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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: 1071814-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) missed virtual medical appointments and community outings, specifically swimming, due to lack of staffing, that the VA was left in soiled clothing for extended amounts of time, and that the facility was not tracking the VA’s food intake. Date of Incident(s): Prior to August 20, 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 September 3, 2026; from documentation at the facility; and through four interviews conducted with the VA’s guardian (G), two management staff persons (P1 and P2), and a facility staff person (P3). Although this investigator met the VA, the VA was unable to provide information due to his/her abilities. Another facility staff person (P4) was contacted to request an interview but P4 did not respond. The VA’s General Information Record showed that the VA was diagnosed with a profound developmental disability, depressive disorder, and arthritis. The VA was non-verbal, and “profoundly” deaf and blind. The VA’s Action Plan stated that the G was worried that the VA did not drink enough liquids, so the VA had a goal to drink liquids daily. Under “services,” the Action Plan stated that staff would take the VA to the YMCA to go swimming one time per week. The VA’s Support Plan showed that the VA enjoyed swimming because it “provides significant sensory and soothing input.” The plan showed that the VA typically went swimming with staff at the YMCA on a weekly basis. Swimming was “incredibly important” to the VA. The VA required complete physical assistance with hygiene, grooming, and toileting. The VA wore adult absorbent undergarments for occasional incontinence and staff persons were to prompt the VA to use the bathroom every two hours. The G provided the following information: · The G scheduled the VA’s medical appointments and once scheduled, the G told P2 about the appointments communicating via phone calls, text messages, or emails. P2 and the G participated in all the VA’s appointments. · Although the G did not remember the date, s/he notified P2 that the VA had a virtual appointment with the VA’s mental health therapist scheduled for July 22, 2026. Before the appointment, P2 told the G that s/he had another obligation during the time of that appointment, but that P4 would attend the appointment with the VA. About 20 minutes before the appointment, the G emailed the link to P4. At the time of the appointment, P4 could not get the link to work and did not join the virtual appointment. The G and the VA’s therapist rescheduled the appointment for August 17, 2026, which was communicated to P2. · On August 14, 2026, the G heard from P1 that P2 was unable to attend the VA’s appointment on August 17, 2026, but that P1 would attend the appointment. Prior to the appointment, the G talked to P1 to ensure that P1 was going to be present for the appointment. P1 told the G that P2 would be available and would attend the appointment virtually with the VA. At the time of the appointment, P2 did not log into the appointment and did not contact the G. The G did not believe that the VA was harmed because of not attending the appointments. · Although the G was not certain whether the VA had a doctor’s order to go swimming at the YMCA weekly, the G told the facility a few years earlier that s/he wanted the VA to swim weekly. Prior to the past year, staff took the VA swimming regularly. However, during the past year or so the VA began to miss weekly swimming. The G was not certain how many times the VA did not go swimming. When the G asked staff why the VA did not go swimming, staff told the G that some of the reasons were because on some occasions the facility did not have a vehicle or the VA had a toileting accident before the planned outing, but the G did not remember the name of the staff person that provided that information. This investigator asked the G to provide documentation (for one year) showing when the VA went to the YMCA for swimming (see below). The G paid for the VA’s membership at the YMCA. · The G had concerns that although s/he requested that staff document the VA’s food intake daily and provide that information to the G monthly, there were times that the data was “late” by a month or two. Another concern reported was that staff left the VA in soiled clothing for extended periods of time. The G was only aware of one time when the VA was transported to a hospital (for reasons not associated with this report), the VA arrived at the hospital and his/her adult undergarment contained fecal matter. P1-P3 stated that when the VA was incontinent, staff assisted the VA to clean up as soon as it was discovered. There was no further information showing that the VA was left in soiled clothing. P2 provided the following information: · When the G planned medical appointments for the VA, the G usually called P2 and they coordinated schedules to accommodate the appointment. · Although P2 did not remember the date, a virtual appointment was made for the VA for July 2026. After the appointment was made, P2 learned that s/he had a training that day that could conflict with the appointment time. Prior to the appointment, P2 communicated with the G about the training and that s/he would not be able to attend the appointment, but that P4 would attend. Because P2 was done with the training earlier than expected, s/he and P4 tried to log into the virtual appointment, but the link, sent by the G, did not work. When P2 called the G, the G said, “It’s just too late,” and that the appointment would be rescheduled. · The July 2026 appointment was rescheduled, but P2 did not remember the date of the rescheduled appointment. P2 was notified of the rescheduled appointment prior to the appointment but P2 learned that his/her family member needed to have surgery, so P2 planned to not work that day. Because P2 could not attend the appointment, P2 asked P1 if s/he would attend the appointment and P1 agreed to do so. · A few days before the rescheduled appointment, which was in August 2026, P2 learned that his/her FM’s surgery was rescheduled, so P2 planned to work and attend the appointment. P2 told P1 that s/he would attend the appointment but did not remember when s/he told P1. P2 believed that the appointment was scheduled for 12:30 p.m. At about that time, P2 called P1 for another reason and during the discussion, P1 asked P2 if s/he was virtually on the appointment. P2 told P1, “No,” because P2 thought that it was at 12:30 p.m., but P1 told P2 that the appointment was at 10 a.m. · Although the VA missed swimming some weeks, P2 did not attribute that to a lack of staffing, but other issues. One staff person was allergic to chlorine, so that person was unable to take the VA swimming. P2 always tried to have staff available who were the same gender as the VA to take the VA swimming, so if there was not a same gendered staff available, that was sometimes a reason why the VA did not go swimming. P2 did not remember how often the VA could not go swimming, but some occasions the VA did not go swimming was because the VA’s YMCA membership fee was not paid and the VA could not go. · The G requested that P2 document the VA’s food and liquid intake, as well as bowel movements and then submit that information to the G monthly. P2 acknowledged that there were a few times when the documentation was provided late to the G. P1 provided information that was consistent with the information provided by P2. P3 did not know whether the VA missed any opportunities to go swimming or on community outings due to lack of staffing. After each meal, P3 documented the amount of food and drink that the VA consumed. There was no information provided that the VA was discharged as a client from the mental health therapist because of missing appointments. Documentation from the YMCA between February 24, 2025, and August 21, 2026, showed that the VA went to the YMCA 35 times. Documentation also showed that between October 17, 2025, and March 27, 2026, the VA had “no active memberships.” The facility’s documentation showed that between June 14, and August 16, 2026, the VA went swimming eight times and between July 10, and August 21, 2026, the VA went on seven community outings. The facility provided documentation of the VA’s food and liquid intake for several months to this investigator. A random review of records showed that staff regularly documented specific foods that the VA ate and amounts of liquid the VA drank daily. There were no dates documented stating when this documentation was provided to the G. The facility’s training records showed that all staff interviewed for this investigation were trained on the VA’s care plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to September 3, 2026. Conclusion: There was a concern that because of the lack of staffing, the VA missed virtual appointments. The VA had an appointment scheduled for July 22, 2026. Prior to the appointment, P2 communicated with the G that although s/he could not participate in the appointment, P4 would attend the appointment virtually with the VA. However, P2 and P4 could not get the link to work and when P2 called the G, it was already too late to do the appointment. The appointment was rescheduled for August 17, 2026. Initially, P2 believed that s/he could attend the August 17, 2026, appointment, but then a scheduling conflict prevented that. As a result, P2 asked P1 to attend the appointment and P1 agreed. However, a scheduling change allowed P2 to attend the appointment so P2 told P1 that P1 did not need to attend. On the day of the appointment, P2 thought the appointment was at a different time so missed it. There was no information that the VA was harmed as a result of missing the two appointments and no information that the VA was discharged from the provider for missing appointments. There was a concern that because of the lack of staffing, the VA did not go swimming weekly. Information showed that the VA missed swimming for reasons such as a staff person being allergic to chlorine, not having a staff person of the same gender as the VA working so s/he could not take the VA swimming. P2 stated that the VA did not miss swimming because of lack of staffing. Documentation showed that between October 17, 2025, and March 27, 2026, the VA had “no active memberships,” at the YMCA and between February 24 to October 16, 2025, and March 27 and August 21, 2026, when the VA had an active membership, the VA went to the YMCA to swim 35 times. In addition, documentation showed that in July and August 2026, the VA went on seven community outings. There were concerns that the VA’s food intake documentation was not submitted to the G in a timely manner. The facility provided documentation that the VA’s food and liquid intake was documented daily but there was no dates showing when documentation was given to the G. P2, who was responsible for compiling the documents and sending them to the G, acknowledged that although the data was collected, there were times that it was submitted to the G late. Although there were concerns regarding the VA’s care, given that the VA went swimming nearly weekly and the reasons given for the VA missing swimming were reasonable and that there was no information that the concerns caused the VA harm or to lose services, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. 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, followed, and that no additional training was needed. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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