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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: 1069861-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) yelled at a vulnerable adult (VA) “on and off” for 20 minutes, pointed his/her finger in the VA’s face, tried to grab the VA’s hand, and threatened to slap the VA. Date of Incident(s): April 5, 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), clause (2): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on April 30, 2025; from documentation and security camera footage at the facility; and through four interviews conducted with two facility staff persons (the SP and P1), a supervisory staff person (P2), and an administrative staff person (P3). The VA’s guardian was notified of this investigation, however, did not have additional information to provide. This investigator met the VA; however, s/he did not engage with this investigator’s attempts to interview him/her or acknowledge this investigator’s presence at the facility. The VA enjoyed eating, reading magazines, and attending religious services. The VA’s diagnoses included profound intellectual disability, depression, impulse control disorder, schizoaffective disorder, and anxiety. The VA’s Individual Abuse Prevention Plan stated that the VA was unable defend him/herself against physically or verbally aggressive persons and was unable to recognize when or if s/he was in an unsafe situation. The VA had a history of hitting people and things when s/he was anxious about something. Staff were trained to verbally redirect the VA or attempt to calm the VA by lightly rubbing his/her forearm. The SP provided the following information: · On April 5, 2025, the SP worked at the facility with P1 from 2 to 8 p.m. Around 6 p.m., the VA was “escalating” by scratching and pounding his/her chair and was slapping on doors with his/her hands. The SP stated that s/he tried “everything” that s/he had been taught to deescalate the VA and calm him/her including verbal redirection and taking the VA outside, however, it did not work. The SP stated that “something flipped” inside him/her and the SP yelled at the VA in a voice “louder than an outside voice.” The SP raised his/her voice at the VA, pointed his/her finger at the VA, and stated, “I’ll slap you back,” after the VA hit the SP. The SP described the VA’s demeanor after s/he yelled at him/her as the same as it was before s/he yelled and did not know how or if it affected the VA. The SP stated that s/he was sorry about what s/he did and saw where his/her mistakes were; s/he stated that s/he needed to ask for help and if that did not work, s/he had to “back off.” · The SP stated that the VA’s behaviors got worse recently, and that his/her doctors were working on adjusting his/her medication. Staff persons were trained to try to take the VA on a walk or a car ride when his/her behaviors were escalating, however it was becoming increasingly difficult, and staff persons were “running out of ideas.” The facility provided four clips from security camera footage each dated April 5, 2025. In each video, the VA was seated in a recliner to the left, the SP was in the middle of the living room approximately two feet from the VA’s recliner, and another client was in the rear in a chair and did not respond or react during the clips. P1 was in each clip, detailed below: · The first video, timestamped at 2:07 p.m., was one minute and nine seconds long. P1 was at the far left, on the other side of the living room from the VA and the SP. During the clip, the VA banged the side of his/her chair repeatedly, and did not say any words or make vocalizations other than coughing. The SP was heard saying, “quit it, “be good,” “no,” and “you don’t understand that do you?” in a voice louder than speaking level. At the end of the clip, the SP walked away from the VA towards P1, and P1 said, “What else to say?” · The second video, timestamped at 2:09 p.m., was 42 seconds long. P1 was in the rear by the front entrance to the facility. The VA did not move, and the SP approached the VA and said, “Are you done now? Are you done hitting the chair? Good – quit it. Be good.” At 20 seconds, the VA tapped the armrest of his/her recliner, and the SP said, “No, no” in a voice louder than speaking level. The SP turned and made eye contact with P1, turned back towards the VA and stated, “Had enough of it,” and walked away from the VA. The VA had no observable response or change in demeanor during the clip. · The third video, timestamped at 2:10 p.m., was 47 seconds long. P1 was still by the front entrance. The VA began coughing, and the SP approached him/her and said, “You put your hand down and be quiet.” The SP pointed his/her finger at the VA and said, “You sit there and behave, you be good.” The SP began to walk away, and said, “No more, no, bad, be good,” and walked away from the VA. The VA had no audible or visible reaction to the SP. · In the fourth video, timestamped at 2:12 p.m., was one minute and seven seconds long. P1 was seated in a chair behind the VA’s recliner. The SP standing up from the couch and said to the VA, “What did I tell you, huh? No.” The SP pointed his/her finger in the VA’s face and repeated, “No.” Eleven seconds into the video, another client came into view, and P1 said, “[The client’s name], go in your room,” but the client stayed in the living room by the front door and put on a coat. The SP then asked the VA, “Do I have to sit by you? No? Better not. No more slapping your chair. No more screaming.” The other client then left the living room from the same place that s/he entered. The SP then said to the VA, “Yeah, take a nap.” The VA then banged on the side of his/her chair and the SP responded, “I said take a nap, didn’t I?” Forty-eight seconds into the video, the SP tried to grab the VA’s hand, and the VA slapped the SP’s hand away, the SP responded, “I’ll [inaudible] slap ya.” The SP then turned to look at P1, shrugged his/her shoulders and walked away. The VA had no audible or visible reaction to the SP. P1 stated that on April 5, 2025, the VA was making noises, slapping his/her chair, and slapping the wall. P1 tried to take the VA outside for a walk, but s/he refused and “flopped” to the ground, so they went back inside. P1’s ears were both “plugged up” and “could hardly hear anything” but stated that it “sounded like” the SP was getting the VA “calmed down.” P1 added that s/he could not remember “anything” else from that day and had no concerns about the SP’s interactions with clients in the past. P1 stated that when the VA had escalating behaviors, they took him/her outside and offered verbal redirection. P3 provided the following information: · P3 stated that the VA experienced increasing agitation and anxiety symptoms for the past year that included vocalizations, hitting other people and items, stealing food, eating non-typical food items, insomnia and restlessness. The facility experienced numerous staffing changes since the beginning of 2025, including at least six long-term staff persons leaving their employment. P3 “presumed” that the staffing changes were affecting the VA’s behaviors. · On April 6, 2025, the SP called the on-call manager (P4) and stated that s/he no longer wanted to work at the facility because of a “terrible day,” but the SP did not provide other details about the day. P4 reviewed client progress notes and forwarded them to P3. Over the next few days, P2 discovered the security camera footage of the SP yelling at the VA, which P3 then also reviewed. P3 added that the VA did not respond when the SP yelled at him/her and had the same facial expression as was “typical” for the VA. P3 stated that there were no previous concerns regarding the SP’s interactions with the VA or other clients and described him/her as “widely liked” by both clients and staff persons. · On April 11, 2025, P3 and P2 met with the SP who “readily admitted” that s/he should not have responded to the VA’s behaviors in as s/he had, and that s/he was “wrong.” The SP was “sincerely apologetic” and stated that s/he “went miliary” and knew that it was “not okay.” P3 added that the behavior was “out of character” for the SP and that the SP had extenuating personal circumstances that s/he was dealing with. P2 stated that on an unknown date after April 5, 2025, received a call from P4 who told P2 that the SP requested to not be scheduled at the facility because of undisclosed “issues.” P4 told P2 that s/he reviewed the VA’s progress notes and other documentation but did not find anything “that bad.” After hearing that the SP no longer wanted to work at the facility, P2 reviewed the security camera footage, and saw P1 “walking around paying no attention” and the SP “intermittently” putting his/her fingers in the VA’s face and “yelling” at the VA. The VA did not react to the SP’s actions and acted “normally” afterwards. P2 stated that the SP’s tone of voice and actions were not consistent with how s/he was trained to interact with clients, and that P1 should have said something to the SP like “you can’t do that.” P2 did not have concerns about the SP’s interactions with clients in the past. According to the facility’s Protection Related Rights policy, all clients had the right to be treated with courtesy and respect and receive respectful treatment of the person’s property.
All staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s Protection Related Rights Policy and the SP, P1 and P2 were trained on the VA’s plans. Based on P3’s role s/he was not required to be trained on the VA’s plans. Relevant Rule and Statute Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) stated in part that a persons’ protection-related rights include the right to be treated with courtesy and respect. Conclusion: Camera footage and information from the SP showed that on April 5, 2025, the VA demonstrated escalating behaviors including hitting his/her chair; afterwards the SP yelled at the VA to “quit it” and “be good,” pointed his/her finger in the VA’s face, and stated that s/he would slap the VA back if the VA hit the SP again. Consistent information provided by P2 and P3 showed that there were no prior concerns with the VA’s interactions with clients, and the SP’s actions did not appear to impact the VA. The SP acknowledged that the way s/he spoke to the VA was a “mistake” and “readily admitted” to P3 and P2 that the way s/he responded to the VA’s escalating behaviors was wrong. The SP’s actions of yelling at the VA were a violation of the facility’s Protection Related Rights Policy and a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). However, given that it was a single incident, and that the SP did not have a history of yelling at clients or the VA, there was not a preponderance of the evidence whether the SP’s single day of yelling at the VA could reasonably be expected to produce emotional distress. It was not determined whether 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The SP was retrained on the Reporting of Maltreatment of Vulnerable Adults, emergency use of manual restraints, prohibited procedures, person-centered planning and service delivery. The SP still worked for the license holder, but no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate corrective action, a Correction Order was not issued for the violation outlined in the report.
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