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AMENDED 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.” NOTICE: This Amended Maltreatment Investigation Memorandum supersedes a version dated June 16, 2023, which must be destroyed. The original version incorrectly identified the facility name, license number, and citation. The amended version contains the correct information.
License Number and Program Type: 1101848-SUD (Substance Use Disorder) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA), who required intensive supervision, left the facility at about 3:20 a.m. and was not discovered to be missing until about 2:30 p.m. It was also reported that rounds were not completed during the overnight shift and that the VA had not been seen since s/he left. Date of Incident(s): April 15, 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 April 25, 2023; from documentation at the facility; and through seven interviews conducted with a facility management staff person (P1), two staff persons (SP1 and SP2), three facility staff persons (P2-P4) and the VA’s probation officer (PO). The VA was not subject to guardianship. Although this investigator attempted to locate the VA so the VA could provide information in an interview, the VA was not located. The facility provided short term residential services to clients with various chemical and mental health concerns. The facility had an office in the central part of a common areas. The office had glass windows so staff persons could look out and monitor the clients. In addition, the office had a white board that documented the first name of the clients, the room they were assigned to, the intake date, and the discharge date. There were two computer monitors at a desk where staff persons could watch various cameras within the facility. There was an enclosed patio (within visual range of the staff person office) that had a lockable door. Within the patio, there was a fence that was about six feet tall. The VA’s Comprehensive Assessment and Assessment Summary showed that prior to coming to the facility on April 12, 2023, the VA was incarcerated, that the VA was “verbally motivated for treatment,” and had been experiencing some withdrawal upon admission. The plan also showed that the VA had received residential treatment at other facilities prior to being admitted to the facility. The VA was diagnosed with severe stimulant use disorder, cannabis use disorder, attention deficit hyperactivity disorder, anxiety, and post-traumatic stress disorder. The VA had difficulty with impulse control and lacked coping skills. The VA enjoyed fixing cars and was “caring and kind.” The VA’s Individual Abuse Prevention Plan did not identify any specific areas of vulnerability. P1 provided the following information: · On April 14, 2023, P2 worked the day shift, P4 worked the evening shift, and SP1 worked the overnight shift between April 14-15, 2023. On April 15, 2023, SP2 worked the morning shift and P3 worked the afternoon shift. · At about 3 p.m. on April 15, 2023, P1 received a phone call from P3 because P3 was unable to locate the VA. As a result, P1, who was not working at the time, went to the facility and reviewed camera footage and learned that the VA left the building through the door leading to the patio and jumped over the fence at about 3:20 a.m. P1 also reviewed documentation and learned that SP1 did not do hourly rounds or bed checks. P1 said that it was somewhat unusual that SP2 did not notice that the VA was gone during SP2’s morning shift, but also that it was somewhat common for new clients to spend more time in their bedrooms than normal because upon intake some clients experienced withdrawal. However, SP1 should have checked on the VA at least hourly during overnight hours. When it was known that the VA had left without supervision, the PO was notified. The PO stated that s/he did not know if the VA had a history of leaving other programs and that facility staff persons were expected to talk to the VA if the VA communicated plans of leaving without supervision. When the PO was asked what level of supervision was expected from facility staff persons, the PO stated that it was expected that staff persons notify the PO if the VA left without supervision. The facility’s Program Abuse Prevention Plan stated that “staff [persons] make rounds at irregular intervals to all areas of the unit 24 hours a day.” The facility had a Shift Responsibilities for ON Shift form that said, “Conduct hourly bed checks and document in log,” and “Lock smoking door at 11 pm-5 am Sun-Thurs & 12 AM Fri and Sat.” A similar form for the morning shift did not indicate that staff persons were to do bed checks on weekends but stated that staff persons were to “conduct rounds periodically to ensure clients are in group” on weekdays. The facility had a form that staff persons were to document hourly bed checks overnight between 11 p.m. and 7 a.m. SP1’s documentation, dated April 15, 2023, showed that there were 11 clients in the program at 11 p.m. and a line was drawn through the remaining hourly checks. P2, who worked the day shift before the VA left, provided the following information: · During day and evening hours, the expectation was that staff persons checked on the clients at least hourly, but the facility did not document that those checks had been done. During overnight shifts, staff persons were expected to check on the clients at least hourly and ensure that they saw “signs of life” when checking clients and then documenting that the checks had been done. · When P2 worked with the VA on April 14, 2023, the VA “seemed really well” and was “comfortable.” P4, who worked the evening shift before the VA left, stated that the VA was “very engaged the whole shift.” P4 also stated that staff persons were expected to check on the clients at least hourly during day and evening shifts and that when P4 served dinner, it was his/her practice to take out the exact number of plates based on how many clients were in the program at that given time so P4 could determine if someone did not come to eat. When that happened, P4 would seek out the client that was missing and see if they wanted to come eat. SP1, who worked the overnight shift between April 14-15, 2023, provided the following information: · When SP1 began working his/her shift, the staff person who worked the evening shift “pointed out” who the VA was because the VA was new, but SP1 was not certain who worked the evening shift. · SP1 last saw the VA, who had his/her own bedroom, watching TV in the common area at about 1 a.m. on April 15, 2023. Although SP1 understood that s/he was supposed to do hourly bed checks, SP1 did not do them that night because some of the clients were “up and moving around” most of the night so SP1 “just didn’t think to do” the hourly checks. · SP1 described the VA as being in a “good mood” on the night of the incident. · When SP1 was asked what could have been done differently, s/he stated that s/he “should have” done the bed checks and locked the door leading to the patio, which was supposed to be locked each night at midnight. Facility documentation showed that at 6:33 a.m. on April 15, 2023, SP1 documented in the VA’s case notes that “client slept through the night. No issues or concerns.” SP2, who worked the day shift on April 15, 2023, provided the following information: · On weekends, clients typically slept in. SP1 stated that s/he was not trained to do bed checks during the day shift. · On the day of the incident, SP2 did not see the VA and that it was “sometimes hard to keep track of these [guys/gals].” · SP2 also said that s/he did not look for the VA because SP2 “didn’t even know what [s/he] looked like.” Facility documentation showed that at 12:15 p.m. on April 15, 2023, SP2 documented in the VA’s case notes that “client ate and spent time in [his/her] room and common areas. No issues or concerns.” P3, who worked the afternoon shift on April 15, 2023, stated that shortly after P3 got to work at about 1:30 p.m., s/he checked the board in the office, which told staff persons how many clients were at the facility at that time. P3 began checking on the clients around 2 p.m. and was unable to locate the VA, who P3 had not previously worked with. When P3 was asked how s/he checked on the clients, s/he stated that if s/he did not see a particular client in the common area, P3 would go to the clients’ room and check on them. When P3 was unable to locate the VA, P3 called P1. A review of SP1’s personnel file showed an Employee Performance Improvement Plan, dated April 19, 2023, which stated that SP1 should have done hourly bed checks during the overnight shift, “The client smoking door needs to be locked at the specific times that are posted,” and “Charting and documentation needs to reflect actual events.” The document also stated, “False documentation was made in Procentive (online documentation system) stating the client slept through the night.” Job descriptions for SP1 and SP2 stated that some of the duties included, “Set priorities in monitoring clients, making house rounds, documentation of pertinent information and completion of other assignments.” SP1 signed his/her job description on May 16, 2022, and SP2 signed his/her job description on August 8, 2022. The facility’s training records showed that all staff persons were trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to April 14, 2023. In addition, SP1 received training on “policies and procedures” and the program abuse prevention plan on May 18, 2022, and SP2 received training on the facility’s “policies and procedures” on August 8, 2022, and the facility’s Program Abuse Prevention Plan on March 5, 2023.
Minnesota Statues, section 245G.09, subdivision 1, paragraph (a) requires the license holder to maintain accurate client records. Conclusion: The VA was admitted to the facility on April 12, 2023. On the afternoon of April 15, 2023, P3 began his/her shift at the facility and began looking for the VA at about 2 p.m. When P3 was unable to locate the VA, s/he called P1. P1 went to the facility and reviewed video footage and learned that the VA left the facility around 3:20 a.m. through a “smoking door” that was supposed to be locked at midnight. SP1 worked the overnight shift and last saw the VA around 1 a.m. in the common area. SP1 understood that s/he was supposed to do hourly bed checks, but SP1 did not do them that night because some of the clients were “up and moving around” most of the night so SP1 “just didn’t think to do” the hourly checks. In addition, SP1 did not lock the “smoking door,” and provided inaccurate documentation stating that the VA “slept through the night,” and “no concerns.” SP2 worked the morning shift and stated that s/he did not see the VA but documented that “client ate and spent time in [his/her] room and common areas. No issues or concerns,” in the VA’s case notes. SP1 and SP2 each inaccurately documented the VA’s status which was a violation Minnesota Statues, section 245G.09, subdivision 1, paragraph (a). Although SP1 did not lock the door, did not do bed checks, and documented that the VA slept through the night when the VA was not there, and SP2 did not see the VA but documented that the VA ate and was in the common area, given that this was an unlocked facility and the VA left without telling anyone and that when P1 learned that the VA was gone, P1 immediately notified the PO, which was the expectation from the PO, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary supervision to maintain his/her safety. 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 Review showed that although policies and procedures were adequate, they were not followed, but the specific staff person(s) that did not follow the policies and procedures was not identified. The facility provided additional training and revised its procedures in terms of how bed checks were to be completed. Action Taken by Department of Human Services, Office of Inspector General: On June 16,2023, the facility was issued a correction order for the violation outlined in this report.
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