|
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: 1116195- WithM (Withdrawal Management) Investigator(s): Lindsay Arth 651-431-6537 Lindsay.Arth@state.mn.us Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was found deceased at the facility. There were concerns that staff persons did not check on the VA as they were trained to do. Date of Incident(s): July 1 or 2, 2025 (On December 23, 2025, the Department of Human Services was made aware of additional concerns regarding the incident and the report was assigned for investigation). 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 for this investigation was obtained remotely, including documentation from the facility, law enforcement records, and medical records; and through 13 interviews conducted with two facility staff persons (P1 and P2), four supervisory staff persons (P3, P4, P5, and P6), four facility registered nurses (RN1, RN2, RN3, and RN4), two facility licensed practical nurses (LPN1 and LPN2), and the VA’s family member (FM). According to the Program Abuse Prevention Plan, the facility provided detoxification services to clients experiencing withdrawal from drugs or alcohol who needed short term 24-hour medical care for stabilization, managing withdrawal, and facilitating access to substance use disorder treatment. The facility served up to 18 clients and clients typically shared a bedroom with an attached bathroom. There was a nurse’s station in the middle of the facility. A minimum of one registered nurse and one “technician” was at the facility at all times. The Assessment and Monitoring of Guest Health said that the client’s health status must be documented on their medical record at least once per shift by a nurse or more often based on acuity or change in condition. The documentation should include vital signs, level of consciousness, activities of daily living, using the toilet, intake/output, acute medical issues, and withdrawal status. The registered nurse and/or recovery technicians were responsible for monitoring client’s health and providing hourly observation. Clients were to be transported to a hospital if they had seizures; a body temperature greater than 101 degrees Fahrenheit; a blood pressure greater than 170 systolic; a pulse greater than 120; a change in pupil response; uncontrolled nausea, vomiting, or diarrhea; and other “emergent” situations. The facility had video footage in the main areas but as of December 23, 2025, the video footage for the time of the incident (July 1 or 2, 2025) was no longer available. However, at the time of the incident the facility reviewed video footage and a summary of that is below. The VA began receiving services from the facility on June 28, 2025, and was diagnosed with severe opioid use disorder, stimulant related disorders, and mild cannabis use disorder. The VA also had a history of depression, anxiety, post-traumatic stress disorder, and borderline personality disorder. The VA enjoyed spending time with his/her family members. The law enforcement Summary provided the following information: · On July 2, 2025, at 8:18 a.m., law enforcement was notified by the facility that the VA was “pulseless” and that cardiopulmonary resuscitation (CPR) was in progress. The VA was also “blue” and “not breathing.” · When law enforcement arrived at the facility, they observed RN1 and another registered nurse (RN5) in the VA’s bedroom with RN5 performing chest compressions on the VA, who was in his/her bed. RN1 and RN5 had also applied an automated external defibrillator (AED) to the VA’s chest which “advised” to continue CPR. RN1 then took over chest compressions for RN5 while law enforcement “prepared to take over medical care.” Law enforcement then administered Narcan to the VA and “observed” that the VA did not have a pulse and his/her cheeks were “cold to the touch.” At 8:29 a.m., the VA was pronounced deceased. · Law enforcement then spoke to RN5 who said that shortly before 8 a.m., s/he took another client (C1) to the VA’s bedroom to be the VA’s new roommate because another client (C2), left the facility the previous night (July 1, 2025), at approximately 8 p.m. While RN5 was in the VA’s bedroom, RN5 observed the VA lying in bed and the VA “appeared deceased.” RN5 then began to “shake” the VA and say the VA’s name but the VA was “unresponsive,” so staff persons called 9-1-1. · RN5 also told law enforcement that prior to 8 a.m., the VA was last seen that morning (July 2, 2025), at 1 a.m. (Note: There was no additional information provided regarding this). · Law enforcement also spoke to other unnamed staff persons, who said that on July 1, 2025, at 1 p.m., the VA was at the nurses station for “medication protocol.” [Note: There was no further information about this.] Around that time, the VA also “complained” of nausea/vomiting. Staff persons told law enforcement that while the VA was at the facility, s/he “slept quite a bit” but which was “typical” for the clients at the facility (due to detoxing from substances). · Law enforcement was unable to determine the VA’s cause of death and did not observe any “drug paraphernalia” or “anything of significance” in the VA’s bedroom. There were no unexplained injuries, signs of drug use, or signs of foul play. The Medical Examiners report said that the VA’s cause and manner of death were undetermined with “contributing” factors being obesity, history of substance abuse, depression, and hepatitis C viral infection. The VA did not have an autopsy or toxicology performed due to “religious objection.” The FM provided the following information: · The facility was a “detox place” and staff persons were “supposed to keep an eye” on the clients, which the FM thought was every 20 minutes. However, at some point following the incident, the FM read the police report which showed that the VA was not checked on for “over” eight hours prior to being found deceased and that the facility cameras showed that the last time the VA was checked on was on July 2, 2025, at midnight. (Note: There was nothing in the law enforcement information report about the camaras and the last time the VA was checked.) The FM also had concerns that the VA was found on the “opposite” side of his/her bed and that the VA was holding his/her dentures when found by law enforcement. The FM did not think that the VA would still be holding his/her dentures if staff persons had performed CPR prior. (Note: There was also nothing in the law enforcement report about this.) · The FM said s/he also read in the police report that at some point on July 1, 2025, the VA went to the nurses station and was not “feeling well.” The FM “imagined” that the VA returned to his/her bedroom to “lie down” and that staff persons “forgot” about the VA for seven to eight hours which was “horrible” and unacceptable.” · The VA did not have an autopsy but the VA did not have any prior medical concerns. The VA was “looking forward to getting detoxed and moving on with [his/her] life.” The VA’s Health History Form, Comprehensive Assessment, Progress Note/Log, Physicians Orders and Stabilization Plan, Condition Specific Protocols: Opioids/Buprenorphine, the Morning Bed Board dated July 1 and 2, 2025, and Clinical Opiate Withdrawal Scale (COWS) provided the following information: · On June 28, 2025, at 8 a.m., the VA was admitted to the facility for “medically monitored withdrawal management” for opioids, stimulants, and cannabis. Upon admission, the VA tested positive for amphetamines, methamphetamine, cocaine, methylenedioxymethamphetamine (ecstasy), tetrahydrocannabinol (THC), fentanyl, and opiates. The VA’s pulse was 78, respirations were 18, oxygen was 99, temperature was 97.6 degrees Fahrenheit, and blood pressure was 111/59. The VA’s “cognition” was “alert.” There were no concerns and the VA did not indicate any pain, nausea, or vomiting. · The VA was on the opioid withdrawal/buprenorphine (Subutex). (Note: Subutex was an opioid medication used to treat opioid use disorder.) Nursing staff persons were to meet with the VA a “minimum” of two to three times a day to check the VA’s vital signs and “assess” needs. However, while completing the withdrawal protocol, it was often “more frequent to complete nursing assessments to assess [the VA’s] withdrawal needs.” Staff persons were to “reassess” COWS (clinical opiate withdrawal scale) every two hours after any dose of Subutex to “determine effect.” The COWS assessment included checking a person’s pulse and noting if the person had gastrointestinal upset, anxiety or irritability, if the person was sweating, and the person’s pupil size. (Note: There were no other vitals checked during the COWS assessment besides checking a person’s pulse.) If any medical concerns arose, the VA was to speak to nursing “right away.” The VA was to “discharge” when “medically and clinically appropriate.”
· On June 28, 2025, at 5:30 p.m., RN3 documented that the VA’s COWS was 5. (Note: According to the scoring chart, 5-12 was mild; 13-24 was moderate; 25-36 was moderately severe; and more than 36 was severe.) The VA received an as needed (PRN) medication for anxiety and muscle spasms per protocol. At 9:30 p.m., the VA’s COWS was 10. The VA was given Subutex and a PRN medication for muscle spasm, anxiety, and sleep per protocol. · On June 29, 2025, at 10 a.m., RN4 said that the VA “complained” of anxiety and “detox,” so the VA was given Subutex per protocol which s/he “tolerated well.” At 1:52 p.m., a staff person (P11), documented that at some point, the VA ate breakfast and was awake for some of the day, including “on and off” while in his/her bedroom. At 2:30 p.m., RN4 documented that the VA “complained” of anxiety and the VA was given medication per protocol which the VA “tolerated well.” At 4 p.m., RN4 documented that the VA was resting in his/her room with no concerns noted. At 5 p.m., the VA’s COWS was 14 and the VA was given Subutex. At 8 p.m., RN4 documented that the VA was nauseated and vomited twice and was given Phenergan (to manage nausea and vomiting) and Subutex. · On June 30, 2025, at midnight, LPN2 documented that the VA was in bed sleeping with regular breathing pattern. At 12:20 a.m., the VA’s COWS was 13. The VA received medication for anxiety, nausea, and “agitation.” The VA then “immediately” vomited the medications and was given Subutex which the VA was able to “tolerate.” The VA then returned to his/her bedroom. · At 2 a.m., the VA was in bed sleeping with regular breathing pattern. At 4 a.m., LPN2 said that the VA’s COWS was 10 and that the VA said that his/her nausea subsided. At 6 a.m., the VA was in bed sleeping with regular breathing pattern and no signs of distress were noted. At 9:30 a.m., RN5 documented that the VA’s vital signs were stable and that the VA’s COWS was 9. The VA received Subutex. The VA’s pulse was 66, respirations were 18, temperature was 98.1 degrees Fahrenheit, and blood pressure was 129/73. The VA did not have any gastrointestinal upset. At 11:30 a.m., it was noted that the VA “declined” the COWS assessment. From 1 to 2 p.m., there was a group offered to the clients but the VA “did not attend.” (Note: There was no additional documentation for the VA between 11:30 a.m. and 8:10 p.m.) · At 8:10 p.m., a registered nurse (RN6) documented that the VA was in bed sleeping with normal chest rise and no signs or symptoms of distress. At 10:20 p.m., RN6 documented that the VA’s COWS was 11 and the VA was given Subutex. · On July 1, 2025, at midnight and 4 a.m., a registered nurse (RN8) documented that the VA was sleeping with normal breathing patterns so the COWS assessment was not completed at either time. At 5:22 a.m., P1 documented that the VA slept through the night. At 8 a.m., a registered nurse (RN7) noted that the VA was asleep so RN7 did not do the COWS assessment. At 9 a.m., a staff person (P12) met with the VA to “firm up” the VA’s discharge, which was set for July 3, 2025, at 11 a.m. No concerns were noted at the time. · At noon, a staff person (P10) documented that the VA was asleep. At 1:15 p.m., RN7 documented that the VA’s pulse was 76, respirations were 16, blood pressure was 133/89, and temperature was 97.9 degrees Fahrenheit. The VA’s COWS was 8. The VA was alert and oriented. The VA was given comfort meds for “symptoms” and Phenergan for nausea and vomiting. The VA was also given Subutex per the “protocol.” RN7 noted, “will continue to monitor.” · At 2 p.m., a staff person (P7) documented that the VA was asleep. At 4:15, 8, and 10 p.m., RN3 documented that the VA was sleeping and that s/he observed the VA’s chest rise and observed normal skin tone. (Note: The video footage review by the facility began at 8 p.m. and did not show RN3 in the VA’s bedroom at 8 or 10 p.m.) Because the VA was sleeping, RN3 did not do the COWS assessment and did not administer any medication to the VA during his/her shift. At 10:19 p.m., a staff person (P8) documented that the VA “appeared to be sleeping” in his/her bedroom “all evening.” (Note: Video footage showed P8 in the VA’s bedroom at 9:14 p.m. and between 9:27 and 9:40 a.m.) At 11 p.m., P8 documented that the VA was asleep. (Note: Video footage showed that the last time P8 was in the VA’s bedroom was at 9:40 p.m.) · On July 2, 2025, at midnight and 1 a.m., P1 documented that the VA was asleep. At 2 a.m., LPN1 documented that the VA was asleep so the COWS assessment was not done. P1 also documented that the VA was asleep. At 3 a.m., P1 documented that the VA was asleep. (Note: Video footage did not show any staff person doing a round or in the VA’s bedroom between 12:34 and 4:03 a.m.) At 4, 5, and 6 a.m., P2 documented that the VA was asleep. (Note: Video footage showed that there was no round done at 6 a.m.) At 6:04 a.m., P1 and P2 documented that the VA “slept through the night.” At 7 a.m., a staff person documented that the VA was asleep but there were no initials as to who completed this. (Note: Video footage showed that at 7:13 a.m., P7 entered the VA’s bedroom to do a round and then no other person entered until the VA was found deceased.) The facility Footage Review Rm 7 provided the following information: · On July 1, 2025, between 8 and 8:20 pm., C2 was in and out of his/her and the VA’s bedroom “several times” and then C2 left the facility. At 9:14 p.m., P8 entered the VA’s bedroom to do a round. Between 9:27 and 9:40 p.m., P8 and a staff person (P9), were in the VA’s bedroom to change C2’s bedding. At 9:49 p.m., P9 did a round. (Note: Per the facility review, doing a round without entering referred to staff persons opening the bedroom door and partially entering the room, vs. going all the way inside.) · On July 2, 2025, at 12:34 a.m. P1 did a round. At 4:03 and 5:10 a.m., P2 did rounds. At 7:13 a.m., P7 entered the VA’s bedroom to do a round. At 8:13 a.m., P7 and RN5 entered the VA’s bedroom with a new client. RN1 provided the following information: · RN1 did not recall the date of the incident but on that date (July 2, 2025), at 7 a.m., RN1 arrived for his/her scheduled shift and worked with RN5 and P7. RN5 was assigned to work with the VA. LPN1 worked the prior shift and during shift exchange, RN1 did not recall LPN1 mentioning any concerns with the VA. · At approximately 8 a.m., RN5 and P7 took C2 to the VA’s bedroom and observed that “something was wrong” with the VA and that the VA was “not breathing.” P7 “ran” out of the room to tell RN1, who was at the nurses station. RN1 then called 9-1-1 and 9-1-1 directed RN1 to go into the VA’s bedroom. During this time, RN5 had grabbed an AED and “quickly applied” that to the VA’s chest while RN1 began doing chest compressions on the VA. The VA was “cold” and “already in rigor.” However, RN5 and RN1 continued chest compressions and using the AED until law enforcement arrived. · RN1 said that the facility had Narcan available and that s/he was comfortable using it but staff persons did not do so because the VA was “so cold and already in rigor” and it was “presumed” that it was not “needed.” However, Law enforcement did administer Narcan and no impact on the VA. Then paramedics arrived who said that because “rigor” had “set in,” the VA was determined to be deceased. · RN1 also worked at the facility on July 1, 2025, from 7 a.m. to 7 p.m. RN1 was not assigned to work with the VA but saw the VA at the nurses station a “few times,” including to receive Subutex. RN1 did not recall which nurse assisted the VA during these times and did not recall what times s/he saw the VA. On the occasions RN1 saw the VA, RN1 could “tell” that the VA was not “feeling well” and described the VA as nauseous, “very anxious,” and “sweating profusely,” which RN1 said was typical with the clients. RN1 did not see the VA vomiting and said that the VA was able to move on his/her own and “make [his/her] needs known.” RN1 did not observe anything concerning. · At the time of the incident, the tech staff persons, including P1 and P2, were trained to do hourly rounds and ensure that the clients were in their bed, but they were not trained to see if the client was breathing. However, during the rounds, a “majority” of the tech staff persons walked into the clients rooms and had a conversation with the clients. RN1 typically worked the day shift and saw the tech staff persons doing rounds as they were trained to do. · It was “required” that the overnight nursing staff persons complete “one” check of a clients vital signs so that they would have a “baseline in case something were to change.” RN1 had only worked the overnight shift one or two times but said that if a client were sleeping, s/he would “wake” the client to check their vitals. RN2 provided the following information: · On July 1, 2025, at approximately 7 or 8 p.m., to July 2, 2025, at approximately 7:15 a.m., RN2 worked the overnight shift with LPN1. The nursing staff persons divided up the clients and on this date and LPN1 was assigned to work with the VA. RN2 did not recall if LPN1 did rounds because s/he was “not looking over [LPN1’s] shoulder.” However, RN2 did not have any concerns with LPN1. RN2 also worked with P1 that night and RN2 saw P1 doing rounds but did not recall how often. · RN2 did not recall seeing or working with the VA while the VA was a client at the facility, including during the overnight shift. · The nursing staff were trained to do rounds on each client they were assigned to ensure the clients were “doing alright.” The nursing staff also checked their assigned clients vital signs to ensure they were “stable” and that they were “breathing.” The frequency of the vital checks varied depending on if a client was at the facility for opioid or alcohol withdrawal. If a client was there for alcohol withdrawal, the nurses checked the clients vitals every hour but for opioids, it was once per shift. If a client was asleep during the scheduled vitals checks, the nursing staff persons would wake them. RN3 provided the following information: · RN3 did not recall the date (later determined to be July 1, 2025), but on that date, s/he was assigned to work with the VA from 3 to 11 p.m. At some point after 3 p.m., shortly after arriving for his/her shift, RN3 checked on the VA and observed the VA sleeping in bed. The VA was breathing and his/her skin tone was “normal.” However, the VA had his/her head at the foot of the bed and his/her feet at the head of the bed which RN3 thought was “unusual.” · RN3 did not go into the VA’s bedroom at any point after this. (Note: The Physicians Orders and Stabilization Plan dated July 1, 2025, showed that RN3 documented that at 4:15, 8, and 10 p.m., the VA was sleeping and RN3 observed the VA’s chest rise and observed normal skin tone. However, the facility’s review of video footage did not show RN3 doing so at 8 or 10 p.m.) At 9 p.m., RN3 saw P8 and P9 in the VA’s bedroom for approximately 15 minutes because they were changing C2’s bedding because C2 had discharged from the facility. RN3 “trusted” P8 and P9 and often worked with them so RN3 asked P9 if the VA was “okay” and P9 said that “everything was good” so RN3 did not go into the VA’s bedroom. Around 11 p.m., RN3 left because his/her shift had ended and LPN1 “relieved” RN3. · RN3 did not give the VA any medications on his/her shift but prior to RN3’s shift, the VA received Phenergan for nausea and vomiting, which RN3 said could cause drowsiness. RN3 thought that also prior to his/her shift, the VA also received “comfort medications” and Subutex so RN3 “expected” the VA to be sleeping. Because the VA received Phenergan, RN3 “assumed” that the VA had been vomiting so RN3 wanted to let the VA sleep. · RN3 said that on July 1, 2025, s/he “varied” from “protocol” which included taking clients vital signs at least once every eight hours. This was due to the VA sleeping and also due to the VA’s body size because the portable blood pressure cuff that nursing used when taking vitals in client’s bedrooms would not fit the VA. The nursing station had a blood pressure cuff that fit the VA but because the VA was sleeping, the VA did not come to the nurses station. At the time of the incident, the facility was “working” on getting a larger portable cuff but the VA “happened to be [at the facility] in that period” when they did not have a portable cuff that would fit the VA. RN3 said s/he “checked in” with P8 and P9, who did hourly rounds, and they did not note any concerns. · At the time of the incident, the tech staff persons did hourly rounds on the clients and RN3 was not aware of any tech staff person, including P1 and P2, missing the hourly rounds. RN3 “counted” on the tech staff persons to ensure that the clients were “alive,” but following the incident, RN3 learned that the tech staff persons only observed that the clients were “present” at the facility but did not check to see if the clients were “breathing and alive.” LPN1 provided the following information: · LPN1 did not recall the date (later determined to be July 1 to July 2, 2025), but on that date LPN1 worked the overnight shift from 11 p.m. to 7 a.m., with RN2, P1, and P2. LPN1 was assigned to work with the VA. When LPN1 arrived around 11 p.m., s/he was not told of any concerns with the VA and said that to the “best of [his/her] knowledge,” the VA was “stable.” Because the VA was “stable” and did not need any medications, LPN1 did not need to check on the VA. However, if the clients received medications during their shift, the nurses “assessed” the clients, including checking vitals. · LPN1 did not see the VA during his/her shift and did not “recall” going into the VA’s bedroom. LPN1 also had not worked any prior shifts with the VA. · That night, P1 and P2 were responsible for doing hourly rounds on the clients. LPN1 said that the “point” of the rounds was to check a client for “breathing.” If a client was not “okay” during a round, the tech staff person was to tell the nursing staff persons. LPN1 said that to the “best of my knowledge,” P1 and P2 did hourly rounds on the night of the incident. The VA’s bedroom was in a corner and at an “angle,” so staff persons needed to “peak” their heads into the VA’s bedroom “a little more” than the other rooms to see the VA. P1 provided the following information: · P1 did not recall the date of the incident but on that date, P1 worked the overnight shift with P2. P1 did not recall who worked prior to him/her but P1 was not told about any concerns with the VA. · P1 did not interact with the VA throughout his/her shift because the VA was sleeping. P1 never met the VA and said that s/he typically did not meet the clients during the overnight shift because they were sleeping. · The duties of the overnight tech staff persons included doing hourly rounds and cleaning and the two tech staff persons typically divided up the rounds. Staff persons were trained to document if the clients were awake, asleep, taking a shower, etc. P1 and P2 did rounds of the date of the indent. P1 thought s/he did them four times and that P2 did the others. P1 did not know why there were rounds that were missed but said that at times, staff persons forgot to sign the round sheet. If both tech staff persons were busy with a work related task, they could ask a nurse to do the rounds. · On the date of the incident, when P1 did the rounds, the VA’s bedroom door was closed, which was typical for clients, and P1 opened the VA’s bedroom door when doing the rounds. The VA’s bed was the furthest from the door and the room was dark. The VA was in bed facing the wall and was “covered completely.” P1 did not see the VA move but said that s/he was not trained to check for breathing, only that client was “there.” P1 did not see the VA sleeping at the opposite end of the bed. P2 provided the following information: · P2 did not recall the date of the incident but on that date it was a “normal night” and P2 worked with P1, RN2, and LPN1. P2 did not recall who s/he took over for at shift exchange but said that there was a 15- minute window where staff persons talked about any concerns, including if clients were not feeling well. P2 did not recall any concerns with the VA. · The overnight shift typically included cleaning, admitting new clients, and conducting hourly room checks. The two tech staff persons typically “split” the tasks. Staff persons were trained to document what the client was “doing” between 12 and 7 a.m. The purpose of the rounds were to ensure that the clients were “safe” and included that the tech staff persons opened the client’s door and “laid eyes” on them and documented if the client was showering, asleep, awake, or something else. · At the time of the incident, P1 and P2 “took turns” doing rounds. P2 recalled the VA “wrapped in covers” facing the bedroom wall and P2 did not have any concerns with the VA. P2 did not see the VA lying on the opposite end of the bed but said that was “typical” for clients because the footboard was closer to the TV. P2 “did not know” if at the time of the incident s/he was trained to check for breathing but said that after, s/he was trained to check for breathing, including looking for the client’s chest “rising and falling.” · When this investigator asked P2 why video footage showed that some of the hourly checks were missed that night, P2 thought there could have been a “miscommunication” between s/he and P1 regarding the rounds. P2 thought s/he did the rounds starting at 4 a.m. and that P1 did the prior ones. P2 also thought that s/he left early that day. (Note: P2’s time entry showed that s/he left at 6:47 a.m., and that P1 left at 7:05 a.m.) LPN2 and RN4 provided the following information: · LPN2 believed s/he worked with the VA a couple days prior to the VA’s death. (Note: This was determined to be June 30, 2025.) At that time, at some point during the overnight shift, the VA walked up to the nursing window for a vitals check and COWS assessment. The VA was “pretty sick,” including nausea, a “small” amount of vomiting, sweating, and “shakes,” but LPN2 said that was “standard opioid withdrawal.” RN4 did not recall working with the VA but saw the VA while at the facility. LPN2 and RN4 each said that there was nothing “out of the ordinary” with the VA and the VA was speaking and moving about the facility normally. · LPN2 and RN4 did not work when the VA was found deceased and LPN2 that s/he was “shocked” when s/he heard about it because LPN2 had worked with the VA a “day and a half” prior and there were “no red flags.” · There was no “specific protocol” for nursing staff persons to do rounds during the overnight shift but LPN2 typically did so at the beginning of his/her shift to ensure all the clients were “accounted for.” Staff persons would not wake the client to take their vitals or do the COWS assessment. The tech staff persons did hourly rounds and LPN2 and RN4 said that “every” staff person they worked with was “really good about rounding.” P4 provided the following information: · On June 29, 2025, P4 did the VA’s assessment and did not recall anything that “stuck” out to him/her regarding the assessment. The VA did not “report” any nausea, vomiting, or loss of appetite at that time and the VA was doing “relatively fine.” However, the VA had used opiates which typically caused the clients to feel “worse” the longer they stayed at the facility, including vomiting and nausea, which felt similar to the “flu.” If a client wanted to “sleep in bed all day,” they were able to because the facility helped clients with “stabilization” and getting them through their withdrawal symptoms. A “lot” of the clients at the facility were “really sick,” including vomiting, chills, and sweating. · P4 “did not recall” if s/he saw the VA after the VA’s assessment but said that s/he typically did not see the clients after due to his/her role. However, the VA met with a “continuing care” staff person on July 1, 2025, who told P4 that the VA was “up and about.” P3, P5, and P6 provided the following information: · P3, P5, and P6 did not work with the VA nor had they met the VA. P3, P5, and P6 each said that the tech staff persons, including P1 and P2, were trained to do hourly rounds for “patient safety” because the facility was a “detox facility.” The checks did not “specify breathing” but staff persons were to have “eyes on” the client and the clients were to be “accounted for.” This could be done by either standing in the doorway or going into the client’s bedroom, depending how “easily” staff persons could see into the room. If a staff person looked in a client’s bedroom and saw that the client was present but sleeping, that was “sufficient.” P6 said that staff persons were trained to ensure that the clients were “okay” but that staff persons did not need to wake the clients. Sleep was a “large part of the healing process” so staff persons tried not to “disturb” a client who was sleeping.
· Following the incident, P3 and P5 reviewed video footage from approximately 8 to 12 hours prior to the VA being found deceased. The video camera pointed “almost directly” to the VA’s bedroom door and P3 and P5 observed that P1 and P2 did not do rounds as trained to do for the VA or any of the clients, who were all on hourly checks. This included that there were “several hour” “gaps” where rounds were not completed including between July 1 at 9:49 p.m. to July 2, 2025, at 12:34 a.m. and July 2, 2025, between 12:34 and 4:03 a.m. (Note: P1and P2 did not start their shift until 11:15 p.m. on July 1, 2025.) There were also no rounds between 5:10 and 7:13 a.m. P3 saw on the footage that P1 and P2 were “preoccupied” with other “duties” such as cleaning which should not “take precedent” over the rounds. · On July 2, 2025, at 7:13 a.m., P7 did a round and did not note any concerns with the VA. The VA was in bed and appeared sleeping during that time which P5 said was “fairly common” for clients. · During the video review, P3 did not see the VA come out of his/her bedroom in the 12 hours s/he viewed the footage prior to the VA being found deceased. However, video footage showed that on July 1, 2025, between 9:27 and 9:40 p.m., staff persons were in the VA’s bedroom to change the bedding because the VA’s roommate left. Prior to that around 2 p.m., video footage showed that the VA was moving about the facility. P5 said it was normal for the clients to remain in their bedroom. · P5 said that the VA was doing “well” at the facility prior to his/her death and had completed his/her “medical protocol” and was “set to discharge” on the morning of July 2, 2025. (Note: The VA’s paperwork said that s/he was scheduled to discharge on July 3, 2025). · P5 said that the nurses did 4-to-12-hour assessments of the clients, depending on the clients withdrawal protocol. The nurses did not do hourly rounds at the time of the incident. Facility documentation showed that P1, P2, P3, P4, P5, P6, RN1, RN2, RN3, RN4, LPN1, and LP2 received training on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section 245F.12, subdivision 1, clause (2) states that withdrawal management programs must have written procedures for a nurse to assess and monitor patient health within the nurse’s scope of practice. Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b), clause (3) states that the license holder shall monitor implementation of policies and procedures by program staff. Minnesota Statutes, section 245F.17, clause (3) states in part that the license holder must maintain a separate personnel file for each staff person which includes documentation of orientation and subsequent training. Conclusion: A. Maltreatment: Information was consistent that on June 28, 2025, the VA was admitted to the facility for “medically monitored withdrawal management” for opioids, stimulants, and cannabis. On July 2, 2025, at 8:29 a.m., the VA passed away at the facility. The Assessment and Monitoring of Guest Health said that the clients health status must be documented on the clients medical record at least once per shift by a nurse or more often based on acuity or change in condition. The documentation should include vital signs, level of consciousness, and withdrawal status. Additionally, the registered nurse and/or recovery technicians were responsible for monitoring clients health and providing hourly observation. P1, P2, P3, P5, P6, RN1, and RN3 said that at the time of the incident, the tech staff persons who did hourly rounds were not trained to see if the client was breathing, only if they were “present.” The VA’s plans, video footage reviewed by the facility, and interviews with P3 and P5 showed that there were “several hour” “gaps” where hourly rounds were not completed including between July 1 at 9:49 p.m. to July 2, 2025, at 12:34 a.m. and July 2, 2025, between 12:34 and 4:03 a.m. There were also no rounds between 5:10 and 7:13 a.m. Despite the video showing that rounds had “gaps” and were not completed as required, staff persons documented multiple times during these times where they indicated that the VA was sleeping. In addition, LPN1 was assigned to the VA and at no point did LPN1 observe or see the VA during his/her overnight shift. Failing to conduct the rounds as required were violations of Minnesota Statutes, section 245F.12, subdivision 1, clause (2), and Minnesota Statutes, chapter 245A.04, subdivision 14, paragraph (b), clause (3). Although it was not known if hourly checks would have prevented the VA’s death, given that the VA was at the facility, which was a detoxification center that provided 24-hour medical care for stabilization and managing withdrawal, and that hourly checks were not completed multiple times during the overnight of July 1 and 2, 2025, and that the VA had not been assessed or in communication with a staff person since July 1, 2025, at 1:15 p.m., which was approximately 19 hours prior to the VA being found deceased, there was a preponderance of the evidence that there was a failure or omission to supply the VA with reasonable and necessary care. It was determined that neglect occurred (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 P1, P2, P3, P4, P5, P6, RN1, RN2, RN3, RN4, LPN1, and LPN2 received training on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Although information was consistent that staff persons were trained on facility policies and procedures including the Assessment and Monitoring of Guest Health and conducting rounds, there was no documentation in staff persons personnel files of the training which was a Minnesota Statutes, section 245F.17, clause (3). However, given that staff persons stated they were trained to visually check and document the whereabouts of each client at least once per hour, yet multiple staff persons failed to check on the VA, that LPN1 was assigned to work with the VA and according to policies was to check on the VA at least once per shift and failed to do so, and that the facility failed to monitor implementation of its policies and procedures when staff persons failed to monitor the VA’s health and hourly supervision, individual staff persons responsibility was mitigated and the facility was responsible for maltreatment of the VA. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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 maltreatment for which the facility was responsible did not meet statutory criteria to be determined as serious. Although the VA was found deceased, it was unknown if the hourly checks would have prevented the VA’s death. Action Taken by Facility: The facility completed an internal review and provided the following information: · Policies and procedures were adequate but not followed. This included that after observing video footage, it did not show P1 or P2 doing hourly rounds. Non-licensed staff persons such as P1 and P2 were responsible for conducting periodic rounds during the evening to verify that clients remained in their rooms and were not engaging in activities prohibited by the facility. However, staff persons conducted “visual rounds through live video monitoring” to ensure the clients remained in their rooms. · Licensing nursing staff persons also conducted health screenings at intervals that “frequently exceeded the statutory minimum of every four to twelve hours” and at no times were the screenings performed at less than the required frequency under Minnesota Statute. · The VA’s health history screening and stabilization plan identified no medical precautions and did not warrant increased rounding frequency. · P1 and P2 were given “corrective action” which included the expectation for rounding practices. A “recommendation” included a specific rounding procedure to account for visual confirmation/safety check and review the procedure of four to twelve hour assessments, specifically identifying when to increase assessments on clients. Additionally, following the incident a new protocol was implemented that staff persons needed to see the clients moving or breathing and “not just seeing the clients in bed.” Action Taken by Department of Human Services, Office of Inspector General: On September 21, 2026, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal.
|
