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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: 1072305-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Danielle Morrison 651-431-2155 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) pushed a staff person (SP), the SP responded by pushing the VA back, and the VA fell backwards into an entertainment center. The VA had a bruise on his/her right bicep and on his/her left side near his/her rib area. Date of Incident(s): June 7, 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 (1); Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. Summary of Findings: Pertinent information was obtained during a site visit conducted on July 19, 2024; from documentation at the facility; and through nine interviews conducted with two supervisory staff persons (P1 and P2), two facility staff persons (the SP and P3), the VA, the VA’s guardian (G), and three of the VA’s housemates (HM1, HM2, and HM3). The VA’s diagnoses included an intellectual disability, autism, cerebral palsy, a seizure disorder, an impulse control disorder, depression, and anxiety. The VA enjoyed listening to and playing music, playing video games and bowling. The VA’s Coordinated Services and Supports Plan (CSSP) stated, “[The VA] is a very kind person, but when feeling overwhelmed or frustrated [s/he] can have behavioral outbursts. [The VA] may hit, kick, throw things, swear, and yell.” The VA’s Risk Assessment stated, “[The VA] may punch [his/her] fist into the opposite hand, the wall, or other nearby items. [S/he] may slap [him/herself] in the face. [S/he] may kick walls or fake head butt walls. [The VA] may throw items, usually [his/her] own, but not always. [The VA] may yell, swear, name-call, spit (rare, but may happen) and fall on purpose. [Staff persons] should talk to [the VA] about what is frustrating [him/her] and help [the VA]. If [the VA] is displaying anger, encourage [the VA] to go to [his/her] safe space, which is usually [his/her] bedroom.” The VA’s Intensive Support Service Assessment stated, “[The VA] is a fall risk and my (sic) trip over things easily, including [his/her] feet. [The VA] frequently falls getting out of bed.” The facility was a rambler style home with a full basement. The main level had three bedrooms, a bathroom, a living room, and a kitchen. There was a short hallway leading from the living room to two bedrooms and the bathroom. There was an entertainment center against a wall next to the short hallway. The basement had a bedroom, a laundry room/office, a bathroom, a living room, and a dining area. The facility’s Incident Report for June 7, 2024, around 10:30 p.m., stated “[HM1] came upstairs and told the [VA] to go to sleep, this aggravated the [VA]. Physical condition of the [VA] was fine other than elevated stress on anger curve, emotional condition was heightened and aggravated [VA] was calling the [SP] a [racial slur] and scratching [him/her]. [The SP] tried to divert [the VA] redirecting [him/her] back to [his/her] bedroom to avoid conflict. [The SP] also attempted coping skills with [the VA]. Length of time in de-escalation: approximately 15 minutes. [The SP] used Physical Intervention Alternative Attempt, ended up having to hold [the VA’s] hand to stop [him/her] from hurting [him/herself] and [the SP]. After the restraint, [the VA] threw a lamp at the ground and attempted to throw chairs at [the SP] and [HM1]. [The SP] got [HM1] downstairs and [the VA] started to ‘calm down’ fairly fast and proceeded with [his/her] nightly routine to go to bed.” The VA’s Note Summary, written by the SP, showed that on the night of June 7 to 8, 2024, the VA was playing video games when the SP arrived. At some point, HM1 told the VA it was time to turn in the television remote to the SP. The VA got angry and started yelling. The SP asked the VA what was wrong, and the VA left his/her bedroom, walked toward the television and tried to break the television. The SP quickly redirected the VA (the SP did not document how), and the VA scratched the SP and called the SP a [racial slur].” HM1 sat in the living room and laughed at the VA and the VA threw a house lamp, chairs, and a wall frame on the floor. The VA apologized to the SP and got ready for bed. The SP made up the VA’s bed and the VA slept all night. The VA provided the following information: · On an unknown date in June 2024, the VA was playing video games in his/her bedroom. HM1 was on the couch yelling and the SP was downstairs in the office. The VA went out to the couch and broke the television by the couch because the VA was “mad.” · The SP came upstairs and told the VA to go to bed. The VA punched and scratched the SP. The SP then put his/her hands on the VA’s stomach and pushed the VA and the VA fell, hitting his/her back and arm on the wall. The VA then kicked the SP, and the SP went “flying backwards” into the couch. · The SP told the VA to go to bed. The VA got ready for bed and the SP told the VA to go to sleep and the VA called the SP a [racial slur].” The SP said, “No one calls me [racial slur],” then the VA punched the SP and told the SP to, “Shut up.” · After the incident the VA’s arm was black and blue and there was a bruise on his/her side too. The SP made the VA cry, and the SP did not apologize when the incident happened, but later that night the SP said, “Sorry [VA],” but the VA did not think the SP was sincere and they could not be friends anymore. HM1 provided the following information: · On an unknown date, HM1 was sitting in the living room and “messing” with the VA while the SP was downstairs. The SP came upstairs yelling. The VA was by his/her bedroom and the SP was in the hallway. The VA yelled that s/he was going to break everything in the house and started to flip a vacuum, then the VA and the SP had a physical altercation. HM1 did not see “a whole lot” and did not see who pushed who first, but saw the SP push the VA and the VA push the SP back. When the SP pushed the VA, the VA stumbled a bit and might have hit a corner of the wall near the hallway on his/her arm. After that the SP told the VA it was time to go to sleep. The VA calmed down and went to bed. · The next morning the VA had “big” bruises on both of his/her arms “and stuff.” HM1 did not know how the VA got the bruises, nor whether the SP gave the VA the bruises. The SP provided the following information: · On an unknown date, the SP arrived at the facility and went downstairs to prepare medication for the following morning. Around 10 p.m., the SP heard noises coming from upstairs and heard the VA shout, “No, leave room.” The SP went upstairs to see what was going on. · Once upstairs, the SP saw HM1 in the VA’s bedroom. The VA was jumping, throwing him/herself around the bedroom, and rolling on the floor. The SP told the VA that s/he had ten more minutes before turning in the television remote for the evening. HM1 said s/he was in the VA’s bedroom to tell the VA to drop the remote. The SP told HM1 that was not his/her job, and told HM1 to leave the VA’s bedroom. · HM1 left the bedroom laughing, which made the VA “more angry.” The VA threw the remote, then went out to the living room to attempt to punch the television out there. The SP told the VA that s/he would hurt him/herself and to “calm down.” The SP tapped the VA’s shoulder, and the VA turned around and scratched the SP. The SP backed away and called P2 to say that the VA scratched the SP and was throwing things. The VA then took a lamp and threw that. HM1 was still laughing at the VA so the SP told HM1 again that that was “not right” and to stop laughing at the VA. The VA kept falling because s/he was tired from what was going on. The VA was jumping, falling into the wall, falling on the floor, and hitting him/herself “like someone who was really mad.” The VA then sat on the floor. HM1 went downstairs while the SP was still talking with P2. The SP said the VA did not fall into the entertainment center. · After the SP was done talking to P2, the SP asked the VA if s/he needed help to sit in a chair. The VA said, “Yes.” The SP helped the VA into the chair, told the VA to take some breaths, and offered the VA water which the VA declined. The SP waited five to ten minutes and then asked the VA if s/he wanted to watch television or go to bed. The VA chose to go to bed, so the SP went to the VA’s bedroom and made up the VA’s bed and picked up a few items the VA had thrown earlier. · The VA “never” fell into the entertainment center. However, when the VA was in the living room and went to throw the lamp, the did VA fall into the wall. · It was not uncommon for the clients to use racial slurs or tell the SP they hated him/her. The SP stated s/he was “used to that” as it was not new, and it was “part of the job.” It usually happened when clients were angry, and it was not something the SP worried about. · The SP denied that s/he pushed the VA and denied that the VA pushed the SP. The SP did not grab the VA’s wrist, but said the VA was holding his/her own wrist and maybe P2 misinterpreted that. The VA only scratched the SP. The SP thought the VA might have gotten the bruises from throwing him/herself around and falling into the wall. The G provided the following information: · On June 15, 2024, the G and the VA were going bowling. The G noticed the VA’s shirt was inside out, so the G helped put it on correctly when the G noticed a bruise on the VA’s right bicep. The G asked the VA what happened, but the VA did not know what happened. The G took a photo of the bruise. · When they returned home from bowling, the G asked if s/he could take more photos of the bruise. The VA pulled his/her arm out of the shirt sleeve and the G asked again what happened. The VA said his/her back also hurt. The G looked at the VA’s back and gasped when s/he saw a “huge” bruise on the VA’s left side over his/her ribs. The VA told the G that s/he might have received the bruises from the SP. The VA said s/he was standing at HM3’s door chatting when the SP told the VA to go to bed. The VA told the SP s/he would go when the SP was ready. The SP approached the VA, so the VA pushed the SP, the SP pushed the VA back, and the VA fell into an entertainment center. · The G described the bruise on the bicep as a circle bigger than a thumb and was purple red, and “yellowing.” The bruise was on the inside of the VA’s arm halfway between the VA’s elbow and shoulder. The G described the bruise on the VA’s ribs as a red, purple, and yellow bruise five to six inches in length and three to four inches wide in the shape of a football. · The VA might “embellish” parts of an incident, but there was generally “some type of truth to it.” If asked a direct question the VA told the truth. The G had prior concerns about staff turnover and housemates at the facility. HM2 provided the following information: · On an unknown date, HM2 was in his/her bedroom and heard the SP yell at the VA and HM1 because they were fighting. The SP told them to knock it off and go to their rooms. The VA got “angrier” and started destroying things. · HM2 did not see the incident, but stated the VA liked to hit people when s/he was angry. During the incident, HM2 heard what sounded like the television moved, and HM2 thought the VA hit the television with his/her fist, but did not hear anything like a person hitting the floor. After that HM2 heard the VA “calm down.” · When the VA hit staff persons, they did not hit the VA back. HM2 got along with the SP and the SP got along “pretty good” with the other housemates. P2 provided the following information: · On June 7, 2024, at 10:23 p.m., P2 received a text message from the SP asking P2 to call the SP. At 10:30 p.m., P2 called the SP and at 11:30 p.m., P2 asked the SP to text a summary of what happened. When P2 spoke with the SP, P2 asked the SP, “Did you hold the VA’s arms?” The SP said, “No, I kind of grabbed the VA’s hand when I tried to stop the VA from hitting the television and hurting him/herself.” · When P2 spoke with the SP, the SP said s/he did not physically grab the VA, but P2 thought that if the SP grabbed the VA’s hand, that was still a “hold” in P2’s opinion. P2 said it might have been a “misunderstanding” on his/her part about the type of grip the SP did and whether the SP’s intent was to restrict the VA’s movement versus to block the VA if the VA was hitting the SP. · P2 “never” heard that the SP pushed the VA. The SP did not tell P2 that and when P2 spoke with the VA, the VA did not tell P2 much about the incident. P2 heard other clients use racial slurs toward the SP and the SP “always” handled it professionally. The SP told P2 that s/he knew the clients could not help it and the SP did not take it personally. In other situations, P2 saw the SP step back to avoid an altercation. · Staff persons were trained to ensure the safety of those present. If necessary, staff persons should verbally redirect, evaluate where a client was, and then physically redirect as a last resort. Text messages between the SP and P2 from June 7, 2024, starting at 10:23 p.m. read, “[HM1] was in [his/her] bedroom upon staff arrival. [S/he] came upstairs to watch TV while staff was in the office. [HM1] went into [the VA]’s bedroom to tell [the VA] it’s time for bed and [the VA] got angry yelling, and staff asked [the VA] what was going on. [The VA] came out of [his/her] bedroom trying to punch the TV screen because [s/he] was mad at [HM1]. Staff tried redirecting [the VA] while [HM1] was laughing at [the VA]. [The VA] threw the lamp, chairs, and wall frame on the floor, [the VA] kept calling staff [racial slur] and kept scratching staff with [his/her] nails. Staff redirected [the VA] to relax and told [HM1] it was time for bed. [HM1] went to bed and [the VA] got ready for bed. [The VA] apologized to staff before going to bed. Staff made up [the VA]’s bed and helped [the VA] with [his/her] night wear. [The VA] is currently sleeping.” P3 provided the following information: · On an unknown date that P3 thought was the morning after the incident, P3 saw a bruise on the VA when s/he helped the VA change his/her clothes. P3 did not remember where on the VA the bruise was, but said it was a “normal” bruise. · P3 asked the VA what happened and the VA stated s/he bumped into the entertainment center. The VA did not tell P3 s/he was pushed or hit. The VA told P3 s/he got into an argument with another housemate (P3 did not recall who) and the SP raised his/her voice to get their attention and got in between them. The VA did not mention anything about pushing or getting hurt. The VA said s/he stumbled into the entertainment center and P3 stated that the VA had done that before. The VA said s/he should not have argued with HM1 and felt bad about calling the SP a name. · That morning, the SP told P3 that the housemates were arguing, and the SP got in the middle of it, in an attempt to separate the housemates. The SP did not say anything about physical contact. That evening when the SP arrived back at the facility, P3 asked how the VA received the bruise, and the SP stated s/he did not know where it came from. · P3 heard the VA use racial slurs toward the SP when the VA was frustrated. P3 had no concerns with the SP’s interactions with the VA. P3 said the SP was “gentle” and did not get mad. Sometimes the VA “made up stories” when s/he was on the phone with the G. An example was one day the VA told the G that staff persons did not do laundry or help the VA shower, when they had actually completed those tasks. P1 provided the following information: · The SP called P1 on an unknown date in June 2024, and stated the VA smashed the television again when s/he was having a behavior. The VA was calm when the SP called P1. P1 then learned that the VA had been on the telephone with the G, left his/her bedroom, and started to smash things in the facility. · Sometimes the VA was accurate with his/her account of events, and at other times the VA exaggerated or lied. Sometimes HM1 lied about what staff persons did, but “nothing major.” HM2 did not lie at all. HM3 was “far from accurate” in describing events. · The SP was the “gentlest soul” P1 knew. The SP remained calm when clients called the SP racial slurs, was levelheaded, and did not physically intervene with clients unless “absolutely” needed. P1 had no concerns about the SP and said the SP was one of the most caring staff persons who worked at the facility. HM3 stated that the SP was “cool.” HM3 did not see a housemate push the SP, but HM3 believed it could have happened. HM3 “never” saw the SP push a housemate. The facility’s Emergency Use of Manual Restraints Policy stated that positive support strategies and techniques must be used to attempt to de-escalate a person’s behavior before it poses an imminent risk of physical harm to self or others. When these s steps were ineffective, staff persons should use the least intrusive intervention necessary to assure the health, safety, and welfare of the individual and other people present. This investigator reviewed photos of the marks taken by the G on June 15, 2024. One mark was on the inside of the VA’s right bicep and was circular. The outer edge was composed of diffuse red marks and the interior was yellow. Another mark was on the left side of the VA’s back, over the ribcage. This mark appeared wider on one end and more pointed on the other. The bottom of the mark was dark purple and the top was a mix of red, purple, and yellow. A Behavior Intervention Reporting Form (BIRF) was completed and the information was consistent with the information provided by P2. Facility documentation showed that the SP, P1, P2, and P3 each received training on Physical Intervention Alternatives and the Reporting of Maltreatment of Vulnerable Adults Act. P1 and P2 were trained on the VA’s plans. Law enforcement was notified, but did not investigate further. Conclusion: Information from all sources was consistent that on June 7, 2024, around 10 p.m., the SP was in the basement office while the VA was upstairs in his/her bedroom and HM1 was downstairs in his/her bedroom. At some point HM1 went upstairs. HM1 and the VA started arguing and the SP went upstairs to intervene. At some point during the SP’s intervention, the VA scratched the SP. There was conflicting information as to the VA’s and the SP’s other physical interactions during the incident: · The VA provided inconsistent information to the G, P3, and the DHS investigator about whether the SP pushed the VA into an entertainment center, or the VA fell into the entertainment center or a wall. · HM1 said the SP pushed the VA at one point during the incident, causing the VA to stumble and the VA might have fallen into a wall corner near the hallway at that time. · The SP denied that any other physical contact occurred between the VA and the SP during the incident. The SP provided consistent information to various individuals, and in documentation, that during the incident the VA threw a television remote, a lamp, and chairs and hit the television; and the SP told the DHS investigator that the VA kept falling during the incident because s/he was tired. Information was consistent that on June 15, 2024, the VA had bruises on his/her right bicep and on the left side of his/her back, which the VA told the G s/he might have received during the June 7, 2024, incident with the SP. However, given that during the incident the VA engaged in actions that could reasonably have caused the injury to him/herself, the VA’s injuries were not clearly attributed to the SP. Given the conflicting information provided by the SP, the VA, and HM1, credibility was a determining factor. The VA’s credibility was diminished because s/he provided different information about the incident to different people over time. The SP’s credibility was augmented because s/he provided consistent information about the incident to various individuals over time, and in documentation. As a result, the VA’s and HM1’s statements that the SP pushed the VA during the incident did not outweigh the SP’s denial that s/he pushed the VA. Therefore, there was not a preponderance of the evidence whether the SP pushed the VA during the incident. It was not determined whether physical abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). Action Taken by Facility: The facility completed an Internal Review and found their policies and procedures adequate; however, the SP was not trained on the VA’s plans prior to the incident. The VA’s plans were updated and the SP and P3 were trained on those updated plans. Action Taken by Department of Human Services, Office of Inspector General: On April 24, 2025, the facility was issued a Correction Order for not training the SP on the VA’s plans as required.
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