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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: 800257-DS (Detoxification Center) Investigator(s): Anna Parkin Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) overdosed on fentanyl while at the facility. Date of Incident(s): February 21, 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 April 9, 2026; from documentation and video footage at the facility, law enforcement records, the VA’s certificate of death, and the VA’s autopsy report; and through nine interviews conducted with a supervisory staff person (P1), four facility staff persons (P2-P5), the VA’s family members (FM1 and FM2), and two community persons (CP1 and CP2) who knew the VA. Attempts were made via telephone and certified mail to obtain information from another staff person (P6), but P6 did not respond to the requests. Information was obtained throughout the investigation that there were concerns with the clients access to illegal substances. Given that the facility policy was to pat search clients of the same gender and visually search the clients of the opposite gender, there were still other methods of getting illegal substances into the facility so this information will not be included in this report. The facility’s Policies and Procedures Manual stated that the facility was a “sub-acute” detoxification center serving both genders. Most clients were under the influence of mood-altering chemicals upon admission. The facility had an intake vestibule where the clients were first brought by law enforcement or other agencies. Once the intake process was complete, the clients were assigned either a single or shared bedroom. All bedrooms were in one hall off the main living area. The facility had video cameras in the main area and hall but not inside the bedrooms or bathrooms. The facility admitted up to 16 clients at a time and generally had two to three staff persons working at a time. On February 19, 2026, the VA was arrested by law enforcement and admitted to the facility at 6:30 p.m. for intoxication of Xanax and methamphetamines. The VA said s/he took 16 Xanax (0.5 milligram) “bars” and an “eight ball of dope” just prior to getting arrested. The VA’s Initial Service Plan provided the following information: · The VA was intoxicated on Xanax, methamphetamines, and opiates. During the first 24 hours the VA detoxed from substances, staff persons measured the VA’s vital signs and evaluated the VA using the Clinical Institute Withdrawal Assessment (CIWA) and/or the Clinical Opiate Withdrawal Scale (COWS). Staff persons checked the VA every four hours and provided medications as needed. If needed, the VA started a substance protocol. · Once the VA was sober, staff persons continued to monitor and treat any withdrawal symptoms that occurred. If the VA was not on withdrawal protocol and vitals were stable, the VA was elevated with CIWA and COWS and checked on every eight hours and given medications as needed. During that time, the VA was given a chemical dependency assessment and recommendations and assistance were given for any chemical dependency treatment, human services, and other external resources. The COWS scale for scoring that staff persons used included: 0-6 no withdrawal, 7-9 mild withdrawal, 10-14 moderate withdrawal, and over 15 severe withdrawal. On February 20, 2026, at 1 p.m., the VA started an opiate protocol and was given ten milligrams of diazepam every four to six hours as needed. Staff persons did not administer the diazepam if the VA’s COWS score was less than five. On February 20, 2026, at 1:20, 5:20, and 9:20 p.m., the VA was given diazepam. On February 21, 2026, at 1:20 and 5:20 a.m., the VA’s COWS was documented as one because of “sweating” so no diazepam was given at those times and staff persons continued to monitor the VA. The law enforcement report stated that on February 21, 2026, at 8:36 p.m., 9-1-1 was called for an unresponsive client, later identified as the VA. When a law enforcement officer arrived, s/he was told by paramedics that the VA was deceased. The VA had no pulse, was cold to the touch, showed postmortem lividity, and rigor mortis set in. There was a “large” amount of foam coming from the VA’s mouth. The VA’s Final Autopsy Protocol stated on February 22, 2026, at 11:25 a.m., the VA’s autopsy was completed and showed the VA tested positive for 28 nanograms per milliliter (ng/mL) of methamphetamine, 5.7 ng/mL of fentanyl, 1.0 ng/mL of norfentanyl (metabolite of fentanyl formed in the body after fentanyl is processed), 82 ng/mL diazepam, and “presumptive positive” for cotinine (metabolite of nicotine). The VA’s Certificate of Death stated the VA’s death on February 21, 2026, at 8:35 p.m., was caused by methamphetamine, fentanyl, and diazepam toxicity and was listed as accidental. According to the Facility Abuse Prevention Plan, to minimize the risk of abuse of clients, clients were monitored “at least” hourly. Staffing ratios were one staff person for every six patients. P1-P5 provided the following information to law enforcement, this investigator, on the VA’s hourly check form, and in the VA’s progress notes: · P1 stated that staff persons were trained to complete hourly checks by opening the bedroom door, checking on the clients, and ensure they were breathing. · P2-P5 each stated that other staff persons trained each on the hourly checks when they started that included the following: o P2 said s/he was trained that if s/he saw or heard a client at any point during the hour that was considered the hourly check. o P3 said was trained to “account where [clients] were at.” P3 looked and saw where each client was and documented their location. o Prior to the incident, P2 and P3 each thought that if s/he heard a client snoring that was a sufficient check. o P4 stated that s/he checked where each client was and that they were breathing. o P5 stated s/he said each client’s name and waited for a response. P5 was initially told that if a client was sleeping during an hourly check s/he was to document their respirations. · On February 19, 2026, from 3 to 11 p.m. P3 and P4 worked. P4 stated that during that time, the VA stayed in his/her bedroom, slept, and refused vitals which was common for persons detoxing from illegal substances. P3 stated that the VA was laughing, joking, and appeared sober. On February 20, 2026, from 3 to 11 p.m., P1 and P3 worked and the VA was talking, eating, and appeared “fine.” The VA did not appear intoxicated. · On February 20, 2026, at approximately 1 p.m., because the VA’s intoxication the day before included Xanax, the facility nurse sent the VA to the emergency room for an electrocardiogram. The VA was accompanied by law enforcement. The emergency room doctor did not believe the VA needed the test and sent the VA back to the facility. · On February 21, 2026, P2 worked from 7 a.m. to 3 p.m. The VA slept most of the day in his/her bedroom. P2 was trained to do vitals every four hours and hourly visual checks. At 9:20 a.m., the VA refused vitals. P2 said s/he did not do visual checks on the VA from 9:20 a.m. to 12:45 p.m. because P2 heard the VA snoring from the hallway so s/he did not go into the VA’s bedroom to checks. · At 12:45 p.m., when P2 went into the VA’s bedroom, the VA was “sleep talking” which P2 described as the VA was “deep gasping” similar to a snore while “deep” breathing. P2 called out the VA’s name and s/he stopped gasping. P2 asked if the VA wanted his/her vitals taken but the VA did not respond. P2 then shook the VA who “grunt[ed]” “leave me alone.” The VA was moving around in bed and breathing at a rate of 16 which P2 said was “normal.” P2 said s/he did not notice anything else unusual at that time. P2 did not think anything was wrong at that time because it was “common” for clients to snore and the VA spoke to P2. At some point between then and 2 p.m., P2 visually checked on the VA twice and there were no concerns. · At 3 p.m., P3 and P4 began working and each stated that P3 was assigned to take vitals every four hours. P3 worked on documentation and P4 was assigned to do the hourly checks. P4 stated both P3 and P4 were assigned to do hourly checks. At 4:45 p.m., P3 opened the VA’s bedroom door and asked the VA if P3 could take his/her vitals and the VA said, “No.” At that time, the VA was lying on his bed under a blanket. · P3 and P4, provided information during their interviews that conflicted with their documentation on the hourly check form. o The hours check form provided the following information: § At 4 and 5 p.m., P4 documented that s/he checked on the VA who was asleep in his/her bedroom. § At 6 p.m., P3 documented that s/he checked on the VA who was in his/her bedroom. § At 7 and 8 p.m., P4 documented that the VA was asleep in his/her bedroom. § There were eight clients with two staff persons. o P3 initially told law enforcement and this investigator s/he did not complete any hourly checks on the VA because s/he was assigned to documentation in the office and take vitals every four hours and P4 was assigned to the hourly checks. When asked about the 6 p.m. hourly check on the hourly check form, P3 later told this investigator that s/he “possibly” did the 6 p.m. check that was documented but did not remember it. o P4 told this investigator that s/he did not remember if s/he completed the hourly checks on the VA between 4:45 and 8:45 p.m. but told law enforcement that s/he had not seen the VA prior to 8:45 p.m. including during hourly checks. P4 did not remember what s/he did during that timeframe but was busy because they were short staffed. · At 8:45 p.m., P3 asked P4 to try and get the VA’s vitals and P4 agreed. P4 then went to the VA’s room, opened the VA’s bedroom door, and called the VA’s name four to five times but the VA did not respond. P4 turned the light on and saw the VA on the bed, foaming at the VA’s mouth. P4 went to and shook the VA, took the blanket off, and felt the VA who was cold to the touch. P4 ran back to the staff office and yelled to call 9-1-1, so P3 called 9-1-1 and emergency services arrived before P3 was able to check the VA. [Note: As outlined above, the law enforcement report stated that the 9-1-1 call was made at 8:36 p.m.] · Law enforcement arrived and pronounced the VA as deceased. Later that night during P4’s interview with law enforcement, P4 said that s/he was aware the VA had his/her vitals taken every four hours and that P4 did hourly checks “once in awhile” but did not know they were required. · P1 reviewed video footage which showed that on February 21, 2026, at 9:20 a.m., the VA went into his/her bedroom and did not leave afterwards. Video footage reviewed for this investigation showed on February 21, 2026, at 4:40 p.m., P3 opened the VA’s bedroom door and stood in the doorway for approximately eight seconds before leaving and closing the door. P3 and P4 did not enter the VA’s bedroom again until 8:33 p.m., when P4 found the VA deceased. CP1 stated on February 20, 2026, at an unknown time, s/he spoke to the VA on the phone. The VA sounded “groggy” like s/he just woke up but CP1 did not think that the VA was under the influence. On February 21, 2026, at approximately 5 p.m., CP1 spoke to another client (C) on the phone and heard the C tell staff persons to check on the VA. CP1 did not know which staff person the C spoke to but did not think staff persons checked on the VA. FM1, FM2, and CP2 did not have information relevant to the investigation. Facility documentation showed that all staff persons interviewed for the investigation, including P1-P5, were trained on the VA’s plans, Facility Abuse Prevention Plan, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: A. Maltreatment: On February 21, 2026, at 8:45 p.m., P4 went to take the VA’s vitals and called out the VA’s name multiple times but the VA did not respond. P4 turned the light on and saw foaming at the VA’s mouth. P4 went and shook the VA, pulled the VA’s blanket off, and the VA was cold to the touch. Law enforcement arrived and pronounced the VA deceased. The VA’s Certificate of Death stated on February 21, 2026, the VA’s death was caused by methamphetamine, fentanyl, and diazepam toxicity and was listed as accidental. P1 stated that according to video, at 9:20 a.m., the VA went to his/her bedroom and did not leave at any point. Between 9:20 a.m. and 2 p.m., the VA’s checks were done and the VA was either sleeping and snoring or verbally responded to staff persons telling staff to leave him/her alone. From 3 to 11 p.m., P3 and P4 worked. According to the hourly check form, from 4 until 8 p.m., P3 and P4 documented that the VA was in his/her bedroom asleep. However, P3 said s/he did not complete hourly checks because P4 was assigned that responsibility, and P4 said s/he did not remember if s/he completed hourly checks and that s/he had not seen the VA prior to 8:45 p.m., when s/he found the VA deceased. Video footage showed at 4:40 p.m., P3 went to take the VA’s vitals while s/he was asleep in bed. P3 said s/he opened the VA’s bedroom door and asked the VA if P3 could take his/her vitals and the VA said, “No.” Given that information provided on the hourly check form was inconsistent with the information provided by P3 and P4 regarding hourly checks, it was most likely that 4:40 p.m. was the last time the VA was checked on prior to being discovered deceased at 8:45 p.m. Although it was not known if hourly checks would have prevented the VA’s death, given that the VA was at the facility, which was a “sub-acute” detoxification center serving persons who were under the influence of mood-altering chemicals, due to intoxication, and that hourly checks were not completed for four hours, between 4:45 and 8:45 p.m., there was a preponderance of the evidence that there was a failure to provide the VA with reasonable and necessary care. 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. P3 and P4 were the staff persons who were responsible for the care and supervision of the VA at the time of the incident and each was trained on the Facility Abuse Prevention Plan and Reporting of Maltreatment of Vulnerable Adults Act. P3 and P4 documented that they completed hourly checks on the VA from 4 to 8 p.m. P3 stated that P4 was assigned to do hourly checks on the clients and P4 stated that they both were doing hourly checks. However, P3 also said s/he did not complete hourly checks because P4 was assigned that responsibility and despite having documented that s/he completed the hourly check at 6 p.m., P3 but told this investigator s/he did not remember doing the check. P4 documented two checks between 7 and 8 p.m. but told law enforcement that s/he had not seen the VA prior to 8:45 p.m. including during the hourly checks. Video footage showed that at 4:45 p.m., P4 stood in the doorway of the VA’s bedroom otherwise P3 and P4 did not go into the VA’s bedroom for the hourly checks. Therefore, P3 and P4 were each 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 in this report for which P3 and P4 were responsible did not meet statutory criteria to be determined as recurring or serious. It was a single incident of neglect and although the VA passed away, it was not known if P3’s and P4’s actions would have impacted the outcome. However, information obtained by the Department of Human Services, in combination with this report, resulted in P3 being disqualified for recurring maltreatment. P3 was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. P1 reviewed video footage at the facility and confirmed that the hourly checks were not completed as documented on the hourly check form. P4 no longer worked at the facility. Staff persons received additional training on hourly checks, documentation accuracy, patient monitoring, recognition of opioid intoxication, respiratory distress and medical instability, and reinforcement of supervision expectations. The facility updated the hourly check procedures, implemented a routine audit of safety checks and documentation, implemented of audit of documentation practices to ensure accuracy and accountability, increased supervision protocols when clients had personal belongings prior to discharge, and enforced restrictions on clients accessing other client rooms. Action Taken by Department of Human Services, Office of Inspector General: P3 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 SP3 was responsible for maltreatment and the disqualification of SP3 are each subject to appeal. P4 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, P4 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 P4’s disqualification. The determination that P4 was responsible for maltreatment is subject to appeal. On June 17, 2026, the facility was issued a Correction Order for not providing annual training on reporting maltreatment as required and not following the procedures on monitoring client health.
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