Minnesota Department of Human Services

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.”

Report Number: 20140264

Date Issued: May 20, 2014

Name and Address of Facility Investigated:

Minnesota Security Hospital
2100 Sheppard Drive
Saint Peter, MN 56082

Disposition: Substantiated as to neglect of two vulnerable adults by the facility and a staff person.

Program License Number: 801558

Rule and/or Statute under which Facility is licensed: Residential Treatment and Services for Adults with Mental Illness


Colleen Cook
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242


Suspected Maltreatment Reported:

It was reported that the facility failed to provide adequate supervision to two vulnerable adults (VA1 and VA2). As a result, VA1 assaulted VA2 causing VA2’s death.

Date of Incident(s): January 22, 2014

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.

Investigation Procedure:

Site visit: January 27 and 28, 2014

Interviews (conducted between January 23 and February 19, 2014):

• Four security counselors (SC1-SC4)

• Four patients (PT1-PT4)

• A health care professional who assisted on the date of the incident (HCP1)

• Four facility management and treating professionals (P1-P4)

• A family member (FM) of VA2

A vulnerable adult (VA1) was interviewed by the Bureau of Criminal Apprehension.

Documents reviewed included:

• A facility incident report dated January 22, 2014

• A Provisional Autopsy Report dated January 23, 2014

• VA1’s file including Individual Abuse Prevention Plan, Forensic Master Treatment Plan, Progress Notes, and assessments

• VA2’s file including Individual Abuse Prevention Plan, Forensic Master Treatment Plan, Progress Notes, and assessments

• PT1-PT4’s Face Sheets, assessments, and Individual Abuse Prevention Plans

• The facility’s Forensic Treatment Services document outlining the facility’s programs and objectives

• The facility’s Abuse Prevention Plan for unit 800

• Law Enforcement records including the initial Complaint and interview transcripts

• The unit 800 Day Rounds Form for January 22, 2014

• The facility’s Unit 800 Shift Communication log for January 22, 2014

• A facility floor plan

• A list of all staff persons working at the time of the incident

• Pass down notes for unit 800 dated January 15 through 22, 2014

• Unit 800 Unit Shift Communication dated January 22, 2014

• A facility Action Plan responding to immediate concerns raised by the Division of Licensing, received February 12, 2014, including facility policies, position descriptions, and meeting minutes

• The facility’s Root Cause Analysis dated March 21, 2014

Pertinent Information/Summary of Findings:

This investigation was conducted in conjunction with the Minnesota Department of Health. The Department of Health reviewed the incident for possible licensing violations under Minnesota Statute, section 144.56 and Minnesota Statute section 144.653. The Department of Health findings can be found under separate cover in the report pertaining to investigative cases #HL01418022 and #HL01418023. This report is a review of the incident as it pertains to Minnesota Statutes section 626.557 (the Reporting of Maltreatment of Vulnerable Adults Act) and Minnesota Rules part 9520.0500 to 9520.0690 (Rule 36). In addition, Law Enforcement conducted an independent investigation. The Minnesota Department of Health concurs with the findings of this investigative memorandum.

According to a Law Enforcement complaint, on January 22, 2014, VA1 entered VA2’s bedroom and punched VA2 in the face. When VA2 fell to the ground, VA1 “stomped” on VA2’s head several times. As a result of the incident, VA2 died. VA1 was charged with second degree murder. At the time of this report, the law enforcement case was still open.

VA2’s autopsy report concluded that VA2’s death was homicide due to closed head trauma. Other significant findings included the occultation (obstruction) of VA2’s airway by aspirated gastric contents.

The Department of Human Services Licensing Division investigation collected information regarding the known history and subsequent treatment planning for VA1 and VA2 prior to the incident; the supervision provided on the date of the incident; the facility’s policies, procedures, and training; and staff persons response when VA2 was found injured. Information showed that staff persons’ responses after VA2 was found injured met training and statutory standards. Therefore, this investigation memorandum focused on the background and events leading up to and during the incident.

At the time of the incident, VA1 and VA2 each resided at the facility on unit 800. Unit 800 is the facility’s “crisis” and “admission” unit. The Forensic Services Overview described patients on unit 800 as persons who displayed significant aggressive or unsafe behaviors, significant psychiatric symptoms that lead to unsafe behavior, or who were at high risk for unsafe behavior and were in need of acute intervention. The primary focus of treatment for patients on unit 800 was to address and stabilize acute psychiatric and behavioral health needs and to facilitate treatment initiation.

Unit 800 is a locked unit with a large common area. In the common area are six tables used for dining and activities such as cards and puzzles. At either end of the common area is an east and west wing. Each wing has split levels with a lower and upper landing. Each landing has a shared television and sitting area as well as four single bedrooms. Each bedroom has a closing door that does not lock. Each bedroom door has a window with a curtain on the outside. In total, the unit has sixteen single bedrooms. The security counselor office is located at the west end of the unit, has windows from waist level up, and is referred to as “the bubble.” From inside the bubble, it is possible to see most areas of the unit; however, there are blind spots. Across from the bubble area, is a washer and dryer for patient use.

VA2’s room was located on the lower east landing. Given the location of VA2’s door and the location of one of the tables in the common area, most of VA2’s bedroom door was in a blind spot and not visible from inside the bubble. The facility’s Root Cause Analysis documented that the area of VA2’s room was not visible from the bubble and was “sufficiently separated that staff could neither see nor hear the assault take place.”

According to VA1’s file, VA1 was diagnosed with schizo-affective disorder-bipolar type, and anti-social personality disorder. VA1 was also diagnosed with Fetal Alcohol Syndrome and had suffered injuries that might have caused a traumatic brain injury. On November 27, 2013, VA1 was admitted to the facility after an assault on a staff person at another facility. On December 19, 2013, VA1 transferred from unit 800 to the facility’s Competency Restoration Program (CRP). On January 15, 2014, VA1 was transferred back to unit 800 from the CRP unit after an assault on a patient that resulted in a broken nose.

VA1’s IAPP provided the following information:

• VA1 stated that s/he had been in approximately 50 fights and that some of the fights were “unprovoked assaults [on others].”

• VA1 was at risk of abusing others and had a “significant history of aggressive behavior toward peers and caregivers.” The risk was identified upon VA1’s admission to the facility. In the section that outlined risk reduction measures to be taken by staff persons, staff persons were to redirect VA1 from aggressive behavior and intervene as necessary if there was an altercation. Staff persons were also to follow “Unit 800 Abuse Prevention Plan: paragraph 2.”

• VA1 had a history of threatening and intimidating behaviors. In the section that outlined risk reduction measures to be taken by staff persons, it stated, “Unit 800 Abuse Prevention Plan: paragraph 8.”

The facility’s Unit 800 Abuse Prevention Plan provided the following clarifying information:

• Paragraph 2 stated:

This unit is one of the most heavily staffed of all forensic units requiring a base staffing of four persons minimum per shift. All staff are required to take Therapeutic Intervention and Physical Intervention as well as yearly refresher courses. All patients have Individual Treatment Plans and IAPPs that identify aggression as a barrier to discharge. All patients are offered individual and/or group therapy/training in alternative behaviors to aggression. Patient behavior is closely monitored and discussed on a daily basis among staff on duty. Staff are trained in Therapeutic Interventions as well as Technical Safety Skills.

• Paragraph 8 stated, “Patients who attack others verbally have Individual Treatment Plans that teach alternate behaviors and provide alternatives for target behaviors. Close observation is maintained at all times. Documentation of incidents is made.”

VA1’s Forensic Master Treatment Plan provided the following information:

• VA1 identified that his/her trigger to aggressive behavior was “being challenged to fight.” VA1’s calming strategies were to watch television or to read.

• VA1’s “long term goal” for aggression and assault was to develop and implement a plan to express anger and frustration in a non-aggressive way. VA1 also had a goal to be free of assaultive behaviors and to be able to verbalize three effective coping skills.

• On a monthly basis, VA1 was to discuss an incident in which s/he engaged aggressively and identify a non-aggressive way that VA1 could have resolved the issue. VA1 was to attend weekly coping skills group and meet with staff on a monthly basis or “more frequently as needed.” VA1 also attended bi-weekly courtroom competency curriculum sessions. On January 17, 2014, (after VA1 assaulted another patient) the treatment plan was updated to include that VA1 was offered a weekly anger management group.

According to VA2’s file, VA2 was diagnosed with schizophrenia, paranoid type. VA2’s Individual Abuse Prevention Plan had no documentation that VA2 was vulnerable to physical abuse by others. VA2 stated that s/he had no history of abuse from others and did not feel vulnerable in this area. VA2 was recently admitted to unit 800 after a parole violation.

A family member (FM) of VA2 stated that when VA2 was on his/her medication, VA2 was “the nicest person you could meet.” The FM stated that VA2 was quiet and polite. Before coming to the facility, VA2 enjoyed spending time with the FM’s dog and spent time shopping with the FM. VA2 thought of him/herself as an inventor.

Three staff persons (P1, P2, and P3) were treatment professionals and provided the following information:

• P1 and P3 met with VA1 weekly. P1 believed that VA1 had good insight into his/her history of aggression. After a month on unit 800, VA1 was in “behavioral control” and transferred to the CRP. VA1 had a provisional diagnosis of paranoid schizophrenia based on his/her history and records. VA1’s symptoms appeared consistent with anti-social personality disorder.

• After VA1 assaulted another patient on January 14, 2014, VA1 was not determined to need increased supervision. P1 was “shocked” when VA1 assaulted a CRP patient on January 14, 2014. P1 and P3 each believed that the assault was an isolated incident in which VA1 targeted a “peer” based on the peer’s criminal history. When P1 met with VA1 on January 17, 2014, VA1 seemed “very calm” and did not want to talk about the January 14, 2014, assault. VA1 told P1 that s/he had no thoughts of hurting him/herself or others at that time. VA1’s IAPP was reviewed and information regarding the recent assault was added.

• Beginning January 17, 2014, one of VA1’s medications was changed to be administered crushed in applesauce due to a suspicion that VA1 was not swallowing the medication and was providing it to another patient. On the date of the incident, P1 was informed that VA1 was upset about the crushing of his/her medication and wanted to discuss the issue with a medical doctor.

• In mid-December 2013, VA2 was admitted to unit 800 as a new admission to the facility. During VA2’s first month at the facility, P1 and P3 met with VA2 weekly. VA2 was cooperative, quiet, and stayed to him/herself. P2 stated that VA2 was vulnerable given that s/he was mentally ill and had a limited ability to engage with others. At the time of the incident, VA2 was determined to be stable enough to transfer from unit 800 to another unit when a bed became available.

• P1 stated that unit 800 was different than other units in that some patients were in crisis, some patients were new to the facility, and some patients were in the process of having mental health assessments. P1 stated that unit 800 “had to take everyone.” P2 believed that there was a facility problem related to the mixed population of “malingering” (criminal) patients being housed with vulnerable patients. P2 believed that the broader (state-wide) system needed more options available for appropriate placement of patients who were on mental health commitments.

Regarding the events of January 22, 2014:

According to information from interviews, facility documentation, and incident reports, on January 22, 2014, unit 800 was staffed with five security counselors (SC1-SC5). There were also two health care professionals working on the unit: a registered nurse (RN1) and a licensed practical nurse (LPN1). RN1 and LPN1 were not responsible for the supervision of patients. Information was consistent that patients ate dinner around 5 p.m. and both VA1 and VA2 were present. After dinner, between 5:10 and 5:25 p.m., SC1 and SC4 completed “window checks” (they walked around the unit and checked the integrity of each exterior window, including a window in VA2’s bedroom). At that time, VA2 was present in his/her room. Around 7:20-7:30 p.m. VA1 came to the window of the bubble and said s/he hurt VA2 right after dinner. SC2 and SC4 responded and found VA2 in his/her room with extensive injuries to his/her head and face. VA1 was put in seclusion and 9-1-1 was called. Cardiopulmonary resuscitation (CPR) was initiated and an automated external defibrillator (AED) was applied. Facility health care professionals and paramedics responded, and VA2 was pronounced dead at 7:55 p.m.

VA1 told Law Enforcement that the assault happened shortly after SC1 and SC4 completed window checks. VA1 left VA2’s room and returned two times to check on VA2. Both times, VA1 stated that s/he heard “snoring” noises coming from VA2 which led VA1 to believe that VA2 was still breathing. VA1 stated that s/he paced the floor for “two hours” after the assault and looked in VA2’s window a number of times before telling a security counselor to check on VA2.

Facility patients (PT1-PT4) provided the following additional information regarding the incident:

• PT1 stated that after dinner, s/he cleaned the tables and then went to the television area on the landing outside VA2’s bedroom. According to PT1, “right after dinner,” PT1 saw VA1 go into VA2’s bedroom and heard VA1 ask VA2, “Are you ChoMo [a child molester]?” VA1 asked VA2 for “papers” to prove it. PT1 then heard fighting going on in VA2’s bedroom. PT1 saw VA1 come out of the bedroom and VA1 appeared “bloody.” PT1 saw VA1 throw a pair of shoes in a garbage can across from the bubble where security counselors were located. PT1 did not tell anyone because s/he thought it was a “regular” fight which happened “all the time” on the unit.

• PT2 stated that between 2 and 3 p.m. VA1 was complaining that his/her anti-psychotic medication was making him/her feel like “jumping out of [his/her] skin.” VA1 asked for assistance regarding medication and staff persons “were blowing [VA1] off.” After VA1 did not get assistance from staff persons, VA1 spoke with a psychologist who said s/he would speak with VA1 in “a bit.” The psychologist never returned to talk to VA1 that day.

• PT2 stated that PT2, PT3, and VA1 had a conversation that PT2 thought was “a joke” how a patient had to assault someone in order to be heard by staff persons. VA1 told PT2 and PT3 that s/he was going to “beat up” a doctor or a staff person. PT2 told VA1 that s/he would be arrested if s/he assaulted a staff person.

• PT2 stated that around 4 p.m., PT2, PT3, VA1, and VA2 were on the lower east landing watching television and VA1 hit VA2 in the back of the head. The incident was unprovoked by VA2. VA2 asked why VA1 hit him/her and then VA1 hit him/her again. VA2 walked away from the area and went into his/her room. PT2 stated that they ate dinner right after this incident. VA1 told PT2 that s/he was going to “fight” VA2 after dinner.

• PT2 stated that shortly after dinner, PT2 saw VA1 who was “out of breath” and had blood on his/her shoes. VA1 asked PT3 to give VA1 PT3’s shoes so that VA1 could wash his/her own shoes. VA1 put PT3’s shoes on. About a half hour later, PT2 saw VA1 again, and noticed that the second pair of shoes, belonging to PT3, was covered in blood. VA1 walked across the unit with PT3’s bloody shoes in his/her hands.

• PT2 stated that between 5 and 7 p.m., PT2 saw VA1 go to VA2’s room at least three times and look in the window. VA1 also went to his/her room, took a shower, and washed and dried his/her clothing. After 7 p.m., PT2 saw VA1 throw PT3’s shoes in a garbage can. PT2 did not feel safe telling staff persons that an incident occurred.

• PT4 was told by PT1 and PT2 that they saw VA1 “beat” VA2 “right after dinner.” PT4 stated that security counselors were watching television right after dinner. PT4 saw VA1 “a couple times” during the evening but did not notice anything unusual about VA1.

SC1-SC4 provided the following additional information regarding the incident:

• During the afternoon, VA1 requested to see a doctor regarding his/her medication. VA1 was told to wait until the following day to talk to a doctor or to talk to a nursing staff person if VA1 had immediate concerns. SC1 stated that between 4 and 4:30 p.m., VA1 requested to see a medical doctor because s/he was having “crazy thoughts.” SC1 asked VA1 if s/he felt like hurting someone and VA1 said, “No.”

• SC1 stated that between 5:35 and 7:30 p.m., SC1 was on the unit in a common television area with several patients. During that time, SC2 checked in with SC1 a couple times. SC3, SC4, and SC5 remained in the bubble from 5:35 until 7:30 p.m.

• SC2 stated that s/he saw VA1 leaving the area of VA2’s bedroom around 6:40 p.m. SC2 did not interact with VA1 when SC2 saw VA1 leaving the east landing. SC2 did not notice anything unusual about VA1.

• SC2 stated that between 5 and 6 p.m. VA1 came to the window of the bubble and requested laundry soap, which SC2 gave to VA1. SC2 stated that later in the evening, VA1 came back and requested more laundry soap. SC3 stated that around 7 p.m. s/he gave VA1 laundry soap. SC4 stated that s/he was in the bubble most of the evening and two or three times during the evening VA1 came up to the bubble and requested laundry soap. SC2-SC4 did not notice anything unusual about VA1 when VA1 requested laundry soap. (Note: VA1 told law enforcement that s/he attempted to clean his/her bloody clothing and shoes after the assault by putting them in the washing machine.)

• SC3 assisted with medications and was out of the bubble on the unit from 7 until 7:20 p.m. After that, SC3 responded to an emergency call and found VA2. SC3 went back to the washing machine and took out the contents, which included PT3’s shoes with blood on them.

The facility’s Root Cause Analysis provided the following additional information:

• Around 4 p.m. VA1 came to the nurse’s window two times which was unusual for VA1. VA1 asked when s/he could see a psychiatrist and RN1 told VA1 that if the doctor came to the unit that day, RN1 would mention VA1’s request. Otherwise, a psychiatrist was scheduled to come in two days.

• During medication administration time around 7:30 p.m., VA1 refused oral medications and became “angry and agitated.” VA1 asked why people were “lying” to him/her about seeing a doctor.

Regarding supervision:

P1 stated that unit 800 did not have increased staffing at the time of the incident. The supervision requirement on unit 800 for patients was the same as the supervision requirement in other areas of the facility. All security counselors throughout the facility had the same orientation and training regarding supervision requirements. (Note: the facility’s Root Cause Analysis documented that the minimum staff to client ratio was four security counselors to 16 patients. On the date of the incident, unit 800 had five security counselors and 14 patients.)

The facility’s Unit Rounds and Monitoring policy defined patient rounds as a process that included staff persons moving through the unit to visually observe and document each patient’s location and status. Patient rounds were not to be completed from the unit bubble or a static location (unless all patients were congregated in that location). The staff person assigned to complete patient rounds was expected to move throughout the living area checking the status of each patient and the living area. Patient rounds were completed every hour by all shifts. The document stated that “the staff member assigned to patient rounds will personally identify each patient by observing their face during waking hours . . . when conducting rounds, it may be necessary to enter a patient’s room for accountability purposes or to check on suspicious behaviors or sounds . . . while conducting rounds, staff will maintain a high level of observation and attentiveness to the environment and each other while ensuring each patient is accounted for.”

The unit 800 Shift Communication Log for January 22, 2014, had no documentation regarding VA1 or VA2.

The Day Rounds Form for unit 800 contained rows with each patient’s name and columns labeled by each hour of the day. The instructions on the form stated that the assigned staff person was to conduct an hourly patient round and enter a location and “status code” (what the patient was doing) when the hourly round was completed.

On January 22, 2014, SC4 was the staff person responsible to complete the Day Rounds Form. SC4 documented that at 5 p.m. VA1 was on the unit eating. At 6 p.m. VA1 was on the unit “pacing.” At 7 p.m. VA1 was on the unit engaged in solitary activity. SC4 documented that at 5 p.m., VA2 was on the unit eating. At 6 and 7 p.m. VA2 was in his/her room engaged in solitary activity.

PT1-PT4 provided the following information:

• PT1, PT2, PT3, and PT4 each stated that on the date of the incident, between 5:40 and 7 or 7:30 p.m. there were no rounds completed. PT2 and PT3 each stated they were watching and waiting for the rounds because they knew an incident had happened. PT4 stated that if a security counselor would have completed a 6 p.m. round, they would have found VA2 and been able to get him/her assistance.

• PT2 stated that after dinner, SC1 was watching television with patients; SC2 was on the floor for a short time working on a puzzle; and all the other security counselors never left the bubble. PT2 stated that security counselors failed to do required rounds “all the time” and often, security counselors played cards by themselves. PT4 stated that there were “a couple” security counselors who were “respectable” to patients, but a “few” were “very rude and unprofessional” to patients and spend their entire work shifts playing cards with each other and not talking to patients.

SC1-SC4 provided the following information:

• SC1-SC4 each stated that the supervision requirements for patients on unit 800 was that one staff person was to observe each patient hourly, unless a patient had an increased supervision requirement designated by a medical professional. There were no additional supervision requirements on the unit at the time of the incident. Staff persons on unit 800 had no special or additional training and staffing was consistent with the staffing on other units. Staff persons were trained that a security counselor should be on the unit at all times. On the date of the incident, this requirement was met. There was no information that security counselors were not to be in the bubble. The normal patient to security counselor ratio on unit 800 was five security counselors for up to sixteen patients and on January 22, 2014, between 1 and 5 p.m. SC2 took some patients off the unit for activities such as going to the canteen. During that time, there were four security counselors working on unit 800.

• SC1 stated that s/he was on the unit with patients on the evening of the incident, and SC2 was assisting patients on and off of the unit. SC3, SC4, and SC5 each did not leave the bubble between 5:30 and 7:30 p.m.

• SC2 believed that at the time of the incident all staff persons were “making good use of their time.” SC2 was told by SC4 that SC4 saw VA2 at 6:30 p.m. SC2 was concerned because security counselors were “not allowed” to question patients when they were in other patient’s areas. Previously, if SC2 saw VA1 on a wing that did not contain VA1’s room, SC2 would have responded by saying, “Get out of that area or we will get you out.” At the time of the incident, there was no rule to forbid patients from going in each other’s rooms and security counselors could only “discourage” the behavior, but could not enforce it. SC2 believed that unit 800 needed increased staffing.

• SC3 stated that s/he was in the bubble most of the evening of January 22, 2014, and did not do anything different than what s/he was trained to do.

• SC4 stated that s/he was responsible for the rounds on January 22, 2014. SC4 stated that s/he did rounds “sporadically” throughout the night. SC4 remembered seeing VA2 “around 5 p.m.” when dinner trays were passed out. SC4 did not remember the “exact time” but thought that between 5:20 and 5:30 p.m., SC4 saw VA2 again when s/he tested the windows. Sometime around 6 or 6:30 p.m., SC4 remembered seeing a hand pull VA2’s door shut. There were no other times that SC4 saw VA2 between 5 and 7:30 p.m. The expectation for hourly patient rounds was to “see” each patient and document it. SC4 stated that s/he did rounds as s/he was trained; however, it was more than an hour between times that SC4 saw VA2. SC4 stated that s/he was in the bubble reviewing another patient’s treatment plan most of the evening, and did not do anything different than s/he was trained.

A health care professional (HCP1) who worked on several units including unit 800 stated that s/he was concerned that there might need to be a higher observation level on unit 800. The facility recently made changes to programing and many of the changes were “for the good,” but some of the changes might have put patients at more risk. In the past, if a staff person felt that a patient was at risk of assaulting another patient, they could be put in mobile restraints until the patient could be assessed for risk. HCP1 believed that supervision on unit 800 was “great” but that if a patient made a decision to take out his/her rage on another patient, “they are going to find a way.” HCP1 heard that VA2 was last seen outside his/her room at 6:30 p.m.

Regarding position descriptions and training:

P1 stated that s/he believed that all staff persons followed the training that they were provided. P1 believed that the issue was that VA1 had criminal behavior and should not have been placed with persons who were vulnerable such as VA2.

SC1-SC4 provided the following information:

• SC1 stated that staff persons were trained to be on the unit, to build rapport with the patients, and to be available for patients. Most security counselors on the unit did this as they were trained. SC1 stated that the facility provided security counselors with a lot of training regarding client centered care, but many staff persons did not want to follow it. SC1 stated that SC3 and SC4 consistently did not follow the training to be on the unit interacting with patients and instead they spent most of their time in the bubble. SC1 stated that s/he brought his/her concern to a facility management person prior to the incident. (Note: There was no documentation of this concern in SC3’s or SC4’s personnel file.)

• SC1 stated that patients’ treatment plans were available for security counselors to read, but SC1 did not read many because all SC1 needed to know was that a person might be dangerous. SC1 was not aware if VA2 was vulnerable to abuse prior to the incident. SC1 had some information about VA1’s and VA2’s histories including VA1’s history of assaultive behavior and that a metal pipe was found in VA1’s bed. SC1 heard of the facility Abuse Prevention Plan but was unaware of what was contained in the plan.

• SC2 stated that when a security counselor started employment, they were trained on a range of patients’ behaviors. A treatment plan was developed for each patient and included things that might agitate or increase unsafe behavior. SC2 knew that staff persons were to review treatment plans, but SC2 never saw VA1’s or VA2’s treatment plan or Individual Abuse Prevention Plan. SC2 knew that VA1 and VA2 each had previous incidents that included aggression, but SC2 did not know anything else about VA1 or VA2.

• When asked what training SC3 received before working with VA1, SC3 stated, “Really, none. We treat most patients the same. I heard the reason [VA1] got shipped to us was a violent assault taken place on a different unit.” SC3 did not know if s/he saw VA1’s treatment plan and did not know if there was a policy or procedure for reviewing treatment plans. SC3 stated that to prevent assaults, staff persons were trained to interact and engage with patients. Several years prior to the incident, the facility revoked the use of physical isolation and mobile restraints. Staff persons were then trained to use the least intrusive means possible to stop the behavior. SC3 believed the change was a “failure” given the nature of the patients on unit 800. SC3 stated that many security counselors believed that unit 800 needed increased use of seclusion and restraints. SC3 did not know if seclusion or restraint would have made a difference in this incident.

• SC3 did not remember if s/he read VA2’s treatment plan and did not know what VA2’s treatment plan said. SC3 knew from “hearsay” that parts of VA2’s history included offenses prior to being a patient at the facility.

• SC4 stated that s/he had no training specific to VA1 or VA2 prior to the incident and added that “it was “totally up to [staff persons]” whether they read a patient’s treatment plan or Individual Abuse Prevention Plan. When asked what tools were provided to staff persons to keep patients and staff safe, SC4 stated that staff were trained to “notice things.” SC4 believed that the discontinuation of protective isolation several years previously may have impacted the outcome of this incident. Patients used to enter the unit on isolation and were only allowed to come out “a couple hours a day.” When the facility stopped using protective isolation it was not replaced with anything else.

The facility’s Root Cause Analysis stated that after the incident, staff members expressed concern about their personal safety with the population of patients on unit 800 and the concern influenced some to spend more of their time in the unit office than out on the unit with the patients. The Root Cause Analysis speculated that more staff presence on the unit may have alerted staff to the assault while it was in progress or caused VA2 to be discovered earlier.

P2 stated that all staff persons were trained on Trauma Informed Care, which was a training that encouraged interpersonal interactions. Each patient had individualized care based on his/her IAPP and treatment plan. Staff persons were made aware of the changing needs of patients at shift change when each patient’s current needs were discussed and documented on the Shift Communication Log. Staff persons were trained to complete hourly rounds.

The facility submitted documentation that at a facility management meeting on April 3, 2013, it was reviewed that all patient treatment plans were to be signed by direct care staff persons acknowledging that they had reviewed the updated plans. The facility’s Root Cause Analysis documented that unit 800 did not maintain the “sign-out log” as required to indicate that staff persons had reviewed patients’ IAPPs and treatment plans.

The security counselor position description stated that security counselors were to “provide direct care, treatment, support, and leisure activities while ensuring a safe environment.” Security counselors were to “protect patients and maintain a positive environment with a supportive approach that facilitates patient participation and independence.” Tasks for this goal included maintaining a calm therapeutic environment, monitoring patients for injury and health problems, and protecting patients from abuse and neglect. Security counselors were to assist patients in following their treatment plans by maintaining awareness of their individual treatment plan and responding appropriately. Security counselors were to maintain a secure setting and to provide patient supervision and emergency intervention as needed. Security counselors were to maintain a presence on the unit and to remain alert to any element that posed a risk.

A security counselor competency checklist outlined that security counselors were to understand the concepts of therapeutic interventions and to demonstrate an ability to approach a patient, model connection, take patient challenges into decision making, and to demonstrate empathy to meet a patient where s/he was. Additionally, security counselors were to understand patient rights and vulnerabilities and the performance criteria to measure such an understanding was passing a vulnerable adult and patient right test. There was no information regarding training on individual patients.

The course descriptions and training content for trauma informed care, technical safety skills, and MANDT training were reviewed and provided the following information: The MANDT training model was training designed to reduce or eliminate workplace violence by “learning how to support people, not just behaviors.” The model taught that all stakeholders must first build healthy relationships. Staff persons were to know and treat each patient individually in ways that support their preference and choice. Additionally, staff persons were “to use skills to de-escalate conflictual situations safely” and to “minimize aggression and violence between people.”

The Patient Services Policy stated that patients had Individual Abuse Prevention Plans (IAPP) that identified their vulnerability to abuse and identified measures to reduce the risk of harm, abuse, or neglect. The facility’s Program Abuse Prevention Plan identified the environmental and demographic characteristics of the unit that determined potential factors contributing to a patient’s vulnerability. Staff persons were to be aware of and received training on these plans and their implementation.

Training records showed that all staff persons interviewed received training on the Reporting of Maltreatment of Vulnerable Adults, unit rounds, therapeutic intervention, and “MANDT” client centered care in the year prior to the incident.

Relevant licensing rules:

Minnesota Rules, part 9520.0640, subpart 2, items B, D and E, states that the facility must develop an individual program plan that identifies specific problems to be resolved; specific, measurable, and time-limited objectives which relate directly to the goals; and specific methods, strategies, and resources, including medications, to be used by the staff to assist the patient to accomplish the goals and objectives.

Minnesota Statutes, section 245A.04, subdivision 14, item (b), subitem (3), states that the facility must monitor the implementation of policies and procedures.

Minnesota Statutes, section 245A,65, subdivision 2, item (a) , subitem (2), states the assessment of the physical plant where the licensed services are provided shall include an evaluation of the condition and design of the building as it relates to the safety of the clients; and the existence of areas in the building which are difficult to supervise.

Minnesota Statutes, section 245A.65, subdivision 2, item (b), subitem (1), states the plan shall include a statement of measures that will be taken to minimize the risk of abuse to the vulnerable adult when the individual assessment required in section 626.557, subdivision 14, paragraph (b), indicates the need for measures in addition to the specific measures identified in the program abuse prevention plan. The measures shall include the specific actions the program will take to minimize the risk of abuse within the scope of the licensed services, and will identify referrals made when the vulnerable adult is susceptible to abuse outside the scope or control of the licensed services. When the assessment indicates that the vulnerable adult does not need specific risk reduction measures in addition to those identified in the program abuse prevention plan, the individual abuse prevention plan shall document this determination.


A. Maltreatment:

On January 22, 2014, VA1 went into VA2’s room and assaulted VA2. The assault resulted in the death of VA2.

Information showed that VA1 believed that s/he was going to see a psychiatrist and that staff persons “lied” to VA1 about seeing a doctor. However, info showed that when VA1 requested to see a doctor s/he was told that s/he may need to wait until the following day and that s/he could speak to a nurse for any immediate concerns. Although the communication may have been unclear to VA1, given that staff persons stated that they asked whether VA1 felt as though s/he was going to hurt him/herself or others, and that VA1 had recently expressed concern about a change in medication administration, there was not a preponderance of the evidence whether the miscommunication related to VA1 seeking consultation with a psychiatrist was maltreatment.

Unit 800 was a crisis and admissions unit and patients on unit 800 were known to display significant aggressive or unsafe behaviors, significant psychiatric symptoms that lead to unsafe behavior, and were at high risk for unsafe behavior. SC1-SC4 described that the supervision requirement on unit 800 was an hourly check of patients by one of the security counselors. The staffing on unit 800 was consistent with staffing on other facility units.

On the evening of January 22, 2014, information showed that three of the five security counselors (SC3-SC5) spent most of the evening inside the bubble. Although documentation showed that the hourly checks were completed, SC4 was responsible for the hourly checks and provided information that s/he saw VA2 between 5:10 and 5:25 p.m., then saw a hand on VA2’s door between 6 and 6:30 p.m., and did not see VA2 again until 7:30 p.m. when VA2 was found injured. PT1-PT4 each stated that the hourly checks were not completed as required. Information from VA1, PT2, and the rounds documentation showed that VA1 was “pacing” on the unit. In addition, information also showed that VA1 went to VA2’s room several times and either looked in the window or went inside the room, started a load of laundry that included bloody shoes, threw away a second pair of bloody shoes, and may have had a fight with VA2 on the unit before dinner. All of these events occurred without a staff person noticing anything unusual. PT1 stated that “regular” fights between patients happened “all the time” on the unit. The facility’s Root Cause Analysis stated that security counselors were trained to spend time on the unit but some expressed concerns for their own safety which led them to spend time in the bubble. PT1 and PT2 each stated that they felt unsafe telling staff persons about the events surrounding the incident.

In addition, both VA1’s and VA2’s IAPPs and treatment plans provided general information regarding security counselor’s role related to VA1’s and VA2’s care, but did not provide security counselors with treatment strategies specific to VA1 and VA2 which was a violation of Minnesota Rules, part 9520.0640, subpart 2, items B, D, and E, and Minnesota Statutes, section 245A.65, subdivision 2, item (b), subitem (1). SC1-SC4 each stated that they had not read VA1 or VA2’s IAPPs and the facility’s Root Cause Analysis documented that unit 800 did not maintain the “sign-out log” which was a violation of section 245A.04, subdivision 14, item (b), subitem (3).

There was a preponderance of the evidence that given the known vulnerabilities of unit 800 patients, and VA1’s known history of assaultive behavior, there was a failure to provide reasonable and necessary supervision to VA1 and VA2. Additionally, the failure to provide staff persons with client specific education and strategies was a failure to provide VA1 and VA2 with reasonable and necessary care or services.

It was determined that 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).

B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c):

When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors:

(1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care;

(2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and

(3) whether the facility or individual followed professional standards in exercising professional judgment.

SC4 was responsible to complete hourly rounds. The documentation showed that the rounds were completed. However, SC4 stated that s/he saw a hand on VA2’s door but did not see VA2’s face as SC4 was trained to do. Additionally, PT1-PT4, and SC1 each stated that the rounds were not completed between 5:30 and 7:30 p.m., and that SC4 was in the bubble during that time frame. SC4 was responsible for neglect of VA1 and VA2.

Additionally, the facility was responsible to follow and enforce licensing standards and to provide staff persons with tools including training, supervision, and client specific strategies to ensure patient safety and to reduce the possibility of incidents of aggression. The facility was also responsible for the maltreatment of VA1 and VA2.

SC4 and the facility were each responsible for maltreatment of VA1 and VA2.

C. Recurring and/or Serious Maltreatment:

The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states:

“Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment.

Minnesota Statutes, section 245C.02, subdivision 18, states:

"Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult.

In the evaluation of the substantiated maltreatment for which SC4 was found responsible, it was determined that neglect did not meet statutory criteria to be determined as recurring or serious given that it was unknown if there would have been a different outcome for VA2 if the hourly rounds were completed as SC4 was trained.


Substantiated as to neglect of VA1 and VA2 by SC4 and the facility.

Action Taken by Facility:

On January 31, 2014, DHS Licensing Division and the Minnesota Department of Health met with the facility to outline potential areas of immediate risk of harm to patients on unit 800. On February 6, 2014, the facility submitted an action plan that included directing staff persons on the expectations and documentation of hourly patient/room checks; staff persons’ training and responsibility toward understanding and implementing treatment plans and their supporting documents such as Abuse Prevention Plans; staff persons’ responsibility toward therapeutic interactions with patients; and staff persons’ understanding and implementation of position descriptions and job expectations. Supervision on unit 800 was increased as part of the February 6, 2014, action plan.

The facility completed a Root Cause Analysis that reviewed 24 areas of possible contributing factors to the incident. The facility determined that several areas may have been part of the root cause of the incident, and the facility created a plan of action to respond to each of the potential areas of concern. The facility made the following determinations and plans of action:

• The facility plan to address this issue related to no “sign-out log” for IAPPs and treatment plans on unit 800 is that all staff will review treatment plans and IAPPs. The facility plan of action is documented as, “audit and education.”

• VA1’s treatment plan did not specify in detail the exact nature, timing, and precipitating events of his/her previous assaults. These facts may not have been considered sufficiently with VA1’s diagnoses when developing his/her IAPP. Staff persons had a lack of detailed information about previous assaults, and a lack of understanding of VA1’s diagnoses. The facility plan is to encourage more detail in IAPPs regarding patient history of aggression and or self-harm.

• The Day Rounds Form did not have area for documenting a specific time of observation and did not require a second sign-off. Additionally, the facility determined that SC4 had a “very vague account of [his/her] understanding of the rounding requirements.” The facility plan is to update the “rounding procedure,” to develop a new form that allows specific times to be entered, and to require eye contact with each patient.

• Staff persons had difficulty with the recent change to trauma centered care and the person centered approach and expressed problems with understanding what tools were acceptable and appropriate for managing the environment. This concern may have resulted in staff persons inaction related to intervention. The plan of action is for “additional staff training.” Additionally, a restraint and seclusion committee will look at “best options,” and the facility will create an environment that balances safety and security while helping patients with recovery. The action plan is for training, coaching, observing, and “reinforcing movement.”

• The facility will enforce increased staff presence on the unit floor through a new unit protocol.

• The facility housed patients in crisis with patients in admission, and determined that the populations are very different and should not be co-located given that admissions patients are frequently more vulnerable to abuse. The short term plan is to reorganize the unit, and the long term bonding bill will enable new construction.

• The facility did not have clear guidelines around physician availability for staff and patients. The plan of action is to develop a protocol and education.

• Unit 800 included blind spots that prevented staff persons from seeing all areas of the unit. The plan of action is to seek funding approval to install cameras.

Action Taken by Department of Human Services, Office of Inspector General:

SC4 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SC4 was notified by the Division of Licensing that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of SC4. The determination that SC4 was responsible for maltreatment is subject to appeal.

On May 20, 2014, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal.

The Commissioner is also extending the conditional status of the facility’s license until December 22, 2016. The conditional status of the facility license includes both the existing terms and additional terms resulting from this investigation.

Action Taken by the Department of Health:

The Minnesota Department of Health issued citations in accordance with Minnesota Statutes, section 144.56 and/or Minnesota Statutes, section 144.653.

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