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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: 1123737-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070370-HCBS (Home and Community-Based Services) Investigator(s): Thomas Nixon 651-431-2155 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had a seizure that required medical attention and two staff persons (SP1 and SP2) were unable to locate necessary medical information/paperwork to provide first responders that caused a delay in medical care. There were also concerns about the VA’s hygiene and cleanliness. Date of Incident(s): April 25, 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 13, 2026; from documentation at the facility, law enforcement report including video, fire department Incident Report, and medical records; and through five interviews conducted with the VA’s guardian (G), two supervisory staff persons (P1 and P2), SP1, and SP2. Attempts were made to contact two fire department responders (FDRs) but neither responded. The VA’s diagnoses included severe intellectual disabilities, refractory epilepsy (drug-resistant epilepsy), fetal alcohol spectrum disorder, seizure disorder, constipation, urinary retention, and a traumatic brain injury. The VA liked to eat, watch cartoons, listen to music, and spend time with his/her family members. The VA lived alone at the facility and there were two awake staff persons at the facility 24 hours a day. The VA needed assistance with all of his/her activities of daily living including positioning, dressing, bathing, mobility, and toileting needs. The VA had a limited vocabulary and answered yes to questions even when his/her response meant to be no. Due to the VA’s disability and verbal limitations, s/he was not interviewed for the investigation. On July 1, 2026, the VA passed away for reasons unrelated to this report. The VA’s Seizure Protocol & VNS (Vagus Nerve Stimulator) Magnet Instructions stated staff persons were to call 9-1-1 if “the seizure lasts longer than [five] minutes.” (Note: According to the Epilepsy Foundation’s website https://www.epilepsy.com/treatment/devices/vagus-nerve-stimulation-therapy, a VNS is used to treat focal or partial seizures. A device is implanted under the skin in the left chest area with an electrode or wire attached to a generator device placed under the skin. The wire is attached or wound around the vagus nerve in the neck. At the onset of a seizure, if a magnet is swiped over the generator in the left chest area an extra burst of stimulation is sent to the brain that may help stop a seizure.) The VA’s Individual Abuse Prevention Plan stated the VA “needs assistance in all aspects of showering and using the bathroom and changing [his/her] [adult absorbent briefs].” The facility was a one-story property in a residential area. The front door opened into a hallway. To the left of the hallway was a staff office and to the right was a laundry room that led to a garage. The far end of the hallway, to the right, was a living room that led to a kitchen area, and to the left was the VA’s bedroom that led to a bathroom. On the living room floor, was a full-sized mattress for the VA to use and sleep on in addition to the mattress in the VA’s bedroom. The facility’s Policy and Procedure on Emergencies stated, “Program Sites will have contact information of a source of emergency medical care and transportation readily available for quick and easy access. In addition, a list of emergency phone numbers will be posted in a prominent location and emergency contact information for the persons served at the facility including each person’s representative, physician, and dentist.” The law enforcement report including video footage, the fire department Incident Report, and the VA’s medical records provided the following information: · On April 25, 2026, at 4:54 p.m. emergency medical services was dispatched to the facility and at 4:57 p.m., the FDRs and a law enforcement officer arrived. The LEO and the FDRs went inside to the living room, where the VA was lying on the mattress wearing a long sleeved t-shirt and an adult absorbent brief and SP1 and SP2 were standing on opposite sides of the mattress. · The LEO thought the VA’s brief was “soiled,” and the VA “smelled of stale urine and feces” and it appeared that the VA had not been “properly bathed” or had his/her fingernails cut “for an extended period of time.” · An unknown staff person said that the VA’s seizure had lasted over five minutes so they called 9-1-1. SP1 told the emergency responders that the VA did not have emergency medication to assist in stopping seizures. The FDR then asked for the VA’s “paperwork” so SP1 went into the kitchen to look for it. SP1, SP2, and the first responders discussed the VA’s history of seizures as someone joined SP1 in the kitchen to look for the VA’s paperwork. · At 4:59 p.m., SP1 was asked for the VA’s “face sheet for the ambulance crew.” SP1 said they did not have one and SP2 said s/he would look in the office and did so. As SP1 continued to look for the VA’s paperwork, s/he provided the VA’s name, that the VA was non-verbal and had seizures. SP2 returned from the office and was not able to find the paperwork but then returned to the office to look again. · At 5:00 p.m., the LEO said the VA was “shaking” as his/her head began to move. A FDR attended to the VA while another FDR joined SP2 in the office. At some point, they exited the office with a binder, walked into the hallway, and looked through the binder as the VA started to make grunting type noises. SP1 and the FDR discussed the VA’s seizures and which hospital the VA should go to. · At 5:01 p.m., the FDR asked for “more of [the VA’s] information” such as the VA’s birthday, medications, and “family information” and said that the information was “kind of a big deal, you [staff persons] need to have if we come here.” · At 5:02 p.m., the VA sat up slightly from the mattress and then returned down. Shortly after, the FDR found the VA’s medication schedule and was provided a copy · At 5:04 p.m., the VA was moved to the ambulance while SP1 and SP2 remained inside the facility. · At 5:06 p.m., and the LEO went back inside the facility and asked SP1 and SP2 when the last time the VA’s brief was changed. SP1 said the VA had been changed prior to the seizure but the VA urinated during the seizure. The LEO asked if the VA also had a bowel movement during the seizure. SP1 and SP2 said they were not aware the VA had a bowel movement. The LEO again told SP1 and SP2 as s/he walked out of the facility that when they called 9-1-1, staff persons needed to have information for the VA available so they do not have to look for while providing care to the VA. The LEO walked to the ambulance. SP2 then came out and asked to ride with the VA but SP2 was told to meet them at the hospital. At 5:11 p.m., the FDR’s left the facility. · At 5:37 p.m. the VA arrived at the emergency room and was administered midazolam (antianxiety) and his/her movements stopped. The VA had an electrocardiogram (ECG) which showed no significant change from one completed on March 25, 2026. The VA also had a computed tomography (CT) scan which showed no intracranial hemorrhage. The doctor noted that it was “suspect[ed]” the VA’s seizure was “related to recent adjustments in medication dosages” because the VA did not “appear ill otherwise.” The VA was observed for “nearly four hours and mental health status [had] returned to baseline.” P1, P2, SP1, and SP2, and the G provided consistent information that staff persons were to note when the VA’s seizures started, use the VA’s VNS magnet, and if the seizure lasted longer than five minutes staff were to call 9-1-1. (Note: The G was not sure if it was longer than five minutes or ten minutes that 9-1-1 was to be called.) The G provided the following information: · The G was aware of the VA’s seizure and said that the VA was not admitted to the hospital but returned to the facility. The G was not aware of SP1’s and SP2’s inability to provide the VA’s paperwork to the first responders. The facility had a binder with the VA’s medical information to give the first responders, and the G also thought the information was kept on the computer and accessible to staff persons. The G thought their might have been “communication issues” or a “language barrier” between staff person and the first responders, that complicated the situation. · The G said that when staff persons changed the VA’s briefs, it “sometimes” got “smeared all over the carpet.” The G was concerned the VA needed an additional staff person on to assist him/her to get a “proper bath” to ensure s/he was “fully clean.” The VA got “more sponge baths” than being “soaked” in a tub to clean. If the VA “struggled” with bathing, staff persons “just stop[ped]” and they gave the VA a bed bath. · The G visited the VA at the facility “every month” and on the “majority” of his/her visits s/he clipped the VA’s fingernails because it was “not done.” Even on a “couple” of visits when the VA’s fingernails were already cut, the G told staff persons there was “food in them.” Though the G emailed the facility with his/her concerns about the VA’s fingernails, the facility “went quiet” and the G did “not get much back” from them. While the G thought P1 was “great with [the VA]” and “advocated” for the VA’s needs, there was a “language barrier” communicating with direct care staff persons. SP1 provided the following information: · The VA typically had seizures during half of SP1’s shifts. SP1 was trained on the VA’s seizure protocol and knew to call 9-1-1 when the seizure exceeded five minutes. SP1 worked with the VA for almost two years prior to the incident and had not previously needed to call 9-1-1 for the VA’s seizures. · The VA’s paperwork was “usually” in a folder, on the floor near the computer “besides the printer” along with “four to five” other folders. The document included the VA’s seizure and medication information and “doctor record” about the VA’s health. · On the date of the incident, SP1 and SP2 were working. At an unknown time between 9 and 11 a.m., the VA, SP1, and SP2 were in the living room. The VA was sitting in a chair and was incontinent. SP1 and SP2 changed the VA’s briefs and put a new shirt on him/her. Because the VA had sat on the chair for “maybe two or three hours,” SP1 and SP2 moved the VA to the mattress on the floor and covered the VA with his/her bedspread. · After the VA lay on the mattress “quietly” for four to five minutes, the VA began to have a seizure. “Right away,” SP1 got the VA’s magnet and put it to the VA’s chest but the seizure continued. SP1 then stood “right by” the VA and observed the AV making sure the VA did not “bump” his/her head on anything. · After about five minutes, SP1 was “surprise[ed]” the VA’s seizure Continued so SP1 told SP2 “call for backup,” and SP2 agreed and did so. SP1 also told SP2 to get the VA’s paperwork for the first responders while SP1 called 9-1-1. · One to two minutes later, the first responders arrived. At this point, SP2 was unable to find the VA’s paperwork and as the first responders came inside, SP2 called P1 to ask where the paperwork was. As the first responders attended to the VA, his/her seizure continued. More persons arrived and at some point one of them asked for the VA’s paperwork/information. SP1 told them that SP2 was looking for it. When SP2 could not find the paperwork, SP1 thought that other staff persons had done some “cleaning up or arranging” and moved it. · While SP1 could have printed off new forms for the paramedics, s/he thought since it was “a few” pages that not something s/he could “print off quickly” and SP2 found the paperwork “very fast.” · As first responders asked questions about the VA, SP1 responded and provided the information. · At some point, SP2 was on the phone with P1 who told SP2 where the paperwork was. (Note: The forms were on the kitchen counter in a black cabinet/shelving unit.) SP1 and SP2 then took the information to the first responders who were outside with the VA. The VA was then put in the ambulance and taken to the emergency room. SP1 provided inconsistent information on how long it took to provide the first responders with the VA’s paperwork. SP1 said SP2 provided the paperwork “in a minute” of looking, and that the VA was put in the ambulance “within three minutes” after the first responders arrived at the facility and they were given the paperwork then. · SP1 said s/he “cannot remember everything” because his/her “focus” was on the VA but that s/he did not help SP2 look for paperwork because s/he did not want to leave the VA’s side. The VA was not incontinent of urine or bowel until after the paramedics transferred him/her to the stretcher. · The VA “never really refused” staff person assistance. When the VA was in the living room, SP1 sat next to him/her and checked on the VA’s brief every two to six minutes to see if s/he was incontinent. SP1 said that when his/her shift started at 3 p.m., “most” of the days the staff persons earlier that day showered the VA. When the VA needed his/her brief changed, “sometimes” SP1 put “water in the bucket” with “a little bit of soap” to clean the VA. If the VA had a bowel moment, SP1 brought him/her into the bathroom and put him/her in the shower to get clean. · SP1 thought P1 and the FM trimmed the VA’s fingernails. The VA did “not allow” other staff persons to do it as s/he became “too rough” and “tried to pull [his/her] finger from [staff persons].” Staff persons risked hurting the VA if they attempted to trim his/her fingernails. SP1 thought the FM “usually” came to the facility “around one to two weeks” and trimmed the VA’s fingernails then. SP2 provided the following information: · On the day of the incident, SP2 worked with SP1. Around 4 or 5 p.m., they were in the living room with the VA who was sitting on the couch. The VA “started yelling” and SP2 checked the VA’s brief and found that s/he urinated. SP1 and SP2 then changed the VA’s brief and saw that the VA “looked tired” they “transfer[ed]” the VA to the mattress on the living room floor. · Once on the mattress, the VA “immediately” started to have a seizure. As SP1 “watch[ed] the time,” and SP2 used the VNS which did not stop the seizure. When the VA’s seizure continued, at five minutes, SP1 called 9-1-1 and stayed with the VA while SP2 looked then looked for the VA’s paperwork. · SP2 was “surprise[d]” it was not by the printer in the living room. The paperwork was “always there” before but SP2 could not find it and thought that the morning staff or P1 moved it when they cleaned. · When the first responders arrived, SP1 talked with them and stayed with the VA to ensure the VA did not roll on to the floor while SP2 continued to look for the paperwork. SP2 called P1 who eventually directed SP2 to folders on the counter which included the VA’s paperwork. SP2 then brought it outside to the first responders who were with the VA who was on a stretcher ready to be put into the ambulance. · SP2 thought the entire incident was “less than ten minutes” from when the VA’s seizure started to when s/he was put in the ambulance. The VA’s seizure lasted five minutes and 9-1-1 was called, the first responders arrived one to three minutes later, and it took one to two minutes from when the paramedics arrived when SP2 was able to get them the paperwork as the VA was put into the ambulance. · The VA “never” held his/her urine, “urinate[d] a lot,” and “immediately” began to “yell” when s/he needed to be change. Staff persons had “cleaning materials ready for the VA. At times when staff attempted to change the VA, s/he struggled against staff persons. SP2 “made sure” the VA was dry. The VA was showered, bathed, and changed by staff persons and s/he “never” stayed in a soiled brief. · SP2 thought staff persons “fear[ed]” attempting to cut the VA’s fingernails as they might cut the VA’s finger. P1 and the FM were the only persons who cut the VA’s fingernails because the VA was “not patient” with other staff persons. P1 and his/her phone log provided the following information: · When the VA had a seizure, staff persons were to watch the VA closely to prevent the VA from falling because on previous occasion during a seizure, the VA “tried to stand” or was “tilting.” The VA “usually sometimes” and about “half” the time had a bowel movement during a seizure. The facility had two sets of the VA’s paperwork printed for staff persons if needed. P1 maintained a set him/herself. One was kept in the staff office and another in the VA’s binder which was next to a computer in the kitchen. Staff persons could also print the VA’s information from the facility’s computer program. · On April 25, 2026, at 5:11 p.m., P1 was not working but saw s/he had missed calls and texts from SP2 and SP1. One text said that the VA had a “over 10 minutes seizure,” and EMS was at the facility needing the VA’s paperwork. P1 then spoke to SP1 and SP2 who provided information to P1 regarding the VA’s seizure and first responders that was consistent with the information each provided during their interviews. · P1 also said that while on the phone with SP2, P1 heard the first responders talking with SP1 and SP2 and told them to which hospital to bring the VA to. P1 told SP1 and SP2 to stay back at the facility to “tidy up” and s/he would meet the VA at the emergency room to figure out what the next steps were. The total call was six minutes. · P1 went to the hospital where the VA was “kind of out of it” due to medications. SP1 and SP2 then arrived at the hospital and P1 left. The VA was monitored for “a couple hours” until 9 p.m. when s/he was discharged back to the facility. · Once back at the facility, there were no reported issues with the VA the rest of the evening. · P1 was not aware of any harm to the VA caused by the amount of time it took for SP1 and SP2 to get the VA’s information to the first responders. The VA had been to the hospital about one month earlier due to repeat seizures and the hospital staff had access to the VA’s information. SP1 and SP2 followed the facility trainings and protocols as they were directed and did “pretty well” handing the situation. · The VA was bathed “every day” and changed “all the time” when s/he was incontinent. The VA “sometimes” fought staff persons while being showered, so the VA received “mainly more bed baths.” When the VA had a “explosive” bowel movement, staff persons cleaned the VA in the shower instead of changing him/her. P1 denied there were situations where s/he saw or heard of the VA not being promptly cleaned by staff persons. · Staff persons did not trim the VA’s fingernails because when they did so, the VA moved his/her hand away and pushed the person and became “behavioral.” As a result of this, in the past the VA got a “cut” on his/her finger and it took staff persons an hour to stop the bleeding because the VA pulled off any bandage or gauze that was applied. The VA’s family member was the only person the VA was “calm” with allowing to trim his/her fingernails, but the family member might not come to visit the VA and trim his/her nails sometimes for “two months.” P2 provided the following information: · All staff persons were trained on the VA’s seizure protocol before they worked a shift with him/her. The VA had bowel movements when s/he had a seizure and staff persons were to “not rush and clean [the VA] up” after a seizure to reduce the change s/he would “go into another seizure” from the “stress” of being changed. · P2 said that SP1 and SP2 should have known where the VA’s information was because it was standard across all of the license holders’ facilities. During training, staff persons were told where the information was maintained. · On the date of the incident, P2 was notified by P1, P2 was not aware of SP1 and SP2 not being able to find the VA’s information for the first responders. · P2 was at the facility and saw the VA “roughly… once a week,” and “every time” s/he was there, the VA was in a clean brief. The only time the facility smelled like feces was when the VA’s soiled brief was being changed or the VA just had a bowel movement. Overall, the facility was kept “pretty clean.” P2 thought staff persons showered the VA “every day possible as long as [the VA] let [staff persons].” · P2 thought that both staff persons and the G attempted to trim the VA’s fingernails, but the VA was “very against it” and did “not like it.” The VA “move[d] quite often” and at times the VA was “cut…, nicked” or his/her nails were cut “too short.” The VA’s nailed were successfully trimmed “probably every other week.” Facility documentation showed that P1, SP1, and SP2 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Conclusion: Regarding SP1 and SP2 locating necessary medical information/paperwork to provide first responders: Information was consistent that on an unknown date in April or May 2026, SP1 and SP2 were at the facility when the VA had a seizure that lasted longer than five minutes. SP1 called 9-1-1 while SP2 looked for the VA’s paperwork to give the first responders. According to the LEO camera footage, the first responders arrived at 4:57 p.m., were provided the VA’s information at 5:02 p.m., and the VA was put into the ambulance at 5:07 p.m. At the end of the footage at 5:11 p.m., the EMS ambulance along with the VA had yet to leave from outside the facility. Although there was a concern that when SP1 and SP2 were unable to find the VA’s paperwork there was a delay in the VA’s medical care, during the five-minutes between when first responders arrived to when they were given the information, the VA was receiving care from the first responders. In addition, even after receiving the information, the ambulance did not leave with the VA for at least an additional nine minutes. Therefore, there was not a preponderance of the evidence whether there was a failure to provide care or services to the VA which were reasonable and necessary to maintain the VA’s physical health and safety. Regarding the cleanliness of the VA and the VA’s fingernails: In addition, while there were concerns about the VA’s cleanliness and fingernails, information from interviews was consistent that the VA’s cares were provided within the VA’s threshold of acceptance to reduce chances of agitation that could lead to injury or a seizure. Staff persons provided consistent information that the VA often was incontinent of urine and bowel after a significant seizure, such as the one that occurred on April 25, 2026. SP1 and SP2 were consistent that prior to the VA’s seizure s/he was just previously changed and cleaned. While there were concerns from both the G and LEO about the smell of the facility, the VA, P1, P2, SP1, and SP2 each stated staff persons were completing what they were able to. On the May 13, 2026, unannounced DHS site visit, there was no odor of feces or urine detected at the facility. Staff persons were consistent the VA was resistant to getting his/her nails trimmed by those s/he was not comfortable with and when it was attempted at times it led to injuries to the VA. At times, those the VA did allow to trim his/her nails, might not visit for over a month and when staff persons did make attempts to trim the VA’s fingernails, in order to avoid causing the VA injury or stress possibly leading to a seizure, they stopped so the nails went untrimmed until someone the VA was more comfortable with was able to complete the task. Given the VA’s tolerance of accepting staff persons assistance with his/her cleanliness and fingernail care and the possible risk of injury and/or seizure causing distress to the VA, and that the VA appeared to not be harmed as a result of those precautions, there was not a preponderance of the evidence whether there was a failure to provide care or services to the VA which were reasonable and necessary to maintain the VA’s physical health and safety. It was not determined whether 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). Action Taken by Facility: The facility completed an internal review and determined that while the facility’s policies were followed, they were inadequate. The facility planned to “implement of reinforce the use of an emergency hospital transfer packet.” Staff persons were to be retrained on the VA’s seizure response procedures, emergency medical response expectations hospital transfer procedures, required emergency documentation and communication of critical medical information during EMS transports. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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