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.”

Report Number: 20165572 Date Issued: November 10, 2016

Name and Address of Facility Investigated: Disposition: Allegation one: Inconclusive

Residential Services of Northeastern MN, Inc. Allegation two: Inconclusive

9549 McCamus Road
Brookston, MN 55711

Residential Services of Northeastern MN, Inc.

2900 Piedmont Avenue
Duluth, MN 55811

License Number and Program Type:

1070744-H_CRS (Home and Community Based Services-Community Residential Setting)

1070738-HCBS (Home and Community-Based Services)

Investigator(s):

Scott Broady
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
651-431-6557

Suspected Maltreatment Reported:

Allegation one: It was reported that a vulnerable adult (VA) was able to leave the facility without a staff person’s
(SP1’s) knowledge. After the VA returned to the facility, it was discovered that the VA consumed a bottle of
vodka and huffed “air duster.”

Allegation two: It was reported that the VA was able to obtain “air duster” at Wal-Mart while being supervised by
a staff person (SP2).

Date of Incident(s): September 13 and 14, 2016

Residential Services of Northeastern MN, Inc.
Report 20165572
Page 2

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c,
paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a):

The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited
to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the
vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction
of the vulnerable adult and which is not the result of an accident or therapeutic conduct.

Summary of Findings:

Pertinent information was obtained during a site visit conducted on September 26, 2016; from documentation at the
facility and medical records; and through interviews conducted with four facility staff persons and the VA.

The facility was located in a rural area. The facility was a farm like setting with several outbuildings. There was
also another residential program, separate from the facility, on the property. The property included outbuildings
which housed cattle, horses, and a donkey. The facility was a two level with the VA’s bedroom being on the upper
level. The main level included a living room, a kitchen, a game room, and a staff office. In the kitchen there was a
set of patio doors with a screen door that led out to the yard of the facility.

The VA’s diagnoses included fetal alcohol syndrome and chemical dependency. The VA enjoyed playing
basketball and playing pool.

The VA’s Individual Abuse Prevention Plan and Self-Management Assessment and Plan stated:

 The VA was to be supervised 24 hours a day by staff persons. During awake hours, while the VA was inside
the facility, staff persons were to complete 15 minute visual checks of the VA. If the VA was in his/her
bedroom, staff persons were to knock on the door and open it to see if the VA was in the bedroom and safe. If
the VA was outside at the facility, the VA was to be within visual sight of staff persons at all times. At night
the VA was to be checked on every 30 minutes.

 The facility had alarms on all the exit doors. In addition, the window screen in the VA’s bedroom had an alarm
which allowed for the window to be opened for air, but if the screen was removed it triggered the alarm. Staff
persons were to ensure that the alarms were in working condition and were to immediately communicate any
concerns to maintenance or supervisory staff persons. Supervisory staff persons were to complete weekly
checks of the alarms and document those checks on a tracking sheet.

 If staff persons found the VA to be missing from the facility, staff persons were to call the VA’s cell phone and
if s/he did not answer call a supervisory staff person. Staff persons were to wait one hour and if the VA did not
return to the facility within that hour, 9-1-1 was to be called and given a description of the VA. When the VA
returned, the VA’s pockets and bedroom were to be searched.

 If the VA was on a community activity, the VA had a one to one staff person who was to keep the VA within
sight and one arm’s length at all times. If a staff person of the same gender as the VA was out in the
community with the VA and a staff person had to use a restroom, the staff person was try to use a multiple stall
restroom and have the VA come into the restroom. Otherwise, if the VA could not go into the restroom, staff
persons were to tell the VA to wait outside the door. This was an area of risk for supervision. If the VA left
without supervision, staff persons were to follow the VA’s protocol.
Residential Services of Northeastern MN, Inc.
Report 20165572
Page 3

 If staff persons had suspicions that the VA was under the influence of drugs, staff persons were to notify a
supervisory staff person. The VA’s probation officer was also to be notified.

 The VA had a history of chemical dependency with chemicals of choice being over the counter cold
medications. The VA also had a history of huffing aerosol cans. All cleaning products were to be kept locked
and if the VA was using cleaning products, the VA was to be within sight of staff persons at all times.

The facility’s Program Abuse Prevention Plan did not have any information related to alarms at the facility.

Facility documentation showed that staff persons interviewed (SP1, SP2, P1, and P2) each received training on the
VA’s Individual Abuse Prevention Plan and Self-Management Assessment and Plan, the facility’s Program Abuse
Prevention Plan, and on the Reporting of Maltreatment of Vulnerable Adults Act.

The “air duster” referred to in this were report was Ultra Duster (Industrial Strength). According to Ultra Duster’s
Material Safety Data Sheet, the vapor reduced the oxygen available for breathing. Overexposure by inhalation may
include non-specific discomfort such as nausea, headache, weakness, confusion, and loss of consciousness. Higher
exposures may cause temporary lung irritation with cough, difficulty breathing, or shortness of breath. Inhalation
of high concentrations of vapor may cause heart irregularities, unconsciousness, or death.

Allegation one: It was reported that the VA was able to leave without SP1’s knowledge. After the VA returned to
the facility, it was discovered that the VA consumed a bottle of vodka and huffed “air duster.”

Information showed that on September 14, 2016, the VA left the facility and walked to a local store. The store was
1.5 miles from the facility. The road to the store was a gravel road. Information was consistent from various
websites on the internet that depending on an individual’s pace, individuals averaged 3 to 4 miles an hour walking
so walking 1 mile would take approximately 15 – 20 minutes.

Four staff person (SP1, SP2, P1 and P2) provided the following information:

 When the VA was at the facility, the VA was to be checked on every 15 minutes and the checks were to be
documented. If the VA was out in the community, the VA was to be within an arm’s length from staff persons.

 There were alarms on the exit doors, with the alarm being on the screen for the patio door. There was also an
alarm on the VA’s window screen in his/her bedroom. If a door or window was opened, staff persons were
alerted via pager that was always kept on a staff person. There were also battery operated audible alarms on the
patio door and the VA’s window. The battery alarms sounded an alarm at the site of the alarm and did not send
a message to the pager.

The VA provided the following information in the internal review report and in an interview with this investigator.
On the day of the incident, the VA walked out the back door off of the kitchen. When the VA left, SP1 was sitting
in the staff office. There was nobody else at the facility. Prior to the VA leaving, SP1 had not checked on the VA
for a few hours. The VA walked to a local store, bought vodka, and then walked back to the facility. While
walking back, P1 saw the VA walking on the road. P1 gave the VA a ride back to the facility. The VA thought
that s/he was gone from the facility for about an hour. Later the VA went to the hospital because s/he was “really”
intoxicated.
Residential Services of Northeastern MN, Inc.
Report 20165572
Page 4

P1 provided the following information in a General Events Report and in an interview with this investigator:

 On September 14, 2016, shortly after 6 p.m. as P1 was leaving the other facility located on the property, P1
encountered the VA a short distance away walking back toward the facility. At that time the VA was sweating
and was “out of breath.” The VA also had his/her hands in his/her pockets. P1 asked the VA if s/he was
feeling okay and the VA replied, yes. The VA told P1 that s/he walked by SP1 when s/he left the facility so s/he
thought SP1 knew s/he left. P1 brought the VA back to the facility and SP1 walked out and told the VA that
s/he thought the VA was upstairs in his/her bedroom. SP1 told P1 that s/he last saw the VA at 5:30 p.m. P1
contacted a supervisory staff person. SP1 then left and another staff person (P3) arrived to work with the VA.

 A short time later, the VA vomited in the restroom. P1 and P3 then checked the VA’s pockets and the VA’s
bedroom. P3 found a can of Ultra Duster in the VA’s bedroom so P1 asked the VA if there were anymore and
the VA said that there was an empty can in the laundry basket. When P1 went to clean up the restroom after
the VA vomited, P1 found an empty bottle of vodka behind a shower curtain. P3 then took the VA to the
hospital. The cans of Ultra Duster were each 12 ounces and P1 estimated that the VA huffed about 20 ounces.
When P1 asked the VA if the s/he had the Ultra Duster in his/her pockets at the time P1 picked up the VA, the
VA said that s/he only had the vodka in his/her pocket.

The VA’s medical records stated that the VA was diagnosed with alcohol intoxication and inhalant abuse.
Laboratory tests were ordered for the VA, but the VA did not require medical care. The VA returned to the facility.

SP1 provided the following information in the internal review report and in an interview with this investigator:

 On the date of the incident during the day, the VA remained in his/her bedroom. SP1 last checked on the VA at
5:30 p.m. and the VA was in his/her bedroom, on his/her bed sleeping. SP1 did not know that the VA was gone
until s/he saw P1 return with the VA shortly after 6 p.m. SP1 did not check on the VA at 5:45 p.m. because
SP1 was on the main level so SP1 would see the VA if the VA came downstairs from his/her bedroom. (The
VA’s Awake Hour Visual Checks stated that SP1 checked on the VA every 15 minutes through 5:30 p.m.
Between 2:30 p.m. and 5:30 p.m. it was documented that the VA was in his/her bedroom.)

 SP1 did not know what door the VA went out when s/he left. SP1 had the alarm pager on his/her person but it
did not go off. SP1 did not hear any alarms when the VA left. SP1 did not check the alarms during his/her
work shift.

P2 provided the following additional information:

 P2 contacted the store where the VA went and they said that their electronic record showed that the VA
purchased a bottle of vodka at 5:48 p.m. (The two cans of Ultra Duster were obtained by the VA at Wal-Mart
the prior day with the circumstances addressed in allegation two.)

 P2 was aware of two prior occasions when the VA left the facility without staff person supervision. On those
occasions, staff persons saw the VA leave, but the VA ran away from the facility and staff persons were not
able to follow the VA.

 The VA told P2 that s/he left out the patio door off of the kitchen. P2 said that if the alarm on the patio door
was working properly, the VA would not have been able to leave without staff person’s knowledge.
Residential Services of Northeastern MN, Inc.
Report 20165572
Page 5

Regarding the facility’s alarm system:

 SP1 said that the alarms did not always work and that sometimes the alarm would go off for no reason and
other times would not go off when they should. P1 said that the alarms did not always work as they were
supposed to. SP2 was not aware of any time that the alarms were not working.

 P2, a supervisory staff person, was aware that there were concerns about the installed alarm system.
Sometimes the alarm went off for no apparent reason and sometimes the alarm did not go off. P2 said if the
front door was not shut tight enough, it might not trigger the alarm if it was opened. Also the back patio door
might not have been aligned properly with the receiver so it did not go off. Prior to this incident, the company
that installed the alarm was told about the issues and facility maintenance staff persons attempted to address the
problem through opening and closing the doors but it was difficult to “replicate” the problem.

 An administrative staff person (P4) stated that when the facility alarms were checked on September 15, 2016,
they were in working order. At that time, the screen door off of the kitchen was bent, but the facility fixed it
after the incident. P4 was not aware if anyone contacted the alarm company about concerns prior to the
incident. P4 was not aware if supervisory staff persons completed weekly checks of the alarms. After the
incident, P2 and P4 developed a daily alarm check list for staff persons to document that daily checks were
completed on the alarm system.

P2 documented the following:

 On September 15, 2016, the alarms were checked and the patio screen door was off track. The door was placed
on track and all doors and window screens were functioning and in place.

 On September 19, 2016, all doors and window screens were functioning and in place. The secondary alarm on
the front door needed the battery replaced.

 On September 29, 2016, all doors and window screens were functioning and in place. The secondary alarm on
the back door needed the battery replaced.

 On October 4, 2016, all doors and window screens were functioning and in place.

Minnesota Statutes, section 245D.07, subdivision 1a, states that the license holder must provide services in
response to a person’s identified needs as specified in the coordinated service and support plan and coordinated
service and support plan addendum.

Conclusion for allegation one:

On September 14, 2016, at approximately 6 p.m. the VA was found walking back toward the facility by P1. P1
drove the VA back to the facility at which time SP1, who was responsible for the supervision of the VA, first
became aware that the VA left the facility. Later after the VA returned to the facility, the VA vomited and a search
of the facility turned up the bottle of vodka that s/he bought earlier while s/he was gone from the facility and two
cans of Ultra Duster (which the VA obtained the prior day at Wal-Mart). The VA was transported to the hospital.
At the hospital, the VA was diagnosed with alcohol intoxication and inhalant abuse, but did not require medical
care.
Residential Services of Northeastern MN, Inc.
Report 20165572
Page 6

Regarding the supervision of the VA

SP1 stated that 5:30 p.m. was the last time s/he checked on the VA. Given that the VA purchased the vodka at
5:48 p.m.; that the VA was found walking back to the facility shortly after 6 p.m.; and that those times were
approximately within the timeframes of normal walking speed, it was possible that the VA could have left the
facility after 5:30 p.m., which was the last time SP1 said that s/he checked on the VA.

SP1 did not check on the VA at 5:45 p.m. as required. However, even if SP1 found the VA missing at 5:45 p.m.,
given that if staff persons discovered that the VA was missing, other than attempting to contact the VA and
completing internal notifications, they were to wait an hour for the VA to return to the facility before taking
additional action such as calling police to report the VA missing and information showed that the VA was walking
back toward the facility within an hour of leaving the facility, it was not determined if the outcome would have
been different if SP1 discovered the VA missing at 5:45 p.m.

When P1 returned with the VA to the facility, staff persons did not search the VA’s pockets in accordance with the
VA’s Individual Abuse Prevention Plan¸ which was in violation of Minnesota Statutes, section 245D.07,
subdivision 1a. Given that an empty bottle was later found at the facility it was likely that the VA had the bottle on
his/her person when s/he arrived back at the facility. However, it was not known how much, if any, vodka the VA
drank on the way back to the facility. This coupled with the information that the cans of Ultra Duster likely were
already at the facility and that the VA did not require medical treatment, even from taking the combination of the
two, it was not determined whether the outcome would have been different if the VA’s pockets were searched when
s/he returned to the facility.

Given the aforementioned, there was not a preponderance of the evidence whether there was a failure to supply the
VA with supervision which was reasonable and necessary to obtain his/her physical or mental health or safety.

Regarding the alarm system at the facility

The facility had alarms that were supposed to alert staff persons if someone left the facility including on the screen
door that the VA used to leave the facility. Information from three of four staff persons interviewed indicated that
the alarms did not consistently work. After the incident, it was observed that the screen door through which the VA
left was not aligned properly so the alarm did not go off. At that time the facility placed it back on track and
subsequent checks showed that the alarm was working. Prior to this incident, the company that installed the alarm
was told about the issues and facility maintenance staff persons attempted to address the problem through opening
and closing the doors but it was difficult to “replicate” the problem. However, there was no documentation that
supervisory staff persons were completing weekly checks of the alarms as required by the VA’s Individual Abuse
Prevention Plan, which is in violation of Minnesota Statutes, section 245D.07, subdivision 1a.

Given that on prior occasions the VA ran from the facility, even when within sight of staff persons, it was not
determined whether SP1 would have been able to prevent the VA from leaving the facility if the alarm alerted SP1
when the VA opened the screen door. In addition, as mentioned above, if SP1 saw the VA leave the facility, no
contacts outside of the facility to report the VA missing would have been made as the VA returned to the facility
within 60 minutes. Therefore, there was not a preponderance whether there was a failure to provide the VA with
reasonable and necessary supervision.
Residential Services of Northeastern MN, Inc.
Report 20165572
Page 7

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).

Allegation two: It was reported that the VA was able to obtain “air duster” at Wal-Mart while being supervised by
SP2.

The VA provided the following information in the facility’s internal review report. The VA obtained the cans of
Ultra Duster at Wal-Mart on September 13, 2016, the evening prior to the above incident, when s/he was left alone
by SP2 when SP2 went to the use restroom. The VA and SP2 were in the electronics section and the restroom was
down a short hallway. When SP2 went to use the restroom, the VA ran to the end of the electronics department,
took two cans of Ultra Duster off of a shelf, and went back to where s/he was standing before SP2 came out of the
restroom. The VA hid the cans in his/her clothing.

SP2 documented the following in the VA’s progress notes. On September 13, 2016, the VA had an appointment at
a community recovery center. The VA asked SP2 to go to Wal-Mart to get a cord for his/her iPod. The VA did not
have much money and asked SP2 to take him/her to pawn shop to sell some video games. SP2 took the VA to the
pawn shop and then to his/her appointment. After the appointment, which lasted about an hour, SP2 took the VA to
Wal-Mart. The VA could not find a “cheap” cord so SP2 and the VA returned to the facility without making a
purchase.

SP2 provided the following information:

 While on a community activity with the VA, the VA asked SP2 to stop at Wal-Mart on the way back to the
facility to purchase a cord for his/her iPod. While looking for cords in the electronic section, SP2 had to use
the restroom. The VA refused to go with SP2 into the restroom. SP2 noticed a unisex restroom near the
electronic section, about 15 feet away. SP2 went to the restroom “quickly” and when s/he came out “not more
than two minutes later,” the VA was standing in the same spot as when SP2 went into the restroom. SP2 said
that the VA took his/her wallet and cell phone out of his/her pocket and SP2 did not notice anything else in the
VA’s pockets. Due to the cost of the cord, the VA chose not to purchase it at that time.

 SP2 said that when staff persons were out in the community with the VA, staff persons were to be within three
feet or an arm’s length of the VA because the VA was “extremely quick and good at shoplifting.” While SP2
was in the restroom, SP2 was not providing the VA with the required supervision. Other than while SP2 was in
the restroom, SP2 remained by the VA’s side in the store. After the incident, SP2 was told that if a staff person
was in a similar situation, that they should have the VA jiggle the handle while the staff person was in the
restroom so the staff person would know if the VA left the area.

P2 said that SP2 was not providing the VA with the required supervision when s/he went to use the restroom. SP2
said that SP2 should have documented that s/he had to leave the VA alone while they were at the store. Prior to
finding the Ultra Duster in the VA’s bedroom, staff persons were not aware that SP2 left the VA without staff
person supervision at Wal-Mart.

SP1, P1, and P2 each stated that if the VA was out in the community, the VA was to have a one to one staff person
and be within an arm’s length and within sight of the staff person.
Residential Services of Northeastern MN, Inc.
Report 20165572
Page 8

Conclusion for allegation two:

On September 13, 2016, prior to returning to the facility from a community activity, SP2 took the VA to Wal-Mart
at the VA’s request because the VA wanted to purchase a cord for an iPod. While in Wal-Mart, SP2 needed to use
the restroom. The VA did not want to go with SP2 to the restroom so SP2 left the VA in the electronics area and
went to a restroom about 15 feet away from the electronic section. SP2 said that s/he was gone less than two
minutes and when s/he returned the VA was in the same location. The VA said that when SP2 went to the
restroom, the VA ran and grabbed two cans of Ultra Duster and returned to the same location before SP2 returned
from the restroom. SP2 said that other than when s/he went to use the restroom, s/he provided the VA with the
required supervision in the store which was to be within an arm’s length of the VA. The following day, an empty
can and partially empty can of Ultra Duster were found in the VA’s bedroom. A bottle of vodka was also found.
The VA was taken to the hospital and diagnosed with alcohol intoxication and inhalant abuse, but did not require
medical care.

It was reasonable for SP2 to be able to use the restroom during his/her work shift. Given that SP2 attempted to
have the VA come with him/her and that the restroom was in close proximity to where the VA was standing, there
was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and
necessary supervision.

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 of each incident. Supervisory staff persons were to review the VA’s
Individual Abuse Prevention Plan and Self-Management Assessment and Plan and training on the updated plans
was to be provided to all staff persons. SP1 and SP2 also received corrective action. An administrative staff person
stated that as result of meeting with the VA’s interdisciplinary team changes made to the VA’s plans included that
staff persons were to use the restroom prior to going on an outing, that if staff persons had to use the restroom on an
outing, if possible the VA was to go into the bathroom with staff persons and staff persons could observe his/her
feet from underneath a stall or if it was not possible to have the VA go into the restroom, the VA was to remain
outside with his/her hand jiggling the handle of the door. If the VA was unsupervised at any time during an outing
staff persons were to ask to do a search of the VA. In addition to a search of the VA’s pockets, staff persons were
to pat down the VA because the VA said that s/he also hid things in his/her sleeves and in the waist of his/her pants.
Staff persons received training on the updates.

On September 15, 2016, all door and window alarms were checked to ensure that they were in proper working
order. At that time they were in working order. The screen door off of the kitchen was bent, but the facility fixed it
after the incident. At the time of the incident, a protocol was in place for the pager to be assigned to a staff persons,
but no protocol for checking to ensure that all alarms were working and screens were meeting the contacts to sound
the alarm. The facility developed a checklist for staff persons to document daily checks on the alarm system.

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

On November 10, 2016, the facility was issued a Correction Order for failing to provide services in response to the
VA’s identified needs, interests, preferences, and desired outcomes as specified in the coordinated service and
Residential Services of Northeastern MN, Inc.
Report 20165572
Page 9

support plan and the coordinates service and support plan addendum in that staff persons did not search the VA’s
pockets when s/he returned to the facility and weekly checks of the exit door alarms were not completed as
required.