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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: 1106340-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Kim Anderson/Scout Peterson 651-431-6553 Suspected Maltreatment Reported: It was reported that when a vulnerable adult (VA) took a bag of chips off the facility kitchen counter and walked to his/her room, a staff person (SP) followed the VA and tried to take the bag away. While they were “struggling” over the bag, both the VA and the SP fell to the floor. The VA went to the hospital via ambulance and was treated for bruised ribs. Date of Incident(s): February 9, 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 17, paragraph (a): 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 February 19, 2025; from documentation at the facility, law enforcement records, and medical records; and through eight interviews conducted with two facility staff persons (the SP and P1), three supervisory staff persons (P2-P4), a quality assurance staff person (QA), the VA, and the VA’s guardian (G). According to the VA’s Coordinated Services and Supports Plan (CSSP), the VA enjoyed fishing, going out to eat, and listening to “oldies” music. The VA’s CSSP also stated that the VA went into town daily to stop at a convenience store where s/he got a sugar-free soda and visited with the workers there with whom s/he was familiar. The VA’s diagnoses included schizophrenia, borderline personality disorder, anxiety, intellectual disability, and diabetes. The VA’s Individual Abuse Prevention Plan stated that the VA was susceptible to physical abuse because s/he did not fully understand what physical abuse was, did not have the ability to identify dangerous situations, nor could s/he deal with physically aggressive persons. Additionally, the VA had a history of abusive behavior towards others including hitting, kicking, biting, manipulation, and verbal aggression. The VA had six hours of unsupervised time at the facility and zero hours of unsupervised time in the community. The facility’s Internal Review stated on February 9, 2025, the SP refused to take the VA to get a soda. Later that day, the VA took a bag of chips to his/her room and the SP followed the VA into his/her room. “A struggle ensued,” and both the SP and VA fell to the floor. The VA was taken to the emergency room twice following the incident and sustained injuries including bruised ribs and an abrasion near his/her eye. The VA reported that the SP “assaulted” him/her, however, the VA had a history of prior incidents of providing inaccurate information. Medical records for the VA showed that on February 9, 2025, the VA was seen at the emergency room (ER) where s/he received a computed tomography (CT) scan of his/her head and an x-ray of his/her right wrist. The CT scan was negative for any findings and the x-ray was negative for any fracture. The VA was diagnosed with an abrasion of the face and right wrist pain, and was instructed to take Tylenol as needed, ice the areas that were in pain, and keep the abrasion clean and dry. On February 10, 2025, the VA was again seen at the ER for rib pain and received a CT of his/her chest. The CT scan showed a contusion on the VA’s left ribs, and the VA was instructed to take Tylenol and ibuprofen for discomfort and ice the area. The VA provided the following consistent information in an interview with the DHS investigator and for the facility’s internal review: · On an unknown date, the VA was “upset” because the SP did not take the VA into the community to get a soda. Later the same day, there were two bags of potato chips on the kitchen counter and the VA took one because s/he was hungry and was going to eat them in his/her room. The SP followed the VA and tried to grab the VA’s hand and, “We both [fell] down.” The SP did not say anything to the VA at that time. The VA hit his/her head and rib on something, but did not know what s/he hit. The SP fell on top of the VA and after they stood up, the SP “came at” the VA again at which time the VA told the SP to get out of his/her room and the SP left. · The VA went to the ER, but did not provide details about the visit other than that a law enforcement officer spoke with him/her there. Regarding his/her injuries, the VA stated that s/he hurt his/her left ribs and right eye, took Tylenol, and iced the areas. Law enforcement (LE) records provided the following: · On February 9, 2025, at 10:50 p.m. the SP told the LE that around 8 p.m. the SP followed the VA into his/her room when the VA took a bag of chips from the kitchen that were supposed to be shared between all the facility clients. When the SP attempted to “grab” the chips from the VA, the VA “pulled back unexpectedly,” and both the SP and the VA lost their balance. The VA landed on top of the SP. After they fell, the SP stood up and went to another room at the facility, while the VA stayed in his/her room with the chips. · Around 9 p.m. P1 arrived to relieve the SP for the night shift, and P1 took the VAto the hospital to be evaluated. Later that evening, the LE went to meet with the VA and P1 at the hospital. P1 told the LE that earlier in the day the VA was upset because the SP did not take him/her to get a soda. · The VA told the LE that the SP “attacked” him/her for taking chips and told the VA that the VA “stole” the chips. The SP followed the VA into his/her room and tried to take the chips from the VA. Both the SP and the VA pulled on the chips, and the SP fell on top of the VA. The VA added that s/he fell on his/her back which caused his/her back to hurt, and that his/her face hurt because s/he had abrasions on his/her face but did not know how his/her face got hurt. The SP provided the following information: · On February 9, 2025, the VA asked the SP to take him/her to the convenience store to get a soda. The SP told the VA that s/he would not do so because s/he was cleaning the facility in preparation for a Superbowl party and because s/he had taken the VA twice the day before. This “upset” the VA. · Between 8 and 9 p.m., the SP laid out food on the kitchen island for all the clients to eat. The other clients got plates of food and went downstairs to watch the Superbowl. After the other clients went downstairs, the VA came out of his/her room and “grabbed” an unopened bag of chips from the kitchen island and started “moving quickly” back to his/her room. The SP followed the VA and said, “Can I have the chips back, I will get you a bowl,” and reminded the VA that the chips were to be shared among all the clients. · The SP followed the VA into his/her room and tried to “grab” the bag of chips from the VA, however, the VA “pulled [the chips] back” and the SP let go. When the SP let go, both the SP and the VA lost their balance and fell to the floor. The SP was lying on his/her back and the VA landed on top of him/her. The SP “pushed” the VA off from over the top of him/her and stood up. When the SP attempted to help the VA up from the floor, the VA kicked the SP, so the SP left the VA’s room. · The SP called P3, but P3 did not answer so the SP called the QA. An unknown amount of time later, P1 arrived at the facility for the overnight shift. The SP told P1 to check on the VA, and after P1 did so, s/he told the SP that s/he was going to take the VA to the ER. The SP left the facility and filed a report with law enforcement because s/he was “shaken up.” The police did “nothing” with the information. P1 provided the following information: · On February 9, 2025, P1 arrived at the facility at 9 p.m. for his/her shift. The SP was in the office “upset” and told P1 that s/he was going to call the LE. The SP told P1 that the VA grabbed a full bag of chips from the kitchen and the SP wanted the VA to put them in a bowl instead of bringing them to his/her room. When the SP reached for the chips, the VA made a “sudden draw-back” and both the SP and the VA fell to the floor. After speaking with the SP, P1 went to check on the VA and noted that s/he had an “open area” under his/her right eye and said s/he had a headache and was hurting in different areas of his/her body but did not specify where. · P1 took the VA to the ER and the VA told the nurses that s/he was assaulted. The VA also asked P1, “Why did [the SP] attack me?” The LE arrived and met with the VA at the hospital. The VA told the officer that s/he wanted to press charges on the SP for assault. The VA had “rugburn” that was “not huge” and consisted of “six dots across the nose area,” and his/her undereye had a “small,” “not deep” open wound that was abraded. The VA received a CT scan that had negative results. The next day, the VA went to the ER a second time for a chest x-ray. P1 stated that the hospital discharged the VA with instructions to take Tylenol for pain, and “didn’t do anything to treat [the VA].” · “A few nights” before P1’s interview with the DHS investigator, the VA told P1 that his/her eye was still swollen. P1 stated that the VA got upset in the past when staff persons did not do “exactly” what the VA wanted. P1 stated, “It would have been a good idea [for the SP] to let [the VA] have [the chips],” and the SP should have let the VA calm and talk about it afterwards. P1 stated that the VA got “upset” with P1 in the past when P1 did not do “exactly” what the VA wanted, and made a comment that s/he “knew how to get rid of people” after the SP no longer worked at the facility. P1 added that s/he trusted the VA to provide accurate information “to a certain extent,” but did not know if s/he provided accurate information about the incident with the SP. P2 provided the following information: · On February 9, 2025, the QA called P2 and stated that the SP told him/her that the VA “attacked” the SP because of a bag of chips. P2 called the SP who stated that the VA brought chips to her room, and the SP followed him/her with a bowl and wanted the VA to put the chips in the bowl. The SP reached to grab the chips, the VA “pulled back,” and they fell to the floor. The SP stated that the VA kicked him/her, and, “I got away as fast as I could.” · P1 arrived at the facility “soon” after the incident and took the VA to the ER because his/her head hurt. The VA received a negative head CT and an x-ray of his/her wrist that showed no fracture or injury. While at the ER, the VA told the LE that s/he was assaulted by the SP and wanted to press charges. · P3 called P2 the next morning and stated that s/he took the VA back to the ER because his/her head hurt, s/he had a lump on his/her head that was growing, and s/he was having trouble breathing. The VA got a chest x-ray that showed “nothing,” and the VA was discharged. · P2 stated that s/he spoke to both the SP and the VA about the incident and they each said that the other person fell on top of them. P2 added that the VA was known to be an inaccurate reporter and wanted to get staff “in trouble.” P2 reiterated to all staff persons that clients do not have food restrictions, and that they should not enter clients’ rooms without permission. The quality assurance staff person (QA) provided the following information:
· On February 9, 2025, at 8:38 p.m., the SP called the QA, who was the on-call manager at the time. The SP told the QA that the VA took a bag of chips off the counter and took it to his/her room. The SP said s/he was “concerned” about the VA’s diabetes, so s/he followed the VA and suggested that the VA put the chips in a smaller bowl instead. The SP told the QA that as s/he attempted to grab the chips from the VA, both s/he and the VA fell to the floor, with the VA falling on top of the SP. · The QA asked the SP if s/he or the VA were injured, and s/he said, “No.” The QA told the SP s/he would ask P1 to come in early to relieve the SP and reminded the SP to fill out an incident report. Because the SP told the QA that there were no injuries, s/he did not call the on-call nurse to report the incident but called P2 to inform him/her of the incident. P3 provided the following information: · On February 9, 2025, in the evening, the SP called P3 and stated that s/he was “attacked” by the VA. The SP stated that the VA pushed, fell on top of, and kicked the SP. The SP told P3 that s/he called the QA and P4, and that they were “taking care of it.” · The next day, February 10, 2025, P3 went to the facility and saw that the VA’s face was scratched and bruised. The VA told P3 that s/he was mad the day before because the SP did not take him/her into the community as requested by the VA. Then later that night, the VA wanted chips and took them from the kitchen. As the VA brought them to his/her room, the SP followed the VA, grabbed the chips, and both the VA and the SP lost their footing and fell. The VA stated that the SP fell on top of him/her. The VA complained of pain, and P3 gave him/her Tylenol and took the VA back to the ER because the VA told P3 it was painful to breathe. The VA was diagnosed with a bruised chest wall. P4 stated that on February 9, 2025, at 9:30 p.m., the SP called P4 and told him/her that the VA was in an “altercation” with a staff person, but did not identify which staff person. The VA was taken to the ER due to “marks” on his/her knee and a swollen undereye. P4 was not contacted regarding any follow-up or outcome of the ER visit. The G was aware of the incident and had no concerns regarding the facility. The facility’s Employee Conduct and Discipline Policy stated prohibited conduct included: negligence, carelessness, or failure to perform acceptable standards of service delivery. The facility’s Safety Policy required staff persons to ensure the well-being of clients, which included preventing situations that may result in harm. Facility documentation showed that P1-P4 and the SP were trained on the Reporting of Maltreatment of Vulnerable Adults, the facility’s Employee Conduct and Discipline Policy, and P1, P2, and the SP were trained on the VA’s plans. Based on their roles at the facility, P3 and P4 were not required to be trained on the VA’s plans Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) and paragraph (b), clause (6) state in part that persons receiving services have the right to be treated with courtesy and respect, have freedom and support to access food at any time. Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a) states the license holder must provide services in response to the person’s identified needs, interests, preferences, and desired outcomes as specified in the support plan and the support plan addendum. Conclusion: A. Maltreatment: Information provided by the SP and the VA was consistent that on February 9, 2025, the SP refused to take the VA into the community as requested by the VA. Later that night when the VA took a bag of chips from the kitchen into his/her room, the SP followed the VA and an altercation took place. When the SP attempted to take the bag of chips from the VA, the VA and SP both fell to the floor. The SP said that the VA fell on top of him/her, but the VA said that the SP fell on top of the VA. The VA was twice seen at the ER after the incident, received tests and scans, and the VA was diagnosed with an abrasion to his/her right eye, contusion on the left ribs, and wrist and rib pain. The VA’s CSSP stated that the VA went into town daily to stop at a convenience store where s/he got a sugar-free soda and visited with the workers there with whom s/he was familiar. The SP’s actions of refusing to take the VA to the convenience store was a violation of the VA’s plans and a violation of Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a). In addition, engaging in a physical altercation with the VA by attempting to take the chips from the VA was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and were violations of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) and paragraph (b), clause (6). The SP’s power struggle with the VA over the chips resulted in each of them falling to the floor and the VA sustaining an abrasion and pain. Therefore, there was a preponderance of the evidence that there was a failure to provide the VA with care or services which were reasonable and necessary to obtain or maintain the VA’s physical health and safety. 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. The SP was trained on the VA’s plans, the Reporting of Maltreatment of Vulnerable Adults Policy and the facility’s Employee Conduct and Discipline Policy. The SP was responsible for maltreatment of the VA. 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 neglect for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and the VA did not require the care of a physician. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP 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 the SP. The determination that the SP was responsible for maltreatment is subject to appeal. Given that the facility took immediate corrective action, a Correction Order was not issued for the violations outlined in this report.
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