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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: 1071934-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas 651-431-3970 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) fell out of bed and sustained a fractured tibia and a fractured hip socket. The VA’s plans stated that mats were to be placed at the sides of the VA’s bed, but two staff persons (SP1 and SP2) did not ensure a mat was placed on the side of the bed the VA fell. Date of Incident(s): April 10, 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 20, 2026; from documentation at the facility and medical records; and through six interviews conducted with two facility supervisors (P1 and P2), three facility staff persons (SP1, SP2, and P3), and the VA. The VA was diagnosed with delusional disorder, schizoaffective disorder, depression, end-stage renal disease, and type two diabetes, and had a below the knee amputation on his/her left leg. The VA liked music, sports, and outdoor activities like fishing. The VA was not subject to guardianship. The VA’s ISSA-Assessment Detail dated January 12, 2026, stated that the VA had a history of falling out of bed and required that staff persons make sure that the rails on the VA’s bed were raised to the correct position and cushioned mats placed on the floor on each side of the bed whenever the VA was in bed. The facility had a Fall Prevention Protocol; this undated document stated that cushioned mats had to be placed on both sides of the bed while the VA was in bed and removed when the VA was out of bed to prevent tripping hazards. The mats were approximately 3.5 inches thick, 30 inches wide, and 70 inches long. SP1 provided the following information: · SP1 worked at the facility once a week from 2-10 p.m. The VA had gotten a new bed with rails about a week prior to the incident, prior to that the VA slept on a regular queen size bed. On March 10, 2026, SP1 worked her/his usual shift; started at 2 p.m. and left at 10 p.m. The VA usually went to bed at 8 p.m. but on March 10, 2026, the VA returned from dialysis and was not feeling well so the VA went to bed sometime between 5 and 6 p.m. A new staff person who was training and shadowing SP1 assisted SP1 with getting the VA to bed. The VA’s head was toward a small fridge in the VA’s room. · The mats for the sides of the VA’s bed were folded up and to the side of the bed, and the mat covers were being cleaned. SP1 stated that s/he thought that the facility did not use the mats anymore because the mat was off to the side and the rails on the bed were sufficient to keep the VA from falling out of bed. The staff persons that were on shift prior to SP1 that day were P2, a supervisor, and P3. SP1 stated that P2 did not mention anything about the mats or the bed that day. SP1 stated that s/he did not notice there was a new bed until after P2 had left, around 4 p.m. · SP1 checked on the VA a few times that evening and the VA had not moved. The next day, SP1 learned that the VA had fallen out of bed. SP1 stated that s/he did not receive any retraining on the use of the mats; did not recall reading any care plans and believed that s/he was not properly trained. SP2 provided the following information: · SP2 worked the overnight shift at the facility. On March 10, 2026, SP2 began her/his shift at 10 p.m., at that time residents were in bed. Around 11 p.m. SP2 switched to sleep time, meaning s/he could be asleep, and then would wake up at 6 a.m. Residents at the facility had call buttons for assistance which would wake SP2 up when needed. SP2 stated that s/he checked in on the VA when s/he first arrived and maybe again at 12 a.m. · Both times that SP2 checked on the VA, SP2 noted that the bed rails were up. SP2 stated that the mat between the window and the bed was on the floor next to the bed but the mat on the other side of the bed was not. SP2 stated that the mat was under the VA’s bed because the night before P2 had taken the covers off to wash them. SP2 stated that s/he was aware that mats were supposed to next to the VA’s bed whenever the VA was in bed but also noted that because s/he was the overnight staff, the mats were supposed to be in place already. · The following morning at 6 a.m. SP2 was working with another resident when s/he heard the VA call out for SP2. SP2 found the VA on the floor, her/his head facing toward a television. SP2 asked the VA how long s/he had been on the floor and the VA replied, “I think all night.” SP2 tried to get the VA up but was unable, SP2 called 9-1-1. As paramedics arrived, so did P3. The VA was transported to a hospital. Medical records showed that the VA was admitted to a hospital with a right tibial fracture and a “subacute right acetabular fracture with superior migration of the femoral head;” a broken hip socket. The VA was prescribed oxycodone and Tylenol for pain management. The VA was discharged on March 17, 2026. P1 provided the following information: · The VA needed to have mats placed at the sides of her/his bed because s/he experienced phantom limbs; the VA would try to get out bed thinking s/he could still walk. The mats were supposed to be down on the floor at the side of the bed whenever the VA was in bed, staff persons moved them out of the way whenever they were assisting the VA into or out of the bed. · The new bed that the VA got was the same or similar to one s/he had previously, about a month and a half prior. P1 stated that all staff persons received a reminder on the operation of the new bed and the need to use the floor mats, including SP1. · P1 stated that SP2, as an overnight staff person, was not required to check on residents throughout the night, but SP2 was required to check in on residents at the start of the shift and if SP2 saw that one mat was not down, SP2 should have put the mat down. P1 stated that s/he spoke with SP2 about the mat not being down and SP2 stated that s/he did not notice that the mat was not down. P2 provided the following information: · P2 stated that the VA had a history of trying to get out of bed on her/his own and sustained injuries in the past, but this incident was the worst the VA had experienced. · P2 confirmed that SP1 was not part of the group text messaging; SP1 had only worked at the facility on Tuesdays for a short period of time. SP1 had not worked at the facility prior to the VA using a regular queen size bed. P2 noted that all staff persons were required to read residents’ plans and sign acknowledgements. P2 also confirmed that at the time of the incident, the covers on the mat had been removed to get cleaned but P2 was not sure if the covers were being cleaned that day or not. · On January 30, 2026, SP1 signed off on the VA’s ISSA which noted the need for mats to be placed at the sides of the VA’s bed. P2 stated that SP1 had attended a staff meeting where they discussed the topic on February 26, 2026. · P2 also stated that SP2 should have checked if mats were in place and the bed rails were up, but it was not explicitly written in her/his responsibilities on the overnight shift. P3 provided the following information: · P3 worked on March 10, 2026, and was relieved by SP1. P3 could not recall if the VA went to bed early that day or if the VA was in bed by the time P3’s shift ended. P3 stated that after the incident staff persons were reminded about the mats and the bed rails. The VA provided the following information: · The VA stated that sometimes s/he tried to get out of bed by her/himself, sometimes the VA had dreams that s/he could “run, walk, and jump, then I wake up and I go to get out of bed and I stand up and I go right down.” · The VA recalled the incident, said that s/he had dreamt that night about being in a competition. The facility’s personnel and training records showed that staff persons interviewed for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident; SP1 and SP2 signed off on acknowledgements of the VA’s ISSA-Assessment, which included information on the use of mats and bed rails. SP1 acknowledged the VA’s ISSA Assessment on January 30, 2026. Conclusion: A. Maltreatment: Information showed that on March 10, 2026, SP1 worked from 2 to 10 p.m. The VA went to bed early, after returning from dialysis around 5 or 6 p.m. SP1 stated that the mats were folded up next to the bed and were being cleaned. SP1 stated that s/he thought that since the bed had rails, that would be sufficient to keep the VA from falling out of bed and the mats were no longer being used. SP1 did not place a mat on one side of the VA’s bed. SP2 arrived for the overnight shift at 10 p.m., relieving SP1. SP2 checked in on the VA twice, before SP2 went to sleep. SP2 told this investigator that s/he noticed that one of the mats was folded up and not next to the VA’s bed but did not place the mat because the mats were already supposed to be in place before the overnight shift. At some point during the night, the VA attempted to get out of bed and fell. At 6 a.m., the VA called out for SP2 and SP2 found the VA on the floor. SP2 called 9-1-1 and the VA was transported to the hospital. The VA was diagnosed with a broken tibia and hip socket. The VA’s ISSA-Assessment stated that the VA had a history of falling out of bed and required that staff persons make sure that the rails on the VA’s bed were raised to the correct position and cushioned mats placed on the floor on each side of the bed whenever the VA was in bed. P1 and P2 both stated that SP1 and SP2 should have made sure the mats were placed next to the VA’s bed. Given that mats were supposed to be placed on both sides of the VA’s bed when the VA was in bed but on one side, no mat was placed, and the VA fell out of bed sustaining a broken tibia and hip socket, 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. SP1 and SP2 were each trained on the VA’s ISSA-Assessment and on the Reporting of Maltreatment of Vulnerable Adults Act. SP1 did not place a mat on one side of the VA’s bed. Although SP1 was the staff person who assisted the VA into bed and should have placed the mat next to the VA’s bed at that time, SP2 saw the mat was not placed and knew it should have been so it was reasonable that SP2 should have placed the mat next to the VA’s bed at that time but did not. Therefore, SP1 and SP2 were both responsible for the 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 for which SP1 and SP2 were responsible for was not recurring maltreatment because the incident was a single occurrence but was serious maltreatment because the VA required the care of a physician. SP1 and SP2 were disqualified from providing direct contact services. Action Taken by Facility: The facility completed an Internal Investigation that policies and procedures were adequate, but that VA’s plans were not followed. In addition, the review noted that SP1 received corrective action and SP2 would acknowledge the VA’s current ISSA-Assessment and all staff would be retrained. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were 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 the SP1 and SP2 were responsible for maltreatment and the disqualification of the SP1 and SP2 are each subject to appeal.
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