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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: 1070501-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Neubauer-Hoffman, Deb 651-431-6567 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was physically restrained in a prone position for four minutes because a staff person (SP1) refused to assist another staff person (SP2) with restraining the VA and SP1 refused to call 9-1-1. Later, when a bruise was observed near the VA’s eye, it was reported that SP1 hit the VA during the incident. Date of Incident(s): March 20, 2024 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 1, 2024; from documentation at the facility and/or law enforcement records; and through seven interviews conducted with the VA, five facility staff persons (SP1, SP2, and P1-P3), and a guardian (G). The VA enjoyed watching various Minnesota sport teams and participating in Special Olympic events. The VA enjoyed bowling, basketball, and softball and like playing games like Bingo, Sorry, and Yahtzee. The VA’s diagnoses included moderate intellectual disability, seizure disorder, autism spectrum disorder, and generalized anxiety. The VA’s Supports and Outcome Methods showed that when the VA became frustrated or overwhelmed, s/he displayed aggressive and inappropriate behaviors. If the VA became physically aggressive, staff persons were to walk away and tell him/her they would assist when s/he was no longer aggressive. If the VA engaged in property destruction, staff persons were supposed to allow him/her to explain why s/he was upset and come up with a compromise and suggest an alternative activity without specifically addressing the property destruction. An Incident Report written by SP2 and/or an interview with SP2 provided the following information. · On March 20, 2024, SP1 was assigned to work with the VA and SP2 was assigned to work with a housemate (HM). · After returning to the facility on March 20, 2024, the HM exited the vehicle and went inside and did not witness the remainer of the incident. · While everyone was still in the vehicle, SP2 told the VA to go to the bathroom, change his/her “brief” and put on his/her pajamas. The VA said that s/he did not want to, and SP1 told the VA, “You need to go do that.” When this investigator asked whySP2 was directing the VA if SP1 was assigned to work with the VA, SP2 said that “a lot of times” SP1 did not remind the VA to use the bathroom and/or change his/her brief at night resulting in the VA being incontinent. · The VA got out of the vehicle, slammed the van door approximately four times, and started throwing things in the garage. When SP1 exited the vehicle, the VA “went after” SP1 and they lost their balance, and both fell to the ground where the VA kicked and hit SP1. SP2 got out of the vehicle and “tried to put [the VA] in a hold which did not work. [The VA] went after [SP1] again and they both fell to the ground.” SP1 held the VA from behind with the VA on his/her side. At some point SP1’s “shirt was ripped off.” · The VA then grabbed SP2 by the hair, punched him/her in the face, and broke SP2’s glasses. SP2 and the VA fell to the ground and while SP2 attempted to restrain the VA, the VA bit SP2’s left wrist. After the VA, SP2, and SP1 each got off the ground, the VA went to SP2’s car and attempted to damage a side mirror by pushing and kicking it. SP2 attempted to get the VA to stop by walking over to him/her and encouraging him/her to go inside the facility. The VA aggressed toward SP2 again and SP2 “got [the VA] to the ground myself” with the VA on his/her stomach. SP2 was “leaning on [the VA’s] upper butt low back to keep [the VA] down” and was “not leaning on [the VA] hard.” SP2 was “not near [the VA’s] head or neck to constrict breathing.” When the VA attempted to get up, SP2’s legs left the ground and SP2 told the VA to “stay down.” The VA was able to verbally respond to SP2’s directive, indicating that his/her breathing was not affected. SP2 asked SP1 for help and SP1 said, “No.” · SP2 told SP1 to call 9-1-1; however, SP1 again said, “No,” because SP1 did not know that address. SP2 called 9-1-1 with his/her cell phone while holding the VA in a prone position for approximately four minutes. During that time the VA continued to struggle but was able to respond verbally when SP2 told the VA to “stay down.” Multiple law enforcement officers arrived within minutes. · During the interview with this investigator, SP2 said that during the incident s/he saw SP1 “swinging” his/her right arm, hitting the VA in the face by the VA’s right eye. (That information was not included in the incident report written by SP2 and s/he did not mention that to anyone until March 24, 2024, when a small bruise became visible on the VA’s cheekbone. The facility’s Investigation Summary stated that on March 24, 2024, the VA was “developing a black eye” and when the VA was asked about it, s/he said, “[SP1] hit me.”) Two Incident Reports written by the local law enforcement showed that officers were called to the facility due to an altercation between the VA and staff persons (SP1 and SP2). Upon arrival, the incident was over, the VA said s/he did not know what happened and eventually stated s/he got upset/angry but did not provide additional details. SP1 and SP2 each provided information that the VA began yelling, kicking vehicles, and assaulting SP1 and SP2 after the VA was advised to prepare for bed. SP2 said that s/he attempted to unsuccessfully “hold” the VA. The VA bit SP2’s wrist breaking the skin, pushed SP2 to the ground, and punched him/her in the face. The VA also assaulted SP1 and bit SP1’s arm but did not break the skin. The VA was interviewed by this investigator 11 days after the incident. When asked about a restraint that occurred out in the driveway, the VA said s/he was injured during the restraint but was not able to indicate where the injury was on his/her body. When asked if anyone hit the VA anywhere on his/her body, the VA said, “No.” P2 lived near the facility and P3 called and asked P2 to go to the facility because the VA hit staff persons and law enforcement was called. When P2 arrived s/he saw an ambulance and several law enforcement vehicles. The VA was sitting on the ground in front of the garage talking to a law enforcement officer. P2 checked on the HM who was inside the facility and the HM told P2 that s/he “did not see anything.” When the VA entered the facility, s/he was tired, had a seizure, and wanted to go to bed. The VA did not tell P2 anything about the incident. The only injury P2 observed was a “scrape” on the VA’s head near the VA’s hairline. P3 said that on March 20, 2024, s/he received a call from SP2 stating the VA punched SP2 “in the face a couple times” and SP2 called 9-1-1. P3 went to the facility and arrived about the same time as P2. The “only” injury the VA told P3 about was a scrape on his/her knee. P2 told P3 about a scrape on the VA’s forehead and a “little cut” on the VA’s knee. A day or two later, P3 “noticed a black eye.” P3 described the black eye as “a little black and blue line, an inch or two long and a couple centimeters wide.” When P3 asked the VA about the black eye, the VA “kept telling” P3 that s/he did not know what caused it. P1, a supervisory person, said that on March 20, 2024, s/he heard about the incident from P3 that same night. P1 provided information consistent with SP2 and the facility’s documentation. P1 confirmed that SP1 was assigned to work with the VA; however, SP2 did not believe SP1 worked well with the VA so SP2 felt s/he needed to “help out” by telling the VA what s/he needed to do before bed. P1 stated it was not SP2’s role to provide that guidance to the VA because it was supposed to be the staff person assigned to work with the VA. SP1 provided the following information: · After the outing, everything was calm in the vehicle until SP2 told the VA that s/he needed to use the bathroom and wear an adult absorbent undergarment. At that point the VA “snapped” and got out of the vehicle, grabbed a wheeled “salt spreader” (described as a large walk behind spreader) and hit the vehicle with the spreader three to five times. The VA told SP1 and SP2 that they were “fired” and could go home. · SP1 and SP2 “tried to stop [the VA] from hitting the van” and were “trying to calm [the VA] down” when all three of them landed on the ground. The VA grabbed SP1 by the shirt and SP1 came out of his/her shirt. The VA also the pulled SP2’s hair and hit SP2 in the face. · When the VA got off the ground, s/he went to SP2’s car, pulled a side mirror, kicked the mirror, and beat on the hood. SP2 restrained the VA on the ground and asked SP1 to call the police but SP1 told SP2 to call the police because SP1 did not know the address of the facility. SP2 called law enforcement and a supervisory staff person, P3. The VA sat up and while SP2 stood over the VA, SP2 held the VA with one hand while making the calls. SP2 told the VA, “Don’t move, you damaged my car.” SP2 continued to hold the VA with one hand until law enforcement officers showed up. · When SP1 was asked about SP2 requesting SP’s help restraining the VA, SP1 said there was a lot of “commotion” and “if [SP2] did, I didn’t hear it.” When asked what s/he was doing while SP2 restrained the VA and made the calls, SP1 said, “I was standing there and [SP2] told me to see if I can fix the mirror.” The VA was calm at that time. · SP1 said that s/he was trained to have two staff persons restrain the VA either face down or on their back; however, it was “best to put face down where [the VA] can’t reach you.” When asked if s/he responded to the incident as s/he was trained, SP1 said, “No, I should have done more. I should have helped [SP2] with [the VA.]” SP1 did not observe any injuries on the VA. · When asked about swinging his/her arm at the VA and/or causing a bruise near the VA’s right eye, SP1 denied swinging his/her arm and said, “Nobody hit [the VA] in [his/her] face.” The G said that s/he was told about the incident; however, the VA did not say anything about it, so the G did not ask. When asked about the VA’s ability to accurately report events, the G said that the VA would be truthful “if you get the accuracy factor first,” however, s/he did not rely on the accuracy of the VA’s statements. The G and the VA “facetime” approximately three times a day and after the incident the G observed “a little discoloration” under the VA’s right eye, the “size of an eraser” on the end of a pen/pencil. The G had no concerns regarding the care or services provided to the VA. Documentation specific to the incident on March 20, 2024, showed that following the incident, injuries to the VA included a “scrape on head” (no specific area identified), and on the VA’s right knee, left side (no further explanation of size). A review of the VA’s health notes and daily log for the day of the incident through the following week showed no mention of a bruise on the VA’s cheekbone or near his/her eye. Facility documentation showed that SP1 and SP2 were each trained regarding the VA’s program plans, therapeutic intervention, and the Reporting of Maltreatment of Vulnerable Adults Act. Documentation also showed that SP1 and SP2 were trained regarding therapeutic intervention holds and prohibited procedures. Relevant Rules and Statute: Minnesota Statutes 245D.06, subdivision 6, paragraph (b) stated that prone restraint was prohibited. Prone restraint means use of a manual restraint that places a person in a face-down position. This does not include brief physical holding of a person who, during an emergency use of manual restraint, rolls into a prone position, and the person is restored to a standing, sitting, or side lying position as quickly as possible. Applying back or chest pressure while a person is in the prone or supine position or face up is prohibited. Conclusion: Facility documentation showed that when the VA became frustrated or overwhelmed, s/he displayed aggressive and inappropriate behaviors. Staff persons were supposed to walk away if the VA became physically aggressive and if the VA engaged in property destruction, staff persons were to allow the VA to explain why s/he was upset and come up with a compromise. Information from SP1 and SP2 showed that on March 20, 2024, the VA became upset after being told s/he needed to use the bathroom and change his/her absorbent adult undergarment. Initially the VA engaged in property destruction and SP2 stated that the VA “went after” SP1 after tSP1 exited the vehicle and they both fell to the ground. The VA was also physically aggressive to SP2 when s/he exited the vehicle. SP1 and SP2 provided information that the VA fell to the ground at least twice during the attempted restraints. At one-point during the incident SP2 attempted to use a two-person restraint by asking SP1 for assistance but SP1 refused resulting in SP2 holding the VA in a prone position for four minutes. SP1 stated that s/he did not hear SP2 request that assistance; however, SP1 also stated s/he was trained to have two persons implementing restraints. SP1 also admitted that s/he declined calling 9-1-1 when SP2 requested because SP1 did not know the facility address. Immediately after the restraint minor scrapes and abrasions were observed on the VA. Additionally, a day or two later, a small bruise was observed under the VA’s right eye and at that time SP2 recalled seeing SP1 swinging his/her arm hitting the VA in that area of his/her head during the incident. The Investigation Summary stated that after the bruise was observed, the VA was asked about it and the VA said SP1 “hit” him/her. However, there was no information that the VA told that to law enforcement officers or P2 who saw the VA immediately after the incident, the VA denied being hit by a staff person when asked by this investigator, and the VA told P3 that s/he did not know what caused the facial bruise. Information showed that the VA was on his/her stomach for approximately four minutes during the restraint. During that period of time SP2 was aware that s/he should not have the VA on his/her stomach and attempted to move him/her by asking for SP1’s assistance. SP2 was “leaning on [the VA’s] upper butt low back to keep [the VA] down” and was “not leaning on [the VA] hard.” SP2 was “not near [the VA’s] head or neck to constrict breathing.” When the VA attempted to get up, SP2’s legs left the ground and SP2 told the VA to “stay down.” The VA was able to verbally respond to SP2’s directive, indicating that his/her breathing was not affected. Although the prone restraint used by SP2 was not in accordance with the facility’s training and was a violation of Minnesota Statutes, section 245D.061, subdivision 3, and a couple days later SP2 stated that SP1 hit the VA in the eye the day of the incident, given that while SP2 restrained the VA, s/he continued to struggle yet was able to verbally respond during the restraint, and that the VA stated no one hit him/her in the eye and SP1 denied doing so, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services or whether all of the staff persons’ actions were therapeutic or whether the VA sustained the injuries by any means other than accidental. It was not determined whether 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). It was not determined whether 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). Action Taken by Facility: The facility completed a Behavior Intervention Reporting Form as required that indicated a prone hold for four minutes and that the VA’s injuries included a “scrape/abrasion.” The facility also completed an internal review and determined that policies and procedures were adequate but were not followed when staff persons did not use negotiation and de-escalation techniques and when the staff person refused to participate in the manual restraint. All staff persons were retrained regarding therapeutic intervention. SP1 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On September 3, 2025, the facility was issued a Correction Order for the citation outlined in this report.
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