., LE arrived at the restaurant due to the report of missing persons. SP1 informed LE VA1 and VA2 went missing at 5:25 p.m. and stated VA1 and VA2 “were not vulnerable adults.” · SP1 told LE s/he went into the restaurant to “stay warm,” as VA1 and VA2 were smoking outside the restaurant. SP1 looked back outside, and VA1 and VA2 were gone. SP1 said s/he and SP2 searched the surrounding area, but were unable to locate the VAs. · LE noted VA1 was found in Minneapolis and completed an evaluation at a medical facility, which showed VA1 had narcotics in his/her system. LE records did not provide any update on VA2’s whereabouts or condition when s/he was located. The facility completed an Internal Review (IR) for VA1 and VA2, which provided the following information: · On February 26, 2026, VA1 and VA2, who required 1:1 supervision, were on a community outing and SP1 and SP2 left VA1 and VA2 unsupervised. A search of the surrounding area was completed, and LE was contacted, however a facility supervisor was not contacted until after two hours after VA1 and VA2 were missing. Thereafter additional personnel searched the area for VA1 and VA2, however they were not located. · VA1 contacted the facility on February 27, 2026, and was transported to a medical facility following alleged substance use. VA1 was stabilized and returned to the facility during the evening of February 27, 2026. · VA2 was located on March 5, 2026, and transported to a medical facility. VA2’s toxicology results showed s/he had used multiple substances. · SP1 and SP2 provided information for the IR, and according to the information SP2 was inside the restaurant and SP1, VA1, and VA2 were outside the restaurant. SP1 “briefly” went to the vehicle to get a phone charger, and after returning VA1 and VA2 were no longer present. · During the internal investigation the facility determined SP1 and SP2 provided conflicting information regarding the areas they searched, and there were inconsistent statements regarding the incident. The facility found SP1 and SP2 failed to maintain the required supervision of VA1 and VA2. VA1’s Progress Notes provided the following information: · SP1 noted that on February 26, 2026, at 3:30 p.m., VA1 left the facility in a vehicle with SP1 and went to multiple stores, prior to stopping at a restaurant for SP1 and SP2. · SP1 noted that between 5 and 7 p.m., SP2 went into a restaurant and VA1 went into a retail store to look at items, thereafter SP1 and VA1 left the retail store, and SP1 entered the restaurant as s/he needed a charger for his/her phone. VA1 and VA2 remained outside the restaurant, but SP1 stated s/he maintained visual contact of VA1 and VA2. · SP1 noted s/he “was looking around and asking [SP2] for a charger,” and “between the time [SP1] searched the store for a charger quickly,” VA1 and VA2 had left. · SP1 and SP2 searched the area for VA1 and VA2, but did not find them. Law enforcement (LE) was contacted after 45 minutes of searching and were on the telephone for “about 20 minutes.” LE did not arrive until 30 minutes after the initial phone call. · After discussing the situation with LE a facility supervisor was contacted and informed of the concern. The surrounding area continued to be searched, however VA1 and VA2 were unable to be located. SP1 completed a General Event Report (GER) which provided consistent information from the above Progress Notes. VA2’s Progress Notes provided the following information: · SP2 noted that on February 26, 2026, at 3:30 p.m., SP1, SP2, VA1, and VA2 left the facility in a vehicle and went to multiple stores, prior to stopping at a restaurant for SP1 and SP2. · SP2 noted that between 5 and 8 p.m., SP2 went into a restaurant to get water, and VA1 and VA2 were outside the restaurant smoking. SP1 entered the restaurant as s/he needed a phone charger, but VA1 and VA2 were within visual sight. SP1 was unable to find a phone charger, and returned outside, however VA1 and VA2 were no longer outside and unable to be located. · SP1 and SP2 searched the surrounding area for the VAs, but did not find them, and law enforcement was contacted. SP2 also completed a General Event Report (GER) for the incident. SP2 wrote that VA1 and VA2 were smoking outside of the restaurant and both SP1 and SP2 were inside the restaurant, “leaving [VA1] and [VA2] unsupervised.” SP2 also noted that “when staff returned outside,” VA1 and VA2 “were missing.” SP1 provided the following information: · SP1 said s/he was outside with VA1 and VA2 and then went into the restaurant to get a phone charger from SP2 who was already inside. SP1 stated that the VAs left without supervision while s/he was inside, and SP1 did not see where or when VA1 and VA2 left. SP1 and SP2 searched the immediate area before contacting 9-1-1. · SP1 said during his/her interaction with SP2, SP2 said there was a charger in the facility vehicle, and SP1 went outside to get the charger, but after finding the charger SP1 noticed VA1 and VA2 had left, and SP1 went back inside the restaurant to notify SP2. Later during the interview SP1 stated s/he was talking to SP2 when it was discovered VA1 and VA2 were no longer present. SP1 said SP2 was at the end of the counter getting his/her food during the interaction. · SP1 said s/he followed the facility protocol regarding VA1 and VA2 leaving without supervision. SP2 provided the following information: · SP2 said they stopped at the retail store and restaurant, and s/he went into the restaurant to get a drink of water, and returned to SP1, VA1, and VA2. Thereafter, SP1, VA1, and VA2 went into the retail store, while SP2 went back into the restaurant to order food. SP2 was in line ordering food when SP1 went into the restaurant and asked SP2 if s/he had a phone charger. SP2 added that SP1 also asked a restaurant worker for a phone charger, before SP2 received his/her food order. SP1 and SP2 left the restaurant, and observed that VA1 and VA2 were no longer outside of the restaurant. SP1 said the surrounding area was searched and LE was contacted. · SP2 said when s/he went to order food, SP1, VA1, and VA2 were in front of the retail store, and SP2 did not have a visual of them. SP1, VA1, and VA2 eventually moved to be directly in front of the restaurant and SP2 could see them through the window. SP2 said s/he lost visual contact with VA1 and VA2 during the time SP1 asked him/her about the charger. The P was interviewed, but was not present for the incident. The P said SP1 was assigned to work 1:1 with VA1, and SP2 was assigned to work 1:1 with VA2. The P said SP1 and SP2 did not follow facility protocols which led to VA1 and VA2 being unsupervised in the community. VA2’s Elopement Protocol showed that staff persons should try to locate the VA for an hour and then contact 9-1-1. If staff persons lost sight of VA2 a supervisor should be contacted immediately. VA1 did not have an Elopement Protocol. Medical Records confirmed VA1 had substances in his/her system on February 27, 2026. VA1 was prescribed NARCAN as needed. Medical Records confirmed VA2 was hospitalized from March 5-16, 2026. Lab tests confirmed VA2 had substances in his/her system, and was prescribed NARCAN as needed and Suboxone as a daily medication. The P, SP1, and SP2 were trained on the VAs’ client specific information, the facility’s policy and procedures, and the Reporting of Maltreatment of Vulnerable Adults. Conclusion: A. Maltreatment: On February 26, 2026, SP1, SP2, VA1, and VA2 were on a community outing and stopped at a retail store and restaurant. SP2 went inside of the restaurant, and SP1 remained outside with VA1 and VA2, however SP1 entered the restaurant, leaving VA1 and VA2 outside without supervision. While SP1 and SP2 were inside the restaurant, VA1 and VA2 left the area, and SP1 and SP2 were unable to locate the VAs. SP1 and SP2 searched the surrounding area, and contacted 9-1-1. VA1 was unsupervised in the community until s/he was located on February 27, 2026, and VA2 was unsupervised in the community until s/he was located March 5, 2026. Medical records showed both VAs tested positive for substances, but did not require treatment. At the time of the incident, SP1 and SP2 were assigned to provide 1:1 supervision to the VAs. SP1 provided inconsistent information to LE, the facility, and this investigator. Based on the information it was unclear the reason SP1 went into the restaurant, or whether s/he was in the facility vehicle searching for a phone charger prior to VA1 and VA2 leaving the area. SP1 said s/he maintained visual contact of the VAs, but they left without SP1 observing them leave the area. SP2 said s/he entered the restaurant for a drink of water, and returned to where SP1, VA1, and VA2 were. Then, SP2 re-entered the restaurant by him/herself, and ordered food. SP2 said s/he maintained visual contact of VA1 and VA2 while ordering food, and waiting to receive his/her food, however lost visual contact of the VAs when SP1 entered the restaurant and asked about a phone charger. Given that SP1 and SP2 were inside a restaurant while VA1 and VA2 were outside, that SP1 and SP2 did not maintain supervision of VA1 and VA2 as required by their plans so that VA1 and VA2 were able to leave without supervision in the community, and that there was substantial risk of harm given that VA1 was not found until the next day and VA2 was not found until March 5, 2026, and both VAs had obtained and consumed substances, there was a preponderance of the evidence that there was a failure to provide VA1 and VA2 with reasonable and necessary care and services to maintain their health and 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. SP1 received training on VA1’s client specific programming, including VA1’s supervision requirement, and was responsible for the supervision of VA1 during the incident. Therefore, SP1 was responsible for the maltreatment. SP2 received training on VA2’s client specific programming, including VA2’s supervision requirement, and was responsible for the supervision of VA2 during the incident. Therefore, SP2 was responsible for the maltreatment. 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 SP1 and SP2 were responsible did not meet statutory criteria to be determined as recurring because it was a single incident or serious because the VAs did not require care of a physician as defined in statute. Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, but not followed. The facility completed additional training with all staff persons regarding community supervision, following the facility’s policies regarding immediate escalation and notification if a person served cannot be located. The event was similar to past events, SP1 and SP2 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of SP1. The determination that SP1 was responsible for maltreatment is subject to appeal. SP2 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP2 was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of SP2. The determination that SP2 was responsible for maltreatment is subject to appeal.
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