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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: 1123501-Intensive Residential Treatment Services/Residential Crisis Stabilization Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a vulnerable adult (VA) was found deceased and there were concerns with a lack of supervision. Date of Incident(s): May 9, 2025 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 October 22, 2025; from documentation at the facility, law enforcement (LE) records, and autopsy records; and through two interviews conducted with facility supervisors (P1 and P2). The facility was a two-story building, and the VA’s bedroom was at the end of a hallway on the second floor. The VA’s bedroom was on the opposite side of the facility as the staff office. The facility provided intensive residential treatment and crisis stabilization services to adults who were diagnosed with a serious mental illness. Length of stay in the crisis stabilization program ranged from one to ten days and in the intensive residential treatment program up to 90 days with reauthorization for individuals requiring longer lengths of stay. Facility documentation showed the VA’s family, religion, and culture were important to him/her. The VA was described as patient, loyal, and protective. The VA had a history of drug possession and use. The VA was diagnosed with bipolar disorder, schizoaffective disorder, and depression. The VA also provided information to the facility that s/he had a brain injury due to a car accident. The VA was motivated to stay abstinent from substances. P1 provided the following information: · P1 was not sure the exact time the incident occurred, but believed the VA was found unresponsive approximately between 11 p.m., and 12 a.m., on May 8 to 9, 2025. P1 said two staff persons (P3 and P4) were working during the incident. P4 was completing hourly rounds and entered the VA’s bedroom and found the VA slumped over, blue, and the VA appeared deceased based on P4’s observation. P1 said P4 did not administer Narcan (an emergency treatment for opioid overdose), but P1 stated that P4 requested assistance from P3, and 9-1-1 was called within minutes of P4 finding the VA. · Upon reviewing camera footage, P1 said on May 8, 2025, a staff person knocked on the VA’s door around 7 p.m. as a notification that the 7 p.m. group session was starting, but the staff person did not open the VA’s door, and the VA did not attend the group session. · P1 said prior to the incident the facility did not have required hourly checks between 7 a.m. and 11 p.m. P1 said staff persons prompted persons receiving services for meals, medication administration, and groups sessions during awake hours. Staff persons completed hourly rounds during asleep hours. The VA’s daily log provided the following information: · On May 8, 2025, between 11 and 11:50 a.m., the VA completed a group session. It was noted during the group session the VA was “stable,” and was active in the discussion. · On May 8, 2025, around 2 p.m., a daily log note showed there were no concerns with the VA. · On May 8, 2025, between 3 and 4 p.m., the VA completed a group session. It was noted during the group session the VA was “stable,” and was active in the discussion. · On May 9, 2025, at 1 a.m., a note was created by P1 that stated at approximately 11 p.m., the VA was found unresponsive during a routine bedroom check. P1 noted P3 and P4 were present for the incident, P1 was contacted by P3 and P4 after 9-1-1 was contacted. P1 arrived at the facility after LE and EMS had arrived. (Note: According to LE records 9-1-1 was contacted at 12:13 a.m., and LE was dispatched to the facility. P3 and P4 each told LE that this check was conducted at 12:10 a.m. so it was determined that P1 was incorrect saying 11 p.m.) · The VA had drug paraphernalia near him/her. The VA was pronounced deceased by medical professionals. A medical examiner arrived at the facility and took the VA’s body for examination. Video recordings provided the following information: · On May 8, 2025, at 5:10 p.m., the VA was seen in the dining area, and was on his/her phone while appearing to eat food. The VA appeared unsettled and fidgeting in comparison to other persons at the tables. · On May 8, 2025, at 5:40 p.m., the VA was seen quickly moving up and down a hallway near his/her bedroom. The VA entered his/her bedroom at 5:41 p.m. · On May 8, 2025, at 7:02 p.m., a staff person knocked on the VA’s bedroom door and attempted to inform him/her that a group session was about to start. The group session was seen starting at the end of the hallway. · The facility did not have a video recording of the time when P4 checked on the VA and found the VA unresponsive in his/her bedroom. The videos mentioned above were saved within 90 days of the incident, however the video recording of when the VA was found deceased was not saved prior to this investigation. The videos on the facility’s recording system expired after 90 days, and the investigation was not assigned until after that timeframe had lapsed, therefore this investigator was unable to obtain the video. Medical Examiner records showed the time of death of the VA was determined to be at 12:13 a.m., on May 9, 2025. The manner of death of the VA was considered “accident,” with an immediate cause noted as “positional asphyxia complicating mixed fentanyl and methamphetamine toxicity.” Webmd.com showed positional asphyxia occurred when the position of a person’s body obstructed their breathing. A cause of asphyxia was drug overdose as opioids affected breathing, and when a person had too high of a dose, it could slow down their breathing to the point that their body did not take in enough oxygen. LE records provided the following: · LE was dispatched to the facility at 12:13 p.m., and the VA was pronounced deceased upon arrival. The VA’s body was “stiff,” and LE was unable to find a pulse. · LE found a “piece of burnt tinfoil along with a torch on the bed” near the VA. LE also found a Post-it note near the lighter and tinfoil. LE believed the items found were a sign of a narcotic related overdose. LE/Medical Examiner found two additional folded Post-it notes on the VA, and it was suspected that both Post-it notes contained fentanyl. It was later confirmed the substance was fentanyl. · P4 told LE s/he completed a routine check at 12:10 a.m. and found the VA lying face down and was unable to find a pulse. P4 observed the VA to be unconscious and not breathing, and P3 contact 9-1-1. P3 provided information consistent with what P4 provided to LE. P1 and P2 provided consistent information as documented above. P1 and P2 shared process changes the facility would attempt to implement to try and prevent any further similar issues of drug overdose. P1 said the VA had the right to refuse group, but all persons served were encouraged to participate in all group sessions. The facility completed an Internal Review (IR) which provided consistent information as stated in LE records and interviews as well as the following information: · The VA was found sitting “somewhat upright but slumped” over on his/her bed. The VA was observed to be “blue,” “unresponsive,” and “not breathing,” when staff persons found him/her. · The facility had a policy that stated that Narcan should be administered in the instance of suspected drug overdose. · P3 and P4 explained they contacted 9-1-1 but did not administer Narcan because the VA was already deceased when P4 found him/her. The facility’s Health and Safety Policy included, but was not limited to the following information: · Staff persons would complete eyes on checks of the persons receiving services regularly throughout the day during each shift. · In a health emergency a staff person should call 9-1-1 or have someone else call 9-1-1. · Staff persons would administer Narcan if a drug overdose was suspected. After the incident the facility implemented an “Enhanced Safety Policy,” and retrained all staff persons on the use of Narcan. The facility trained all staff persons on client specific information, the facility’s policy and procedures, basic first aid, and Reporting of Maltreatment of Vulnerable Adults. Conclusion: On May 9, 2025, P4 found the VA unresponsive at the facility during a routine check. P4 was unable to find a pulse, the VA was blue, and the VA appeared deceased. 9-1-1 was contacted, and LE was dispatched to the facility at 12:13 p.m. LE noted the VA did not have a pulse, his/her body was stiff, and the VA was pronounced deceased. While in the VA’s bedroom LE identified multiple signs of a drug use and it was later confirmed the VA had fentanyl in his/her system. On May 8, 2025, the VA was observed last by a staff person at 5:10 p.m. A video recording showed the VA moving quickly in a hallway near his/bedroom around 5:40 p.m. At around 7 p.m., a staff person knocked on the VA’s bedroom door in an attempt to engage him/her in a group session but the VA did not attend group. P1 said the VA had the right to not complete group sessions. Routine checks were not conducted during awake hours but were conducted at night. Facility documentation completed by P1 at 1 a.m., on May 9, 2025, showed the VA was found unresponsive during a routine check at 11 p.m., however, during an interview P1 stated the routine check was completed sometime between 11 p.m. and 12 a.m. and P1 was not present so it was determined P1 incorrectly stated the time. LE records showed P3 and P4 each told law enforcement the VA was checked on at 12:10 a.m., and they called 9-1-1 at 12:13 a.m. P1 stated P3 and P4 contacted 9-1-1 within minutes of finding the VA unresponsive, P3 and P4 then called P1, and P1 arrived at the facility after LE and EMS. Information was mostly consistent that the VA was likely found at 12:10 a.m. and that 9-1-1 was called at 12:13 a.m. Although P3 and P4 did not start CPR and did not administer Narcan when P4 found the VA, the VA appeared to be deceased. Given that 9-1-1 was called immediately after finding the VA unresponsive and deceased, that the VA was not required to be checked on during awake hours, that P4 checked on the VA once overnight checks began, and that the VA’s cause of death was an “accident,” 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). 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 staff persons regarding the incident response. The event was not similar to past events and no corrective action taken by the facility regarding the incident. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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