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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: 1071776-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Alice Percy 651-431-2155 Suspected Maltreatment Reported: It was reported that a staff person (SP) drove a vulnerable adult (VA) in his/her car on a personal errand. The SP had an instruction permit, but not a valid driver’s license. While driving, they were in a car collision, resulting in cuts and bruises to the VA, who was taken to a hospital for evaluation. Date of Incident(s): October 7, 2024 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 March 10, 2025; from documentation at the facility and medical records; and through twelve interviews conducted with a facility staff person (P1), four administrative staff persons (P2 – P5), the VA, two of the VA’s case managers (CM1 and CM2), the VA’s guardian (G1), the VA’s former guardian (G2), the VA’s family member (FM), and a law enforcement officer (LEO). Attempts were made via email and mail to contact and interview the SP, but the SP did not respond to the requests. The VA enjoyed going on community outings, going to the movies, going to the gym, and spending time with his/her friends and family members. The VA’s diagnoses included bipolar disorder, traumatic brain injury, antisocial personality disorder, and schizophrenia. The VA’s Risk Assessment Detail stated that the VA had four hours of unsupervised time in the facility and in the community each day. The intersection (42nd Avenue and Douglas Drive) where the incident occurred, had a stop light. 42nd Avenue had four lanes of East and West bound traffic, two in each direction with single designated left turn lanes and concrete dividers at the intersection. Douglas Drive had two lanes of North and South bound traffic, one in each direction, with designated left and right turn lanes and concrete dividers at the intersection. The speed limit on both roads were 35 miles per hour (mph). The facility’s Internal Review stated that on October 7, 2024, at approximately 4:30 p.m., the SP drove the VA in his/her car to cash a check at a local store. At the time of the incident, on 42nd Avenue a school bus was driving eastbound and the SP was driving westbound. The SP was in the left turn lane and turning onto southbound Douglas Drive when the school bus hit the SP’s car. The school bus driver provided information to the LEO that s/he had a green light at the time of the incident. Neither the SP nor the VA had a valid driver’s license. The SP was treated at the scene and released and was cited for failure to yield and driving without a valid driver’s license. The VA was taken to the emergency room via ambulance and discharged later with “no broken bones” and a neck brace. The LEO stated that when s/he arrived at the scene, s/he saw a school bus in the intersection as well as the SP’s car, which was “spun around.” The LEO determined that the SP’s car was hit by the school bus when the SP failed to yield while making a left turn in front of the bus. The VA was in the front passenger seat and was wearing a seat belt at the time of the incident. The VA had to be extricated from the car by the fire department and was then transported to a hospital. Because the SP had only a learner’s permit, s/he was cited for driving without a valid driver’s license and failure to yield. The VA provided the following information: · On the day of the incident, P1 asked the VA to show the SP where s/he could cash a check. The SP and the VA took the SP’s car to a store to cash his/her check and then the SP purchased gas for his/her car. As they drove back to the facility, the SP was merging in and out of lanes, which caused other drivers to honk at him/her. As they arrived at an intersection, the left turn signal light was blinking yellow. The SP turned left even though the signal light was blinking and a bus hit the SP’s car on the passenger side, causing the airbags to deploy. The VA was covered in glass from a window breaking and had some abrasions from the glass. The VA sustained a bruise near his/her eye, his/her legs were “numb,” and his/her neck hurt. The VA’s car door did not open, so the fire department used the “jaws of life” to get the VA out of the car. The VA was then transported to a hospital. Prior to the incident, the VA had not ridden in a staff person’s car, but only in the facility’s van. · A few days after the incident, the VA returned to the hospital, where the physicians checked the VA’s mouth and determined the VA had broken or missing teeth. The VA also had a concussion. P1, P2, P3, P4, and P5 provided the following information: · On September 18, 2024, the SP began working at the facility and, at the time of the incident, had completed his/her training. The VA did not need a staff person to accompany him/her when s/he went into the community, frequently “went out on [his/her] own,” and spent a lot of time with his/her family members. At the time of the incident, the facility did not have a van to transport the clients and the staff persons typically borrowed a van from another program when a client needed transportation. · P1 stated that on October 7, 2024, at approximately 4:30 p.m., s/he and the SP were in the living room talking about the SP having a check s/he wanted to cash. The VA told the SP that s/he knew of a place that would cash the check because s/he went there with his/her family members and asked the SP if s/he could show him/her where to cash his/her check. The VA and the SP then left the facility in the SP’s car. Approximately 30 minutes later, the SP called P1 and told him/her that they were in a car collision and the VA was taken to the hospital by ambulance. P1 then called P3 and told him/her about the incident and P3 then called P2. P4 stated that after the incident, the SP had lacerations on his/her right arm. · P5 stated that after the incident, s/he talked to the SP, who told P5 that the traffic light turned yellow and the SP “thought [s/he] could make it through the light” but as s/he made a left turn s/he was hit by the bus. The VA’s hospital discharge paperwork did not say that the VA had a concussion. · P1 was unaware that the SP did not have a valid driver’s license and believed that all of the staff persons were required to have a valid driver’s license when they began working at the facility. P2 and P3 were also unaware that the SP did not have a valid driver’s license. P4 was aware that the SP did not have a driver’s license and stated that the SP was told to let a supervisor know when s/he received a driver’s license. P5 stated that s/he was aware that the SP did not have a driver’s license when s/he was hired to work at the facility. The SP was given a period of time to complete the driver’s test and qualify for his/her driver’s license. The SP was told that s/he was not allowed to drive any of the clients anywhere until s/he got his/her driver’s license. P2, P3, P4, and P5 each stated that the staff persons were not supposed to transport the clients in their personal cars. The staff persons were also not allowed to run personal errands on work time. CM1 stated that the VA told CM1 that s/he went with the SP on an errand and the car was hit by a bus. The VA also told CM1 that the SP did not know how to drive well and that the VA was telling the SP how to operate the car, which made the VA feel unsafe. The SP did not have a driver’s license or insurance on his/her car. The VA was taken to the hospital, where s/he was diagnosed with cuts and bruises. The VA told CM1 that s/he “blacked out” and did not recall being put into an ambulance. The VA’s teeth also “got mashed up” in the collision and the VA might require oral surgery in the future. CM2 stated that prior to the incident, the VA did not express concerns to CM2 about the care the VA received at the facility. G1 stated that s/he recently began working with the VA. At some point after the incident, the VA was afraid to return to the facility because the SP “made” the VA go with him/her to a store to cash his/her check and they were then involved in the collision. The VA told G1 that s/he did not want to stay at the facility and G1 accompanied the VA to the facility so that s/he could get his/her personal items. G2 stated that the VA was independent in many ways, but did not always recognize dangerous situations. The VA felt “guilty” about getting into the SP’s car and told G2 that s/he did not want to get into the car, but “did it anyway.” The FM stated that after the VA was taken to the hospital after the accident, the hospital arranged transportation for the VA to return to the facility. The VA called the FM and told him/her that s/he was in pain so the FM went to the facility and took the VA to his/her home. A few days after the incident, the FM took the VA back to the hospital, where s/he was diagnosed with a concussion. The VA also had a possible hairline fracture to his/her jaw. The hospital’s Emergency Department Provider Notes stated that on October 7, 2024, the VA was seen by a physician after being involved in a motor vehicle accident where the car the VA was riding in was “T-boned” by a school bus. The fire department extricated the VA from the car. The VA had pain in his/her right knee, left ankle, back, and left shoulder. The VA had “scattered abrasions” on his/her face, hand, and hip. Several tests, including computed tomography (CT) scans, showed no fractures or serious injuries. The VA was released from the hospital the following day. The facility’s Safe Transportation Policy stated that the staff persons were responsible for the supervision and safety of the clients while being transported. The staff persons were required to follow all traffic safety laws while transporting the clients, including maintaining a valid driver’s license and obeying traffic signs. Facility documentation showed that the SP, P1, P2, P3, P4, and P5 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. Minnesota Statutes: Minnesota Statutes, section 171.02, subdivision 1, paragraph (a), states that a person shall not drive a motor vehicle upon a street or highway in this state unless the person has a valid license under this chapter for the type or class of vehicle being driven. Minnesota Statutes, section 171.02, subdivision 1, paragraph (a), states in part that the instruction permit entitles the applicant to drive a motor vehicle if the permit holder has the permit in immediate possession and is driving the vehicle while accompanied by an adult licensed driver who is actually occupying a seat beside the driver. Conclusion: A. Maltreatment: On October 7, 2024, at approximately 4:30 p.m., the VA accompanied the SP in his/her personal car when the SP ran a personal errand to cash a check at a local store. On the way back from the store, the SP made a left turn on a blinking yellow signal light and the car was hit on the passenger side of the car by a school bus. The VA was in the front passenger seat and wearing a seat belt at the time of the incident. The VA had to be extricated from the car by the fire department and was then transported to a hospital, where s/he was diagnosed with cuts and bruises. The SP did not have a driver’s license and had only a learner’s permit. The SP was issued citations from law enforcement for driving without a valid driver’s license and failure to yield. The SP did not provided information for this report.
The SP’s actions of driving the VA without a valid driver’s license was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, were a violation of the facility’s policies, illegal, and placed the VA at risk when in a vehicle driven by the SP. In addition, the SP failed to yield to oncoming traffic which resulted in the collision. Therefore, there was a preponderance of the evidence that there was a failure to supply the VA with care which was reasonable and necessary to maintain the VA’s physical health or safety. 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. Facility documentation showed that the SP 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. 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 did not meet statutory criteria to be determined as recurring or serious. It was a single incident and although the VA sustained injuries and may have had injuries to his/her mouth/jaw that required future surgery, there was no documentation to support the need for future care and when the VA was at the emergency room, the VA did not require the care of a physician. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate, but were not followed by the SP. 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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