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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: 1071179-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) provided care to a vulnerable adult (VA) but did not ensure that the VA’s food was cut into small pieces. SP1 placed the plate of food near the VA, and SP2 was adjusting the footrests on the VA’s wheelchair. The VA took a whole bratwurst from the plate, began to eat it, and choked. Date of Incident(s): August 27, 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 10, 2026; from documentation at the facility, the VA’s medical records, and interviews conducted with facility staff persons (SP1, SP2, P1, and P2), and the VA’s guardian (G). This investigator met the VA, who communicated with vocalizations but was not able to participate in an interview. Facility documentation showed that the VA’s diagnoses included generalized anxiety disorder, epilepsy, and “severe” intellectual disabilities. The VA could eat independently but s/he might place large amounts of food into his/her mouth and attempt to swallow before thoroughly chewing the food. Staff persons were to cut the VA’s food into bite sized pieces and stay with him/her while s/he ate. The plans did not say who was to cut the food or whether it was to be cut into pieces before it was placed within the VA’s reach. The VA used a wheelchair for mobility but was unable to propel him/herself in the chair and depended on assistance from staff persons for most activities of daily living. The VA enjoyed listening to old rock and roll music and liked spending time on the water. The VA’s G, who was also a family member, was very involved in the VA’s care. Facility documentation, the Internal Review, the VA’s medical records, and interviews with this investigator provided the following: · Information was consistent from SP1, SP2, P1, and P2 that at about 5 p.m., on August 27, 2026, the VA obtained a bratwurst (brat) that was not cut up, and bit off a large piece or pieces of the brat. The VA choked on the brat and was hospitalized. The size/weight of the brat was unknown. · SP1 said that when the incident occurred, s/he had worked at the facility for about a month, was in training, and was not permitted to work unsupervised. That evening, SP1 prepared brats for supper on the grill outside and SP2 made vegetables inside the facility. At about 5 p.m., SP1 placed a brat and vegetables on a plate for the VA, then put the plate of food on the dining table. The VA was sitting at the table in his/her wheelchair, SP2 was standing beside the VA, and P1 was downstairs telling other individuals who resided at the facility to come upstairs for supper. SP1 did not cut up the VA’s food prior to placing the plate on the table and thought that SP2 would do it. After putting the plate on the table, SP1 returned to the kitchen and made plates of food for the other individuals. · SP1 did not see the VA put food in his/her mouth but heard the VA choking. SP2 began giving the VA back blows and abdominal thrusts and told SP1 to go get P1 from downstairs. SP1 went downstairs to get P1 and they came upstairs together. SP1 called 9-1-1 while P1 called a facility health care professional (HCP) and a supervisory staff person (P3) simultaneously using the house phone and his/her cell phone. First responders arrived at the facility and P2, who worked the next shift, came to the facility a few minutes later and said that s/he would go to the hospital with the VA. SP1 knew that the VA’s food should be cut up and had watched other staff persons cut it but had not cut up the food him/herself or assisted the VA to eat. · SP2 said that prior to the incident, the VA was sitting in the living room and seemed happy and excited to eat the brats. When SP1 finished grilling the brats, s/he placed a plate of food on the table while SP2 and P1 assisted the VA to move from the living room to the dining table. P1 went downstairs to ask the individuals to come upstairs to eat supper while SP2 placed a shirt protector on the VA, then leaned down to adjust the footrests on the VA’s wheelchair so the VA could get closer to the table. · When SP2 stood, s/he saw the VA quickly take the brat from the plate and place it into his/her mouth. SP2 took the brat from the VA but thought that the VA bit off about half of the brat before SP2 took it. SP2 prompted the VA to chew the piece of the brat in his/her mouth and moved the plate of food out of the VA’s reach. After about 15 seconds, the VA began to wheeze and choke, and SP2 gave the VA about seven back blows and ten upward abdominal thrusts, then gave the VA additional back blows. · SP1 and P1 came upstairs, and they called 9-1-1 and supervisory staff persons while SP2 continued back blows and abdominal thrusts. The VA spit out two pieces of the brat but it seemed that something was still stuck in the VA’s throat. First responders arrived, assessed the VA, and began giving him/her back blows and abdominal thrusts, but could not dislodge more of the brat from the VA’s airway. First responders transported the VA to the hospital by ambulance. SP2 said that the VA’s food was to be cut into bite sized pieces before it was placed on the table within reach of the VA. · P1 said SP1 grilled the brats, and s/he reminded SP1 that the VA’s food had to be cut up and SP1 said, “Okay.” However, no information showed whether anyone clarified whose responsibility it was to cut the food into pieces. Just before 5 p.m., P1 went downstairs to tell other individuals that supper was ready and to use the bathroom. SP1 went downstairs and told P1 that the VA was choking, and they both went upstairs, assisted SP2, called 9-1-1, the HCP, and P3. The VA went to the hospital via ambulance. · The VA’s medical records showed that on August 27, 2026, the VA was evaluated at the emergency department of a nearby hospital (hospital one) and diagnosed with acute respiratory failure from choking. The VA was transferred to a larger hospital (hospital two) for additional care. An unspecified number of “large chunks” of brat type sausage were removed from the VA’s respiratory system with forceps and suction. The VA was intubated and sedated. A bronchoscopy procedure found three small pieces of sausage in the VA’s respiratory system that were suctioned and brought up. When the VA was stable, s/he was transferred to a room on the medical floor at hospital two. The tube was removed from the VA the day after s/he was admitted and s/he was prescribed an antibiotic to prevent aspiration pneumonia. The VA was at his/her baseline according to information in the records provided by the VA’s family members and was discharged back to the facility on August 29, 2026, with a follow up appointment with a physician on August 31, 2026. · The G said that the facility quickly notified him/her about the incident. According to the G, the facility knew that the VA ate really fast and that his/her food was to be cut into cut into small pieces. The G thought that the VA took the brat from the plate, bit off a piece of it, and then took another bite which s/he “just swallowed” without chewing. When the VA got to hospital one, s/he was in rough shape and had to be transferred to hospital two, because hospital two had specialized equipment to remove pieces of brat lodged in the VA’s airway. The G was upset; this situation was a “close call” and a “big error.” The G believed that staff persons were trained on the VA’s needs but if they had been sitting with the VA when s/he obtained the brat, this incident would not have happened. Prior to the VA residing at the facility, the G checked into multiple facilities and felt that Mt. Olivet best met the VA’s needs. There had been no issues with the VA’s care for years and the G was relieved that the facility took this incident seriously. The G had no other concerns regarding the VA’s care. Facility documentations showed that SP1, SP2, and P1 were trained on the Reporting of Maltreatment of Vulnerable Adults Act and on the VA’s plans. Conclusion: Information was consistent that just before 5 p.m., on August 27, 2026, the VA choked on a brat that was placed within reach of the VA and not cut into bite sized pieces as specified in the VA’s plans. This investigator met the VA but did not interview him/her. The VA’s plans showed that the VA ate independently but s/he might attempt to swallow large amounts of food before thoroughly chewing it. The VA’s food was to be cut into bite sized pieces, but no information showed which staff person was to cut the food or whether it was to be cut before placing it within the VA’s reach. SP1 was a new employee but knew that the VA’s food should be cut into pieces. After SP1 grilled the brats, s/he put a brat and vegetables that were not cut into pieces on the plate for the VA and placed the plate of food on the table where the VA was seated. SP2 was beside the VA and P1 was downstairs. SP1 returned to the kitchen to prepare food for the individuals. SP1 heard the VA began to choke, and s/he saw SP2 give the VA back blows and abdominal thrusts. SP2 instructed SP1 to tell P1 to come upstairs and P1 and SP1 then called 9-1-1, the HCP, and P3. SP2 said that s/he assisted the VA to the table, placed a shirt protector on the VA, then adjusted the footrests on the VA’s wheelchair to get the VA closer to the table. SP2 did not see SP1 place the food on the table, but after adjusting the footrests, SP2 stood and saw the VA take the brat from the plate and bite off about half of the brat. SP2 encouraged the VA to chew the brat, but the VA began to wheeze and choke. SP2 gave the VA back blows and abdominal thrusts but was unable to dislodge all of the brat. First responders arrived, assessed the VA, and continued back blows and abdominal thrusts, but were unable to clear the VA’s airway. The VA was transported to hospital one via ambulance. The VA’s medical records showed that the VA was evaluated at the emergency department of hospital one and transferred to hospital two for additional care. The VA was intubated and an unspecified number of pieces of the brat were removed from the VA’s respiratory system using forceps and suction. The VA was diagnosed with acute respiratory failure from choking but returned to his/her baseline according to information from his/her family members in the records. The VA became stable and moved to a room at hospital two. The tube was removed, the VA was prescribed an antibiotic, and s/he was discharged back to the facility on August 29, 2026. Minnesota Statutes, section 626.5572, subdivision 17, paragraph (c), clause (5), states, A vulnerable adult is not neglected for the sole reason that an individual makes an error in the provision of therapeutic conduct to a vulnerable adult that results in injury or harm, which reasonably requires the care of a physician; and: (i) the necessary care is provided in a timely fashion as dictated by the condition of the vulnerable adult; (ii) after receiving care, the health status of the vulnerable adult can be reasonably expected, as determined by the attending physician, to be restored to the vulnerable adult's preexisting condition; (iii) the error is not part of a pattern of errors by the individual; (iv) if in a facility, the error is immediately reported as required under section 626.557, and recorded internally in the facility; (v) if in a facility, the facility identifies and takes corrective action and implements measures designed to reduce the risk of further occurrence of this error and similar errors; and (vi) if in a facility, the actions required under items (iv) and (v) are sufficiently documented for review and evaluation by the facility and any applicable licensing, certification, and ombudsman agency. Although the VA obtained the brat that was not cut into pieces as specified by his/her plans, choked on the brat, and was hospitalized from August 27-29, 2026, given that SP1 thought that SP2 would cut the food into pieces and that SP2 was adjusting the footrests on the VA’s wheelchair and did not know that SP1 placed food on the table within reach of the VA, that SP2 took immediate action when the VA choked, and there was no delay in seeking medical care for the VA, for the following reasons, it was determined that the SPs’ actions of not ensuring the VA’s food was cut constituted an error in the provision of therapeutic conduct: (i) Immediately after the August 27, 2026, incident, the SPs provided immediate care to the VA including calling 9-1-1, back blows, abdominal thrusts, and SP2 asked P1 to contact P2 and the HCP for assistance. First responders answered the 9-1-1 call and transported the VA for a medical evaluation within minutes of the incident, and the VA was sedated and intubated to remove pieces of the brat from his/her respiratory system. The VA was hospitalized but was discharged back to the facility on August 29, 2026. (ii) The VA returned to his/her pre-existing condition; (iii) There was no information that this error was a pattern of errors by the SPs; (iv) The facility immediately reported the incident as required under Minnesota Statutes, section 626.557; (v) The facility identified and took corrective action to reduce further occurrences; and (vi) The facility’s actions were sufficiently documented for review and evaluation. This error in the provision of therapeutic conduct to the VA by the SPs was not maltreatment. It was determined that neglect did not occur (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 its policies and procedures were adequate and were followed. The incident was not similar to past events with the persons served or services involved. The facility retrained staff persons regarding preparation of the VA’s food and provided a visual example showing that the VA’s food should be cut into pieces no larger than a dime. Staff persons were instructed that going forward, the VA’s food was to cut up prior to the plate of food being placed on the table. SP1 was no longer employed at the facility when this report was written. Action Taken by Department of Human Services, Office of Inspector General: The SPs were not substantiated as perpetrators of maltreatment of the VA because the Department of Human Services found that the incident for which the SPs were responsible met the criteria to be determined an error. The SPs were each notified by the Office of Inspector General that any future incident of possible neglect of a vulnerable adult for which the SPs are responsible might not be considered an error.
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