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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: 1111171-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lisa Shock 651-431-6142 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) who had 1:1 supervision was left unsupervised in a car by a staff person (SP) who went into a store. Date of Incident(s): June 29, 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 July 10, 2026; from documentation at the facility; and through five interviews conducted with two supervisory staff persons (P1 and P2), two staff persons (SP and P3), the VA, and the VA’s guardian (G). The VA’s diagnoses included intermittent explosive disorder and unspecified intellectual disabilities. The VA enjoyed going on outings, talking to his/her mom on the phone, playing sports and being involved in Special Olympics. The VA’s Individual Abuse Preventon Plan and Self-Management Assessment Plan provided consistent information that the VA had a history of sexual conduct and assault towards children. The VA “may seek out children and reoffend.” The VA has 1:1 staffing and “will be visually supervised when in the community, if children are present staff should remain in arm’s length” of the VA. The VA lacked self preservation skills and staff persons were to remain with the VA at all times. The VA did not like to be around children and was aware that children were a “trigger” for him/her. The VA may leave areas in the community without telling someone so staff persons “will visually supervise [the VA] in the community.” P1-P3 and the VA provided consistent informaiton that on June 29, 2026, the VA and the SP went on an outing to Target. The SP went into Target alone and left the VA unsupervised in the car. The VA required 1:1 supervision in the community. P2 and P3 were not working at the time but happen to be in the parking lot of the store and saw the VA in the SP’s car. The VA waved at them and stepped out of the car. The VA was unsupervised and the SP was not there. The VA, P2, and P3 did not know how long the VA was left unsupervised in the car but the SP came out to the car approximately three to five minutes after P2 and P3 were with the VA and said, “Hi.” The SP did not say anything further and the SP and the VA got in the car and left. P2 then notified P1 about the incident. The VA had was not injured as a result of this incident. The SP stated that s/he was making dinner and needed another ingredient. The SP asked the VA if s/he wanted to go to the store with him/her and the VA agreed. They then left the facility and went to Target. When they arrived, the VA did not want to get out of the car because it was “too hot” outside. The SP then left the VA in the car with it running and the air conditioning on and went inside the store. The SP said s/he was in the store for “maybe ten minutes” and when s/he came out s/he saw the VA talking to P2 and P3 on the side of the car. The SP stated that s/he “recognized that it was a mistake” to leave the VA in the car and that s/he did not follow the VA’s supervision requirements. The G was aware of the incident but did not have any concerns and felt that the staff persons and facility took good care of the VA. Facility documentation showed that P1-P3, and the SP, were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: A. Maltreatment Information was consistent that when the VA was in the community s/he was to have 1:1 staff person supervison at all times and was to be within visual site and/or within arms length if children were present. On June 29, 2026, the SP left the VA alone and unsupervised in a running car in a Target parking lot. The SP stated that s/he was in the store for approximately ten minutes. P2 and P3 stated that they were with the VA for approximately two to three minutes before the SP returned. Therefore, it was likely that the VA was without supervision for seven to eight minutes. Although the VA was not harmed and/or engaged in actions that put him/her in danger or face legal consequences, given that the VA was to have 1:1 visual supervision of a staff person when in the community and had a history of leaving areas unsupervised, yet was left unsupervised in a Target parking lot in a running car for seven to eight minutes, giving the VA unsupervised access to the community and community persons, there was a preponderance of the evidence that there was a failure or omission to supply the VA with care or services which were reasonable and necessary. 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 responsible for the care and supervision of the VA at the time of the incident. Th e SP wastrained on the VA’s plans and supervision. Therefore, the SP was 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 the SP was responsible was not recurring or serious maltreatment because it was a single incident which did not meet the definition of serious. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The facility provided retraining to all staff on the VA’s plans. The SP no longer worked at the facility. 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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