The report goes on to state that the Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The resident had a well-known history of substance abuse, wandering, and impulsivity, yet the facility did not take reasonable steps to supervise the resident to ensure his well-being and safety. Overnight unlicensed personnel and morning incoming unlicensed personnel both arrived late for work and never checked the resident’s room or facility to ensure the resident was in the facility which delayed the opportunity to immediately begin searching for the resident. The resident went unaccounted for until 12 hours later when the resident’s family member arrived at the facility and requested staff check to see if the resident was in his room. In addition, unlicensed personnel slept during overnight shifts.

The investigator conducted interviews with facility staff members, including administrative staff, and unlicensed personnel. The investigator interviewed the resident’s family member, mental health practitioner, and case manager. The investigation included review of the resident’s facility record, external medical records, death record, personnel files, staff schedules, law enforcement report, and related facility policy and procedures.

The police report indicated 16 days after the resident left the facility, police were dispatched to an apartment building where they found the resident deceased in the stairwell. Drug paraphernalia was found next to the resident. The resident’s death certificate indicated his immediate cause of death was fentanyl toxicity.

 In conclusion, the Minnesota Department of Health determined neglect was substantiated