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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: 1068860-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Elisa Montgomery Suspected Maltreatment Reported: It was reported that a staff person (SP) was observed by facility cameras dragging a vulnerable adult (VA) on a concrete driveway. Date of Incident(s): June 25, 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 July 11, 2025; from documentation and camera footage at the facility; and through seven interviews conducted with facility staff persons (P1-P5), the SP, and the VA’s guardian (G). Due to the VA’s diagnoses, the VA was not able to provide information related to this investigation. The VA liked to watch football games, sit outside, and look at magazines. The VA went to a day program on weekdays from 8:00 a.m. until 2:00 p.m. The VA was diagnosed with cerebral palsy and a seizure disorder. The VA was nonverbal and utilized a wheelchair and walker for mobility. The VA required assistance from staff persons and a gait belt used with his/her walker when standing. The SP provided the following information: · When assisting the VA to get on a bus to go to day program, the SP typically pushed the VA in his/her wheelchair outside to the bus and the VA would use his/her walker to stand. The SP would stand behind the VA while s/he went up the stairs on the bus and followed the VA from behind to his/her seat on the bus. · On June 25, 2025, the SP was assisting the VA with getting on the bus to go to his/her day program. The VA struggled to get up the stairs and wanted to sit down while on the steps of the bus. The SP struggled to assist the VA with standing and the VA sat down on the steps of the bus. · The SP was not able to assist the VA with standing and assisted the VA off the stairs by looping his/her arms under the VA’s arms. The SP assisted the VA onto a concrete driveway/sidewalk next to the bus in a sitting position. The SP attempted to get the VA off the ground by lifting the VA under his/her arms but was not successful. · The SP pulled the VA away from the bus by standing behind the VA and looping his/her arms under the VA’s arms by his/her armpits and pulled the VA backwards in a scooting motion, out of the way of a different bus that was coming to pick up the VA’s housemates. The VA’s pants had slid down so the VA’s buttocks was on the ground and was scraped on the concrete. · The SP was the only staff working at the residence and the VA’s housemates’ bus was to arrive shortly, so the SP left the VA sitting on the concrete for approximately five minutes and assisted the VA’s housemates with getting on the bus. · After getting the VA’s housemates on the bus, the SP went inside and got a Hoyer lift to assist with getting the VA off the ground. The SP was able to utilize the Hoyer lift to get the VA up and into his/her wheelchair and the SP transported the VA to his/her day program with the facility van. · The SP stated that s/he was not trained on what to do when the VA was struggling to get on the bus and sat on the stairs. The facility and transportation company were aware that the VA was struggling with his/her mobility and ability to continue using stairs to get on the bus and it was requested two months prior to the incident occurring that the VA utilized a bus that had a wheelchair lift. · The bus driver from the transportation company did not offer any assistance to the SP when s/he was attempting to assist the VA on and off the bus after the VA sat down on the steps of the bus. · The SP wished that s/he would have gotten the Hoyer lift and got the VA up and inside first instead of leaving the VA outside alone while assisting the VA’s housemates. P1 provided the following information: · After the VA arrived at day program the day of the incident, P1 was informed that an incident occurred. P1 reviewed video footage and determined that the SP made errors and did not follow proper training relating to the incident that occurred. · Staff persons were trained to talk to the VA if s/he was struggling to get on the bus and if the VA continued to struggle to get on the bus, staff persons were to transport the VA to his/her day program using the facility van. · The VA had been struggling with his/her mobility due to his/her diagnosis of cerebral palsy. P2 provided the following information: · On June 25, 2025, the bus driver for the transportation company informed P2 that the SP brought the VA out to get on the bus and that the VA was having trouble getting on the bus and that the SP dragged the VA on the ground. · P2 said that staff were trained to lower the VA to the ground and attempt to assist the VA with getting back up. If that did not work, staff would get the Hoyer lift and get the VA up from the ground with the assistance of the Hoyer lift and then go assist other housemates. · The VA’s mobility had declined due to the VA’s diagnosis of cerebral palsy. P3 provided the following information: · P3 worked with the VA at his/her day program. At the day program, two staff persons would assist the VA with getting on the bus and the VA would struggle with using the stairs on the bus. · Typically, the VA arrived at his/her day program via bus between 7:50 and 8:10 a.m. and on June 25, 2025, the VA arrived around 8:40 a.m. · The VA would leave from his/her day program around 2:00 p.m. · P3 observed an abrasion on the VA’s right knee and an abrasion on the VA’s backside on the right. · A few days after the incident, the VA was transferred to another bus that had a wheelchair ramp. P4 provided the following information: P4 worked with the VA at his/her day program. The VA would struggle to get on the bus using the stairs and would, at times, sit down on the steps to take a break. Shortly after June 25, 2025, the VA was transferred to another bus that had the wheelchair lift. P5 provided the following information: · On June 25, 2025, P5 was at the facility when the VA got off the bus from his/her day program. P5 observed four scrapes/abrasions located on the VA’s knee and backside ranging from sizes of a quarter and a 50-cent piece. The VA was assessed by the facility nurse and did not require further medical assessments. · The VA struggled with the stairs to get on the bus prior to the incident occurring on June 25, 2025, and P5 had requested more than a month prior that the VA be transferred to a bus with a wheelchair ramp. The VA had transferred to a bus with a wheelchair ramp on July 2, 2025. · The VA needed extra time and encouragement in the mornings when getting on the bus and would routinely sit down on the stairs. · P5 did not have concerns with the SP when s/he was working at the facility. Video footage from the incident on June 25, 2025, provided the following information: · 7:09 a.m.- The bus was parked in the driveway of the facility. The SP and VA were seen coming out of the facility. The VA was in his/her wheelchair. The SP pushed the VA up to the open bus door and the VA used his/her walker to stand up and the SP moved the walker out of the way so the VA could go up the stairs. · 7:18 a.m.- The VA knelt on the third out of four stairs on the bus while the SP was behind the VA on the second stair. · 7:19 a.m.- The SP attempted to assist the VA with getting on the bus for a second time. · 7:23 a.m.- The VA was not able to get on the bus using the stairs, so the SP attempts to assist the VA with sitting down in his/her wheelchair but was not successful. The SP lowered the VA to the ground. The VA’s t-shirt was caught on the foot brackets of the wheelchair and the VA’s shorts had fallen slightly causing half of the VA’s buttocks to be on the concrete. The SP moved the VA away from the bus by sliding him/her on the concrete with four separate pulling motions. · 7:24 a.m.- The SP went back into the facility leaving the VA on the ground outside by him/herself and another bus pulled into the driveway.
· 7:26 a.m.- The SP brought the VA’s housemate out to the bus that had a wheelchair lift and assisted the bus driver with getting the VA’s housemate on the bus. The VA was on the ground where the SP had left him/her, and the VA was laying on the ground on his/her side. · 7:28 a.m.- The SP talked to the bus driver and sat down on the patio chair outside of the facility. · 7:29 a.m.- The SP went inside the facility and brought out the Hoyer lift and sat down on the patio chair outside of the facility. · 7:32 a.m.- The bus left the driveway, and the SP brought the VA’s wheelchair inside the facility and then went out of the facility. · 7:36 a.m.- The SP laid the Hoyer lift sling on the concrete driveway and helped the VA lay down on the Hoyer lift sling properly. The SP uses the Hoyer lift to get the VA off the ground. The SP wheeled the VA into the residence while the VA was suspended in the air in the Hoyer lift. · 8:05 a.m.- The SP pulled the facility van in front of the facility door and opened the wheelchair ramp. · 8:08 a.m.- The SP and VA went out of the facility and the SP assisted the VA with getting in the facility van. The G did not have concerns with the facility. All staff person’s interviewed were trained on Reporting of Maltreatment of Vulnerable Adults and the VA’s plan of care. Conclusion: Information from the SP was consistent that on June 25, 2025, the SP was assisting the VA with getting on the bus to go to his/her day program. The VA struggled to get up the stairs and wanted to sit down while on the steps of the bus. The SP struggled to assist the VA with standing and the VA sat down on the steps of the bus. The SP was not successful in his/her attempts to get the VA back into his/her wheelchair. The SP assisted the VA to the ground and pulled the VA backwards on the concrete. The VA’s pants slid down so his/her buttocks was directly on the concrete when the SP was pulling him/her backwards causing the abrasions to the VA’s right buttock and right knee which was observed by P3 and P5. The VA did not require further medical attention outside of the facilities nurse checking the abrasions and determining that the injuries were surface level. Minnesota Statutes, section 626.5572, subdivision 17, paragraph (c), clause (4), states, "A vulnerable adult is not neglected for the sole reason that an individual makes an error in the provision of therapeutic conduct to a vulnerable adult which does not result in injury or harm which reasonably requires medical or mental health care." Although the SP drug the VA on the concrete which caused injury to the VA given that the injury that the VA sustained was checked by the facility nurse and determined that no further care was needed, that the SP was moving the VA out of the way of a bus that would be soon arriving and the VA would not stand, and that the SP was the only staff person working, it was determined that the SP’s actions were an error in the provision of therapeutic conduct. This error in the provision of therapeutic conduct to the VA by the SP was not maltreatment. It was determined that neglect did not occur (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). Action Taken by Facility: The facility completed and internal review and found that their policies and procedures were adequate but were not followed by the SP. The SP no longer worked at the facility. The VA was transferred to another bus that had a wheelchair lift for the VA to utilize. Action Taken by Department of Human Services, Office of Inspector General: The SP was not substantiated as a perpetrator of maltreatment of the VA because the Department of Human Services found that the incident for which the SP was responsible met the criteria to be determined an error. The SP was notified by the Office of Inspector General that any future incident of possible neglect of a vulnerable adult for which the SP is responsible might not be considered an error.
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