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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: 1123520 -H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Elisa Montgomery/Tessa Ripka Minnesota Department of Human Services 651-431-6474 Suspected Maltreatment Reported: It was reported that a staff person (SP) threatened a vulnerable adult (VA) with a stick and headbutted the VA. Date of Incident(s): March 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 2, paragraph (b), clause (1); 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 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 9, 2025; from documentation at the facility; and through four interviews conducted with facility staff persons (the SP, P1, and P2) and the VA’s guardian (G1). Attempts to contact the VA’s second guardian (G2) were unsuccessful. The VA was diagnosed with autism spectrum disorder, developmental disability, and speech apraxia. Given the VA’s diagnoses, the VA was not able to provide information related to the incident. The VA enjoyed going to the park, playing soccer, and listening to music. The VA had 24- hour supervision at all times and required to two staff persons present. According to the VA’s Positive Support Transition Plan, the VA has a history of displaying physically aggressive behavior toward others attempting to redirect him/her to a safe activity/location. The VA had a history of leaving without supervision from caregivers or family and engaged in self-injurious behaviors. Staff were trained to only implement Emergency Use of Manual Restraint (EUMR) when there was an imminent risk of physical harm to the VA or others. According to the VA’s Individual Abuse Prevention Plan, due to the VA’s diagnoses, the VA did not understand what constituted physical abuse and would not be able to report any type of abuse in a timely manner or to the proper person. The VA would not understand why someone was upset with him/her or if the person was trying to harm him/her; therefore, s/he would attempt to protect him/herself against physical abuse. The VA would pick up objects and pretend like s/he would hurt somebody but might not engage in the behavior, which could cause another to have a physical reaction toward the VA. Staff would respond to situations that presented a serious risk to the VA’s health, safety, or rights by verbal redirection first, then attempting to guide the VA to a safe area using the least restrictive manner possible. P1 provided the following information: · On March 9, 2025, around 4:00 p.m., the VA, the SP, and P1 went to the park to meet G2. The VA and G2 went for a 40-minute walk by themselves. When the VA and G2 came back, the VA did not want to get in the vehicle. The VA expressed that s/he needed to use the restroom but the restrooms at the park were closed. P1 suggested that they should go back to the facility to use the bathroom and after 20 minutes of reassuring, the VA agreed. · While in the van on the way back to the facility, the SP stated to the VA, “You really made me mad today,” and “I’m mad at you.” The VA responded by saying, “I’m going to hurt you,” and the SP responded, “I’d like to see you try.” · Around 5:00 p.m., when the VA, the SP, and P1 arrived at the facility, the SP opened the door for the VA and said, “Well, let’s see what you can do.” The VA began to run down the driveway toward the road. P1 and the SP followed and were able to block the VA from entering the road. The VA attempted to hit both P1 and the SP so P1 and the SP implemented a EUMR hold on the VA by assisting the VA down to the ground safely while P1 held the VA’s legs, and the SP held the VA’s arms. · The SP stepped away and grabbed a stick and was waving it at the VA. The VA grabbed the end of the stick, and it broke so both the SP, and the VA had a piece of the stick. The SP dropped his/her part of the stick and went toward the VA’s upper body and headbutted the VA while P1 was holding the lower half of the VA’s body. The VA said, “Ow, that hurt,” and the SP stepped away from the VA. P1 helped the VA up and talked to the VA about being safe and not entering the roadway and headed toward the facility. · When inside, the VA asked for his/her iPad to talk to G1. The SP told the VA that s/he needed to shower first. The VA grabbed a picture frame and P1 did not know if it was glass or not but had taken it from the VA and went to put it back. The VA went into his/her bedroom where the SP was. · P1 walked into the VA’s bedroom and observed the SP over the VA, and the VA was laying face up on his/her bed. The SP appeared to be on the bed with the VA and had his/her legs on the VA’s chest but P1 was not sure. P1 then witnessed the SP grab the VA’s wrist and began motioning the VA’s hands to hit him/herself and saying to the VA, “Why are you hitting yourself?”. · After the incidents, P1 observed that the VA had a small cut on his/her lip and that it was bleeding. P1 was not able to determine if the injury had occurred because of the hold outside or when the VA was headbutted by the SP. P1 took a photo and sent it to the facility’s nurse. The photo had shown that the VA had a small cut on the inside of his/her lip. · P1 did not have knowledge of the VA being injured during an EUMR hold prior to this incident. Prior to this incident, P1 did not have concerns with the SP. The SP provided the following information: · On March 9, 2025, the SP worked with P1. In the afternoon, G2 had made plans to meet the VA at the park. The SP and P1 took the VA to meet G2 at the park. The VA and G2 went for a walk in the park for approximately 40 minutes. · When G2 and the VA came back from the walk, the VA did not want to leave the park. The SP offered to call the VA’s family member, and the SP called the VA’s family member to talk to the VA. G2 also talked to the VA about leaving the park and then the VA got in the vehicle to go back to the facility. · On the way to the facility, the VA began calling P1 the “f-word” and “b-word”. P1 seemed to be “antagonizing” the VA and getting frustrated so the SP told P1 to “knock it off” as. The VA began to hit the windows of the vehicle. · When the VA, the SP, and P1 arrived at the facility, the SP opened the VA’s door and the VA got out, the SP asked the VA if s/he wanted to go inside. The SP took a couple steps back from the VA and P1 “tackled” the VA to the ground. The VA grabbed for a stick, but the SP grabbed the VA’s hands and began talking to the VA and offering to go inside with the VA and take a warm shower. The VA, the SP, and P1 then went inside. · When inside, the VA picked up a picture frame and appeared like s/he was going to throw the picture frame. The SP talked to the VA and the VA put the picture frame down. · The SP denied “headbutting” the VA and denied threatening the VA with a stick. The SP did not observe any injuries on the VA following the VA being “tackled” by P1. The SP stated that s/he pinned the VA down on his/her bed and the SP was “protecting” him/herself from the VA pulling out the SP’s hair because on a previous occasion, the SP pulled out a “chunk” of the SP’s hair. P2 provided the following information: · P2 relieved P1 and the SP on March 9, 2025. P2 was told by the SP that the VA had a “good day” and that it was “rough” getting the VA in the vehicle. The SP did not share any additional details with P2 and left the facility. · P1 discussed with P2 that the VA had struggled to leave the park with G2 and get in the vehicle and that when in the vehicle, the SP said to the VA, “You really made me mad.” P1 also shared that the SP had “antagonized” the VA and when the VA attempted to leave without supervision, the SP “pinned” the VA down at the end of driveway. · P1 discussed additional details with P2 and shared that the SP threatened to hit the VA with a stick and then headbutted the VA. When the VA, the SP, and P1 entered the facility, P1 asked the SP why s/he acted that way, and the SP said that they were “allowed” to do that. · P2 did not observe any injuries on the VA and said that s/he did not have prior concerns with the SP. G1 provided the following information: G1 did not have prior concerns with P1 or P2. G1 reported that the SP had worked with the VA in the past. During that time, the SP had been involved in a separate incident with the VA. There were concerns that the SP had not provided accurate information related to that incident and it was found that video footage had shown that the SP had not provided accurate information related to the prior incident when previously working with the VA. The facility’s internal review provided the following information: · P1 described that on the way back from the park, the SP told the VA, “You really made me mad today,” and on the way back to the facility, the VA said, “I’m going to hurt you,” and the SP responded with, “I’d like to see you try”. When back at the facility, the SP opened the vehicle door for the VA and the VA ran down the driveway toward the road. · P1 and the SP followed the VA and blocked the VA’s direction. Due to the VA swinging his/her arms and attempting to hit P1 and the SP, the VA was put in a hold. P1 was holding the VA’s legs, and the SP let go of the VA’s upper body and grabbed a stick. The VA also grabbed the stick and the stick broke, and the SP started swinging the stick at the VA in a “threatening” manner. · The SP threw his/her part of the stick and P1 had taken the VA’s part of the stick and threw it toward the woods. The VA was still laying on the ground and the SP was holding down the VA’s arms and headbutted the VA. The VA expressed that s/he was hurt. The SP and P1 let go of the VA and P1 helped the VA up and P1, the VA, and the SP went inside the facility. · The SP described that when they arrived back at the facility from the park, that the VA did not want to go inside, and the VA took a couple steps backwards and P1 “tackled” the VA. The VA bit his/her lip when P1 and the SP implemented a hold on the VA. During the hold, the VA grabbed a stick, and the SP took the stick from the VA and during the hold. Then, the VA said that s/he wanted to go inside. · The VA provided limited information regarding the incident but was able to identify that the SP had implemented the hold when s/he got of the vehicle and that the SP had grabbed the stick first and hit the VA in the head. All staff persons interviewed were trained on Reporting of Maltreatment of Vulnerable Adults Act, the facilities policies and the VA’s plan of care prior to the incident. Conclusion: A. Maltreatment: P1 provided consistent information related to the incident that occurred on March 9, 2025. P1 and the SP implemented an EUMR hold on the VA when the VA ran down the driveway toward the road. During this, the SP picked up a stick and waved it at the VA in a “threatening” manner. At some point, the SP “headbutted” the VA. After they went inside, P1 then saw the VA and the SP on the VA’s bed with the SP’s legs on the VA’s chest. The SP had the VA’s hands and was motioning the VA’s hands like they were hitting the VA. It was not able to be determined by P1 when the VA bit his/her lip causing his/her lip to bleed. The SP provided information that was inconsistent regarding whether the VA had received any injuries following the incident on March 9, 2025. The SP stated that the VA had not received any injuries, but the facility’s internal review indicated that the SP had observed that the VA bit his/her lip and did have an injury. The VA provided limited information regarding the incident but was able to identify that the SP had implemented the hold when s/he got out of the vehicle and that the SP grabbed the stick first and hit the VA in the head. Although the SP denied the allegations and stated P1 “tackled” the VA, given the SP had reason to minimize his/her actions for fear of consequences and provided inconsistent information; that P1 provided consistent information that the SP headbutted the VA, threatened the VA with a stick, and was on top of the VA with the SP’s legs on the VA’s chest in the VA’s bed; and that the VA stated the SP put him/her in the hold, there was a preponderance of the evidence that the SP’s actions were not accidental and could be reasonable expected to produce physical pain or injury or emotional distress and that the SP failed to provide the VA with reasonable and necessary care and services. It was determined that physical abuse and neglect 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; 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 responsible for the VA’s care at the time of the incident and was trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plan of care prior to the incident. 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 physical abuse and neglect for which the SP was responsible each did not meet statutory criteria to be determined as recurring or serious because the SP’s conduct was considered a single incident, and it was not determined how the VA sustained the lip injury. Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were adequate but not followed by the SP. 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.
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