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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: 1071279-HCBS (Home and Community-Based Services) Investigator(s): Samantha Wueste Samantha.wueste@state.mn.us Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) fell during his/her unsupervised time in the community. Later that day, the VA told a supervisory staff person (SP) about the incident and that the VA had pain in his/her right ankle. It was alleged that the SP did not seek medical attention for the VA until seven days later, when the VA was diagnosed with a fractured ankle. Date of Incident(s): August 24, 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 October 19, 2026; documentation at the facility and medical records; and through seven interviews conducted with the VA, the VA’s guardian (G) who was also the VA’s family member, the VA’s case manager (CM), an employee (E1) from the VA’s day services provider, a supervisory staff person (SP), and two administrative staff persons (P1 and P2). Multiple attempts were made via phone and email to contact and interview two additional employees from the VA’s day services provider (E2 and E3), but the attempts were not successful. The VA’s diagnoses included hemochromatosis (a disorder in which the body absorbs/stores too much iron), hyperlipidemia (a condition where a person has too many fats in his/her blood), moderate intellectual disability, and anxiety disorder. The VA enjoyed watching T.V., going shopping, playing with his/her cat, and spending time with his/her family members and friends. The VA lived by him/herself in an apartment, also referred to as the facility throughout the report, that shared a building with 121 other apartments. The license holder leased 14 apartments and provided services to the residents in the 14 apartments. [Note: The license holder was to provide the VA with integrated community supports (ICS). The VA’s apartment and 13 other apartments in the building were “provider-controlled” ICS settings. An ICS setting was a setting in which a provider had an approved setting capacity report and had direct/indirect control over a person’s living unit (e.g., apartment), which meant that the provider either owned, operated, or leased the living unit, or had direct or indirect financial interest in the property or housing, including a financial relationship with the property owner. A person who lived in an ICS setting was not required to receive ICS. However, when a person lived in an ICS setting, ICS could only be delivered by the provider who controlled the setting.] The facility also leased an additional staff apartment so that staff persons were able to provide supports and services to the facility clients (including the VA) as needed throughout the day. The VA’s MnCHOICES Assessment, Support Plan, Support Plan Addendum, and Individual Abuse Prevention Plan provided the following information: · The VA had a history of impulsivity, anxiousness, isolation, attention-seeking behaviors, and providing inaccurate/false information reports including “faking” or “exaggerating” injuries. Due to the VA’s diagnoses and history, the VA had a 24-hour plan of care but wanted to remain “independent as possible.” The VA had one hour of remote and two hours of in-person 1:1 staffing for ICS services per day, seven days a week. During the weekdays, the VA attended a day program up to five days per week that provided the VA with daily transportation to/from VA’s apartment, as well as vocational supports and services twice a week (including a job at a local fast-food establishment twice a week, for two and a half hours per day). The VA was able to be alone in his/her apartment and in the community, with facility staff being available to assist the VA as needed and/or scheduled each day. · The facility provided the VA with supports and services including community integration, medication management, and staff assistance to complete activities of daily living. The facility was also responsible for helping manage the VA’s health in coordination with the G, which included staff assistance with scheduling, transporting, and/or attending the VA’s medical appointments as needed. The VA’s Support Plan stated that staff were to ask the VA if s/he “felt any aches or pains” and that it was “important” for the VA to “feel listened too and respected.” The VA’s care plans also stated that employees from the VA’s day program were to assist in managing the VA’s health, as needed. · The VA’s IAPP stated that the VA demonstrated adequate self-preservation skills and was able to advocate for him/herself. The VA said s/he enjoyed living at the facility and “liked” the staff who worked with him/her, including the SP. The VA stated that “one night” on an unknown date/time, the VA was walking to a store from his/her apartment and when stepping off a curb to cross the street, s/he “tripped a little.” The VA’s right ankle “twisted to the side” but the VA kept walking and did not remember it “hurting that bad” until some point later the next day. At an unknown date/time after this, the VA showed the SP and employees from his/her day program a bruise that was on his/her (right) ankle, and so the SP “kept giving [the VA] medicine and ice.” The VA stated that s/he did not like to ice his/her ankle because the ice packs were “too cold.” At some point later, the VA went to “the doctor” who told the VA that s/he “broke” his/her ankle “just a little.” The VA then had to wear “a [walking] boot” for “a long time.” The VA did “not like” wearing the boot because it caused the VA’s ankle to “hurt more.” The VA did not provide any further information. E1 provided the following information: · On August 25, 2026, at some point during the early afternoon, the VA “complained” of pain in his/her right ankle to “several” of the employees at the day program, including E2 and E3. The VA showed E2 his/her ankle which had “some minor” bruising at that time but the VA declined any first aid because it was “almost time” for the VA to go home. The VA told E2 that the day prior, while walking alone in the community, s/he “tripped and fell.” Shortly thereafter, the VA left the day program and went home. · On August 26, 2026, at approximately 9:30 a.m., E3 arrived at the VA’s apartment to take the VA to the day program and saw the VA “limping” as s/he walked towards the van. E3 asked the VA if s/he was “okay” and the VA told E3 about how s/he “tripped and fell” a “few” days prior and showed E3 a “long, purple” bruise that was on the VA’s right ankle. The VA told E3 that s/he rested and iced his/her ankle the previous evening and “thought it was better” until walking on it that morning. E3 then asked the VA if s/he was able to work at the day program and the VA responded that s/he “had to” go to work or the SP “might get mad” and “yell” at him/her. The VA said that the SP was aware that the VA’s ankle was “hurting” but the SP “insisted” that the VA was “fine” and “refused” to seek any medical attention for the VA at that time. E3 called and told E1 who stated that the VA had a history of making “fake reports” related to injuries and told E3 to drive the VA to the day program as scheduled. At some point during this time, the SP walked out of the apartment building to where the van was parked and “sternly” told the VA that s/he was “fine” and that the VA needed to go to the day program and work that day as scheduled. · Shortly after the VA arrived at the day program, the VA continued to tell the day program employees that his/her ankle hurt. At some point later that morning, E1 checked on the VA and saw that the VA’s ankle was swollen and bruised. E1 then called the facility and spoke to the SP telling the SP that the day program was “sending [the VA] home early” because of the VA’s ankle injury and that the VA required a “doctor’s note” to return. Shortly thereafter, the VA was taken home. E1 stated that to his/her “knowledge,” the VA did not receive medical attention until August 31, 2026 (five days later). At that time, medical healthcare professionals completed diagnostic imaging of the VA’s ankle that showed the VA fractured his/her ankle. · E1 was not aware of any employees from the day program contacting the G about the incident/injury and/or providing first aid to the VA’s ankle at any point on August 25 and/or 26, 2026. The SP; the VA’s medical records; the facility’s Incident Report and Internal Review completed by the SP and P1; the VA’s daily service notes completed by the SP dated August 24 to 31, 2026; and email communication between the G and the facility’s administrative team (including the SP, P1, and P2) regarding the situation provided information that was mostly consistent with information provided by E1. The SP, the VA’s medical records, and facility documentation also provided the following additional information: · On August 24, 2026, at approximately 7 p.m., the VA was walking to a nearby store and when stepping off a curb while crossing the street s/he “tripped and fell”. The VA “twisted” his/her ankle but said s/he did not hear “any cracks or pops” and was able to stand up and continue walking to the store as planned. Later that evening, the VA walked back to his/her apartment and saw the SP as s/he entered the apartment building. The VA told the SP that s/he “tripped and fell” while walking to the store but was “fine.” The SP did not “notice” any visible injuries to the VA at that time but told the VA to “get some rest” and to contact staff if s/he “needed anything.” The next morning (August 25, 2026), the VA woke and went to the day program without “mentioning” any injuries to the SP or other facility staff at that time. · At approximately 3 p.m., an employee from the VA’s day program called and told the SP that the VA “complained” of ankle pain and had a “small bruise” on his/her right ankle which the VA said was from the evening prior when s/he “tripped and fell.” Shortly thereafter, the VA returned to the facility and the SP asked to “look” at the VA’s ankle. The VA’s right ankle was “slightly swollen and bruised” so the SP gave the VA over the counter (OTC) pain relieving medications (two 200 milligram (mg) tablets of ibuprofen) and encouraged the VA to elevate and ice his/her ankle. The VA took the medication but declined to ice/elevate his/her ankle at that time. The SP then called and notified the G about the situation, who also “briefly” spoke with the VA during the call. The VA told the G that the previous night s/he “tripped and twisted” his/her ankle but did not ice/elevate his/her ankle at that time because the VA did not have “much” pain “right after” the incident occurred. However, the VA then “walked around” on his/her injured ankle “all day” and throughout the day it began to “hurt worse”. The G told the VA to ice/elevate his/her ankle, to rest, and that they would “reassess” the situation in the morning. After talking to the VA, the G asked the SP to “just keep an eye on [the VA]” and to follow up with him/her the next day or if the VA’s symptoms worsened, to which the SP agreed. · The next morning (August 26, 2026), at approximately 8:30 a.m., the SP went to the VA’s apartment to check on him/her. At that time, the VA again took ibuprofen, iced his/her ankle for approximately 20 minutes, and told the SP that his/her ankle was “feeling a lot better.” The SP and the VA then called the G to update him/her on the situation. The G told the VA that s/he needed to go to work at the day program and that the G would call later that afternoon to “check on” the VA. The SP then left the VA’s apartment so that the VA was able to get ready for work. · At approximately 9:30 a.m., the SP was working in the staff apartment and received a call from a supervisory employee at the VA’s day program because the “van driver” was “still” outside the facility with the VA, who was “hesitant” to go to work. The SP then walked outside to where the van was parked and “encouraged” the VA to go to the day program, which the VA then agreed to. However, about three and a half hours later, the SP received another call from the day program informing him/her that the VA was being transported back to the facility at that time and needed a doctor’s note to return due to the VA continuing to complain of ankle pain. The SP “immediately” contacted and updated the G about the situation. The G told the SP that the VA was “not” an accurate reporter of information in situations “like this” and requested that the SP make an appointment with one of the VA’s primary medical doctors (MD). The SP then called the VA’s primary healthcare clinic and scheduled the VA’s appointment for August 31, 2026, which was the first available appointment at that time. After the VA returned, the SP continued to administer ibuprofen to the VA and encouraged the VA to elevate/ice his/her ankle which the VA did. The SP stated that the condition of VA’s ankle did “not necessarily improve” but also did “not worsen at all” during the four days that the VA rested waiting for the appointment, which the SP “thought” was “pretty typical” for this “type” of injury. · On August 31, 2026, at approximately 11:15 a.m., the VA attended a medical appointment with the MD, accompanied by the SP. During the appointment, a physical examination and imaging (x-rays) of the VA’s right ankle/foot were completed and showed that the VA sprained his/her right ankle, which was an injury “consistent” with the VA’s account of how s/he was injured during the incident on August 24, 2026. The MD instructed the VA to continue to rest, ice/elevate his/her ankle, and prescribed 800 mgs of ibuprofen to be taken three times per day, for seven days, to relieve pain. After this, the VA was to take OTC pain medications (ibuprofen and/or Tylenol), as needed. The VA was scheduled for a follow up appointment the next morning (September 1, 2026) to be “fitted” for a controlled ankle motion (CAM) boot (walking boot) that the VA was to wear at “all” times (except when sleeping or bathing) until “medically cleared” by the MD or another healthcare provider. The VA was also referred for a two-week follow-up appointment with an orthopedic specialist. The MD provided a letter stating that the VA was unable to work at that time due to injury but “anticipated” that the VA would be able to return to work on September 7, 2026. · On September 9, 2026, at approximately 10 a.m., the VA attended a medical appointment with the orthopedic specialist, accompanied by the SP. During the appointment, additional imaging was completed which showed a “small talus avulsion” fracture (a small chip of bone) with recommended treatment the same as an ankle sprain injury. The VA was to continue to rest, ice/elevate his/her ankle, take OTC pain medications (ibuprofen and/or Tylenol) as needed, and wear the CAM boot for one to two more weeks before transitioning to an ankle brace. The orthopedic specialist provided written “approval” “permitting” the VA to go horseback riding during an upcoming “trip” that the VA had scheduled for the following week, as well as to return to work on September 23, 2026. The VA recovered without any further complications or concerns. · The SP stated that s/he maintained ongoing communication about the situation with the G and with employees from the VA’s day program. The SP also stated that s/he was “attentive” to the VA’s injuries and followed the directives of the G at “all” times in how to care/respond to the VA’s injuries, which were “reasonable” given the VA’s history and the type of injury that this was. The SP denied that s/he “refused” to seek medical attention for the VA’s injuries at “any point” or that the SP interacted with the VA in a manner that would cause the VA to “think or feel” that s/he was “not allowed to see a doctor.” The G and P1 each stated that s/he was aware of the situation and provided information that was consistent with the information provided by the SP, facility documentation, and the VA’s medical records and care plans. The G also stated that s/he did not have any concerns regarding the care the VA received from the facility. P1 stated that there were no prior concerns with how the SP interacted with or provided care for the VA and/or other facility clients. The CM and P2 each stated that s/he was aware of the situation but did not have any additional information to provide. The facility’s Emergency and Reporting Policy stated the following:
· In the event of a minor illness or injury, staff persons were supposed to administer basic first aid.
· In the event of a medical emergency, unexpected serious illness, or accident requiring physician treatment or hospitalization, staff persons were to call 9-1-1.
· In the event a person needed “immediate attention,” but did not require an ambulance, staff persons were to ensure the person was transported to an emergency room.
· In the event staff persons were “unsure” if the person required “immediate attention,” they were to call an urgent care facility or an emergency room, and follow the healthcare professionals’ instructions. According to the facility’s Code of Conduct, staff persons had a “commitment” to the clients and “working in service to” rather than “controlling” the clients. Additionally, staff persons were to interact with clients in a professional and respectful manner at “all times.” Facility documentation showed that the SP, P1, and P3 each received training on the VA’s care plans; the facility’s policies and procedures, including the Emergency and Reporting Policy and the Code of Conduct; and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: According to the VA’s plans, the VA was able to be alone in his/her apartment and in the community. The VA also had a history of attention seeking behaviors and “faking/exaggerating” injuries. The VA’s health was to be managed in coordination by the VA’s care team which included the G, facility staff persons (including the SP), and employees of the VA’s day program. Consistent information was provided that on August 24, 2026, the VA tripped and twisted his/her right ankle while walking alone in the community. Later that evening, the VA told the SP about the incident, said that s/he was “fine,” and did not have any visible injuries at that time. The next afternoon (August 25, 2026), the VA had a bruise on his/her ankle and complained of ankle pain, and so the SP contacted the G, who advised the SP to help monitor the VA’s symptoms. The SP then gave the VA ibuprofen, and had the VA ice his/her ankle and rest it. The next morning (August 26, 2026), the VA told the SP that s/he was “feeling better” and went to work, but the VA then complained of pain and returned to his/her apartment shortly thereafter. The G was updated on the situation and requested that the VA’s ankle be assessed by the VA’s primary medical provider. The SP scheduled the VA the first available appointment with the MD which was Monday, August 31, 2026, and then until the appointment continued to provide the VA with ibuprofen, ice, and rest for the remainder of the week/weekend. During the appointment, the VA was diagnosed with spraining his/her right ankle and was instructed to continue to ice, rest, and take OTC pain medications (ibuprofen and/or Tylenol, as needed). The VA was also provided a prescription dose of ibuprofen for seven days and a “walking boot” to be worn for approximately two weeks. It was not until September 9, 2026, during a follow-up appointment with an orthopedic specialist that additional imaging was done and the VA was diagnosed with a “small talus avulsion” fracture to his/her right ankle. At that time, the VA was directed to continue the same treatment plan for another one to two weeks. The VA recovered without any further complications or concerns. Although there was a seven-day delay in getting the VA medical care, given that the VA was provided with ibuprofen, ice, and rest until s/he was seen by a doctor, which were the same instructions given by the VA’s primary medical provider and again by the orthopedic specialist, and that the VA was not diagnosed with a fracture until nine days after s/he saw his/her primary doctor, there was not a preponderance of the evidence whether there was a failure or omission to supply the VA with reasonable and necessary care and services. It was not determined whether 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). Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were adequate and were followed. Action Taken by Department of Human Services, Office of Inspector General: No additional action taken.
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