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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: 1104337 H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) accessed a medication cabinet and ingested Tylenol because a staff person (SP) left keys to the medication cabinet unattended. Date of Incident(s): June 8, 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 June 16, 2026; from documentation at the facility, law enforcement records, and the VA’s medical records; and through five interviews conducted with the VA, a facility management person (P), a facility staff person (SP), a hospital employee (HE), and the VA’s guardian (G). Although this investigator contacted the VA’s case manager (CM), the CM did not respond to requests to be interviewed. The VA’s Admission Form and Data Sheet showed that some of the VA’s diagnoses included post-traumatic stress disorder, borderline intellectual functioning, and intermittent explosive disorder. The VA’s Coordinated Service and Support Plan (CSSP) Addendum stated that the VA “can be without staff at [the facility] or in the community for [two] hours daily.” The VA’s support plan showed that the VA enjoyed playing video games and visiting with his/her family members. The VA lived at the facility with two other clients. According to the P, medications were stored in a locked medication cabinet. There were three sets of keys to the medication cabinet. One set for each of two staff working at a given time and an additional set of keys that was stored inside the cabinet. Staff persons were expected to always keep their set of keys on their person in their pocket and ensure that the medication cabinet was locked when not in use. The VA stated that the date of the incident, the SP, P, and other clients left the facility around 11 a.m. or 12 p.m. The VA said that s/he was feeling “fine,” but when the SP, the P, and the other clients were away from the facility, the VA began feeling “some anxiety.” The VA found a set of keys on a kitchen counter and accessed the medication cabinet. The VA took “more than 20” ibuprofen and Tylenol tablets and within a few minutes, the VA began feeling “funny.” The VA did not know the time but thought it was around 12:35 p.m. that s/he then called the G. After the VA talked to the G, the G called the P. The SP, the P, and the other clients returned to the facility around 12:45 p.m. The P told the VA that the G called him/her. The P took the VA to the hospital and then the VA was discharged back to the facility that same day. The VA stated that s/he did not tell the SP or the P that s/he had anxiety prior to the incident. The P provided the following information: · Although the P did not remember the date, s/he remembered that the day of the incident, s/he and the SP worked together and the VA “was good” and “acting like [his/her] normal self.” · At about 11:45 a.m., the P, the SP, and other clients left the facility for an outing and the VA stayed at the facility. At the time of the incident, the VA could be at the facility unsupervised for two hours. · When the P, the SP, and other clients arrived back at the facility at about 12:35 p.m., the VA was “throwing up in the kitchen sink.” The VA also vomited on the floor and the kitchen counter. The P told the VA to “get cleaned up” and that the P would clean the kitchen. · As the P cleaned, s/he saw there were two pills the P thought were ibuprofen in the VA’s emesis. When the P asked the VA what happened, the VA told the P that s/he did not know “what happened.” About 25 minutes later, the VA told the P that the VA “just had [pills].” When the VA said that s/he had an “upset stomach” and “was feeling sick,” the P suggested that the VA “rest for a little while,” so the VA did. · At about 1:05 p.m., the P received a phone call from the G. The G told the P that the VA “found a pair of staff keys and accessed the medications” and ingested “a bunch of pills.” When the call ended, the P talked to the VA and the VA said that s/he found a set of keys on the kitchen counter. After the VA accessed the medication cabinet and ingested the pills, the VA put the keys back on the kitchen counter. When the P asked the VA how many pills s/he ingested, the VA stated that s/he took “some pills,” but did not specify an amount. The P found a bottle of Tylenol in the garbage can that had water in it, so the P was unable to determine how many pills were missing. The P called for an ambulance and the VA was taken to an emergency room (ER) for evaluation. The P followed the ambulance to the ER. · When the P, the SP, and other clients left the day of the incident, the P did not see the SP’s keys unattended. The P acknowledged that s/he saw the keys on the kitchen counter after everyone returned to the facility, but s/he did not remember at what point s/he saw them. · Prior to the incident, there was not an occasion that the SP left his/her keys unattended. The HE provided the following information: · Although the HE did not remember the date, the VA was seen in the ER because the VA had ingested Tylenol. When the HE talked to the VA about the incident, the VA stated that s/he “snuck” the keys to the medication cabinet and wanted to “die,” but the VA changed his/her mind. · The VA did not remember how many Tylenol s/he ingested. The P told the HE that the VA “vomited” and the P did not know how many Tylenol the VA ingested. · While the VA was in the ER, tests were done and the VA did not have “Tylenol toxicity.” The HE contacted poison control and was given guidance to redo the test in four hours. When the test was redone, four hours later, the result again showed that the VA did not have Tylenol toxicity. No medical treatment was provided to the VA, and the VA was discharged the same day. The law enforcement report, dated June 8, 2026, provided limited information but stated that on June 8, 2026, the VA “took a bunch of pills,” and vomited “a little bit.” Although attempts were made to obtain the ambulance report, the report was not received. The VA’s medical records stated that because the VA was “upset,” the VA “took several” Tylenol and ibuprofen tablets and “threw up with staff noting some pills vomited up.” The records stated that when hospital personnel talked to the VA, the VA stated that s/he took “between 10-15 pills.” The records stated that the VA’s “initial acetaminophen level [was] not significantly elevated,” and “no signs of severe overdose or toxicity requiring treatment and [the VA was] medically cleared based on advice from poison control.” The SP stated that prior to the incident, the VA was “fine,” and “nothing” was “different.” When the SP, the P, and the other clients returned to the facility, the VA was “kind of wandering around” inside the facility. The P and the other clients went inside the facility before the SP, who was outside by the van collecting items to bring inside. When the SP got inside, the P told the SP to “stay” with the VA in the living room because the VA “took some medication.” At this point, the VA had cleaned him/herself up and the P was trying to determine how much medication the VA took. When the SP talked to the VA, the VA did not disclose how much medication s/he ingested or where s/he got the medication from. The P told the SP that s/he had information that the VA used the SP’s keys, that were left on the kitchen counter, to access the medication cabinet. The SP stated that s/he “must have left them on the counter, my mistake.” The SP understood that the medication cabinet was to be locked at all times. Prior to the incident, the SP was not aware of a time that s/he left the keys unattended. The G provided the following information: · Before the incident, the VA had unsupervised time in the community, but the G did not know how much time the VA had. The VA could be at the facility without staff supervision as long as medications were locked in the medication cabinet. · On the day of the incident, the VA called the G and stated that s/he was not “feeling very well” because the VA found the keys to the medication cabinet, while the VA was at the facility by him/herself. The VA accessed the medication cabinet and ingested a “bunch of pills,” but the VA did not know how many s/he ingested. The G told the VA that s/he was going to call the P so the VA, who had a history of overdosing on over-the-counter medications, could be taken for medical evaluation. After the call ended, the G called the P, who was at the facility, and told him/her what the VA said. The facility’s Policy and Procedure on Safe Medication Assistance and Administration stated that the medications were stored in a “locked storage area.” The facility’s training records showed that all persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the P and the SP were trained on the Policy and Procedure on Safe Medication Assistance and Administration prior to June 8, 2026. Conclusion: Information showed that on June 8, 2026, the P, the SP, and clients left the facility while the VA remained at the facility. The VA could be at the facility without supervision for two hours and the P and the SP each stated that the VA appeared to be fine when they left. While the VA was by him/herself at the facility, s/he gained access to the SP’s keys, which were left on the kitchen counter by the SP, for the medication cabinet and accessed the medication cabinet. The VA said that s/he ingested more than 20 tablets of Tylenol and ibuprofen and began to feel ill. When the SP and the P returned to the facility, the VA was vomiting in the kitchen. At some point, the VA called the G and told him/her what happened, and the G called the P. The VA was then transported to the ER. The VA’s medical records stated that the VA did not have signs of severe overdose or toxicity requiring treatment so the VA was discharged the same day and there was no treatment provided to the VA. There were three sets of keys to the medication cabinet. The two staff persons working were to each keep a set of keys on their person and the third was kept in the locked medication cabinet. The SP stated that s/he “must have left” his/her set of keys to the medication cabinet on the counter, “my mistake.” The P stated that the SP did not leave his/her keys unattended on other occasions. Minnesota Statutes, section 626.5572, subdivision 17, paragraph (c), clause (4), states, "A vulnerable adult is not neglected for the sole reason that an individual makes an error in the provision of therapeutic conduct to a vulnerable adult which does not result in injury or harm which reasonably requires medical or mental health care." Although the SP left his/her keys unattended by “mistake,” which allowed the VA to access the medication cabinet and consume medications, given that there was no information that there were prior incidents of the SP leaving his/her keys unattended and that the VA did not require medical treatment, the SP leaving his/her keys unattended was considered an error in the provision of therapeutic conduct and was not maltreatment. It was determined that neglect did not occur (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). Action Taken by Facility: The facility’s internal review showed that although policies and procedures were adequate, they were not followed. Although the review did not specifically state what was not followed or by whom, additional training was provided to all staff persons related to “safe keeping of medications.” Action Taken by Department of Human Services, Office of Inspector General: The SP was not substantiated as a perpetrator of maltreatment of the VA because the Department of Human Services found that the incident for which the SP was responsible met the criteria to be determined an error. The SP was notified by the Office of Inspector General that any future incident of possible neglect of a vulnerable adult for which the SP is responsible might not be considered an error.
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