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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.”
License Number and Program Type: 1067715-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scout Peterson 651-431-6578 Suspected Maltreatment Reported: It was reported that a staff person (SP) made several “verbal threats” towards a vulnerable adult (VA) and called law enforcement. When law enforcement arrived, the SP had cut marks on his/her arms and provided false information that the VA cut him/her. Date of Incident(s): August 25, 2024 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 2, paragraph (b), clause (2): Conduct which is not an accident or therapeutic conduct with produces or could reasonably be able to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. Summary of Findings: Pertinent information was obtained during a site visit conducted on September 13, 2024; from documentation at the facility, law enforcement records, and medical records; and through five interviews conducted with two facility staff persons (P1 and the SP), two supervisory staff persons (P2 and P3), and the VA. Attempts were made via telephone and mail to contact and interview another staff person (P4). P4 did not respond to the requests, but provided information for the facility’s Internal Review that was included below. P4 and the SP have an interpersonal relationship outside of the facility. The VA enjoyed writing, reading, and playing video games. The VA lived at the facility for supports in “improving [him/herself]” and focusing on managing his/her mental health, hygiene, socialization, and home management skills. The VA was diagnosed with autism spectrum disorder and generalized anxiety disorder. The VA was the only resident at the facility. The VA had 1:1 staffing overnight and an additional five hours of 1:1 staffing during the day. The main entrance of the facility led to a living room. On the left side of the living room was an entrance to a dining room with an attached kitchen and an entrance to a hallway. Down the hallway were three bedrooms, a bathroom, and a laundry room. The VA’s bedroom was the furthest down the hall on the right side. The staff bedroom was midway down the hallway on the left side, across from the laundry room. The VA’s Individual Abuse Prevention Plan (IAPP) stated that the facility was not aware of the VA having committed a violent crime or act of physical aggression and stated that the VA “does not present a risk to others.” The VA’s IAPP also stated that s/he was susceptible to emotional abuse. The VA’s Intensive Service Assessment stated the VA “can manage his/her behaviors” and “is aware of [his/her triggers] and what to do when [s/he] is upset.” The law enforcement report provided the following information: · On August 25, 2024, at 7:42 p.m. law enforcement officers were dispatched to the facility because a resident cut a staff person with a knife. · At 7:49 p.m. law enforcement arrived at the facility. When they arrived, the SP was standing in the driveway of the facility and appeared to be injured. A law enforcement officer (LEO) asked the SP who cut him/her and the SP told the LEO that the VA cut him/her and that that the VA was “crazy.” · The SP showed the LEO his/her injuries. The LEO described the injury as “multiple cuts 2.5 inches long and a couple half inch cuts on each side on [the SP’s] upper left forearm. The cuts did not appear to be very deep with minimal blood loss.” The LEO encouraged the SP to go to the hospital, which the SP did. The SP was “later treated at [the local hospital] ER with a bandage.” · An officer spoke with the VA “through the bedroom door.” The VA then came out of the bedroom unarmed and yelled, “[The SP] said I had a knife, seriously, oh my god, oh my fucking god.” The VA “started screaming” and began crying, stating “Why did [the SP] do this to me?” Law enforcement officers found a knife in the kitchen with blood on it that appeared to be from the facility’s kitchen block of knives. Law enforcement officers also found two knives and marijuana VA in the VA’s bedroom that belonged to the VA. · The VA then “calmed” and spoke with law enforcement officers. The VA denied cutting the SP and if s/he did, s/he “would not [have] stopped.” The VA stated that after the SP arrived to work, the VA told the SP that s/he had “thoughts” of hitting the SP so the SP called 9-1-1. The VA continued denying that s/he cut the SP. At that time, the VA said s/he was experiencing suicidal ideation so the VA was transported to a local hospital for evaluation. The hospital attempted to locate a mental health facility for the VA, however, there were no beds available. The VA was “medically cleared,” discharged, and transported to a local jail where s/he was charged with second degree assault and spent two nights in jail. The VA’s medical records provided the following information: · On August 25, 2024, at 9:53 p.m. the VA arrived to the hospital due to “suicidal ideation.” The VA was “accused of cutting [a staff person] on forearm with knife.” · The VA told hospital personnel that s/he “got mad at the staff and ran into [his/her] room yelling a threat that [s/he] wanted to hurt [the SP].” The VA denied any violence against the SP. The VA also told hospital staff that s/he wished the SP would have killed the VA and the VA wished s/he was dead. · Hospital personnel called “over 16 psychiatric units” and none were able to accept the VA. The VA agreed that s/he will not hurt him/herself or anyone else and was discharged to police custody and transported to jail. The VA provided the following information, · On August 24, 2024, the VA told P4 that s/he “hated” the SP and that s/he was “tempted to hit” the SP and P4 “defended” the SP. · On August 25, 2025, the SP was working and around 7:30 to 8 p.m., the SP called the VA out of his/her bedroom. The VA and the SP were in the hallway outside the VA’s bedroom and the SP was “side facing” the VA and stated, “I heard you hate me and have been tempted to hit me.” The VA told the SP that s/he was “unable to judge” the SP’s character. The SP then told the VA, “You threatened me. I’m going to call the cops.” The VA then “got real angry” and “screamed” at the SP and stated, “I did not threaten you.” The VA then called P4 to tell him/her what was “going on.” The VA went to the bathroom and hoped that the SP was “lying” about calling the police. The next thing the VA remembered was that s/he received a call from P1, asking the VA if s/he had a knife. The VA did not respond to P1 and hung up the phone. After the VA hung up the phone, s/he opened his/her bedroom door and talked to law enforcement. The VA was handcuffed and s/he “fell apart.” · After the VA “collected” him/herself, s/he answered law enforcement’s questions. At that time, the VA learned that the SP said that the VA cut the VA on his/her forearm, but they were shallow cuts. The VA was then taken outside and put in a law enforcement vehicle. While in the vehicle, the VA called P3 and told P3 that s/he was in the back of a police car, but did not provide further details to P3 at that time. The VA was then taken to the ER and later transported to jail. · The VA stated that s/he did not cut the SP and never physically hurt the SP. The VA stated, “I know assault with a deadly weapon is a felony,” and that if s/he was “willing to commit a felony against [the SP], I wouldn’t have stopped at one cut.” The VA described his/her emotions towards the SP as “rage” and “pity.” · The VA stated that the SP did not make any verbal threats towards the VA. The only thing the SP said to the VA was, “You threatened me, so now I’m calling the cops.” The SP provided the following consistent information to law enforcement, in the facility’s Internal Review, and in an interview with this investigator: · On August 25, 2024, P4 went to the SP’s house and P4 shared concerns about the VA. The SP could not remember details of what P4 told him/her but recalled that it was “something about suicide” and the SP. · That night, the SP worked the overnight shift at the facility. The SP was the only staff person working at the time. The SP was scheduled to start work at 7 p.m. but arrived at the facility between 6:30 and 6:45 p.m. After the SP arrived, s/he went to the staff bedroom as was typical. The staff bedroom was located next to the VA’s bedroom down a hallway from the kitchen. The SP noticed that the trash can in the staff bedroom needed to be emptied, so s/he took the bag of trash into the kitchen to throw it away in the kitchen garbage can. · The SP walked back down the hallway to the staff bedroom and saw the VA open his/her bedroom door. The VA came out of his/her bedroom and stood in front of the SP face-to-face. The SP provided varying information about how far the VA was standing from the SP. [It was reported by the SP that the VA was either 2 or 5 feet away.] The VA then started to “scream” at the SP, stating that the SP was “not supposed to” be at the facility until 11 p.m. and that P3 stated the SP’s schedule changed and s/he was scheduled at 11 p.m. The SP told the VA, “[P3] is not my boss” and then did not say anything else to the VA that evening or make any “threats” towards the VA. · The SP then saw that the VA was holding a kitchen knife in his/her right hand. The SP “turned away” and tried to block the VA from cutting the SP but got “a little cut” on the forearm. The VA again cut the SP, so the SP “pushed” the VA, turned around, and ran outside. The SP did not say anything to the VA during the incident. The SP then called 911 and P1. The SP described the VA’s actions as “not a stabbing motion, more of a cutting motion” and demonstrated with his/her hands a motion similar to slicing. The SP went outside the facility, and the VA remained inside. · After law enforcement arrived, they told the SP to get into his/her car and leave. The SP got in his/her car and drove down the block away from the facility where s/he parked and waited for further instructions from law enforcement. After an unknown amount of time, the 911 dispatcher called the SP to ask for the VA’s phone number because the VA would not come out of his/her bedroom. After an unknown amount of time, P1 arrived at the facility and assisted law enforcement in speaking to the VA. · At some point, the SP left with P1 and went to the ER accompanied by P1. The SP was assessed at the emergency room but did not need sutures or antibiotics. · The SP could not recall any time the VA was aggressive in the past and stated that that the VA’s plans did not have anything “to be aware of” regarding a history of aggression. The VA also did not have anything in his/her plans about limiting access to weapons or knives. The SP said that law enforcement found marijuana in the VA’s room so the SP thought that the VA’s medications may have had a negative interaction with marijuana which caused the VA to “want to hurt” the SP. · The SP stated that the VA “didn’t trust” the SP because the VA had a “tough life at home,” the VA had a family member with the same name as the SP, and the SP previously reported another staff person who the VA liked working with to management for falsifying his/her hours and the other staff person subsequently stopped working at the facility. The SP stated that “all [she] could do” was give the VA “time” to build trust. P1 provided the following information: · The night of August 24, 2024, P1 received a message from P4 saying that the VA was “upset” and told P4 that s/he “disliked” the SP. On August 25, 2024, around 8 p.m. P1, who was not at the facility, received a call from the SP stating that P1 needed to come to the facility because law enforcement was there because the VA attacked the SP. P1 immediately went to the facility. · When P1 arrived at the facility, law enforcement officers told P1 that the VA was in his/her bedroom and was not answering the door. P1 called the VA and asked him/her to open his/her door because law enforcement was there to speak with him/her. The VA told P1 that s/he did not know anyone was outside the door. Law enforcement directed P1 to ask the VA if s/he still had a weapon. P1 did so and the VA responded, “Oh my god. I can’t believe it.” The VA “got very upset,” hung up the phone, and opened his/her bedroom door. · Law enforcement placed the VA in handcuffs and led him/her to the living room. The VA was “very visibly upset” so law enforcement officers tried to “deescalate” the VA as P1 went outside to look for the SP. · P1 went outside, found the SP, and P1 asked what happened. The SP told P1 that s/he brought the garbage out of the staff bedroom to the kitchen and was walking back to the staff bedroom when the VA came out of his/her bedroom and told the SP that s/he was not supposed to be working yet. The VA also told the SP that P3 said the schedule was changed and the SP was scheduled to start later. The SP told the VA that P3 was not his/her boss. P1 did not have any information regarding “threats” made by the SP towards the VA. The VA “got mad” and “attacked” the SP with a knife. P1 saw cut marks on the top of the SP’s forearm about halfway between his/her elbow and wrist. There was one “deep” cut with “side scratches” alongside. P1 described the cuts as “fresh” and “new,” and stated that there was visible blood on the SP’s forearm. · P1 stated that s/he “always felt safe” around the VA and s/he “would like to believe” that the VA would not harm the SP, but “based on [the VA’s] escalation,” s/he did not know whose story was accurate. P1 believed the VA was escalated the night of the incident because the VA incorrectly thought the SP was at work earlier than s/he was supposed to be and that may have “triggered” the VA. P2 provided the following information: · On August 26, 2024, when s/he arrived at work, s/he had a “flood” of emails and messages about an incident between the VA and the SP. P1 told P2 about what occurred and provided information that was consistent with the information P1 provided during his/her interview. · P2 stated that the VA did not have a history of violence, however, s/he believed the SP’s account as told to P1 of what occurred to be true. P2 stated that it was a “very weird situation” overall. P3 provided the following information: · The VA “disliked” the SP. P3 stated that the VA was not a “violent person” and was “easy going.” · P3 was not working the day of the incident but missed a call from the VA. When P3 called the VA back, the VA told P3 that s/he was in the back of a a law enforcement vehicle but did not provide additional information about why or what happened. P3 then tried to call P1, who did not answer, so P3 went to the facility. When P3 arrived at the facility, P1 was there and told P3 that P3 had to leave. P1 also told P3 that s/he could not give P3 any information about what happened. · At an unknown later date, P3 spoke with the VA about the incident. The VA told P3 that s/he was in his/her bedroom when the SP knocked on the door and said, “You don’t like me,” and “You want to hurt me.” The VA came out of his/her bedroom and spoke with the SP, but shortly after returned to his/her bedroom to “avoid” the SP. “The next thing [the VA] knew” was that law enforcement and P1 were at the facility saying the VA had a knife and cut the SP. · P3 stated that s/he does not know the SP’s account of what happened, but s/he did not believe the VA harmed the SP because P3 always felt safe around the VA and that the VA was “a good human.” P3 did not have any information regarding “threats” made by the SP to the VA and stated that the VA never told P3 that the SP made “threats” towards the VA. P4 provided the following information in the Internal Review: · On August 24to 25, 2024, P4 worked the overnight shift. The VA had a “rough day,” and made “threatening” comments about punching the SP in the face and that s/he “wanted to hurt [him/herself]” so P4 told P1. · On August 25, 2024, P4 told the SP about the comments that the VA made the night before. That evening around 7:45 p.m. the VA called P4 and “sounded very loud and erratic.” The VA told P4 that the SP called 9-1-1 because the SP knew the VA wanted to punch the SP in the face. P4 then called the SP who told P4 that s/he called 9-1-1 and that the VA “attacked [him/her] with a big knife.” P3, P4, and the SP were trained on the VA’s support plans. P1-P4 and the SP were each trained on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Although it was reported that on August 25, 2024, the SP made “verbal threats” toward the VA, the VA stated that the SP did not make any verbal threats towards the VA, neither P1 nor P3 had any information that showed the SP threatened the VA, and the SP denied threatening the VA. The SP and the VA were the only two people at the home at the time of the incident. Information provided by the VA and P4 showed that on August 24, 2024, the VA disclosed that s/he had thoughts of hitting the SP. The SP provided consistent information on separate occasions to this investigator, law enforcement, and for the facility’s internal review, that when the VA became upset with the SP, the VA cut the SP with a knife. Given that the SP and the VA were the only two persons present at the time of the incident, that the SP and the VA each denied that the SP threatened the VA, and that the SP and the VA provided conflicting information regarding how the SP sustained the cut, there was not a preponderance of the evidence whether the SP threatened the VA, provided false information that the VA cut him/her, or engaged in any interactions with the VA that would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. It was not determined whether emotional abuse occurred (conduct which is not an accident or therapeutic conduct with produces or could reasonably be able to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening). Action Taken by Facility: The facility completed an Internal Review and found that policies and procedures were adequate and followed. The facility determined that there as a need for corrective action to be taken in order to protect the health and safety of [the VA], and it was recommended that the VA move to another facility. Additionally, “training is being implemented to reinforce critical polices and ensure staff remain fully informed about their responsibilities. By revisiting key policies on maltreatment reporting, prohibited conduct, and home-based service standards, the organization aims to ensure that staff understand and adhere to best practices in recognizing and preventing abuse and neglect, fostering a heightened sense of vigilance in protecting vulnerable adults.” Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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