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 MALTREATMENT INVESTIGATION MEMORANDUM Office of Inspector General, Licensing Division Public Information 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: 1070817-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070806-HCBS (Home and Community-Based Services) Investigator(s): Christine Henne Minnesota Department of Human Services Office of Inspector General Licensing Division PO Box 64242 Saint Paul, Minnesota 55164-0242 christine.henne@state.mn.us 651-431-3444 Suspected Maltreatment Reported: It was reported that a staff person (SP) brought a vulnerable adult (VA) to the home of a drug dealer and smoked marijuana with the VA. Date of Incident(s): Prior to January 28, 2023 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 February 27,2023; from documentation at the facility and medical records; and through 12 interviews conducted with two supervisory persons (P1 and P2), five facility staff persons (P3-P7), a community person (CP) who was an advocate for the VA, an administrative person (P8), the VA, a client (C) who also lived at the facility, and the SP. The VA told this investigator that s/he liked to paint, journal, and watch movies. The VA’s diagnoses included depression, chronic pain, and struggled with chemical dependency. The VA was also in remission for cancer. The VA was not subject to guardianship and had up to two hours unsupervised time in the community and up to six hours at home. The VA provided consistent information to all staff persons that s/he has a medical marijuana card but had not at any point shown any staff person despite multiple requests. The VA provided the following consistent information during his/her interview and in the Internal Review: · The SP knew the VA smoked marijuana and that the VA had a medical marijuana card from his/her doctor. However, since the VA moved into the facility, the VA could not afford medical marijuana. The SP “always” had marijuana that “came from many places” with him/her. The VA thought the SP was his/her “friend” and they smoked marijuana provided by the SP “every day” for “three months.” Every time the SP worked, the VA and the SP “went out” and “more or less [the SP] let [the VA] smoke” because the SP “always” had a “pipe” or a “joint” or “something.” The first time they smoked marijuana was the SP’s second day of work during the summer 2022, “maybe” August. On that day, the SP asked the VA if s/he wanted to go for a ride to a park. When they got into the SP’s car, the car smelled of marijuana and the VA said to the SP, “Oh, you got that whacky tobacco.” The SP laughed and told the VA s/he had never heard it said that way. Once they got to the park, they smoked together and watched people play basketball. The next day, the SP took the VA to Minneapolis, where they smoked marijuana again. That same day the SP also picked up family members and “all different people.” · About one month after the above incident, the SP started taking the VA to a house not far from the facility. The VA thought it was just the SP’s friend’s house, but “there was more to it.” The house was “more or less” a place where “they all re-up, smoke, or exchange” and where the SP picked up a lot of his/her “stuff.” Once or twice a week, the VA and the SP went to the house, totaling “maybe fifteen” times. · On an unknown date (Note: According to medical records, it was January 27, 2023), the VA thought the SP told P1 they were going to Walmart, but because something was wrong with the SP’s tire or brakes, they went to a gas station instead to have someone look at it. While outside at the gas station, the VA smoked marijuana provided by the SP. After they left the gas station, they went to the aforementioned SP’s friend’s house. Within a couple of hours after the VA smoked the marijuana, the VA felt like it was “the worst case of food poisoning [s/he] had ever had in [his/her] life.” The VA thought the marijuana was “spiked” and went to a hospital later that night (Note: Medical records showed January 28, 2023, around 2:56 a.m.) The VA thought it was “odd” that the SP did not smoke the marijuana with VA, because the SP “always shared” (smoked with the VA). At some point after the incident, the SP was “mad” at the VA for a “couple days” because the VA “said something different” to P1 than what the SP told P1 regarding the above incident. The SP told the VA to tell P1 that they were “only” going to pick up the SP’s family member. (Note: According to the Internal Review, the VA said the following day after the incident occurred, s/he asked another staff person to take him/her to Walmart since s/he did not go the previous day. According to the VA, P1 asked the VA what the VA and the SP did instead of going to Walmart and the VA told P1 about the SP’s car issue and the SP taking the VA to another person’s house but did not tell P1 they smoked marijuana. The VA thought the SP got “in trouble” for taking the VA to another person’s house and was then upset that the VA “told” on him/her. The next time the SP worked, s/he gave the VA marijuana, but did not smoke it with the VA, which seemed odd since the SP always smoked marijuana with the VA. Either that same night or the next night, the VA called an ambulance because s/he believed the marijuana the SP gave him/her was “laced.”) · On an unknown date, P4 was in the back seat of the SP’s vehicle while the VA and the SP smoked marijuana. P4 and the SP were “friends” so the VA did not know if P4 would tell the “truth” about it. The VA told P1 that information. · The VA told this investigator s/he also texted the SP regarding some of the aforementioned information such as picking up the VA and smoking together on the SP’s “day off.” The facility provided multiple photocopied text messages between the VA and the SP with dates ranging from December 25 to 30, 2022.: · The first text message provided was dated December 25, 2022, at 12:48 p.m. and showed the VA texted the SP asking not to “forget” the VA’s cigar. Later that date, at 2:24 p.m., the VA asked if they were able to “do anything hopefully before [the C] gets in.” The SP replied at 2:24 p.m., “Idk.” The VA replied, “Are we going to be able to get out and smoke anything if you get what I mean what a day I did not plan.” There was not information that the SP replied to the message. · On December 28, 2022, at 8:40 p.m., the VA texted the SP, “Don’t get mad at me can you take me out to smoke before you leave is that possible since you will be here till Monday please if you have it with tons of sugar on top and I don’t bother you I promise I won’t drive you crazy just asking.” The SP’s short reply was illegible from the photocopy. · On December 29, 2022, at 8:42 p.m. the VA texted the SP and said s/he “really” needed to “smoke” and would give the SP $30 Monday if s/he could get a “small bud.” The VA also texted that s/he “promise[d]” to give the SP “30 bucks” to get a “little bit more weed” and that “everything you do or say to me stays with me I promise you that on my soul hear me I do keep my word I do not give a s*** about all the rumors and b***** this back and forth he said she said b******* I know myself I know my hear and I think you know me too hey talk to you later.” The SP replied, “Can you please stop texting me this is inappropriate.” · On Friday December 30, 2022, at 2:34 p.m. the VA texted the SP and said, “Hey I will erase this as soon as I send it to you will you be close by in the next couple hours, I got 40 and I really need your help to do the fact those bastards really f***** me over again if you call I’ll explain it to you.” At 2:34 p.m., the SP replied and said, “Ok hold on.” Attempts were made to obtain video footage from the gas station the VA said s/he and the SP smoked marijuana at together, but the gas station refused to provide video footage without a court issued subpoena. P1 provided the following information: · On January 28, 2023, the VA told P1 that “last Thursday,” (January 26) the SP did not take the VA to Walmart and instead they smoked “weed” together. The VA told the information to P1 because the SP “pissed [him/her] off.” The VA told P1 that s/he “felt” the weed the SP gave him/her was “laced” because it made him/her “sick” with “diarrhea.” · That Thursday, P1 and the SP both worked at the facility. At some point, the SP and the VA left the facility and shortly after they left, P1 brought another client who lived at the facility to Walmart. While at Walmart, P1 called the SP, and they laughed about both being at Walmart. · The VA had a lot of ongoing sicknesses and went to the hospital “a lot.” One of the hospital visits was due to illness from the “laced” weed. · The VA told P1 that s/he smoked marijuana (provided by the SP) with the SP since the SP started working at the facility. · When the VA was “manic,” s/he made “accusations” and staff persons needed to use their judgment regarding them. The VA’s ability to report accurate information depended on whether s/he was manic. When the VA was not manic, s/he was very “shy” and would not talk “much.” When the VA was manic, s/he went weeks without sleeping and was “really emotional.” · According to P1, anything that was illegal was not allowed at the facility. The VA used “Delta 9” gummies that were legal, and s/he purchased them him/herself. However, staff persons were not allowed to use “Delta 9” while at the facility. The VA had a doctor’s approval for medical marijuana but could not afford it. · According to the Internal Review, P1 said that on the morning of January 28, 2023, the VA went to the hospital by ambulance due to heart palpitations and returned to the facility later that afternoon. Upon return, s/he reported to P1 that since the SP started working at the facility a few months ago, s/he took the VA to smoke marijuana and that the marijuana that s/he smoked the “other day” was “laced” with something that caused the adverse reaction and heart palpitations. Medical records stated that on January 28, 2023, around 2:56 a.m., the VA went to the ER and presented with multiple complaints including experiencing diarrhea for the past four days. The VA told hospital personnel that s/he believed s/he had C. diff (Clostridioides difficile- a bacterium that causes an infection in the colon that can cause life-threatening diarrhea) because s/he recognized it from past infections. The VA also said his/her heart felt like it was skipping beats due to low potassium and magnesium levels, had chest pain, and continually stated s/he “feels like [s/he’s] going to die. The VA also reported at the hospital that s/he smoked cigarettes and used marijuana. C. diff test was negative and the VA was diagnosed with palpitations, diarrhea-unspecified type, and Crohn’s disease without complication, unspecified gastrointestinal tract location. The VA was discharged that same day. P2 provided the following information: · P2 was notified about the allegation but could not remember who informed him/her. P2 talked with the VA regarding the incident and the VA told P2 that s/he was “using” and “selling drugs” with the SP and was in the SP’s car when the SP did “drug deals.” The VA also showed P2 text messages between the VA and the SP. The messages were unclear if they referenced drugs. However, the SP at one point texted the VA that it was inappropriate and should not message him/her. · According to P2, staff persons should not give clients their personal phone numbers. However, a phone list was posted at the facility that included the SP’s number. · While P2 looked at facility documentation, s/he stated that on January 28, 2023, at 1:55 a.m., the VA came out of his/her bedroom and told P3 that s/he called an ambulance because s/he was having irregular heartbeats. P3 offered to take the VA’s blood pressure, but the VA declined. The ambulance arrived at 1:58 a.m., and P3 walked the VA outside and confirmed they were taking the VA to the ER. This was not “abnormal” for the VA to go to the ER and typically went about once a month when s/he was “manic.” A staff person documented that the VA went “down the street” to another house earlier that day. P2 said s/he knew that the VA used marijuana at that house. · According to P2, the VA was “manic” when s/he made the allegations and P2 was unsure how accurate of a reporter the VA was because the VA had a history of providing consistent information to “interviewers” but inconsistent information when compared to others. P2 said the VA’s perception to him/herself was “very real.” However, the “inconsistencies” gave question to whether things happened the way the VA thought they did. · P2 said that the VA’s prescribed marijuana cost about $300 a month and the VA could not afford it once s/he moved into the facility. However, the VA used “Delta 8” gummies. P3 said that when the SP worked at the facility, s/he “always” wanted to “go out” with the VA and would be gone for up to two hours. P3 asked the SP on many occasions where they went, and the SP said they drove around, went sightseeing, or got fast food. The SP and the VA were “really close.” P3 heard from P1 that the SP smoked marijuana, but P3 never saw the SP do so. P3 said that the VA was able to accurately report information. P4 said that s/he never saw the SP or the VA smoke marijuana. According to the Internal Review, P4 started working at the facility around January 2023. On an unidentified date, two or three weeks after P4 started working at the facility, P4 rode to the gas station with the SP and the VA because P4 wanted to get a “pop” and the SP purchased a “Black and Mild” cigar for the VA because the VA could not afford it him/herself. Neither the VA nor the SP smoked anything and the SP’s vehicle did not smell like marijuana. The following week the SP was not able to come to work due to the allegations. The VA was “sometimes” able to report accurate information, but it depended whether the VA was “manic.” When the VA was “manic” s/he talked in “circles” and said a lot of “off the wall type stuff.” If the VA was “manic,” the VA’s information was not accurate and would possibly make things up. One time, the VA told other persons that P4 “quit” which was not true and P4 did not know where that information came from. Other staff persons also told P4 that the VA would make up “stuff” when s/he was manic and would “mix up” other persons words. P5 said s/he did not know about any staff persons smoking marijuana with the VA. However, the VA asked P5 to ask the SP for a “joint,” but P5 did not do so because s/he did not want to get involved. P5 did not know why the VA asked him/her to ask the SP for a joint because P5 did not smoke marijuana and never gave the VA a reason to think s/he would help the VA do so. On an unidentified weekday, P5, P1, and the VA were in the kitchen at the facility. The VA asked P5 to take him/her to Walmart to exchange some clothes. P1 asked the VA why s/he was asking P5 that because s/he thought the SP already took him/her the day before. The VA said they did not go to Walmart and just “rode around.” P6 said that the VA smoked cigarettes or “Black and Mild” cigars. P6 thought the VA also smoked marijuana that s/he got from his/her friend’s house down the street from the facility because the VA told P6 that s/he tried to buy marijuana from the friends, but it ended up being “spices” or “oregano” and not marijuana. P6 said the VA also went to his/her friend’s house when s/he was out of cigarettes. P6 did not know anything about the VA using marijuana with a staff person or being hospitalized for bad marijuana. The VA told P6 that a couple times community persons at a gas station purchased cigarettes for him/her because s/he did not have enough money. The SP “used” to smoke cigarettes, but P6 did not see him/her smoke them recently. When the VA was “manic” the VA sometimes went to the hospital. P6 gave the VA the “benefit of the doubt” when it came to the VA’s ability to report accurate information. P6 said the VA was “sometimes” accurate but one time the VA thought there was “thorns” on his/her hands and feet during a manic episode. When the VA was not manic, P6 did not question the VA’s credibility. P7 said that the VA had a prescription for marijuana. On an unknown date between November 2022 and January 2023, the VA and the C told P7 that the SP smoked marijuana while they were in the SP’s car. P7 did not know if the VA also smoked marijuana while with the SP. The C did not like it so stopped going out with the SP. The VA told P7, the SP “gets high all day.” P7 then told P1 what the C and the VA told him/her. P7 said s/he never saw the SP smoke marijuana but smelled it when the SP came in from an outing with clients. On one of P7’s shifts, s/he was told the VA and the SP went to Walmart, but P7 never saw any Walmart bags. Sometime after, the VA told P7 that they went to the SP’s “friend’s house or uncle’s house or something” and the VA just sat in the car while the SP did “whatever [s/he] need[ed] to do.” P7 told P1 what the VA told him/her. When P7 asked the SP about where they went, the SP would “blow [P7] off” and ask why s/he was asking him/her questions and said, “I just took [the VA] to Walmart” or that they “went somewhere real quick.” P7 said that the VA had the ability to accurately report information. The C said that s/he did not remember any staff persons smoking marijuana or being in a staff person’s car while they were smoking marijuana. The CP said that the VA got “manic” often and when s/he was manic did not “make a lot of sense” and was “out of touch” with reality and had a “twisted view” of what was going on. The CP would not depend on the VA to be an accurate reporter and if the VA had a “grudge” against someone or if s/he was going to be in “trouble” for something s/he would not be “completely honest” (even when the VA was not manic). The VA was “always bringing up” staff “stuff” such as staff persons do not know where his/her medications are and do not give them to him/her. However, the CP said sometimes the VA would refuse his/her medications. On a Sunday, a couple of weeks prior to March 7, 2023, the CP talked to the VA while the VA was in the hospital. When the CP talked to the VA, s/he was “manic,” and the VA told the CP s/he was in the hospital for an infection. During that time the VA was in the hospital, he VA also told the CP about other homes on the block near the facility and that persons smoked there and mentioned an interaction with a staff person getting marijuana for the VA and going to someone’s house, but the CP did not know specific details or who the staff person was. P8 said that the VA told him/her that the SP and the VA drove around and smoked cigarettes and marijuana and that it was going on for a while whenever the SP was working. The VA said that the SP brought the VA to his/her house as well as the SP’s friend’s house and the SP’s “dealer’s house.” P8 talked to the SP who denied smoking with the VA as well as giving or selling drugs to the VA. However, the SP said s/he did give rides to people such as his/her family member and the VA was with the SP during that time. P8 was unsure how accurate of a reporter the VA was but said there was some “truth” to what the VA said, but there might be some “blurred lines” for exact details. The SP provided the following consistent information during his/her interview and in the Internal Review: · The SP “adamantly” denied smoking marijuana with or around the VA and denied ever giving the VA marijuana to smoke. The SP said s/he took the VA to the smoke shop to purchase marijuana gummies and had occasionally purchased them for him/herself but never supplied the VA with any illicit drugs. · The SP said that the VA never had money and “guessed” the VA “traded” cigarettes for marijuana with the VA’s friend who lived within walking distance from the facility. The SP denied taking the VA to his/her friend’s house. However, the SP said s/he gave rides to people while s/he was out with the VA and the VA did go to the SP’s house. · The SP said the VA smelled marijuana on the SP and asked for marijuana, but the SP always said, “No.” The SP thought that VA could be “mad” at him/her for not taking the VA to Walmart and made up the allegation in response. According to the VA’s annual plan, the VA did not have a history of false reporting information. · The SP denied ever giving the VA marijuana or “gummies,” but said s/he bought the VA “Black and Mild” cigars when the VA did not have money because they were inexpensive. All staff persons interviewed, including the SP, were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans. Conclusion: The VA provided consistent information to this investigator, P1, P2, P7, P8, and the CP that s/he smoked marijuana with the SP on multiple occasions and P5 stated that the VA asked him/her to ask the SP for marijuana which P5 did not do. P7 also stated that the VA and the C said that the C was in the car when they smoked marijuana and P7 smelled marijuana on the VA and the SP when they returned from an outing. However, the C told this investigator that s/he did not remember any staff persons smoking marijuana or being in a staff person’s car while they were smoking marijuana. Information from all sources was consistent that the VA had a card for medical marijuana but that s/he could not afford to purchase it and had not shown any person the card. However, a staff person supplying marijuana to and smoking it with a vulnerable adult was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and at the time, would have encouraged the VA to participate in illegal activities. Although the VA provided consistent information at different times to six persons, information was consistent that when the VA was in a “manic” state, his/her accuracy in providing information was diminished. The CP and P2 each stated that at the time the VA provided the information s/he was experiencing a manic state. Given this and that the SP denied the allegations, there was not a preponderance of the evidence whether the SP smoked marijuana with the VA, drove the VA while under the influence of marijuana, or that the marijuana the SP allegedly gave the VA caused the VA to be hospitalized. 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 their policies and procedures were adequate, but not followed. The SP violated Policy A-17 regarding employee professionalism and conflicts of interest, which stated that employees may not conduct personal business while on duty and may not take a person served to their personal residence unless approved in advance by the supervisor. The SP received prohibitionary employee counseling and was transferred to a new program within the company and no longer worked with the VA. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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