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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: 1076665-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Heidi Murphy 651-431-6544 Suspected Maltreatment Reported: It was reported that a staff person (SP) left a vulnerable adult (VA) without supervision in the community and the VA purchased and consumed alcohol. Date of Incident(s): April 17, 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 May 14, 2026; from documentation at the facility; and through seven interviews conducted with one facility staff persons (SP), three facility supervisory staff persons (P1, P2, and P3), the VA’s case manager (CM), the VA’s guardian (G), and the VA. The VA’s diagnoses included a brain injury and substance use disorder. The VA enjoyed working out, playing basketball, and being active. The VA had a rights restriction, dated June 25, 2025, and revised on August 5, 2025, and May 13, 2026, for engaging in chosen activities and access to personal possessions at any time, including financial resources. The VA “has a long history of accessing alcohol and consuming an excessive amount.” The VA had a history of purchasing alcohol in the community when s/he had access to his/her money. The VA’s team felt the VA placed him/herself in harm’s way when s/he drank alcohol due to the VA’s inability to stop drinking alcohol once s/he started. The VA “will be accompanied by staff anytime [the VA] accesses the community. Staff will hold on to [the VA’s] money when [the VA] goes into the community to purchase items.” The VA “will not be allowed to purchase or possess any type of alcohol.” If staff persons believed the VA was in possession of alcohol or under the influence of alcohol, staff persons searched the VA’s bedroom and disposed of any alcohol. The VA’s Individual Absolutes/Specific Instructions stated the VA “cannot carry [the VA’s] own money because [the VA] may purchase alcohol.” When alcohol was located, staff persons removed the alcohol from the VA’s possession and contacted P2. When the VA consumed alcohol, staff persons performed 15-minute checks to ensure the VA was safe. The VA agreed to let staff persons “carry” the VA’s money and assist with purchases in the community. The VA’s Intensive Services Agreement (ISA) stated, the VA “has a drug and alcohol [use disorder] as well as a brain injury. When it comes to alcohol/drugs, [the VA] does not display any type of self-control and will drink excessively (a liter in a couple of hours). Drinking this much in such a short period puts [the VA’s] health and safety at risk.” The VA’s Individual Abuse Prevention Plan (IAPP) stated, “Staff will remain within auditory and/or visual range of [the VA], responding to situations that present a serious self-injurious abuse to [the VA’s] health and safety.” The VA provided the following information: · The VA stated s/he was allowed to carry his/her money pouch in a store and had unsupervised time in stores to shop without staff persons on several occasions prior to the incident. The money pouch and receipts were given to staff persons after purchases were made. · On April 18, 2026, the SP took the VA to Walmart to purchase some items. The SP gave the VA the money pouch before the VA entered the store. While in the store, the SP needed to use the bathroom and left the VA unsupervised with his/her money pouch, which contained cash and a debit card. · The VA shopped and made a purchase and then the VA exited the store and entered the liquor store that was attached to Walmart. · The VA had an “urge” to consume alcohol and purchased a “pint” of vodka with his/her debit card. The VA put the vodka in his/her jacket pocket, which was not visible to others. · The VA went back into Walmart and met the SP at the front of the store. The VA had a plastic bag with his/her purchases from Walmart. The VA estimated s/he was unsupervised for 30-45 minutes. · The VA and the SP went back to the facility. The VA drank the vodka around 8:30 p.m., when P1 was working. The VA estimated s/he consumed all the vodka by 11 p.m. and threw the empty bottle in the garbage. The VA did not need any medical treatment for intoxication. The SP provided the following information: · On April 17, 2026, the SP took the VA to Walmart. The SP gave the VA his/her money pouch before they entered the store. The SP told the VA s/he needed to use the restroom and left the VA unsupervised in the store. The VA said s/he would wait in the vitamin department. The SP estimated s/he was in the restroom for eight minutes. · The SP went back to the vitamin department and the VA was gone. The SP looked around the store and did not locate the VA. The SP walked to the front of the store and saw the VA holding a bag indicating that s/he already made a purchase. The SP looked in the bag and saw personal items but did not see any alcohol. The SP got the money pouch back from the VA and they went back to the facility. · The next morning, the SP saw a missed call and a text from P1. The SP called P1 and P1 asked how the VA’s day went the previous day. The SP said it was “great.” P1 informed the SP that alcohol had been found in the VA’s room. The SP thought, “It didn’t happen with me.” A few minutes later, the SP remembered s/he had used the bathroom and left the VA unsupervised with the money pouch. · P2 called the SP and asked the SP to go to the office. The SP met with P1, P2, and the VA and “went over things.” The SP was retrained on the VA’s plans and was told if staff persons needed to use the restroom, to go to the office or to a restroom furthest away from a liquor store. · The SP stated, “My mistake was I didn’t get the finance bag from [the VA] before I went to the bathroom.” · On previous outings, the SP gave the VA the money pouch before entering the store to give the VA “some dignity,” but never left the VA’s side. The SP had never needed to use a restroom on previous outings and had never left the VA. The SP did not think it was ever specified to “not give [the VA] the bag.” The SP was unsure if money was supposed to be counted before outings and said s/he had never counted the VA’s money. · The SP felt “terrible” about what happened and apologized to the VA. The VA told the SP, “I saw an opportunity and I took it.” P1 provided the following information: · On April 17, 2026, at 3 p.m., P1 started work at the facility. The VA spent time in his/her bedroom and “everything seemed normal throughout the day.” · Around 9:30 p.m., the G called P1 and said the VA had contacted a family member (FM) and said, “If you knew you were going to die, what would you do?” P1 went into the VA’s bedroom to check on the VA. The VA got up and turned his/her music down. The VA’s movements were “wobbly,” and his/her speech was “slurred.” P1 searched the VA’s bedroom and did not locate any alcohol. The VA was questioned and denied consuming any alcohol. · P1 performed 15-minute checks on the VA and contacted P2. P2 told P1 where the VA usually hid alcohol and P1 was able to find an empty .75-liter bottle of vodka in the bottom of a garbage can between 12:45 a.m. and 1 a.m. · The VA did not need medical attention. · The VA was “never supposed to have the money pouch.” Staff persons gave the VA his/her card or money at the register and the VA handed it back to staff persons after the purchase was made. P1 counted the VA’s cash at the beginning of P1‘s shift when P1 knew the VA went out on an outing. No one at the facility had access to the VA’s card transactions as the G monitored that activity. Staff persons did not know if the VA used the card unless staff persons were present during the transaction. · When staff persons needed to use the bathroom on an outing, they were allowed to use the bathroom but staff persons were in possession of the VA’s money pouch. Although P1 was unaware of any staff persons previously needing to use the restroom on outings with the VA, P1 stated the VA would go outside and smoke to wait for staff persons. · The VA did not have any unsupervised time in the community, other than two hours unsupervised time with the VA’s significant other. The VA also had six hours of unsupervised time with family and two hours unsupervised time at the facility. · The VA had one staff person during the day and one awake staff person and one asleep staff person at night. P2 provided the following information: · The VA had a rights restriction that allowed staff persons to have possession of the VA’s money and to search the VA’s room and belongings and confiscate alcohol if staff persons suspected the VA had consumed alcohol. · When the VA made purchases, staff persons gave the VA his/her card or cash, the VA made the purchase, and the VA gave the card or money and the receipt back to the staff person. · The VA’s cash was counted at every shift change and when a purchase was made. Receipts for debit card purchases were collected and the G monitored that activity. · The SP would not have known the VA purchased the alcohol unless the VA told the SP. · The VA would not have been able to purchase alcohol if the VA did not have his/her money pouch. · All staff persons were retrained on the policies, procedures, and VA’s plans and rights restrictions. P3 said that the VA had a rights restriction that said staff persons handled the VA’s money, verified purchases, and checked purchases when they got back to the facility. It would have been “feasible” for the VA to wait in the restroom, but not in the stall, while the SP used the restroom. The G and CM provided the following information: · On April 17, 2026, around 9 p.m., the FM contacted the G with concerns about the VA’s comments. The VA contacted the FM and asked, “How do you handle it if you know the day you are going to die.” The FM also said the VA was “slurring” his/her words. · The G contacted P1 and asked P1 to check on the VA. P1 told the G that there was “something going on” with the VA. · On April 18, 2026, around 1 a.m., P1 contacted the G and said the VA had been drinking and an empty bottle was located. · The G and CM did not have any concerns with the facility or staff persons. The SP, P1, and P2 were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Information showed that on April 17, 2026, the SP took the VA to Walmart. The SP gave the VA his/her money pouch before they entered the store. The SP needed to use the restroom and left the VA in a specific area within the store while the SP used the restroom. The VA exited the store and went next door to a liquor store and purchased a pint of vodka with a debit card hiding the liquor in his/her jacket pocket. The SP returned and looked for the VA eventually locating him/her at the front of the store. The VA had already made a purchase at Walmart with his/her debit card and the SP did not see any alcohol in the plastic bag. The SP and the VA went back to the facility, and the SP finished his/her shift and left. Around 9:30 p.m., the G contacted P1 and stated the VA had contacted the FM and asked what s/he would do if s/he knew when they were going to die. The FM also stated the VA was “slurring” words. The G asked P1 to check on the VA. P1 stated the VA was slurring words and his/her movements were “wobbly.” The VA denied consuming any alcohol and P1 searched the VA’s room. P1 located an empty bottle of vodka in the garbage can. P1 conducted safety checks on the VA every 15 minutes and updated the G and P2. The VA did not need any medical treatment. Given that the VA’s plans stated the VA had no unsupervised time in the community and could not carry his/her own money because s/he might purchase alcohol, that the SP did not follow the VA’s plans and allowed the VA to carry his/her own money, that the SP left the VA unsupervised in possession of the VA’s money, and that the VA used his/her money to purchase alcohol, there was a preponderance of the evidence that the SP failed to supply the VA with reasonable and necessary care or services. 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. The SP was trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for the VA’s supervision at the time of the incident; therefore, the SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the SP was responsible was not “recurring” or “serious” maltreatment because it was a single incident and the VA was not injured and did not receive any medical treatment. Action Taken by Facility: The facility completed an internal review and determined policies and procedures were adequate and not followed, there were four known previous incidents of the VA consuming alcohol, and there was a need for staff person retraining and corrective action. The SP was retrained on the VA’s plans and facility policies. The SP “failed to promptly disclose the supervision lapse involving the VA being left unattended in the community. The delayed recognition and reporting of the event created a delay in identifying the source of the alcohol access and delayed supervisory response to the underlying safety concern.” Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.
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