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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: 1101004-H_CRS (Home and Community-Based Services-Community Residential Setting) 1069963-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported that a staff person (SP) did not complete a vulnerable adult’s (VA) required supervision checks during an overnight, and during the overnight the VA jumped out of his/her bedroom window with a cord tied around his/her neck. Date of Incident(s): June 13 and 14, 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 June 29, 2026; from documentation at the facility, and law enforcement records; and through five interviews conducted with the VA, a facility staff person (P1), a facility supervisor (P2), the VA’s guardian (G), and the SP. Facility documentation showed the VA was friendly, outgoing, helpful, and hardworking. The VA had a gift for interacting with people and advocating for him/herself. The VA liked going on walks in the community and at malls, and enjoyed spending time painting, writing, and making music. The VA was diagnosed with borderline personality disorder, post-traumatic stress disorder, bi-polar disorder, and developmental disabilities. The VA had a history of psychogenic nonepileptic seizures. The VA had an extensive history of leaving the facility without supervision, and an “extensive” history of self-injurious behaviors which included, but not limited to cutting him/herself, swallowing objects, attempts of strangling him/herself, and laying down in the middle of the road. The facility provided the VA with 24-hour supervision with 2:1 staffing. During overnight hours, the facility provided one awake and one asleep overnight staff person for the care of the VA. During an emergency or crisis, the asleep staff person was woken up to assist with the situation. The VA’s plans did not state how often staff persons were to check on the VA at the facility. Staff persons did not document specific overnight checks on the VA. The VA’s Individual Abuse Prevention Plan (IAPP) showed the VA was susceptible to all forms of abuse and neglect. The VA had a history of being charged criminally for assaults while in the community, but the VA had not been convicted. The VA had “unlimited independent time” at the facility with staff persons present. The facility was a split-level single-family home with a living room and a kitchen area located on a main level off a front entry door. The VA’s bedroom was up a stairway and down a hallway from the living room. A bedroom used for the asleep overnight staff was across the hall from the VA’s bedroom. The SP was scheduled to work an awake overnight shift on May 13, 2026, and worked until the next morning, May 14, 2026. P1 worked the asleep overnight shift that night. The VA said at some point the VA went to the kitchen to get something to eat and s/he observed the SP sleeping in the living room, and then the VA went back into his/her bedroom. The VA said during the time the SP was sleeping the VA jumped out of the bedroom window, with his/her phone charging cord. The VA said s/he was not significantly injured during the incident but had a few bruises and scratches from falling. The following information was consistent from the Internal Review (IR), General Event Report(s), and the VA’s daily progress notes (T-Log): · On May 14, 2026, the VA discussed his/her day with the SP prior to the VA going to bed around 11 p.m. The SP stated s/he completed the VA’s routine checks and observed the VA sleeping in his/her bed. · At approximately 12:00 a.m., law enforcement (LE) arrived at the facility and informed the SP the VA was at a neighbor’s home. LE stated the VA had exited the facility by jumping through his/her window and had left the facility unsupervised. LE also stated the VA had tied a “rope” around his/her neck. · The SP and P1 responded to the location identified by LE and observed the VA being assisted by emergency medical services. The VA was later transported by ambulance to a medical facility for further evaluation. The VA was discharged from the medical facility around 5:30 a.m., on May 14, 2026. LE Records provided the following information: · On May 13, 2026, at 11:34 p.m., LE was dispatched after 9-1-1 was called by a community person because the VA was at the community person’s house and was having difficulty breathing. The VA had “something tied” around his/her neck. LE arrived at the scene at 11:39 p.m. Prior to LE arriving the community person cut a cord that was around the VA’s neck. · LE was able to find the VA’s pulse, and the VA responded to a “sternum rub.” LE noted there were visible marks around the VA’s neck, and an ambulance transported the VA to a medical facility. · LE records did not state when LE notified the SP that the VA left without supervision. Medical Records provided the following information: · The VA was seen at the medical facility on June 14, 2026, and was diagnosed with, “acute pain of right knee,” and “abrasions of multiple sites.” While at the medical facility the VA informed medical personnel that s/he had “wrapped a charging cable around [his/her] neck.” The VA said a bystander cut the cord, and the VA had lost consciousness during the event. · The VA was provided with a bacitracin ointment for his/her minor abrasions. The VA was discharged back to the facility at 5:08 a.m. P1 provided the following information: · P1 said s/he interacted with the VA and the SP until approximately 11 p.m., at which time s/he went into the staff bedroom. P1 then attempted to sleep, but could hear the VA, and asked (speaking to the VA through a wall) if s/he was okay. P1 said the VA responded and P1 had no further concerns. P1 did not hear any additional sounds from the VA’s bedroom before falling asleep. · P1 said the SP woke him/her up after LE was at the facility, and P1 and the SP worked together to complete the documentation related to the incident. P2 provided the following information: · P2 said awake overnight staff persons were supposed to check on the VA every 15-30 minutes. P2 did not think the SP completed the VA’s routine checks every 15-30 minutes on the day of the incident because the time LE interacted with the VA, and the time the SP stated (around 11 p.m.) s/he had completed the routine checks was not within the 15-30 minute timeframe. · The VA told P2 s/he saw the SP sleeping prior to the VA leaving out of his/her window. P2 said the SP did not complete any documentation regarding the overnight shift. · P2 said from his/her understanding P1 arrived at the facility around 10 p.m., on May 13, 2026, interacted with the VA briefly, before going to the staff bedroom and was sleeping during the alleged incident. P1 was awoken by the SP after LE arrived at the facility to inform them the VA had left the facility. The SP provided the following information: · The SP said s/he interacted multiple times with the VA prior to the VA going to his/her bedroom around 11 p.m. The SP added that s/he adjusted a blanket for the VA while the VA was in his/her bedroom and the SP estimated that occurred after 11 p.m. The SP was unable to provide an exact timeframe that interaction took place. After the interaction the SP returned to the living room, sat down, and remained in the living room/common area until LE arrived at the facility around 11:40 p.m. · The SP said s/he did not hear the VA leave the facility and was not aware the VA left using the bedroom window until LE arrived. · The SP said that P1 went into the staff office around 11 p.m. Then, the SP notified P1 of the incident when LE arrived. · The SP said s/he and P1 worked together to complete incident documentation. · The SP denied falling asleep at any time during his/her shift. The SP said s/he was instructed to check on the VA every 15-30 minutes depending on the VA’s “attitude.” The VA’s daily progress notes from June 14, 2026, showed the VA interacted with the SP and P1 before going to bed, and the SP stated s/he completed the VA’s routine checks. The G said s/he did not have any prior concerns with the care and services the VA was being provided at the facility. P1, P2, and the SP were trained on the VA’s client specific information and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information showed that on May 13, 2026, the VA left the facility unsupervised after jumping out of his/her bedroom window sometime after 11 p.m., with a phone cord around his/her neck. The VA went to a neighbor’s house who cut off the cord and called 9-1-1. LE went to the facility and informed the SP where the VA was so the SP and P1 went there. The VA was taken to the medical facility and discharged back to the facility early morning of May 14, 2026. The VA did not require medical treatment. The VA required one awake and one asleep overnight staff person. P2 and the SP each stated that during overnight shifts routine checks were to be completed on the VA every 15-30 minutes but the VA’s plans did not state how often the VA was required to be checked on. The VA had “unlimited independent time” at the facility. The VA stated s/he went to get something to eat, and s/he observed the SP sleeping prior to the VA leaving the facility out his/her window. The SP denied sleeping while working the shift and said s/he had completed the VA’s checks and was in the living room when the VA left the facility by jumping out of his/her bedroom window. P1 said s/he interacted with the VA and the SP prior to going into the staff bedroom around 11 p.m., and had a verbal interaction with the VA after 11 p.m. The SP stated s/he put a blanket on the VA sometime after 11 p.m. but did not know exactly when. The exact amount of time the VA was unsupervised was unknown because the SP and P1 each stated they interacted with the VA after 11 p.m., the neighbor called 9-1-1 and LE were dispatched 11:34 p.m., and LE notified the SP at 11:40 p.m. that the VA was not at the facility. Although the VA was able to leave the facility without supervision by jumping out his/her bedroom window, given that it was unknown what time the VA left so was unknown if the VA required a check by the SP prior to LE information the SP the VA left, that the VA’s plans did not state how often the VA needed to be checked on overnight, and that the SP and VA provided conflicting information regarding whether the SP was asleep, 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 the policies and procedures were adequate, but were not followed. The facility developed a training plan for staff persons to be re-trained on documentation of incidents, completion of overnight checks, and emergency protocols. The SP was no longer employed at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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