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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: 1067928-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jamie Randall 651-431-4121 Suspected Maltreatment Reported: It was reported that when a vulnerable adult (VA) had seizure activity, two staff persons (SP1 and SP2) did not follow the VA’s seizure protocol, and the VA was admitted to a hospital. Date of Incident(s): February 14, 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 4, 2026; from documentation at the facility; and through nine interviews conducted with four supervisory staff persons (P1-P4), three facility staff persons (P5, SP1, and SP2), a facility nurse (P6), and the VA’s guardian (G). This investigator met the VA, but the VA was not interviewed due to his/her disability. The VA enjoyed arts and crafts, going out to eat, going for boat rides, and fishing. The VA’s diagnoses included severe intellectual disabilities, epilepsy and recurrent seizures, and cerebral palsy. The VA’s seizure protocol was posted on a wall in the staff office and on the back of the VA’s bedroom door. The protocol said that staff were to “help [the VA] move to a safe space when [s/he] is having a seizure. Preferably this would be in [his/her] room with a mat on the floor.” Staff were not to “put anything” underneath the VA’s head or to “restrain” the VA so the VA was able to “move around” while s/he had a seizure. Staff were to track the total time of the seizure. If the VA had seizure activity for more than five minutes, two milliliters (ml) of diazepam was to be administered “into [the VA’s] cheek.” If seizure activity continued for twenty minutes after the diazepam was administered, 9-1-1 was to be called. The facility was a ranch style home. The VA’s bedroom was on the main level next to a bathroom and a staff office. The VA had a padded mat that was kept in his/her bedroom and was placed on the floor when the VA had seizures. The VA’s medications were stored in a cabinet in the staff office. SP1 and SP2 provided the following information during their interviews and in progress notes: · On January 14, 2026, SP1 and SP2 worked a shift at the facility. SP1 said that toward the end of the shift, SP1 and SP2 were assisting one of the VA’s housemates in his/her bedroom when SP2 “stopped what [he/she] was doing” and left the bedroom. SP1 thought s/he heard one of SP2’s personal medical devices make a noise and assumed SP2 was turning the noise off but SP2 did not come back into the bedroom. SP1 continued assisting the housemate. · When SP2 left the housemate’s bedroom, s/he assisted the VA with getting ready for bed in the bathroom. SP2 asked the VA, who was sitting on the toilet, to remove his/her clothes as SP2 left the bathroom to get the VA pajamas from the VA’s room. At 7:15 p.m., when SP2 returned to the bathroom, SP2 saw that the VA was having a seizure and assisted the VA to the floor. The VA had removed his/her clothes and was sweating. The VA was “alert” despite the seizure activity and SP2 asked the VA to go to his/her bedroom. SP2 then placed a blanket over the VA and the VA crawled on the floor from the bathroom to the VA’s bedroom, where the VA then lay on a floor mat. SP2 went to the staff office to get the VA’s diazepam and when s/he returned to the VA’s bedroom, s/he administered two ml of diazepam buccally to the VA as per the VA’s seizure protocol. · About 15 minutes after the VA’s seizure started, SP2 called an on-call supervisor. SP2 did not remember who the supervisory staff person was but SP1 said it was P3. SP2 told P3 that the VA was having a seizure but P3 could not understand SP2 and asked if s/he could speak with another staff person. · SP2 went to SP1 and after SP1 clarified with SP2 that the VA was having a seizure, SP1 told P3 as such and P3 told SP1 to check on the VA. · SP1 and SP2 went back the VA’s room, where the VA remained on the floor still have a seizure. SP1 asked SP2 if s/he had started to time the seizure and SP2 said, “We are not worried about that now,” to which SP1 responded that s/he “was worried about that,” and needed the time. SP2 told SP1 that s/he already administered the VA’s diazepam and had the diazepam bottle and a syringe in his/her hand. SP1 asked SP2 if it had been twenty minutes to which SP2 said, “Yes, it was past twenty minutes.” SP1 did not know how the VA got from the bathroom to the bedroom and SP2 said the VA “crawled.” · SP1 then gave the phone back to SP2, who asked P3 why s/he did not understand SP2. P3 said it was due to the phone. SP2 provided different information regarding administering the VA’s diazepam. SP2 told this investigator that s/he administered the diazepam prior to calling P3 but SP2 wrote in the progress notes that s/he administered the diazepam at 7:23 p.m. after s/he got off the phone with P3. SP1 then left the VA’s room to assist another housemate as SP2 remained in the VA’s room with the VA. · Shortly after, P4 arrived at the facility which was approximately 20 minutes after SP2 had administered the diazepam. P4 went into the VA’s bedroom and told SP1 and SP2 to call 9-1-1 and then P4 left. SP2 said that s/he called 9-1-1 prior to P4’s arrival while SP1 said that SP2 called after P4 left. SP1 said emergency services arrived five minutes later and took the VA to a hospital. SP2 said that emergency services arrived at 7:50 p.m. and the VA was transported to the hospital at 8 p.m. SP2 followed the ambulance to the hospital. · SP2 stayed at the hospital for three or four hours and was told that the VA was going to be admitted and s/he could leave. SP2 arrived back at the facility “around” 10:30 p.m. · SP2 said when the VA had seizures, s/he lay down on the mat in his/her room and then got up on both knees to kneel. During seizures, the VA was “still alert” and could do certain things when asked such as crawl to his/her mat. After the VA had five minutes of seizure activity, staff administered the VA two ml of diazepam buccally and if the seizure activity continued for twenty minutes after the diazepam was administered, staff called 9-1-1. Medical records provided the following information: · On February 14, 2026, at 8:13 p.m. emergency medical services (EMS) were dispatched to the facility. The ambulance arrived at the facility at 8:22 p.m. and staff persons told the EMS that the VA had, “Seizure like activity [that] started at 8 p.m.,” and that they had administered diazepam. At 8:32 p.m., the VA was brought to the emergency room via ambulance. · At 8:47 p.m., the VA arrived at the emergency room (Er) and had “approximately 35 minutes of seizure activity” prior to arriving to the ER. The VA appeared to be “maintaining some awareness” but was “unable to follow commands.” The VA had “medium amplitude, rhythmic jerking movements of all four extremities.” The VA was given four milligrams (mg) IV lorazepam and received 4.5 grams levetiracetam/Keppra and the VA’s seizure activity “halted.” At 10:56 p.m., the VA was admitted to the neurology department. · On February 14, 2026, at 10:21 p.m., a neurologist documented that on February 7, 2026, the VA tested positive for COVID-19 and influenza and had been admitted to the hospital until February 12, 2026. The neurologist suspected the VA’s seizure was the result of a “lowered seizure threshold” due to the recent illness. · The next day, the VA returned to baseline and on February 16, 2026, the VA was discharged back to the facility. The VA’s daily Keppra was increased and the VA was to follow up with his/her neurologist in three months. P4 provided the following information during his/her interview and for the facility’s internal review: · On February 14, 2026, at 7:45 p.m., P3 called P4 and said that the VA was having seizure activity and asked if P4 knew the VA’s seizure protocol. P4 was not sure of the protocol and told P3 that if s/he wanted P4 to go to the facility to call P3 back. · At 7:57 p.m., P3 called P4 again and told P4 that s/he was “worried” about the VA so P4 drove to the facility. At 8:01 p.m., as P4 drove to the facility., P2 called asking about the VA. P4 told P2 that s/he was on the way to the facility and ended the call around 8:05 p.m., when P4 arrived at the facility. · Once at the facility, P4 went to the VA’s room where the VA was unclothed on the mat on the floor. The VA was having seizure activity and could hardly hold his/her head up. P4 told SP2 to call 9-1-1 and SP2 said they were following the seizure protocol. P4 told SP2 to call 9-1-1 immediately. Once SP2 called 9-1-1, P4 left the facility but did not leave the facility and remained in his/her vehicle. · At 8:11 p.m., P4 called P3 and told P3 what s/he saw and that 9-1-1 was called. At 8:23 p.m., P4 called P2 and told P2 that the ambulance was called and P4 could “hear the sirens.” P4 was not sure of the exact time that the ambulance arrived at the facility. P3 provided the following information during his/her interview and in supervisory notes: · On February 14, 2026, at 7:19 p.m., P3 received a call from SP2 that the VA was having an “episode.” P3 did not understand what SP2 was trying to tell him/her and asked to speak with SP1. SP1 said that the VA was having a seizure. P3 told SP1 that s/he would contact P2 to get “clarification” on the VA’s seizure protocol. [Note: There was no information provided by SP1 and/or SP2 that they asked P3 for clarification regarding the VA’s seizure protocol.] · At 7:23 p.m., P3 called P2 twice and left a voicemail regarding questions about the VA’s seizure protocol. P3 then text P2 twice, which showed a “read” notification. P3 then called P4 and asked P4 if s/he was familiar with the VA’s seizure protocol. P4 was not familiar but lived near the facility and said s/he would go to the facility. At 7:46 p.m., P2 called P3 and told P3 the steps of the VA’s seizure protocol. · At 7:52 p.m., P3 called SP2 and told SP2 that 9-1-1 was to be called if it had been twenty minutes since the VA received diazepam per the VA’s seizure protocol. SP2 told P3 that when s/he called P3 before it was to ask if s/he could administer the diazepam to the VA. P3 told SP2 that if a protocol was written to administer a medication, that SP2 did not need permission and should administer the medication. P3 told SP2 to call 9-1-1 as it had been over thirty minutes of seizure activity. · At 8:11 p.m., P4 called P3 and said the VA was actively convulsing and signing for food. P4 had told SP2 to call 9-1-1 and SP2 asked if it was necessary to which P4 replied that it was. · At 8:38 p.m., SP1 called P3 and said that the VA went to the hospital accompanied by SP2. · At 10:16 p.m., SP2 called P3 to ask if s/he could provide the hospital with the on-call supervisor phone number. P3 asked to speak with a hospital nurse and provided them with the number. The hospital nurse told P3 that SP2 told him/her that the VA had seizure activity that started at 8 p.m. to which P3 replied that the VA had seizure activity which started before 7:19 p.m. when SP2 initially called P3. P5 stated that on February 16, 2026, at 1 p.m., P6 and P5 met at the hospital because the VA was being discharged. P6 and a hospital worker assisted the VA to P5’s vehicle, and P5 drove the VA to the facility. The VA was a “little congested” but was “happy” and interacted with stuffed animals that were in P5’s vehicle. P5 left the facility shortly after. The G was aware of the VA’s seizure on February 14, 2026. The VA had a history of “small seizures” but had not had a seizure in the past year. P2 provided information that was consistent with the information provided by P3 and P4 regarding their respective phone calls to P2. P1 completed the facility’s internal review and was provided similar information that staff persons interviewed provided for their interviews. Facility records showed that P1-P6, SP1 and SP2 were trained on the VA’s plans, the VA’s seizure protocol, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: On February 14, 2026, the VA had seizure activity that started when s/he was in the bathroom as SP2 assisted the VA with getting pajamas on. SP2 went to the VA’s bedroom to get pajamas and when s/he returned to the bathroom, the VA had taken his/her clothes off, was sweating, and was having seizure activity. SP2 assisted the VA to the floor of the bathroom. The VA was still “alert,” and SP2 asked the VA to crawl to his/her bedroom. SP2 placed a blanket on the VA, and the VA crawled to his/her bedroom and laid on the mat on his/her bedroom floor. SP2 went to the staff office and collected the diazepam for the VA. SP2 went back into the VA’s room and administered two ml of diazepam buccally to the VA as per the VA’s seizure protocol. At 7:19 p.m., P3 received a phone call from SP2 where SP2 said that the VA was having an “episode” for twenty minutes and P3 did not know what SP2 meant. P3 asked to speak with SP1, who was also working the shift with SP2. SP1 clarified to P3 that the VA was having seizure activity. SP2 told this investigator that s/he administered diazepam to the VA prior to calling P3 but progress notes written by SP2 said it was after the call at 7:23 p.m. SP1 said that s/he did not see SP2 administer diazepam but SP2 had a syringe and diazepam in his/her hand. At 7:52 p.m., P3 called SP2 and told SP2 that 9-1-1 was to be called if it had been twenty minutes since the VA received diazepam. SP2 told P3 that when s/he called P3 before it was to ask if s/he could administer the diazepam to the VA. P3 told SP2 that if a protocol was written to administer a medication, that SP2 did not need permission and should administer the medication. P3 told SP2 that s/he needed to call 9-1-1 if the VA was still having a seizure as it had been over thirty minutes. SP2 said s/he called 9-1-1 twenty minutes after s/he administered the diazepam to the VA. Shortly after, P4 arrived at the facility and told SP2 and SP1 to call 9-1-1. P4 said that s/he got to the facility at 8:05 p.m. SP1 told this investigator that 9-1-1 was called after P4 came to the facility and P4 said that s/he left the facility after SP2 called 9-1-1. Emergency services arrived and took the VA to the hospital via ambulance. SP2 said that emergency services arrived at 7:50 p.m., while SP1 said that they arrived five minutes after P4 left the facility, and P4 said that s/he heard sirens at 8:23 p.m., while s/he was on the phone with P2. SP2 followed the ambulance in his/her vehicle. The VA was admitted to the hospital where s/he was given two antiepileptic medications and the VA’s seizure activity stopped. The VA returned to baseline the following day and was discharged back to the facility on February 16, 2026. Although information regarding times of events the evening of the incident differed so it was not able to be determined how many minutes passed between the beginning of the VA’s seizure activity, the administration of the diazepam, and 9-1-1 being called, given that the VA was administered diazepam and 9-1-1 was called which were both included in the VA’s seizure protocol, that because the VA was crawling and doing other actions during the seizure activity it was not able to be determined if the VA was having seizure activity the entire time or when the seizure actually started, that the VA returned to his/her baseline, and that SP1 and SP2 continued to monitor and care for the VA including calling supervisors, there was not a preponderance of the evidence as to whether there was a failure to supply the VA with care or services which were reasonable and necessary to maintain the VA’s physical or mental health or safety. It was not determined whether neglect occurred (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 were not followed by SP2. The VA’s primary care provider wrote a new seizure protocol for the VA and SP1, SP2, and P5 were retrained on the VA’s seizure protocol. All other staff persons were to be retrained on the seizure protocol. SP1 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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