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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: 1071711-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Brittany Dolen/Judith Schwanke 651-431-6701 Suspected Maltreatment Reported: It was reported that a supervisory staff person (SP1) had inappropriate interactions with three vulnerable adults (VA1-VA3) that included slapping them, pushing them, yelling at them, calling them names, and neglecting their care. It was also reported that an administrative staff person (SP2) was aware of the concerns and failed to act. Date of Incident(s): Ongoing prior to March 13, 2025 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), clauses (1) and (2); and subdivision 17, paragraph (a): 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. · 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. 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 April 1, 2025; from documentation at the facility; and through 13 interviews conducted with an administrative staff person (SP2), one supervisory staff person (SP1), five staff persons (P1-P5), a quality assurance (QA) staff person, VA1’s and VA3’s guardian (G1), VA2’s guardian (G2), VA1’s case manager (CM1), VA2’s case manager (CM2), and VA3’s case manager (CM3). This investigator met and spoke with VA1, VA2, VA3, and another resident at the facility (R), but each were unable to provide information for this investigation due to their diagnosis. VA1 was diagnosed with profound intellectual disabilities and was nonverbal. VA1 enjoyed going on walks and car rides. VA2 was diagnosed with mild intellectual disabilities and was nonverbal. VA2 had a history of physical aggression and self-injurious behavior which required behavioral intervention and redirection by staff persons. VA2 enjoyed listening to music, going to movies and going out to eat. VA3 was diagnosed with obsessive compulsive disorder, bi-polar anxiety and Polycythemia vera, which was a “rare blood cancer.” VA3 used a walker and gait belt to assist with ambulation and used a wheelchair for long distances. The walker also had a seat to sit on which at times, VA3 used. VA3 completed daily exercises to help keep his/her muscles from tightening and required reminders from staff persons to complete these exercises. VA3 enjoyed crafts, watching television, shopping and playing board games. P1-P5 each provided information that on various dates each saw SP1 engage in non-therapeutic interactions with VA1-VA3 that included slapping, pushing, yelling, calling names and neglecting their care and provided the following: Regarding Physical Abuse: · P1 stated that on his/her first day working at the facility, VA3 asked SP1 for coffee, and SP1 told VA3 s/he could not have coffee right then. When VA3 continued to ask for coffee, SP1 “got upset and started screaming.” SP1 had light blue medical gloves in his/her hand and “whopped” VA3 in the face with them and then SP1 “got in [VA3’s] face.” P1 said s/he stepped between VA3 and SP1 and “pulled” SP1 back. VA3 punched SP1 in an attempt to get away and SP1 “shoved” VA3 hard enough that VA3’s walker moved backwards with VA3 on it. · On an unknown date, as VA3 sat on his/her walker, P1 and P3 each saw SP1 grab the handles and brake of VA3’s walker, as VA3 sat there and “threw” the walker to the side. SP1 then “got in [VA3’s] face.” P1 stepped between VA3 and SP1 and “pulled” SP1 back. VA3 punched SP1 in an attempt to get away and SP1 “shoved” VA3 hard enough that his/her walker moved backwards as VA3 sat on it. When P1 intervened, SP1 shoved P1. After the incident, P1 called SP2 and told him/her what had happened. · P1-P5 provided consistent information that they had observed SP1 “push” and “shove” VA2 towards his/her bedroom. Staff persons were trained to guide residents to their bedroom, however SP1 would become “annoyed” and use one hand to push VA2 in the back. VA2 was upset when this happened and “ran” to his/her bedroom. P1-P5 also saw SP1 push VA1 in the same manner. · P4 stated that when SP1 walked VA2 to his/her bedroom, SP1 “pushed” VA2 with one hand, using his/her palm first followed by his/her fingers. When SP1 pushed VA2, VA2 walked forward and then again stop walking, so SP1 pushed VA2 again. On two to three occasions, P4 noticed bruising on VA2’s arms and back that looked like “fingerprint motion like pushing.” P4 documented this bruising and told P1 what s/he saw. · VA2 often pinched staff persons to indicate s/he needed something, and staff persons were working with a behavior analyst to provide VA2 choices, in an attempt to avoid pinching. P1, P2, P4, and P5 each provided information that they saw SP1 slap VA2’s hands in response to his/her pinching. SP1 told staff persons that G2 told him/her to do this, however, G2 denied that s/he would ever allow staff persons to slap VA2’s hands. · P1 saw SP1 slap VA2 on his/her hands, arms, chest and back “more than 10 times” and witnessed SP1 “dig” his/her fingernails into the palm of VA2’s hand and tell G2 that VA2 did it to him/herself. P1 stated there would be marks left on VA2’s hand when this happened. · On an unknown date, P2 saw unexplained bruising on VA1’s bottom. Additionally, P2 found that no staff persons had documented or tracked the bruising, as they were trained to do. P2 stated that times when s/he notified SP1 of unexplained bruising on VA1, as well as other residents, SP1 would say that the individual did it to themselves or it was from “running into things” but P2 did not believe that. P2 notified SP2 of this via text message. Regarding Emotional Abuse: · When SP1 screamed at VA3, s/he would be “almost nose to nose” with VA3, called VA3 names and “belittled” VA3. SP1 told VA3 s/he needed to quit asking “dumb questions,” quit “being a child,” and quit “being ignorant.” · On an unknown date, after P1 witnessed SP1 slap VA3 in the face with a pair of medical gloves, P1 said SP1 “got in [VA3’s] face” and P1 had to step between VA3 and SP1 and “pull” SP1 back. VA3 was “cowering down, almost with [his/her] head to the table”, was “very scared” and P1 saw “fear” in VA3’s eyes. · P1 said that SP1 screamed at VA3 “pretty much every day.” When SP1 yelled and screamed, it “set the whole house in an uproar.” The R paced the floor and VA1 and VA2 started screaming. · Information was consistent that SP1 did not typically yell or scream at VA1 and/or VA2. Regarding Neglect and SP1’s cares of VA1-VA3: · On November 19, 2024, P2 saw a medication error for VA3 and called SP1 to ask what to do. SP1 stated, “Just give it to [him/her].” P2 asked SP1 if s/he should call G1 or the pharmacy and SP1 stated, “No, just give it to [him/her] and act like nothing happened.” P2 was uncomfortable with this response, so s/he called the pharmacy and was told to not give VA3 the medication. The pharmacist told P2 that had s/he given VA3 the missed dose, it could have “seriously injured or killed” VA3. P3 then text SP2 about the incident. · On one occasion, P1 discovered that VA3 had not received one medication for approximately three days. P1 called SP1 and told him/her about the medication errors. SP1 told P1 to remove the pills from the packet, put them in a zip lock bag, label them with the appropriate information, and put the bag in the medication destruction bin. P1 asked SP1 to walk him/her through how to complete the medication error form and SP1 told P1 they would complete it together the following day. When SP1 arrived to work the following day, the pills were gone and there was no paperwork filed regarding the medication error. · P1-P5 provided consistent information that when they arrived to work following SP1’s shift, VA1 and VA2 were often “soaked” with urine through their brief and clothing, and did not appear to have been changed for “a period of time.” When SP1 was asked about this, s/he stated s/he had “just changed” VA1 and VA2. On one occasion, P3 told SP1 it did not appear VA2 had been changed recently and SP1 asked P3 if s/he was calling SP1 a liar. Information provided also indicated that VA1’s-VA3’s bedding, facility furniture and chuck pads would also be soaked with urine after SP1 had worked. · On November 28, 2024, P2 worked and found feces in VA1’s bed. SP1 worked prior to P2, so P2 sent a photo of the feces to SP1 because SP1 was the last to change bedding at the facility. SP1 told P2 that the feces was not there when s/he made VA1’s bed earlier and P2 replied to SP1 that the feces “had to have been” and was “dried up” and “not fresh.” P2 stated s/he thought the feces was human because animals were not allowed at the facility. P2 told SP2 about the incident. · On March 9, 2025, P1 noticed that P5 had not administered VA2 his/her morning medication. P1 told P5 s/he needed to call SP1 and P5 took the packet of pills and said s/he would “tend to it.” Approximately 20 minutes later, P5 returned and told P1 s/he “handled it” and that s/he “flushed the pills down the toilet and burned the packet.” P1 called SP1 and SP2 and informed them what happened, but did not think there was any disciplinary action. P1 thought there were five to six medication errors by P5 that were not handled properly. Regarding Neglect and SP2’s addressing concerns regarding SP1’s interactions with VA1-VA3: · P1 and P2 each provided consistent information that on multiple dates, they told SP2 their concerns regarding SP1 via text message, telephone call and in person conversations, and neither had knowledge of any corrective action related to the behaviors. · On November 13, 2024, P2 text SP2 regarding concerns with SP1 “smacking” VA2’s hands when s/he pinched and that SP1 told P2 to do the same when VA2 pinched. SP2 acknowledged the concern and stated G2 “said to do that with [VA2’s] hands.” · P1-P3 provided information that SP1 and SP2 were friends outside of work and believed this caused SP2 to not follow appropriate protocol in addressing concerns about SP1. In addition, the QA stated that SP2 was responsible to report concerns to his/her supervisor and the QA, which s/he did not, and that there had been “ongoing” issues with SP2 continually trying to “deal” with concerns on his/her own rather than bringing concerns to his/her supervisor and the QA so the appropriate process could be completed. · On November 19, 2024, P2 told SP2 via text message that SP1 told P2 to give VA3 a missed medication without consulting a medical professional. Following the text message there was a telephone call in which SP2 thought P2 was “lying” because his/her story changed. P2 said s/he did not feel comfortable sharing the information because SP2 included SP1 on the telephone call. An incident report was created regarding the missed medication, however SP2 did not include information from a medical professional that had VA3 been given the medication, s/he could have been seriously injured or killed. · On November 28, 2024, P2 told SP2 via text message that there was feces in VA1’s bed and that SP1 had been responsible for making the beds prior to P2 starting work. · On an unknown date, P2 notified SP2 via text message, of concerns with unexplained bruising on VA1’s bottom and that the bruising had not been documented by staff persons. P2 did not think VA1 caused the bruising to him/herself, and did not think SP2 addressed the concern with staff persons. SP1 denied that s/he ever slapped, pushed, yelled, called names, and/or neglected VA1-VA3. SP1 denied being told that slapping VA2’s hands would be an appropriate response to his/her behaviors. SP1 denied that s/he yelled at VA1-VA3 and indicated s/he would raise his/her voice “just a little over talking level.” SP1 denied that s/he ever pushed VA2 and stated s/he would “guide” VA2. SP1 denied that VA3 pushed or punched him/her and denied ever pushing VA3. SP1 denied telling P2 to give VA3 medication without direction from a medical professional. When asked why someone would say s/he engaged in these interactions if s/he had not, SP1 stated multiple times that s/he “could not speak for anyone else on what their thoughts are.” SP2 provided the following information: · In August 2024, SP2 asked management at the facility for “help with a bunch of stuff” because s/he was “pretty much drowning” but s/he did not receive assistance from management. · On an unknown date, SP2 was told by P2 that SP1 slapped VA2’s hand in response to VA2 pinching. SP2 spoke with multiple staff persons about what they were trained to do when VA2 pinched and all of them stated they were trained to redirect and that they were never told to slap. SP2 thought P2 was “upset” with SP1 over his/her schedule. SP2 stated s/he did not complete a report on this incident and “felt” like s/he informed his/her supervisors but did not remember dates or times. SP2 did not remember how P2 gave him/her this information and stated that in his/her “right mind” SP2 would have documented those concerns/conversations but s/he did not do so. · On an unknown date, P2 called SP2 and told him/her there had been a medication error with VA3 and that SP1 told P2 to give VA3 the medication. SP2 stated s/he had a phone call with P2 and SP1 and P2 “retracted [his/her] statement in literal minutes.” SP2 said s/he needed to use his/her best judgement in this situation and stated, “When they tell you one thing and retract, to me, you are lying.” SP2 was “pretty sure” s/he completed an incident report regarding this medication error, but the facility had no documentation that this was completed. · SP2 was aware that feces was found in VA1’s bed and said that the feces was on a blanket on the floor, and not in the bed. SP2 did not know if the blanket had been moved from the bed to the floor but the feces was from a staff persons pet and that the pet being at the facility had been “approved through the company for a long time.” SP2 denied that pets were not allowed at the facility and said if “anyone above [him/her] was saying no, they are lying.” · SP2 denied seeing SP1 scream at residents and said that any time s/he went to the facility the residents appeared happy and the facility was clean. · SP2 stated, “I may have missed some things in the past years, but not out of malice, not out of cover up, not out of anything bad. But I tried to do my best and make sure people were well taken care of.” G1 said there were more medication errors than s/he was aware of “throughout the years” but did not provide specific information or details. G1 talked to SP1 about medications errors and SP1 told G1 there were “struggles” with the pharmacy and how the orders came in because there were multiple providers prescribing medications to VA3. G2 provided the following information: · G2 denied telling SP1 to slap VA2’s hands and said s/he would “never allow that.” · On an unknown date, G2 saw that VA2 had what looked like “scratches” or “pinches” in the palm of his/her hand and a bruise on his/her arm. G2 asked SP1 about the marks and bruise and SP1 told G2 that VA2 did it to him/herself, but G2 had “never seen anything like that before.” · G2 had concerns with staff persons care of VA2. When G2 went to the facility, VA2 had “dirty clothes” and “greasy hair”, and his/her bedding was not always clean. G2 talked to SP1 “a lot” about those concerns because it was “usually” when SP1 worked that VA2 looked that way. The concerns were also addressed in a meeting with VA2’s team “a few months ago.” CM1 stated that in February 2025, s/he had concerns with staffing and supervision at the facility because the facility was paid for two staff persons for VA1 “at all times” but there was only one staff person working. On an unknown date in February 2025, CM1 met with SP1 and SP2 and SP2 told CM1 that the facility was “going through staff like crazy” and that staff persons at the facility “don’t get paid as much because the residents don’t have exceptional rates” which CM1 “had not heard before.” CM2 stated that s/he had previous concerns with cares provided to VA1. On an unknown date in January 2025, a team meeting was held with staff persons from the facility and G2 regarding VA2’s frequency of urinary tract infections, which s/he had not gotten before. The day program that VA2 participates in had also told CM2 that VA2 was “showing up wet” to the program. Following this meeting, the facility started doing daily logs of when VA2 was changed/showered and when s/he went to the bathroom and CM2 was not aware of any more issues following the meeting. CM3 did not provide information regarding the allegations and did not have previous concerns with the facility. The facility’s personnel files showed that P1-P5 and SP1 and SP2 were all trained on the VA1’s-VA3’s plans and the Reporting Maltreatment of Vulnerable Adults Act. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), states in part that a person’s protection-related rights included the right to be treated with courtesy and respect. Conclusion: A. Maltreatment: Information from P1-P5 showed that there were multiple concerns with SP1’s interactions with VA1-VA3 and that SP2 was aware of these concerns but did not do anything about it. Regarding Physical Abuse: P1-P5 provided consistent information that on multiple unknown dates, SP1 was observed using his/her hands/fingers to “push” and/or “shove” VA2 on the back towards his/her bedroom. P4 stated that on two or three occasions s/he saw bruising on VA2’s arms and back that looked like “fingerprint motion like pushing.” P1-P5 also saw SP1 push VA1 in the same manner and P2 stated s/he observed unexplained bruising on VA1 and when s/he talked to SP1, SP1 would say that the individual did it to themselves or it was from “running into things” but P2 did not believe that. SP1 denied shoving VA1 and/or VA2. P1 saw SP1 slap VA2 on his/her hands, arms, chest and back “more than 10 times” and witnessed SP1 “dig” his/her fingernails into the palm of VA2’s hand and tell G2 that VA2 did it to him/herself. P1 stated there would be marks left on VA2’s hand when this happened. SP1 denied slapping VA2. On an unknown date, G2 saw scratches or pinches in the palm of VA2’s hand and a bruise on VA2’s arm. G2 asked SP1 about the marks and SP1 told G2 that VA2 did it to him/herself. P1 and P3 provided consistent information that on an unknown date, SP1 shoved VA3 while VA3 was in his/her walker. As a result of this shove, VA3’s walker moved backwards with VA3 sitting on it. Staff persons had to intervene. VA3 did not sustain injuries related to this incident. On another occasion, P1 saw the SP “shove” VA3 hard enough that VA3’s walked moved backwards with VA3 on it. SP1 denied shoving VA3 while s/he was in his/her walker and denied that staff persons had to intervene. P1 stated that on his/her first day of work s/he observed the SP “whop” VA3 on the face with light blue medical gloves. P1, P2, P4, and P5 each provided information that they saw SP1 slap VA2’s hands in response to VA2 pinching. SP1 told staff persons that G2 told him/her to do this, however, G2 denied that s/he would ever allow staff persons to slap VA2’s hands. P1-P5 provided consistent information that on multiple unknown dates, SP1 was observed to hit and slap VA3 in response to VA3 requesting assistance with basic needs. SP1 denied hitting or slapping VA3. SP1’s physical interactions with VA1, VA2, and VA3 were a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). Although SP1 denied shoving, hitting, and/or slapping VA1-VA3, SP1 had reason to minimize his/her actions for fear of repercussions. Given that multiple staff persons witnessed SP1 shoving, hitting, and slapping VA1-VA3 on more than one occasion, which was not accidental or therapeutic conduct, and that VA1 and VA2 each had unexplained bruising that some staff believed occurred from SP1’s interactions, there was a preponderance of the evidence that SP1’s physical interactions including slapping, hitting and/or shoving VA1-VA3 produced or could be reasonably expected to produce physical pain or injury. It was determined that 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). SP1’s physical interactions including slapping, hitting and/or shoving were a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). Regarding Emotional Abuse: On multiple unknown dates, SP1 was observed yelling and screaming “almost nose to nose” at VA3 while hovering over him/her and calling VA3 names such as “ignorant” and “child.” VA3 appeared fearful of SP1 during these incidents, and staff persons had to intervene to stop SP1’s behavior. Staff persons said that when SP1 did this, the R “paced” the floor and VA1 and VA2 started screaming. SP1 denied yelling or screaming at VA3. SP1’s verbal interactions with VA3 were a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). Although SP1 denied yelling or screaming at VA3, s/he had reason to minimize his/her actions for fear of repercussions. Given that multiple staff persons witnessed SP1 yell and scream at VA3 and call VA3 names on multiple occasions, there was a preponderance of the evidence that SP1 engaged in repeated oral language toward VA3, and treatment of VA3, that a reasonable person would consider disparaging, derogatory, humiliating, harassing or threatening, and produced or could reasonably be expected to produce emotional distress. It was determined that emotional 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: 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). Regarding Neglect and SP1’s cares of VA1-VA3: SP1 was a supervisory staff person and P1-P5 stated, on multiple unknown dates, when staff persons arrived at the facility, VA1 and VA2 were soaked in urine and on one occasion there was dried feces in VA1’s bed. There was no information provided that VA1 or VA2 sustained any harm as a result. SP1 denied the allegations. SP1’s actions of allowing VA1 and VA2 to be soaked with urine were a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). Information obtained showed that SP1 was aware of and failed to address more than one medication error in addition to disposing of three days’ worth of VA3’s missed medications. On November 19, 2024, SP1 advised P2 to administer a missed medication to VA3 without consulting a medical professional. Had VA3 received this medication, s/he could have been “seriously injured” or “killed.” SP1 denied the allegation and denied that s/he told P2 to administer the medication. Although SP1 denied the allegations, SP1 had reason to minimize his/her actions for fear of repercussions. Given that multiple staff persons observed VA1 and VA2 soaked with urine after SP1 had worked, that multiple staff persons were aware of medication errors that were not addressed, and that SP1 disposed of VA3’s missed medications, there was a preponderance of the evidence that SP1’s actions were not accidental or therapeutic conduct and were a failure to supply VA1 -VA3 with care or services which were reasonable and necessary. It was determined that 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). Regarding Neglect and SP2’s addressing concerns regarding SP1’s interactions with VA1-VA3: P1 and P2 each stated that they informed SP2 via telephone, text message, and in person about their concerns regarding SP1’s care, treatment, and interactions with VA1-VA3. November 13, 2024, P2 text SP2 regarding concerns with SP1 “smacking” VA2’s hands when s/he pinched and that SP1 told P2 to do the same when VA2 pinched. SP2 acknowledged the concern and stated G2 “said to do that with [VA2’s] hands.” SP2 stated that s/he spoke to staff persons regarding slapping VA2’s hands and all stated that they were never told to slap. SP2 stated that although s/he should have, s/he did not document the concern or conversations about the slapping. P1-P3 provided information that SP1 and SP2 were friends outside of work and believed this caused SP2 to not follow appropriate protocol in addressing concerns about SP1. The QA stated that SP2 was required to report concerns to his/her supervisor and the QA so they could be addressed in the appropriate manner. However, SP2 did not do this and did not properly document incidents that were reported to him/her. In addition, there had been “ongoing” issues with SP2 trying to “deal” with concerns on his/her own rather than notify his/her supervisor and the QA. SP2 said that s/he was “pretty much drowning” and needed help that s/he did not receive. Given that multiple staff persons notified SP2 of concerns with SP1’s care, treatment, and interactions with VA1-VA3, yet SP2 failed to address the concerns, there was a preponderance of the evidence that SP2 failed to supply VA1-VA3 with care or services which was reasonable and necessary. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care. (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. SP1 and SP2 were trained on VA1’s-VA3’s plans and the reporting Maltreatment of Vulnerable Adults Act. Regarding SP1: At the time of the incidents, SP1 was a supervisory staff person and providing direct care of VA1-VA3. SP1 was responsible for the physical abuse and neglect of VA1-VA3 and the emotional abuse of VA3. Regarding SP2: SP2 had significant administrative and supervisory authority over the operation of the facility and ensuring staff persons compliance with rules and statutes. SP2 was responsible for the neglect of VA1-VA3. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated physical and emotional abuse and neglect for which SP1 was responsible was “recurring” maltreatment because SP1 physically abused and neglected VA1- VA3 and emotionally abused VA3 on multiple unknown dates. It was determined that the substantiated neglect for which SP2 was responsible did not meet statutory criteria to be determined as recurring or serious because SP2’s lack of action was considered a pattern of behavior and therefore a single incident which did not reasonably require the care of a physician. Action Taken by Facility: The facility completed an internal review which determined that their policies and procedures were adequate but not followed. Staff persons were retrained on the facilities policies and procedures and SP1 and SP2 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1 was notified that s/he was responsible for recurring and serious maltreatment and that any future background studies for facilities, programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03, will result in his/her disqualification. The determination that SP1 was responsible for maltreatment is subject to appeal. SP2 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP2 was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of SP2. The determination that SP2 was responsible for maltreatment is subject to appeal. On May 30, 2025, the facility was issued a Correction Order for the violation outlined in this report.
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