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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: 1071009-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh/Beth Virden 651-431-3444 Suspected Maltreatment Reported: It was reported that after a vulnerable adult (VA) passed away, bloodwork showed the presence of a medication that was not prescribed to the VA. The VA’s autopsy listed his/her cause of death as probable mixed drug toxicity. Date of Incident(s): February 3, 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 15, 2026; from documentation at the facility and law enforcement- and medical-records; and through 23 interviews conducted with the VA’s guardian (G1) who was also the VA’s family member, a housemate’s guardian (G2), facility staff persons (P1-P7), supervisory staff persons (P8 and P9), administrative staff persons (P10 and P11), facility nurses (P12 and P13), a county medical examiner (ME), a pharmacist (P), and medical doctors (MD1 and MD2). Another family member of the VA’s, the VA’s two case managers, and a hospital care coordinator were interviewed but did not provide information relevant to this report. This investigation was completed in conjunction with a law enforcement officer (LEO), whose case was pending review by a county attorney. The VA’s support plans, including Intensive Services and Support Assessment, provided the following information: · The VA liked watching TV, listening to music, and going out to eat and on van rides. · In 2024, the VA moved into the facility seeking services and support relating to his/her diagnoses, which included: developmental disability; Down syndrome; early-onset dementia, which included a gradual decline in the VA’s cognition and memory; and insomnia, which led to frequent naps during the day. The facility supplied the VA with at least one staff person 24 hours a day who helped with the VA’s care and supervision and activities of daily living. · The VA could not independently identify or administer his/her medications or follow treatment orders. Staff were to schedule, transport, and accompany the VA to his/her appointments, and set up and administer the VA’s medications as prescribed. Staff were to watch the VA for signs and symptoms of discomfort and/or illness and treat accordingly.
The facility was a single-family house where the VA lived with a housemate (H). There were also two other housemates, but they were not part of the investigation. Information obtained through interviews, the VA’s records, facility documentation, and internet sources provided the following information: Regarding the VA’s death: · Consistent information was provided that in October 2025, the VA was diagnosed with a heart valve leak, which required ongoing monitoring through outpatient appointments. MD1 said that the VA had “moderate to severe aortic insufficiency,” which would eventually lead to heart failure and cardiac arrest of which the expected timeline was unknown. · The facility’s shift notes showed that between January 1 and February 2, 2026, the VA’s health, demeanor, and behaviors were typical and consistent most days with no obvious concerns. · On January 12, 2026, G1 and MD1 signed a Provider Orders for Life-Sustaining Treatment (POLST) for the VA. P8 was also present at this appointment. [Note: According to mn.gov, a POLST is for people with advanced illness or frailty, and it documents the person’s wishes for medical treatment in their current state of health.] The VA’s POLST stated that if the VA had a pulse and was breathing, s/he wanted to receive basic medical treatments aimed at treating any new or reversible illnesses. “Transfer to hospital if indicated. Generally, avoid the intensive care unit.” If the VA was pulseless and not breathing, s/he did not want to receive CPR or be intubated. · [Note: During this investigation, staff interchangeably used the terms – POLST; DNR (do not resuscitate order); and DNI (do not intubate order) – when referring to the VA’s POLST. The VA did not have a DNR or a DNI. The main difference among these documents is the scope. A POLST addresses CPR and other life-sustaining treatments whereas a DNR addresses CPR-only and a DNI addresses intubation-only. However, none of these documents prevent someone from calling 9-1-1 if a person was critically ill or required medical attention. Rather, emergency personnel should be informed of the document when treating a person who is critically ill or requiring medical attention – see mn.gov, goodrx.com, and mnmed.org.] · P9 said that on January 27, 2026, P8 held a staff meeting to go over the VA’s POLST. Prior to the meeting, P9 told P8, “Make sure to go through, you know, if anything happens, we still call 9-1-1.” · The facility’s meeting minutes for January 27 stated, “We will be discussing [the VA’s] POLST and what it means for you and for [the VA] … You may have seen it hanging on the medication cabinet. We need to discuss this in depth.” [Note: The meeting minutes did not provide additional detail regarding what exactly was discussed.] P1-P6 each said that they attended this meeting but could not recall what, if anything, was discussed about calling 9-1-1 and/or what to do if the VA was unresponsive. · On February 3, 2026, at 7 a.m., P2 and P8 arrived for the start of their respective shifts. P2 said that the VA was awake and appeared “chipper” (lively, cheerful) and “normal.” P2 helped the VA take a shower and then sit on the toilet. Almost immediately, the VA appeared “really sleepy” and “dozed off” while on the toilet. P2 tried to wake the VA up but s/he did not respond or open his/her eyes. The VA had a pulse and was breathing and looked like s/he was sleeping. The VA typically napped during the day but not to the point of being unresponsive. P2 called out for P8, and P8 told P2 that the VA’s unresponsiveness was related to the VA’s preexisting heart condition and that the VA was actively dying. P2 said that s/he asked P8 if they should call 9-1-1, but P8 said that there was nothing they could do for the VA at that point and said that s/he would call G1 to discuss next steps. They then carried the VA into his/her bedroom to await G1’s response. P2 said that s/he did not call 9-1-1 because P8 was a supervisor and had previously told P2 that s/he was also a “nurse,” so P2 did what P8 said to do. P2 was not a supervisor or a nurse. · P8 said that the VA looked like s/he was “sound asleep, snoring, with nothing visibly wrong.” P8 said that P2 never asked to call 9-1-1 but that even if s/he had asked, P8 still would have wanted to call G1 prior to calling 9-1-1. P8 wanted to let G1 make the decisions on how to proceed and G1 previously said s/he wanted the VA to die in his/her own bed and be comfortable. · G1 said that around 8 a.m., P8 called and said that the VA was “unresponsive” and actively dying due to his/her preexisting heart condition, which was expected to one day cause heart failure. P8 told G1 that if they brought the VA to the emergency room, the doctors would stick him/her with needles and make him/her uncomfortable, so P8 said that they should leave the VA at the facility to “peacefully” pass away. G1 agreed to not call 9-1-1 at that time because the VA had wanted to be comfortable at the end of his/her life and die in his/her own bed. “We thought [the VA] was dying a natural death.” Around 9 or 9:30 a.m., G1 arrived at the facility to be with the VA. “[P8] was in my ear all morning saying [the emergency room doctors] are only going to poke [the VA] with pins and needles and make it uncomfortable for [him/her].” G1 said that P8 was a “nurse” so G1 “was trusting [P8] as a nurse.” [Note: While speaking to the DHS investigator and the LEO, G1 repeatedly referred to P8 as “the nurse.”] · P3, P4, and P6 each said that at various times on February 3, 2026, P8 called and asked each of them to come into work because the VA was actively dying from his/her heart condition. P3, P4, and P6 each saw the VA and said that s/he appeared to be sleeping but would not wake up. · P3 said that after the VA was initially carried from the toilet to his/her bed, s/he asked P8 if they should call 9-1-1 but P8 said, “No,” because G1 wanted the VA to die peacefully in his/her own bed. P3 said that s/he heard P2 and G1 each, at different times, ask P8 if they should call 9-1-1 and heard P8 say, “No,” and heard P8 tell G1 that it “wasn’t a good idea” because the emergency room would poke and prod the VA and make him/her uncomfortable. P3 said, “[G1] kept questioning calling 9-1-1 and [P8] said (to G1) it would be best if [the VA] was back in [his/her] room … [G1] kept saying, ‘Gosh, maybe we should call 9-1-1’ and each time, P8 said that it “wasn’t a good idea.” · P8 said that no one asked him/her about calling 9-1-1. P8 said that s/he was, personally, “very uncomfortable” about not calling 9-1-1 but was leaving the decisions to G1. P8 was hopeful that eventually G1 would decide to call 9-1-1. P8 was checking the VA’s vital signs every 10-30 minutes, and all were within normal limits. The VA’s blood pressure was initially elevated but was otherwise normal. The VA’s blood oxygen level was around 92%, which was “fine.” P8 said that if the VA’s blood oxygen had been 88%, the VA would have needed supplemental oxygen; 92%-93% were “typical” values and 96%-98% were “better” values. The VA continued to show no distress and looked like s/he was sleeping. · G1 and more than one staff person said that they saw P8 checking the VA’s vital signs. · According to webmd.com, “Blood oxygen saturation level … should be 95%-100% if everything is normal. If it's lower than 95%, you should be monitored by a doctor. If your measurement is 90%-92% or less, you may need supplemental oxygen.” · P8 said that around 1 or 2 p.m., s/he reached out to the VA’s primary care doctor (MD1) to ask about next steps. P8 told MD1 that the VA was not waking up and “everyone thought” it was related to the VA’s heart. P8 said that MD1 could not determine if the VA was dying without seeing him/her in person. According to P8, MD1 said, “If they wanted [the VA] looked at, [the VA] would have to come in.” P8 hung up and discussed options with G1 and let G1 make the decision about how to proceed. G1 did not want the VA to die at the emergency room, so P8 did not call 9-1-1 or take the VA to see MD1 at that time. · MD1 said that at 12:21 p.m., P8 spoke to MD1’s nurse. P8 said that staff were unable to wake the VA up and that the VA was actively exhibiting a “death rattle” (sound occurring in someone who is nearing the end of life). The nurse told P8 to take the VA to the emergency room, and P8 agreed to do so, and the call ended. Medical records showed the nurse’s documentation stated, “Advised that they take [the VA] to the ER … they will bring [him/her] in.” · G1 said that s/he was present when P8 spoke to the nurse on the phone but could only hear P8’s side of the conversation. When P8 hung up, s/he told G1 that the nurse said to take the VA to the clinic to see MD1 or to the emergency room. However, “[P8] started saying again [the VA] was going to get poked and pushed on and prodded” at the emergency room. G1 wanted the VA to be comfortable and die peacefully and so they did not call 9-1-1 or take the VA to see MD1 at that time. However, as the day progressed, G1 started calling his/her friends, who were nurses, and each said that the VA needed to go to the emergency room, and so at some point later that evening, G1 told P8 to call 9-1-1. G1 added, “I am not a doctor or a nurse. I don’t know medical things so I relied on the people I thought I could talk to.” · The VA’s medical records stated that at 6:56 p.m., P8 called 9-1-1. Emergency medical services (EMS) arrived and observed the VA “unconscious” and “pale.” The VA’s blood pressure and heartrate were “normal,” but the VA was hypoxic with a blood oxygen level of “high 70s to low 80s.” While on the way to the emergency room by ambulance, the VA showed some improvement with supplemental oxygen but remained unresponsive. · MD2 said that s/he was working when the VA arrived at the emergency room. The VA was initially diagnosed with a decreased level of consciousness and possible cardiac failure or stroke. The VA was admitted to a hospital; however, s/he never regained consciousness and passed away on February 6, 2026. [Note: See Autopsy Report below regarding cause of death.] · P9-P13 each said that they were not called or notified that the VA was unresponsive or actively dying until after s/he was taken to the emergency room on February 3 or not until days after. P9-P13 each said that based on their respective roles, they should have been called right away when the VA became unresponsive. Staff were trained to first call 9-1-1 and then the guardian, a supervisor, and a nurse. · P1-P13 each said that they were trained to call 9-1-1 right away if a client was unresponsive; however, in this instance, P2, P3, P4, and P6 each said that they did not call 9-1-1 because P8 was the supervisor and had previously told each of them that s/he was a “nurse,” so they each believed that P8 knew what s/he was doing. P2, P3, P4, and P6 were not nurses. P3 and P4 each said that P8 commented how the VA’s skin was “mottling” and that s/he had a “death rattle,” which P3 and P4 did not know what any of that meant but believed P8. P2, P3, P4, and P6 also believed that since G1 was present with the VA, G1 was choosing not to call 9-1-1 and to keep the VA at the facility to die peacefully. P2, P3, P4, and P6 each said that they might have seen or read the VA’s POLST, but they could not remember what it said. P2, P3, P4, and P6 each assumed P8 and G1 knew what the POLST said and were following it. P5, P7, and P9 also said that P8 told them that s/he was a “nurse.” The facility’s policies and procedures regarding medical emergencies stated that staff should call 9-1-1 “immediately” if a person was unconscious. “When the rescue team arrives, be prepared to give health information and DNR status about the individual.” Staff should then contact a supervisor, who designated a staff person to contact the person’s guardian or emergency contact. Regarding the VA’s medications: · The facility’s Medication Administration Records showed on February 3, 2026, P3 administered the H’s medications at 6:08 a.m. and the VA’s at 6:32 a.m. P3 said that s/he was confident s/he administered the right medications to the right person. P3 could visually identify the housemates’ medications and said that the H had been taking Dilantin (anticonvulsant) extended release 100 or 200 milligrams (mg) for years. The Dilantin capsule was “big” and “bright orange.” P3 was confident s/he administered the H’s Dilantin to the H that morning. P3 was also confident that the Dilantin blister pack was present (not missing) and that P3 returned the Dilantin blister pack to the H’s shelf in the locked medication cabinet. P3’s shift ended at 7 a.m. when P2 and P8 arrived. [Note: The medication cabinet was locked and located inside the staff office; all staff had access to the cabinet and office.] · P8 said that on February 3, 2026, at 7:12 a.m., prior to the VA becoming unresponsive, s/he called the H’s guardian (G2) because the H fell that morning. During the call, they reviewed the H’s medications and at that time, P8 discovered the H’s Dilantin blister pack was missing from the medication cabinet. P8 called P3 and asked him/her to return to the facility to look for the blister pack. However, then around 8 a.m., the VA became unresponsive and so P8 (and P3 when s/he arrived) were distracted and did not look further into the missing Dilantin blister pack at that time. Later that same day, P8 notified P9 of the missing blister pack and searched the office to no avail. [Note: G2 remembered speaking to P8 that morning but could not recall what they discussed. No one else recalled the H falling that morning.] · P9-P13 each said that they did not receive any calls from P8 or anyone else about a missing Dilantin blister pack. If a client’s medication was missing, staff were trained to call a supervisor or a facility nurse. · P4 said that as the day progressed on February 3, and the VA lay unresponsive, P8 said to P4, “This looks like a Dilantin overdose,” in reference to the VA’s condition and said that the H’s Dilantin blister pack was missing. P8 did not state what made him/her think the missing blister pack was connected to the VA’s condition. P4 did not tell anyone about P8’s statement. (The facility’s time sheet records showed P4 arrived that morning at 8:31 a.m.) Although P4 could not recall what time this conversation occurred, P4 said that the VA was lying in a recliner near the refrigerator and P4 and P8 were talking in the kitchen, which means the conversation occurred earlier in the day but not right away when the VA became unresponsive. [Note: Consistent information was provided that P2 and P8 initially carried the VA to his/her bed; however, later that morning, staff carried the VA into the living room recliner to be more comfortable. Then, later, they moved the recliner into the VA’s bedroom when the other housemates were arriving from work. When 9-1-1 was called, the VA was in the recliner in his/her bedroom.] · G1 said that at some point on February 5, the day prior to the VA’s death, P8 called and said that it was possible staff might have administered Dilantin 200 mg and Xanex (benzodiazepine) 1 mg to the VA on February 3 and possibly some days prior too. P8 said that there was a Dilantin blister pack and a Xanex blister pack missing; each were prescribed to a different housemate and not the VA. The Xanex was a PRN (as needed), which the housemate did not take frequently, and was not subject to routine counting by staff and so it was unknown when the Xanex blister pack went missing. · MD2 and the VA’s medical records provided consistent information that on February 5, G1 told MD2 that Dilantin and Xanex were missing from the facility and G1 asked that the VA be tested for these substances. MD2 could not check the VA’s blood for Xanex because s/he had been given similar medications in the hospital; however, MD2 could test for Dilantin, which the VA was not prescribed. MD2 ordered bloodwork of which the results were pending when the VA passed away on February 6, 2026. When the results were later available, they showed the presence of “Dilantin 0.9” in the VA’s blood. MD2 did not know what measurement “0.9” referred to and could not state if this was micrograms per milliliter or some other measurement. MD2 also could not state if 0.9 meant that a single dose or more than one dose of Dilantin 200 mg was given to the VA. MD2 said that the “normal range” for someone who was prescribed Dilantin was between 1.0 and 2.5 micrograms per milliliter. MD2 said that one dose of Dilantin 200 mg might have caused the VA to experience some drowsiness but MD2 was doubtful that it would have caused the VA to lose consciousness. · The VA’s Autopsy Report and the medical examiner (ME) provided information that the VA’s cause of death, included: 1) probable mixed drug toxicity, 2) bilateral pulmonary edema, 3) Down syndrome, and 4) calcified tricuspid aortic valve cusps. The DHS investigator asked the ME about “probable mixed drug toxicity” and the ME said that at the time of the VA’s autopsy the medication levels in the VA’s bloodstream were “not toxic by themselves.” The ME could not state what the VA’s medication levels might have been when s/he became unresponsive on February 3, 2026. · The pharmacist (P) said that it was difficult to retroactively determine the level of a medication in the VA’s bloodstream or how that might have affected the VA’s heart. · MD1 said that s/he did not know if a single dose or more than one dose of Dilantin 200 mg would affect the VA’s heart condition. · P1, P3, P5, P7, and P9 each said that at various times between February 4 and 9, 2026, they helped P8 search for the Dilantin and Xanex blister packs. P7 said that on an unknown date, s/he looked behind the staff desk and did not see the blister pack; P7 did not pull the desk out from the wall. On February 9, 2026, P8 arrived at work and immediately told P1 that they were going to find the missing Dilantin blister pack that day. P8 walked into the staff office by him/herself and about five minutes later, called out to P1 to help check behind the office furniture. P8 immediately pulled out the staff desk and the Dilantin blister pack slid to the floor as though it had been hung up or stuck between the desk and the wall. There should have been four days’ worth of capsules left in the blister pack; however, there were none. There were no initials from staff to indicate who removed the capsules; however, at that time, staff were not required to initial the blister packs. Some staff believed the blister pack looked “smeared” or intentionally rubbed off in spots. Some staff believed that it was not possible for the blister pack to have fallen behind the desk and said that staff did not typically have medications at that spot on the desk. Regarding the VA’s ability to swallow a Dilantin capsule, some staff believed that it was unlikely the VA could have swallowed it due to its size. · P11-P13 each said that when they heard staff refer to P8 as a “nurse,” they each verified by other means that P8 was not a nurse or licensed by the board of nursing. P8’s application to work at the facility stated that s/he was a certified nursing assistant (CNA). · P8 said that s/he rarely did direct care with the housemates and was the “boss of other employees, did schedules, and oversaw everyone.” P8 told the DHS investigator and the LEO that s/he was a certified medical assistant (CMA), which was classified “in the nursing group … similar to being an LPN.” P8 referred to him/herself as a “nurse” when speaking to the DHS investigator and the LEO. P8 said, “The nurse in me felt like I should have called 9-1-1 but like, I don’t know, with the POLST and what [G1] wanted ….” [Note: According to redcross.org, a CNA worked under the direction of a registered nurse or licensed practical nurse and was trained to help with daily tasks like bathing and dressing and checking vitals. A CMA worked under the direction of a physician and helped with administering medications, checking vitals, and giving immunizations. In addition, according to the Minnesota Board of Nursing Credential search, P8 was not a licensed or registered nurse.] · [Note: The H had a seizure disorder and was prescribed Dilantin to prevent seizures. There was no information the H experienced an increase in seizure activity during any specific periods or to indicate the H was not receiving his/her Dilantin as prescribed. The other housemate’s Xanex blister pack was never found. Following this incident, the facility made changes so that medications were counted at each shift change.] P8’s position description said that s/he was “full time and considered a supervisor.” P8 was responsible for supervising staff persons; overseeing the day-to-day operations; monitoring the clients’ health and communicating with medical professionals; and implementing the clients’ support plans and health care. Facility documentation stated that the staff persons interviewed for this investigation received training on the VA’s support plans including Intensive Services and Support Assessment, the facility’s policies and procedures regarding medical emergencies, and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.05, subdivision 1, paragraph (a), states that the license holder is responsible for meeting health service needs assigned in the support plan or the support plan addendum, consistent with the person's health needs. Minnesota Statutes section 245D.10, subdivision 1, states that a license holder providing either basic or intensive supports and services must establish, enforce, and maintain policies and procedures as required in this chapter, chapter 245A, and other applicable state and federal laws and regulations governing the provision of home and community-based services licensed according to this chapter. Conclusion: A. Maltreatment: Regarding the VA’s death: Consistent information was provided that on February 3, 2026, around 8 a.m., the VA became unresponsive despite multiple attempts to wake him/her up. P1-P13 each said that they were trained to call 9-1-1 right away if a client was unresponsive, which was also consistent with the facility’s policies and procedures regarding medical emergencies. However, P2, P3, P4, P6, and P8 each were present with the VA at various points, and no one called 9-1-1 until 6:56 p.m. The VA had a POLST; however, this did not have anything to do with calling 9-1-1 or preventing someone from calling 9-1-1 for the VA. In addition, no one contacted a supervisor or a facility nurse and when P8 contacted MD1 at 12:21 p.m., P8 did not follow MD1’s directive to take the VA to the emergency room. Although it was not determined if calling 9-1-1 sooner would have changed the outcome, the failure to call 9-1-1 for over ten hours was inconsistent with the VA’s health service needs as specified in the VA’s support plan or the support plan addendum, the facility’s policies and procedures, and/or the standards of professional caregivers in a facility licensed by the Department; and it was a violation of Minnesota Statutes section 245D.05, subdivision 1, paragraph (a), and Minnesota Statutes section 245D.10, subdivision 1. Most importantly, it delayed necessary medical attention and care for the VA. Therefore, there was a preponderance of the evidence that there was a failure to supply the VA with care or services, including health care and immediate emergency medical services when the VA became unresponsive, that were reasonable and necessary to obtain or maintain the VA’s physical health. 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). Regarding the VA’s medications: Although the VA’s Autopsy Report listed the VA’s cause of death as probable mixed drug toxicity, the ME said that the medication levels in the VA’s bloodstream at the time of his/her autopsy were “not toxic by themselves” and the ME listed other causes of death, including bilateral pulmonary edema, Down syndrome, and calcified tricuspid aortic valve cusps. Although the presence of a non-prescribed medication in the VA’s system was concerning, there was inadequate information to determine the effect Dilantin had on the VA’s outcome. The VA had a preexisting heart condition that was expected to progress and one day lead to heart failure and there was inadequate information whether a single dose or more than one dose of Dilantin would have affected the VA’s heart. However, for the VA to have Dilantin in his/her system, it would have had to be removed from the blister pack and administered to the VA, and therefore, it was unlikely another client was responsible, and the VA was not capable of doing so him/herself. Therefore, given that staff had access to the Dilantin and were responsible for administering the VA’s medications, there was a preponderance of the evidence that a staff person failed to supply the VA with reasonable and necessary health care when they incorrectly administered at least one dose of Dilantin to the VA. 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. P2, P3, P4, P6, and P8 were each responsible for the VA’s care on February 3, 2026, and each received training on the VA’s support plans including Intensive Services and Support Assessment, the facility’s policies and procedures regarding medical emergencies, and the Reporting of Maltreatment of Vulnerable Adults Act. Regarding the VA’s death: P2, P3, P4, and P6 each said that they did not call 9-1-1 for the VA because P8 was a supervisor and a “nurse” and told them the VA was dying from his/her heart condition, which was an expected outcome, and that G1 wanted the VA to die peacefully in his/her own bed. Given that P2, P3, P4, and P6 were not supervisors or nurses and were doing what P8 told them to do, and that P2, P3, P4, and P6 were not privy to P8’s phone call with MD1’s nurse or to all the conversations between P8 and G1; P2’s, P3’s, P4’s, and P6’s responsibilities were mitigated. P8 was responsible for supervising staff persons; monitoring the clients’ health and communicating with medical professionals; and implementing the clients’ support plans and health care. On February 3, 2026, while the VA lay unresponsive for over ten hours, P8 repeatedly dissuaded others, including G1, from calling 9-1-1 and previously told multiple people that s/he was a nurse, which s/he was not a nurse nor licensed/registered by the board of nursing and therefore, did not have the authority to determine what the cause of the VA’s unresponsiveness. Therefore, P8 was responsible for maltreatment of the VA. Regarding the VA’s medications: Given that all staff had access to the medication cabinet and that more than one dose of Dilantin was missing, it was not determined who administered Dilantin to the VA or how many times the VA was administered Dilantin. Therefore, the responsibility for the neglect of the VA was inconclusive. 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 P8 was responsible was “recurring” maltreatment. P2, P3, and G1 each asked P8, at different times and more than once, if they should call 9-1-1 and each time, P8 dissuaded them from doing so. At 12:21 p.m., MD1’s nurse told P8 over the phone to take the VA to the emergency room, and P8 said she would do so, but did not. At another point, P8 told P4, regarding the VA, “This looks like a Dilantin overdose,” but P8 did not seek medical attention at that time or tell anyone about the Dilantin concern until days later. P8 was a supervisor and for over ten hours had more than one opportunity to rethink what s/he was doing and make a different decision but repeatedly chose not to seek emergency medical services for the VA and/or notify a facility nurse or other supervisor of what was happening. P8 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 relating to medication administration and when to seek outside medical attention. The facility provided additional training for all staff and P8 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: P8 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 P8 was responsible for maltreatment and the disqualification of P8 are each subject to appeal. P8 told multiple people that s/he was a nurse, but s/he was not a nurse or licensed by the board of nursing. Therefore, the report was referred to the licensing board. On July 1, 2026, the facility was issued a Correction Order for the violations outlined in this report.
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