The Minnesota Department of Health determined neglect was substantiated. 

The resident’s individual abuse prevention plan (IAPP) indicated the resident was not at risk of eloping/wandering as he had his own car and drove to and from work. However, the IAPP indicated the resident was an “elopement threat” due to a previous run away attempt from his parent’s home. The IAPP noted in the comment section “the resident has a history of suicidal ideation and behaviour (sic).” Interventions were not developed or implemented to minimize
the resident’s risk for elopement or suicidal ideation.
Progress notes in the resident’s record indicated the resident did not return to the facility one Saturday evening. Staff did not report the resident missing to facility management or to the police. Progress notes further indicated the resident did not return on Sunday or Monday, and staff did not know the location of the resident. Staff again failed to report the resident as missing to management or the police. Facility staff were not aware of the resident’s location until Monday afternoon, when the resident’s parents informed the facility nurse that he had attempted suicide and was hospitalized.

The sheriff’s office report indicated that shortly after noon on Saturday, deputies responded to reports of a male jumping off a bridge. Deputies pulled the resident out of the water. The resident told law enforcement he lived “at a group home.” A deputy attempted to call the
facility, but no one answered the phone.

During an interview, the licensed assisted living director (LALD) indicated she was not informed of the incident until Monday, after one of the resident’s parents tried to call her to tell her the resident was hospitalized. The LALD stated facility policies and procedures were not followed, and staff did not file a police report or inform anyone that the resident was missing, even after police were at the facility questioning the resident’s whereabouts.

During an interview, the resident’s case manager and the resident’s psychiatrist stated thewere not immediately notified when the resident went missing or the resident’s attempt at suicide. Both the case manager and the psychiatrist’s office stated they were notified by other people several days after the suicide attempt but not by the facility. In conclusion, the Minnesota Department of Health determined neglect was substantiated.