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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: 800941-Intensive Residential Treatment Services/Residential Crisis Stabilization Investigator(s): Carla Hariveux Minnesota Department of Human Services 651-431-6616 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) left the facility at about 1:30 a.m. on June 22, 2026, but staff persons (SP1, SP2, and SP3) did not notice that the VA was missing until about 9 a.m. on June 23, 2026. The VA was found deceased in a nearby wooded area on June 26, 2026. Date of Incident(s): June 22, 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 t or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on July 20, 2026; from documentation at the facility, law enforcement records, and the VA’s autopsy report; and through interviews conducted with facility staff persons (P1, P2, P3, SP1, SP2, and SP3), and the VA’s family member (FM). The facility offered Intensive Residential Treatment Services (IRTS) for adults with up to 90 days of structured 24 hour a day/7 day a week care that focused on helping residents achieve psychiatric stability, make emotional adjustments, become self-sufficient, and gain skills needed to transition to more independent settings. The facility had two floors with eight bedrooms on each floor. There were motion-activated lights in hallways and common areas that turned on when anyone walked into the areas but turned off when no one was present. Facility doors were self-locking to prevent others from entering the facility without approved access, but residents inside the facility could exit the facility at will. However, the facility’s Level of Freedom of Movement requested that residents use the “buddy system” during their first week at the facility. The Client Handbook explained that using the buddy system meant that with staff person “permission” residents might take walks or go into the community with a buddy who was also a facility resident. If residents followed facility policies and procedures and there were no safety concerns, they could leave the facility between groups. If a resident was actively using substances, s/he was asked to remain on the facility grounds and if there were concerns for a resident’s safety, s/he was asked to accept additional support and have more frequent safety checks. Staff persons were to complete hourly safety checks on each resident, and all residents were expected to be in the facility during overnight hours. The Shift Duties sheets showed that staff persons who worked evening and overnight shifts were to divide the duties between them. There were two staff persons assigned to complete checks on the residents on the first floor in bedrooms 1-10 and do other assigned tasks, and a third staff person to complete checks on residents on the second floor in bedrooms 11-16 and do other tasks. On the date of the incident, SP1 and SP2 worked on the first floor and SP3 worked on the second floor. A tour of the facility on the date of the site visit showed that there were alarms on the facility’s exit doors that on the date of the incident were off. The alarms were off because residents who resided at the facility complained that the alarms sounded when anyone entered or exited the facility, and residents frequently came and went from the facility for various reasons, which prevented others from sleeping. On the date of the incident, the facility did not have a policy or procedure requiring the use of the door alarms and the facility was not a locked facility. Facility documentation showed that the VA’s diagnoses included major depressive disorder, post-traumatic stress disorder, unspecified dissociative disorder, and unspecified psychosis. The VA felt a strong connection to his/her spiritual and cultural identity. The VA had a history of attempting to harm him/herself using substances and in May 2026, prior to residing at the facility, the VA ingested a substance and was hospitalized. On June 5, 2026, the VA was discharged from the hospital to the facility, but s/he told staff persons that s/he did not have a plan to self-harm. The VA was not subject to guardianship but had been court ordered to receive services at the hospital. When s/he no longer needed treatment at the hospital, the VA could be discharged to an appropriate placement or released to treatment facility or community-based treatment program. The VA was not specifically ordered to receive care at the facility. The VA’s Crisis History stated that s/he was impulsive and might disregard his/her safety in the community. The VA was prescribed aripiprazole and quetiapine which were commonly prescribed for mental health disorders, and propranolol which might be used to treat heart related issues, migraines, tremors, or anxiety. The VA had no known history of leaving facilities without supervision and was not on increased supervision when the incident occurred. The facility’s Missing Persons Procedure showed that residents were to notify staff persons when they planned to leave the facility. Staff persons were to check on each resident at the facility once an hour and note where the resident was. At night, or when the residents were in their bedrooms, staff persons were to open the residents’ bedroom doors and confirm their presence. If a resident was determined to be missing, staff persons were to search the facility and its immediate exterior property for the resident and call the resident’s cell phone if applicable. After four hours, staff persons were to call the resident’s known contacts if the resident was not seen or accounted for, then notify a clinical supervisory staff person and follow plans established for the specific situation. If a resident’s whereabouts was unknown for 24 hours, staff persons were to make a missing person report with the law enforcement agency. No additional policies or procedures instructed staff persons how they were to do bed checks or verify residents’ status or presence in their bedrooms. Facility documentation, records from the law enforcement agency, records from a medical examiner’s office, the facility’s Internal Review, and interviews with this investigator provided the following: · Information was consistent that shortly after 1:30 a.m., on June 22, 2026, the VA exited his/her bedroom on the first floor, then left the facility without staff person supervision or knowledge. · Facility video recordings showed that at 1:33 am, the VA opened his/her bedroom door and when the motion activated lights in the hallway came on, the VA exited the bedroom wearing a long coat, long pants, and athletic shoes, then walked down the hallway and turned left, toward a facility common area. At 1:35 a.m., a camera that recorded an exit door at the back of the facility which opened into a patio area showed that the VA exited the facility, walked to the left away from the facility, and did not return. · At 10:30 a.m., on June 22, 2026, P1 went to check on the VA when s/he did not come to a morning meeting and observed that the VA had arranged pillows and bedding to make it appear that s/he was lying in bed. The VA left his/her phone, personal belongings, and medications in his/her bedroom with an undated note saying that s/he was sorry and that s/he was thankful for his/her loved ones, but s/he was not at peace and intended to harm him/herself. Staff persons searched the facility and its grounds for the VA, and notified the FM, a law enforcement agency, and the VA’s case manager (CM) that the VA was missing. At 10:35 a.m., the facility completed an Incident Report. · At 4:30 p.m., on June 22, 2026, the facility notified the Department of Human Services because the VA had not returned to the facility. On June 26, 2026, a facility staff person (P4) located the VA in a wooded area near the facility. The VA was deceased. P4 contacted the law enforcement agency, and the agency requested assistance from a medical examiner’s office. The facility notified the Ombudsman’s office of the VA’s passing. · Records from the law enforcement agency showed that at 1:17 p.m., on June 26, 2026, P4 contacted the agency and said that s/he observed a deceased person that s/he thought to be the VA when s/he was walking in the wooded area near the facility. Law enforcement officers (LEOs) went to the facility and P4 led them to the deceased person. The LEOs determined that the person was about 25 yards from the “wood line,” and that the person was deceased. P4 told the LEOs that s/he called 9-1-1 as soon as s/he observed the person, and s/he was upset because s/he previously checked the woods for the VA when s/he was discovered missing but did not see the VA. The LEOs reviewed the video recording of the VA leaving the facility and determined that the clothing on the body matched the clothing the VA wore in the video when s/he left the facility. The agency closed its investigation and took no further action. · Records from the medical examiner’s office showed that their examination of the person found in the wooded area was determined to be the VA and that s/he died by suicide. · Hourly check sheets completed by staff persons showed that on the overnight shift of June 21, 2026, from 11:30 p.m. to 7:30 a.m. on June 22, 2026, SP1 documented that s/he completed hourly checks on the VA and other facility residents and noted that s/he thought that s/he observed the VA breathing while lying in his/her bed. When P1 arrived for his/her shift on the morning of June 22, 2026, s/he became responsible for conducting checks on facility residents. The check sheets showed that P1 checked on the VA at 9 a.m., to prompt the VA to attend a 9:30 a.m. group meeting. However, he VA did not come to the 9:30 a.m. group meeting, and when P1 went to check on the VA because s/he did not attend the meeting, s/he discovered that the VA placed items in his/her bed to make it appear that s/he was in the bed, but s/he was not in the bedroom or at the facility. P1 marked the VA absent from the facility at about 10:30 a.m. that morning. · According to SP1, s/he and SP2 met at the beginning of the June 21, 2026, shift and agreed that SP2 would complete the hourly checks on the VA and residents on the first floor during the overnight hours. However, staff persons did not document how they divided duties each shift and there was nothing written to support this statement. SP1 said that s/he performed all staff person duties assigned to him/her and most duties assigned to SP2 on the date of the incident, and that SP3 was responsible for staff person duties on the second floor. SP1 said that SP2 went into the intake/office area of the facility about an hour after the shift began for unknown reasons and did not return for approximately five hours. · There was a tablet computer that permitted staff persons to monitor the video recordings/cameras from anywhere in the facility. SP1 took the tablet with him/her during parts of the shift but sometimes left the tablet in the staff person office. SP1 said that s/he previously was cautioned not to “micromanage” other staff persons, so s/he did his/her job but did not tell SP2 what to do. SP1 thought that SP2 might have gone into the office to sleep, but was not sure, and added that SP2 left the shift early the next morning. SP1 thought that s/he last checked on the VA at 7:30 a.m. on June 22, 2026, and believed that the VA was breathing when s/he saw the VA in his/her bed. · SP2 said that s/he and SP1 agreed that SP1 would complete checks on the residents, and that SP2 would clean and work in the kitchen and office during the shift. SP2 went to the intake room/office to complete work on the computer but took a blanket and pillow with him/her because it was cold in the office and s/he had back pain. SP2 could not recall what work tasks s/he completed on the date of the incident but denied that s/he slept in the office. · Information was consistent from P2 and P3 (supervisory/administrative staff persons) that video recordings confirmed SP1’s account of events, showed that SP1 checked on the VA and other individuals during the shift, and showed that SP2 entered the intake room/office with a pillow and blanket during the shift and remained there for about five hours. SP2 was suspended and later resigned. SP3 worked on the second floor of the facility on the date of the incident, so was not responsible for the VA’s supervision. · The VA’s Progress Notes showed that the VA was working to decrease the level of depression s/he experienced and attended daily therapy sessions at the facility for support, but no information showed that the VA was experiencing suicidal thoughts or increased anxiety immediately prior to leaving the facility without supervision. · The FM said that s/he thought that the facility might have supervised the VA more closely given the VA’s history and was concerned that it took the facility three hours to notice that the VA was absent from the facility. However, the FM thought that it was the VA’s decision and that s/he might have made the same choice regardless of where s/he was. The FM felt that the facility was lacking in compassion when they talked with him/her regarding the VA and s/he would have liked to have been shown more empathy. Facility documentations showed that the SPs were trained on the Reporting of Maltreatment of Vulnerable Adults Act and on the VA’s plans. Conclusion: The facility provided services to adults with mental illnesses and had a video recording system that recorded the exit doors and common areas of the facility. There were alarms on the facility’s exit doors, but the alarms were not used because the facility was not a locked facility, and they woke residents when the doors were opened. Information was consistent that the VA left the facility without staff person knowledge or supervision shortly after 1:30 a.m. on June 22, 2026. When the VA left, there were no policies or procedures regarding the alarms, but staff persons were to complete hourly checks on the location of the VA and residents at the facility. Hourly check sheets showed that on June 21, 2026, from 11:30 p.m. to 7:30 a.m. on June 22, 2026, SP1 documented hourly checks on the VA and other facility residents and marked that s/he thought that s/he saw the VA breathing in his/her bed. SP2 worked with SP1 on the shift, but video recordings showed that SP2 went into the intake room/office at the facility with a pillow and blanket and remained there for several hours, which was not consistent with facility policies and procedures. On June 22, 2026, P1 arrived for his/her morning shift and began making checks on facility residents at 9 a.m. At about 10:30 a.m., P1 checked on the VA again because s/he did not attend a morning meeting and P1 discovered that the VA was not in his/her bedroom or on facility grounds. The facility made timely notifications of the VA’s absence and reported the VA missing to the law enforcement agency. On June 26, 2026, P4 located a deceased person in a wooded area near the facility and called 9-1-1. Records from the law enforcement agency showed that LEOs came to the facility and requested assistance from the medical examiner’s office. It was determined that the deceased person was the VA, and that s/he died by suicide. SP1 said that s/he and SP2 discussed their responsibilities at the beginning of the June 21, 2026, shift and agreed that SP2 would complete hourly checks on the VA and residents on the first floor. However, SP1 said that s/he performed all duties assigned to him/her and most of SP2’s. SP1 said that SP2 went to the intake/office area about an hour into the shift and remained there for about five hours. SP1 thought s/he last checked on the VA at 7:30 a.m. on June 22, 2026, and believed the VA was breathing. SP2 said that s/he went to the intake room/office to use the computer but took a blanket and pillow because it was cold in the office and s/he had back pain. SP2 could not recall what tasks s/he completed but denied that s/he slept during the shift. SP2 stated that SP1 agreed on the division of duties for the shift. P2 and P3 each stated that that video recordings confirmed SP1’s account of events including SP1 completing checks and that SP2 entered the intake room/office with a pillow and blanket and remained there for about five hours. SP2 was suspended and later resigned. SP3 worked on the second floor and was not responsible for the VA’s supervision when s/he left. The VA had a mental illness, and s/he was court ordered to accept services, but s/he was actively participating in activities at the facility and no information showed that the VA was experiencing suicidal thoughts or increased anxiety immediately prior to the incident. The VA was not on increased supervision when s/he left the facility. Although the VA died by suicide after leaving the facility without staff person knowledge or supervision, given that SP1 documented s/he completed hourly checks and was seen on video completing checks and the VA left the facility at 1:33 a.m. and made his/her bed to look like s/he was in it; that the facility was not a locked facility and that alarms were not required to be activated on exit doors; that the VA was not on increased supervision at the time s/he left and was not subject to guardianship so could leave the facility if s/he chose to; that no information showed that the VA was experiencing suicidal ideation when s/he left; that SP1 said that s/he believed that the VA was breathing in his/her bed when s/he checked on the VA; that once discovered missing, the facility took immediate action; and that the law enforcement agency closed its investigation and took no further action, there was a not a preponderance of the evidence whether there was a failure to provide the VA with care or supervision which was reasonable and necessary to maintain his/her physical health or 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 policies and procedures were adequate but not followed by SP2. The facility re-evaluated its intake process, including the procedure of screening residents for suicidal risk, and whether additional screens or interventions were necessary for client safety. Staff persons were retrained on processes to add warnings to the client’s records regarding risks/suicidal ideation. In addition, the facility evaluated the frequency/consistency of safety checks, assessed whether checks were completed thoroughly and documented accurately, determined whether expectations and monitoring practices were sufficient to ensure compliance and implemented a procedure and training for all involved staff persons. Regarding overnight staff persons sleeping during shifts, the facility re-evaluated supervisory oversight, accountability measures and expectations that overnight staff persons did not sleep during shifts. Staff persons were reminded that they were to remain awake during all shifts and random spot checks of video recordings and unannounced drop in visits from supervisory/administrative staff persons were implemented. Regarding alarms and building security, the facility installed audible door chimes to alert staff persons when residents exited the facility and was in the process of evaluating whether an additional tablet computer might be purchased to permit staff persons a portable way to monitor the facility’s video cameras especially the ones at exit doors, and the possibility of assigning a shift lead for each shift to enhance staff persons’ abilities to provide care to the residents. Regarding overnight respiratory checks, the facility planned to assess the need for additional training, policy clarifications, changes to the environment or staffing patterns that were needed to ensure that respiratory checks were completed safely and consistently. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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