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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: 1101213-Intensive Residential Treatment Services/Residential Crisis Stabilization Investigator(s): Anna Parkin Suspected Maltreatment Reported: It was reported that when staff persons (P3 and P4) did overnight checks, they did not see a vulnerable adult (VA) inside his/her bedroom. It was later discovered that the VA was in a bathroom and had overdosed on over the counter medication. Date of Incident(s): January 15 and 16, 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, law enforcement records, and a coroner report; and through seven interviews conducted with four facility staff persons (P1-P4), a facility registered nurse (RN), and two clients (C1 and C2). According to the facility’s website, the facility offered “intensive monitoring and care” for depression, trauma, suicidality, and anxiety. The facility offered a “safe setting” with activities and structure and “opportunities to practice life skills and bond with peers.” The facility had 24-hour staff person supervision. The facility had two levels. On the lower level was a staff office and a bathroom. On the upper level was the medication area, a community room, and the VA’s bedroom. There were multiple outside doors on both levels that were unlocked. Next to the facility was a parking lot where clients parked their personal vehicles. The clients were “encouraged” to sign out on a form when leaving and sign in when returning. The facility did not check clients or their personal items when returning to the facility. The VA was diagnosed with bipolar disorder and severe depression and moved into the facility on January 6, 2026. The facility’s IRTS Supervision of People Served policy stated staff persons monitored the “well-being and whereabouts” of the clients through “general observation” in common areas and by “encouraging” the clients to use the sign in and out sheet when leaving and returning to the facility. If staff persons determined that a client was “missing” staff persons took “appropriate action” through the missing persons procedures. The facility’s When to Call the On Call Person policy stated staff persons were to call the on-call staff person if there was a missing person (someone out after curfew and staff do not know where they are) or staff persons called P1 if a person has been gone for 24 hours. The on-call staff person provided “a model of intervention that promote[d] stratified, moderated, and clinically sound actions” and provided “working guidelines and skills interventions, and crisis management that “enhance[d] safety factors, improve[d] person outcome, and promote[d] professionalism.” According to the VA’s Abuse Assessment and Plan and Crisis Plan: · The VA was not susceptible to neglect. On January 6, 2026, the VA was at risk of self-abuse because of his/her mental health, previous suicide attempts, and current suicidal ideation. The VA was on “high risk status” for suicide so staff persons completed hourly visual checks of the VA while s/he was awake. The VA’s medications were locked in the medication room and staff persons performed “mouth checks” to ensure the VA took his/her medication. On January 9, 2026, a mental health practitioner met with the VA for a reassessment and removed the hourly checks and established a crisis plan. · The VA’s Crisis Plan stated that if the VA had an increase in mental health symptoms, staff persons supported the VA by meeting 1:1 with him/her and having check-ins throughout the day. The VA “expressed self-capacity and capability of identify[ing] potential harmful thought experiences with staff and communicating.” · On January 12, 2026, the VA had “high suicidal ideation with plan and intent.” The VA planned on driving his/her vehicle to purchase medication or a knife to “end [his/her] life.” The facility held onto the VA’s keys to his/her personal vehicle “if needed.” · On January 14, 2026, the VA stated s/he “struggled” with self-injurious behaviors and “plans with intent.” The VA was “open” to telling staff persons when s/he had suicidal ideation and reported low ideation at that time. There were self-injurious behaviors the previous night so the facility locked up some of the VA’s personal items (sewing machine) when they were not in use. [Note: There was no documentation regarding the VA’s self-injurious behavior.] The VA’s Initial Needs Assessment, IRTS Treatment Plan, and progress notes provided the following information: · On January 6, 2026, the VA had “immediate needs” including “current suicidal ideation” with “no plan of intent.” The VA wanted “more frequent checks” from staff persons. The VA’s goal was to “acclimate” to the facility by participating in the program, including groups, attending meals, and interacting with other clients and staff persons. The VA learned a coping skill, such as breathing techniques, to manage his/her anxiety and decreased his/her suicidality by stating three “positive things” daily. Prior to discharge from the facility, the VA was to independently administer his/her own medications safely and accurately. · On January 7, 2026, a staff person that was a clinical trainee (P6) noted that staff persons checked in daily with the VA regarding suicidal ideation using a 1-10 scale, create a safety plan (Crisis Plan) with the VA, and staff persons completed five-minute walks with the VA each day to reduce stress and support an active lifestyle. · On January 8, 2026, a mental health practitioner who worked that the facility (P7) assessed the VA who was at “moderate risk factor” for self injury because of “multiple” risk factors and “few” protective factors. The hourly checks were removed. · On January 12, 2026, the VA told P6 s/he felt suicidal and had a plan to take his/her car, buy pills to overdose, and to get a knife. The VA acknowledged having “intent” and was unsure if s/he was able to keep him/herself safe. The VA gave P6 his/her car keys until the VA “felt better.” The VA was placed on checks that night. · On January 13, 2026, the VA’s goal was becoming more stable on his/her medications. The VA learned coping skills, such as breathing techniques, and how to manage his/her anxiety while “distressed.” The VA reviewed housing options for after discharge from the facility and said that prior to discharge s/he wanted to independently administer his/her own medications safely and accurately. There was no mention of mental health concerns regarding the VA. · On January 14, 2026, P6 worked with the VA on coping skills such as distraction. The VA had been taking his/her medications as prescribed and had a scheduled meeting with the CM on January 20, 2026. · On January 15, 2026, P7 met with the VA. The VA said s/he felt “a little anxious” after driving. [Note: There was no information in the facility documentation regarding when the VA’s car keys were returned to him/her.] The VA denied having self-injurious thoughts “at the moment” and “acknowledged” anxiety. P7 and the VA discussed ways to reduce anxiety when driving in the future including listening to music. The VA took his/her as needed anxiety medication. Staff persons continued checking in with the VA regarding self-injurious and ruminative thought processes. The facility’s Program Abuse Prevention Plan stated that the facility provided intensive residential treatment for adults with serious and persistent mental illness and provided the following additional information: · Population factors included: o Mental Functioning: The residents have a range of mental functioning. Mental and emotional health is assessed to determine that they would benefit from psychiatric rehabilitation and treatment services on an individual basis and plans are adjusted accordingly. . . . Staff assess whether the resident has: § Had two or more episodes of inpatient care for mental illness within the past 24 months; § Had continuous psychiatric hospitalization or residential treatment exceeding six months’ duration within the past 12 months. § Been treated by a crisis team two or more times within the past 24 months; § A diagnosis of schizophrenia, bipolar disorder, major depression, or borderline personality disorder; evidence of a significant impairment in functioning; and has a written option from a mental health professional stating he or she is likely to have future episodes requiring inpatient or residential treatment unless community support program services are provided; and/or § In the last three years, been committed by a court as a mentally ill person under Minnesota Statutes, or the “adult’s commitment” as a mentally ill person. o Self-harm and suicide risk: Residents served by Recovery Residence may have histories or even current suicide attempts, suicidal ideation and may experience other secondary risk factors: § All residents are screened using a Suicide Risk Assessment (C-SSRS) within 24 hours of admission. Based on risk observed in this process, a plan can be developed with the Suicide Risk Assessment and IAPP [Individual Abuse Prevention Plan]. Additional documentation of planning and support can be found in the Crisis Plan completed during a resident’s stay. § When needed sharps are removed from person’s belongings and secured for check out. Facility sharps are locked in the kitchen, nursing office or staff offices as appropriate. · Staffing patterns included: o During the day and evening hours, staff maintain awareness of client absence from the milieu and seek out residents who are not present in groups, mealtime, and other activities. o A practitioner-level staff person is on-call and available for consultation. Additionally, the Clinical Director is available for on-call consult. Nursing staff rotates of on-call consult. The Residential Clinical Operations Director is also available via phone daily. o During the night, staff conduct bed checks at least two times per night, and more frequently for clients exhibiting increased symptoms. Night staff work in the milieu and are alert of unusual sounds in the residence. · [Note: Information was consistent that staff persons checked on all clients twice per night, usually around 1 and 5 a.m. They opened each bedroom door and used a flashlight to look at the client for signs of anything unusual. They then documented the checks online.] · Areas difficult to supervise were equipped with cameras located inside and outside of the facility including the backyard, smoking area, and parking lots. P2-P4 (who were working the overnight shift at the facility) provided the following information to this investigator and to law enforcement: · On January 15, 2026, at approximately 9 p.m., P2 walked past the VA who was sitting on the floor in front of the elevator on the upper level with a towel over his/her shoulders. P2 thought it was “weird” but because s/he was not familiar with the VA, P2 went downstairs and asked P4 to assist while P3 stayed on the lower level. P2 and P4 then went upstairs and found the VA watching television in the community room with C1. P2 and P4 asked the VA how s/he was doing and the VA responded, “Fine.” · The VA stood up and walked to his/her bedroom and P2 and P4 followed. P4 stated while walking into the bedroom, the VA had an unsteady gait and once they got to the room, the VA lay in his/her bed. P2 said s/he did not notice anything unusual as the VA walked in and sat on his/her bed. P4 asked the VA what was wrong and the VA responded in a manner that P4 could not understand. P2 and P4 again asked the VA how s/he was doing and the VA responded that s/he was “fine” and fell asleep, so P2 and P4 left the bedroom. That was the last time P2 saw the VA. · At approximately 10 p.m., P4 went back to the VA’s bedroom to check on him/her. At that time, the VA was sitting up in bed with his/her legs crossed and was using his/her tablet. P4 asked the VA how s/he was and the VA responded that everything was fine. P4 stood in the doorway for a minute and asked the VA a few questions that s/he responded to and the VA said good night to P4. P4 was not concerned about the VA, so s/he left the VA’s bedroom and closed the door. That was the last time P4 saw the VA. · P2 and P4 were in the medication room and P3 was in the staff office on the lower level. At approximately 12 midnight and 4 a.m., P3 and P4 did the nightly checks and on both occasions the VA was not in his/her bedroom. P3 and P4 were each aware that the VA had a history of attempts to take his/her life, but they were not concerned because the VA was no longer on the extra checks. P4 checked in the common areas and the outside smoking area to see if the VA was outside smoking but did not see the VA. P3 and P4 each stated they “assumed” that the VA had left the facility in his/her vehicle so they returned to the staff office between the checks. · At approximately 5 a.m., P4 cleaned the bathrooms and when s/he went to the bathroom on the lower level, the door was locked so P4 assumed it was out of order. [Note: P1 stated that the facility had a “chronic problem” of toilets clogging so it was not unusual for a bathroom to be out of order and locked.] At approximately 4 or 5 a.m., P2 went into the upstairs bathroom and found a cell phone and keys. P2 did not know who they belonged to so s/he put them in the medication room. (It was later determined they belonged to the VA.) P3 went to the kitchen and cleaned until s/he left the facility at 7 a.m. P4 left the facility at approximately 7:30 a.m. P2 notified the RN when s/he got to the facility that the VA was not there during room checks and P2 left at approximately 8:30 a.m. · P2 was trained to check the sign in and out sheet if staff persons did not see a client in their bedroom during room checks. If the client was not listed on the sheet, the staff person called P1 or the client’s cell phone. P2 stated that clients did not consistently sign in and out on the sheet. P4 was trained if a client was not in their bed during a check, they notified a supervisory staff person at the morning shift change. P3 stated if a client was not in their bedroom, staff persons documented it on the form and checked the client’s plans to see if there were additional steps to take. P1 and the RN provided the following information to this investigator and law enforcement: · On January 16, 2026, at approximately 7 a.m., the RN arrived at the facility. P2 told the RN that at approximately 10 p.m. the night before, the VA was found sitting on the floor outside the medication room with a blanket over his/her head and that P2 had walked the VA back to bed his/her bedroom and the VA “stumbled” and “immediately” fell asleep in his/her bed. Then at approximately 11 p.m., P4 checked on the VA who was still in his/her bedroom and the VA was sitting upright in bed. That was the last time a staff person saw the VA. When staff persons checked on the VA at 1 and 5 a.m., the VA was not in his/her bedroom and staff persons assumed that the VA had left the facility. · The RN administered medications to the clients and then went to the VA’s bedroom and the VA was not there. The RN thought the VA left the facility so s/he tried calling the VA’s cell phone but the VA did not answer. At approximately 7:30 a.m., the RN again checked the VA’s bedroom and did not see the VA. · Because of the VA’s past history of high-risk behavior and past suicide attempts, at 8:25 a.m., the RN texted P1 that the VA was not at the facility. P1 did not respond. At approximately 9 a.m., P1 arrived at the facility and reviewed video camera footage but did not see the VA leave the facility. P1 walked around inside the facility and discovered the lower-level bathroom door locked. · At approximately 9:30 a.m., P1 got the bathroom key from the medication room and P1 and the RN unlocked the bathroom door and found the VA lying face down on the bathroom floor with “pink” vomit underneath him/her. Another staff person (P5) called 9-1-1 while P1 and the RN turned the VA onto his/her back and started chest compressions. Shortly after, law enforcement officers and paramedics arrived and determined that the VA was deceased.
· The RN stated that s/he thought staff persons should have notified P1 or the RN when the VA was not in his/her bedroom after his/her “overall” high risk behavior while at the facility. P1 stated that staff persons did not need to take additional steps, including notifying P1 or the RN, because the VA was not on increased checks and the last time staff persons saw the VA s/he was sitting up in bed and appeared fine. · P1 stated clients left the facility often especially when they had their own vehicle at the facility. The law enforcement report provided the following information: · On January 16, 2026, at 9:38 a.m., P1 called 9-1-1 stating that the VA was found with a “blue face and not breathing.” At 9:40 a.m., two law enforcement officers (LEO1 and LEO2) arrived at the facility and saw the VA lying on the bathroom floor. The RN was performing chest compressions on the VA and the VA’s face was “dark bluish-purple” in color. · LEO1 checked the VA vital signs and found that the VA’s hands and wrists were cold to the touch and LEO1 did not feel a pulse. The VA’s fingers were “stiff and rigid” and s/he was not breathing. There was a pink substance on the floor around the VA and some on his/her face that smelled like vomit. There was also the floor tile pattern on the VA’s abdomen indicating that s/he had been lying on his/her stomach for “an extended period of time.” At 9:45 a.m., the VA was pronounced deceased. · While searching the VA’s bedroom, LEO2 found one full and one empty bottle of antihistamine. The label showed 365 pink pills per bottle. LEO2 then searched the VA’s personal vehicle and found a receipt from a store showing that the VA purchased the antihistamine on January 14, 2026. According to the VA’s Minnesota Document of Death, the VA passed away on January 16, 2026, from toxic effects of diphenhydramine (antihistamine). The manner of death was listed as suicide. C1 stated on the night of the incident, at approximately 9 or 10 p.m., s/he saw the VA sitting in the community room watching television. C1 did not talk to the VA and did not see any “strange behaviors” from the VA. A few days prior to the incident, the VA drove C2 to a gas station. C2 purchased cigarettes but the VA did not buy anything. C2 did not notice anything unusual about the VA. Facility documentation showed that all staff persons were trained on the VA’s plans, the facility’s Program Abuse Prevention Plan, the facility’s IRTS Supervision of People Served and When to Call the On Call Person policy, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (a) states in part that the license holder shall develop program policies and procedures necessary to maintain compliance with licensing requirements. Conclusion: A. Maltreatment: On January 16, 2026, at approximately 9:30 a.m., P1 and the RN found the VA not breathing in a bathroom that had been locked. 9-1-1 was called and law enforcement and paramedics arrived and at 9:45 a.m., the VA was pronounced deceased. The previous night, around 9 p.m., P2 saw the VA sitting outside the elevator. As P2 and P4 helped the VA to his/her bedroom, the VA had an unsteady gait and once they got to the room, the VA spoke in a manner that P4 was not able to understand. P2 and P4 again asked the VA how s/he was doing and the VA responded that s/he was “fine” and fell asleep so P2 and P4 left the bedroom. At 10 p.m., when P4 checked on the VA, the VA was sitting up in bed with his/her legs crossed using his/her tablet and responded to P4’s questions and appeared fine. Although at 10 p.m. the VA appeared fine, approximately one hour prior the VA had an unsteady gait and was talking in a manner that was not understood and no calls were made to consult with a supervisor, practitioner level staff, the clinical director, and/or on call nursing. Then throughout the night, when the VA was not in his/her bedroom during checks, no additional steps were taken to try to find the VA and it was solely assumed the VA left the facility and there was no information provided that any staff person checked the outside or inside cameras. In addition, staff persons did not follow up on the locked bathroom door. Combined, this resulted in almost 12 hours between when the VA was last seen sitting in his/her bed until P1 took action and found the VA. Given the VA’s history of high suicidal ideation including overdosing on medication and was at the facility for assistance with his/her mental health including severe depression, that the VA demonstrated signs of possible intoxication by having an unsteady gait and not talking in a manner that was understood and then was not located or seen for almost 12 hours, there was a preponderance of the evidence that there was a failure or omission to supply the VA with reasonable and necessary care. It was determined 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. The license holder’s program abuse prevention plan identified that staff completed twice nightly checks of clients. Clients could independently come and go from the facility, but there was no policy or procedure in place to ensure staff knew the whereabouts of the client so that nightly checks were carried out as indicated in the PAPP, this was a violation of Minnesota Statutes, section 245A.04, subdivision 14, paragraph (a). In addition, given that multiple staff persons did not take additional steps including consultation/notifications when the VA was walking with an unsteady gait and talking in a manner that was not understood, and that when the VA was not in his/her bedroom during multiple checks, additional steps were not taken to locate the VA for almost 12 hours, and that there was inconsistent information on what steps staff were to take in the event a resident was not able to be located, individual staff responsibility was mitigated and the facility was responsible for maltreatment of the VA. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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 the facility was responsible did not meet statutory criteria to be determined as serious. Although the VA passed away, it was not a direct result of the neglect. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The facility provided additional training to all staff persons about room checks, expectations if encountering a locked door and master key location, and incident reporting. P4 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On July 9, 2026, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal.
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