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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: 1071773-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that after a vulnerable adult (VA) had an unwitnessed fall, a staff person assisted the VA with walking and did not notify anyone of the fall. The following morning, the VA had swelling and was diagnosed with an ankle fracture. Date of Incident(s): June 29, 2026 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on July 6, 2026; from documentation at the facility, and from the VA’s medical records; and through six interviews conducted with the VA, a management staff person (P1), three facility staff persons (P2-P4), and the VA’s guardian (G). The VA lived at the facility with two other clients. The VA’s bedroom was on a lower level. The VA received one to one staffing, primarily due to behavioral concerns, such as physical aggression toward others, verbal aggression toward others, and self-injurious behavior. The VA’s Support Plan showed that the VA enjoyed playing video games and bowling. The plan also stated that the VA was diagnosed with a moderate developmental disability and a seizure disorder. The VA’s ISSA Assessment Detail showed that the VA had a history of a behavior of stating that s/he was sick and of falling to the floor because the VA wanted 9-1-1 to be called so s/he could go to the hospital. Staff persons then could not tell if the VA was actually having a serious because of these behaviors so if staff persons saw that the VA was not talking, his/her eyes were rolled back into his/her head, and the VA was drooling, staff were instructed to call 9-1-1. The VA did not need assistance with walking and did not need staff present in the bathroom with him/her. A review of the VA’s plans did not show that the VA needed supervision when s/he used the bathroom and did not provide specific guidance to staff in terms of the level of supervision that was to be provided to the VA. Prior to the incident, the VA did not have any mobility concerns. The VA provided limited information but stated that s/he fell while P4 worked. The VA did not provide additional information including details about what happened when s/he fell. P4 provided the following information: · P4 worked on June 24, 2026, as the VA’s one to one staff, but did not remember the time s/he started working. P4 stated that the shift was normal and that the VA seemed “normal.” · At about 8 p.m., the VA told P4 that s/he was going to use the bathroom on the lower level. When the VA had not returned to the main floor after about five minutes, P4 went to check on the VA. The VA was sitting on his/her buttocks on the floor in the bathroom and there was “poop” on the floor and on the VA’s body, which was somewhat unusual for the VA. The VA told P4 that s/he fell but did not provide a reason. P4 assessed the VA for any possible injuries and did not see anything concerning or any bruising. P4 did not believe that the VA had a seizure because the VA did not show typical signs of a seizure after the fall, such as drooling or being tired. · When P4 extended his/her hand toward the VA, the VA “got up” on his/her own. P4 assisted the VA with taking a shower and “was okay.” After the shower, the VA walked independently from the bathroom to his/her bedroom. P4 then assisted the VA with dressing, which was normal. The VA did not show any signs of being in pain. When the VA was ready for bed, P4 returned to the main floor and the VA remained in his/her bedroom. · About 15-20 minutes later, P4 noticed that the VA was sitting/laying on the couch in the living room. Although P4 asked the VA why s/he was there and not in his/her bed, the VA did not respond. P4 documented what s/he observed related to the VA but did not believe that the incident warranted a call to anyone because the VA was not demonstrating signs of pain or having a seizure. P4 did not see the VA climb the stairs from the lower level to the main floor and did not see any bruising on the VA’s forehead. P3 stated that s/he worked from 2-10 p.m. on June 24, 2026, and did not have any concerns related to the VA, his/her mobility, and did not see any bruising or red marks on the VA. The VA did not express any pain to P3. P3 did not see the VA climb up the stairs from the lower level to the main floor. P2 provided the following information: · Although P2 was not certain of the date, s/he came to work at 10 p.m. At the time, the VA was sitting/laying on the couch in the living room. The VA greeted P2 but did not say anything else. · P4 told P2 that the VA got up from the bathroom floor, after the unwitnessed fall, without assistance and that P4 assisted the VA with taking a shower. After the shower, P4 assisted the VA with dressing. · During the overnight shift, the VA remained on the couch and did not use the bathroom or get up, which was not unusual. The VA slept, but P2 did not remember how long the VA slept. · At about 7:15 a.m., P2 talked to the VA and noticed that his/her left ankle was somewhat swollen. P2 also noted that the VA had small bruises on both knees and an abrasion/bruise on his/her forehead. When P2 attempted to put a sock on the VA’s left ankle, the VA stated that s/he had pain. · P2 called P1, but P1 did not answer. Shortly thereafter, P1 arrived at the facility and P2 told P1 about the swelling and that the VA was demonstrating pain. 9-1-1 was called and the VA was transported to a hospital. P1 provided the following information: · Although P1 did not remember the date (information from the investigation showed that the date was June 25, 2026), s/he arrived for work at the facility at about 7:55 a.m. P2, who worked the overnight shift, told P1 that the VA “seems to be in pain.” · P1 talked to the VA, who was sitting in a chair in a living room. The VA provided limited information but told P1 that s/he fell the previous night. P1 observed some bruises, about the size of a quarter, on both of the VA’s knees and on his/her forehead. P1 also noted that the VA had swelling on his/her left leg and the VA appeared to be in pain. · P1 called 9-1-1 and the VA was transported to a hospital. The VA’s medical records showed that the VA was admitted to the hospital on June 25, 2026, diagnosed with a “left lateral malleolar ankle fracture,” and discharged from the hospital on July 3, 2026. The facility’s training records showed that all staff interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to June 25, 2026. Conclusion: Information showed that on June 24, 2026, P4 found the VA sitting on his/her buttocks in the lower-level bathroom at about 8 p.m. The VA told P4 that s/he fell but did not provide additional information. P4 extended his/her hand toward the VA and the VA got up independently. After P4 assisted the VA with taking a shower, the VA walked to his/her bedroom and P4 assisted the VA with dressing for bed. A short time later, P4 noticed that the VA was sitting/laying on the couch in the living room. P3 and P4, who were working at the time, did not see the VA go up the stairs from the lower level to the couch. P4 did not see any bruises on the VA and the VA did not appear to be in pain or injured. P2 said that when s/he went to work at 10 p.m., the VA was sitting/laying on the couch. The VA remained there the whole night, which was not unusual. The VA did not communicate any signs of pain to P2 until about 7:15 a.m., when P2 attempted to put a sock on the VA’s left ankle, the VA stated that s/he had pain. P2 noticed that the VA’s left ankle was somewhat swollen, that the VA had small bruises on both knees, and that the VA had an abrasion/bruise on his/her forehead. Shortly thereafter, P1 arrived at the facility, and they called 9-1-1. The VA was transported to the hospital. The VA was admitted to the hospital and was diagnosed with an ankle fracture and was discharged on July 3, 2026. Although the VA fell in the bathroom and was diagnosed with an ankle fracture the next day, given that the VA did not require assistance or a staff person present with him/her in the bathroom so could be without supervision in the bathroom, that when P4 found the VA on the bathroom floor, the VA stood without issue and did not have signs of pain or injury, that the VA used the stairs at some point after, and that in the morning when P2 noticed swelling and bruising, medical attention was sought immediately, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care. 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’s Internal Investigation showed that policies and procedures were adequate, followed, and that additional training was provided. However, the facility changed the VA’s documentation to reflect that staff would contact a supervisor any time s/he fell. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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