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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: 1083905-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a staff person (SP) used profanity to vulnerable adults (VA1 and VA2), called VA1 a “brat,” yelled at the VAs, told VA2 not to touch him/her with his/her “nasty hands,” and pushed VA2 into his/her bedroom then shut the door. Date of Incident(s): Prior to June 26, 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): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on August 7, 2025; from documentation at the facility; and through interviews conducted with facility staff persons (P1, P2, P3, and the SP), VA1’s case manager (CM1), VA1’s guardian (G1), VA2’s case manager (CM2), and VA2’s guardian (G2). This investigator met the VAs and their housemates, but they were unable to provide information regarding the concerns in this report. Facility documentation showed that the VAs were diagnosed with developmental disabilities and were non-verbal The VAs were vulnerable to all forms of maltreatment. VA1 tended to crowd into the space of others, which might make them uncomfortable. If VA1’s behavior changed, it might indicate that s/he was upset or was ill. VA1 had a history of obtaining or attempting to obtain food that belonged to others or discarded food, then eating it. VA1’s Behavior Support Plan (BSP) showed that if the VA took food that belonged to others, staff persons were not to “scold” or lecture VA1 or try to make him/her return the food. Staff persons were to replace the food that was taken and encourage VA1 to move away from the person whose food s/he had taken. VA1 was generally happy and enjoyed interacting with others. VA2 had a history of property destruction and physical aggression; his/her Behavior Support Plan (BSP) showed that maintaining a consistent routine, showing patience, and offering verbal praise paired with “thumbs up” were successful redirections for VA2. VA2 liked it when others smiled at him/her. Interviews with this investigator, facility documentation, and the facility’s Internal Review, provided the following: · P1 said on the date of the incident, the SP was in a bad mood and arguing with his/her significant other (SO) on the phone when P1 and the SP worked a shift together at the facility. P1 said that s/he was preparing to assist VA1 to take a shower, but the SP was upset and called VA1 a “brat.” The SP went outside to take a break, but when s/he came back inside, VA2 had obtained the SP’s chocolate from the kitchen. The SP took the chocolate from VA2, told him/her that it was “fucking rude” of him/her to take the chocolate, told VA2 not to touch him/her with his/her nasty hands, then pushed VA2 into his/her bedroom and closed the door. In addition, the SP yelled at VA1 to stop moving furniture. P1 thought that the SP used profanities when speaking to the VAs during the incident and to describe supervisory staff persons, but P1 was not able to hear everything the SP said. P1 checked on VA2 in his/her bedroom and assessed him/her for injuries, but s/he seemed “okay,” and did not have visible injuries. The VAs were not able to verbally describe the incidents, but did not seem to be affected by them. P1 said that s/he moved furniture in the common areas of the facility to sweep and mop during his/her shift on the date of the incident, and sometimes staff persons rearranged furniture at the facility. P1 had picked up shifts at the facility off and on for two or three months, but s/he enjoyed being a float and preferred to work where s/he was needed. · The SP provided consistent information in an interview with this investigator and/or in the facility’s Internal Review which showed that on the date of the incident, P1 assisted VA1 to take a shower, but the SP did not. According to the SP, P1 used his/her mobile phone constantly, and frequently went outside during the shift. In addition, P1 moved the furniture in the living room and in the VAs’ bedrooms to sweep under it, but VA1 became upset when furniture and other items were moved because s/he had a preferred seat in the living room and did not like change. The SP denied calling VA1 a “brat” and said that when VA1 pushed the furniture to return it to its initial position, P1 stopped him/her and said, “We don’t push furniture,” and instructed VA1 to leave the furniture where it was. · According to the SP, VA2 took or attempted to take food from two individuals. When VA2 took the SP’s chocolate, the SP obtained the chocolate from VA2 and threw it away, then redirected VA2 to wash his/her hands. VA2 was “grabby” during the shift, but it was common for VA2 to take food from others, and the chocolate was inexpensive. The SP redirected VA2 to his/her bedroom and held VA2’s elbow while they walked to his/her bedroom together. VA2 walked willingly with the SP at his/her own pace and when they entered VA2’s bedroom, VA2 “played” with his/her personal items. The SP exited VA2’s bedroom but did not close the door and did not recall whether VA2 closed the door. VA2 could open and close doors without assistance and did not stay in his/her bedroom unless s/he wanted to. The SP denied that s/he used profanity when redirecting the VAs and said that s/he did not intentionally raise his/her voice to them, but s/he had health issues that affected his/her ears, so it was possible that s/he talked loudly with the VAs. · The SP said that P1 was a “float” who had worked at the facility a few times, but did not usually work there. According to the SP, P1 told others that s/he wanted to stop working in a float position so s/he could work at the facility full time because s/he liked it. The VAs’ housemates were at the facility when the incident occurred, but the SP was unsure whether they witnessed the incident or were able to describe it. · P2 worked the shift after the SP’s and said that the SP told him/her at shift change that during the SP’s shift, the SP yelled at VA1 to, “Sit down and stop touching things,” that the SP “got in” VA2’s face and yelled, and that the SP told the VAs that s/he would use a sterner voice with them if necessary. The SP repeated the same information several times to P2, who found the information upsetting. · P3, a supervisory staff person, said that s/he received consistent information over time from P1 and P2 regarding the SP’s actions, but prior to this incident, there were no concerns with the SP’s work. VA1 had a history of moving/pushing furniture around and if it was not bothering anything or hurting anyone, staff persons generally did nothing and let VA1 move furniture. When necessary, staff persons might redirect VA1 from moving furniture to a preferred activity. If VA2 took food from staff persons or others, staff persons were to redirect him/her away from the kitchen and food storage areas, but if s/he obtained food that belonged to others and could not be verbally redirected, staff persons did not physically intervene unless VA2’s actions put him/her or others at risk for harm. VA2 might walk fast, and staff persons could walk with him/her gently holding his/her elbow to guide him/her. VA2 could open and close doors independently and leave his/her bedroom when s/he wanted to. · CM1 and G1 provided consistent information that VA1 was non-verbal and unable to communicate using spoken language. VA1 had a history of getting into the personal space of others, but it likely was not intentional. G1 often stopped by the facility to check on VA1 and observed that there was frequently a seasoned staff person paired with a newer staff person on shift which reassured G1 because s/he thought that newer staff persons might learn to mimic seasoned staff persons working with VA1. G1 had no concerns regarding VA1’s care and appreciated the follow up from this investigator and the facility. · CM2 and G2 each stated that VA2 liked living at the facility and they did not plan to move VA2. Spending time in the facility’s fenced back yard delighted VA2 and s/he seemed happier than s/he had been at other facilities. VA2 arranged his/her bedroom as s/he preferred it, and his/her housemates were not permitted to enter his/her bedroom. However, if housemates or staff persons moved items or furniture in the common areas of the facility, VA2 might become upset until items/furniture were returned to their previous locations. G2 said that VA2 had good eyesight, and s/he was certain that an inability to see well was not the cause of VA2’s behavior changes when items/furniture were moved at the facility. The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procedures prior to the incident. However, the SP had not “acknowledged” VA1’s BSP. The SP acknowledged VA2’s BSP on April 10, 2025. Relevant Statutes: Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6), states that a person’s protection-related rights include the right to be treated with courtesy and respect and receive respectful treatment of the person’s property. Conclusion: Information was consistent that the VAs and the individuals who resided at the facility did not communicate using spoken language. P1 said that the SP called VA1 a “brat,” yelled at VA1, screamed at VA2, told VA2 that it was “fucking rude” of him/her to take the SP’s chocolate, and told VA2 not to touch him/her. The SP then pushed VA2 into his/her bedroom and closed the door. The VAs did not seem to be affected by the incidents and VA2 could independently open and close doors. P2 stated that the SP told him/her that s/he yelled at the VAs and told them that s/he would use a sterner voice if necessary. P2 was upset by the SP’s statements, but no information showed that VAs sustained physical injuries during the incident. The SP said that P1 assisted VA1 with a shower on the date of the incident, and added that P1 moved furniture in the facility, which upset VA1. When VA1 attempted to return furniture to its initial location, P1 stopped him/her and told VA1 not to push furniture. The SP denied that s/he called VA1 a “brat.” The SP stated that VA2 attempted to take food from others and took the SP’s chocolate. SP obtained the chocolate from VA2, threw it away, and instructed VA2 to wash his/her hands, then walked with VA2 to his/her bedroom at VA2’s pace. In the bedroom, VA2 began playing with his/her personal items and the SP exited the bedroom, but did not recall whether s/he closed the bedroom door. The SP denied that s/he used profanity or raised his/her voice, but s/he might have talked loudly because s/he had health issues that affected his/her ears. The Gs and the CMs had no concerns regarding the VAs care at the facility. G1 said that s/he visited the facility frequently, and G2 stated that VA2 seemed happier at the facility than s/he was in previous service locations. P1 and P2 provided consistent information regarding the SP’s actions. The SP denied that s/he called VA1 a brat, used profanities with the VAs, or pushed VA2, but the SP had reason to minimize his/her behavior, and it was likely that the SP engaged in some of the behaviors the Ps described which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, were not accidental or therapeutic conduct, and were a violation of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6). However, given that it was a single incident, and that no information showed that the VAs were affected by the SP’s actions, there was not a preponderance of the evidence whether the SP engaged in conduct that caused or could reasonably be expected to cause emotional distress and or physical pain or injury to the VAs. It was not determined whether 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; or 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 which determined that its policies and procedures were adequate but not followed. The VAs appeared unaffected by this incident. When this report was written, the SP was no longer employed at the facility. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate action when it became aware of the SP’s actions, a correction order was not issued for the violation outlined in this report. No further action taken.
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