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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.”
1069140-HCBS (Home and Community-Based Services) Investigator(s): Scout Peterson Suspected Maltreatment Reported: Allegation One: It was reported that when a supervisory staff person (SP) took a vulnerable adult (VA) for a drive, the VA pulled the SP’s hair. In response, the SP stopped the car at a gas station, got out, went to the back where the VA was sitting, and pulled the VA’s hair taking out a piece of hair from the VA’s head. The SP then went the gas station leaving the VA in the locked car while it was running. Allegation Two: It was reported that the SP was “dismissive, disrespectful, and intimidating” towards the VA. Allegation Three: It was reported that the SP took the VA’s cell phone. Date of Incident(s): Allegation One: May 7, 2025 Allegation Two: Ongoing Allegation Three: Unknown 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); and subdivision 9, 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 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. In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property 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 June 2, 2025; from documentation at the facility and law enforcement records; and through six interviews conducted with two supervisory staff persons (P1 and P6), the VA, the VA’s guardians (G1 and G2), and a staff person from the VA’s day program (D. Arrangements were made in-person and via phone twice to interview P2, however, P2 did not answer the phone at either scheduled time; P2 provided information for the facility’s Internal Review that was included below. Attempts were made via certified mail, phone, and email to contact and interview the SP; however, the SP did not respond to this investigator’s requests. The SP provided information for the facility’s Internal Review which was included below. The VA was diagnosed with mild developmental disability, pervasive development disorder, anxiety, obsessive compulsive disorder, vision and hearing loss, and had a heart condition. The VA enjoyed shopping, spending time with his/her family, and liked taking care of babies. The VA received 15 hours per day of 1:1 individualized home supports with training and 9 hours per day of night supervision. The VA lived alone independently in the community lived alone. The VA’s Individual Abuse Prevention Plan stated that the VA was susceptible to physical and verbal abuse and financial exploitation. Staff were to be within visual or auditory range of the VA unless s/he was utilizing his/her one hour of alone time at his/her home. The VA had no unsupervised time in the community and was unable to self-manage in the area of community survival skills due to his/her history of physical aggression and verbal abuse towards others and property. The VA’s Self-Management Assessment stated that the VA had a history of pulling hair and kicking others. Staff were required to verbally prompt the VA to discontinue the behavior and offer an alternate activity or a change in his/her environment. The VA’s Coordinated Services and Supports Plan stated that the VA’s designated shopping day was Wednesday and that it was “very important” to the VA that s/he was able to go shopping on that day. The VA “threw fits” when s/he did not get something that s/he wanted but was “quick to get over it and apologize.” Consistency was also important to the VA, and s/he liked to know ahead of time any changes to his/her schedule. The facility’s Provider Attestation Policy stated that staff persons must support people’s freedom to control their own schedule and activities. The SP and P1 were each trained on the Reporting of Maltreatment of Vulnerable Adults Act, the VA’s plans, and the facility’s policies and procedures. Facility documentation also showed that staff persons were trained to ensure that clients were treated with “dignity and respect.” Relevant Rule and/or Statute Minnesota statutes 245D.07, subdivision 1a, paragraphs (a) and (b), states in part that the license holder must provide services in response to the person’s identified needs, interests, preferences, and desired outcomes as specified in the support plan and the support plan addendum and services must be provided in a manner that supports the persons’ preferences, daily needs, and activities and accomplishment of the person’s personal goals and service outcomes. Minnesota Statutes, 245D.04, subdivision 3, paragraph (a), clause (6 and 15) stated in part that the VA had the right and to be treated with courtesy and respect and engage in their chosen activities. Allegation One: It was reported that when the SP took the VA for a drive, the VA pulled the SP’s hair. In response, the SP stopped the car at a gas station, got out, went to the back where the VA was sitting, and pulled the VA’s hair taking out a piece of hair from the VA’s head. The SP then went the gas station leaving the VA in the car while it was running and locked. The VA stated that on May 8, 2025 [later determined to be Wednesday, May 7, 2025], the VA asked the SP to take him/her shopping. The SP was “mad,” and did not want to take the VA shopping, but took the VA for a car ride instead. The VA sat directly behind the driver’s seat while they were in the car. The VA said s/he pulled the SP’s hair while they were in the car, and the SP then stopped the car and pulled the VA’s hair “hard.” The VA could not recall specific details of the additional stops as they drove, however, at one point during the ride the SP pulled the car over, locked the doors, left the car running, and did not let the VA out of the car while the SP went into a gas station. The VA stated that the SP refused to take the VA home until s/he “calmed down.” The VA showed this investigator how to unlock the car and open the door. G1 and G2 each stated that on an unknown date, the VA told G1 and G2 that on May 1 or 2, 2025, [later determined to be May 7, 2025] the SP took the VA on a car ride. While the VA was in the back seat s/he reached up and pulled the SP’s hair. The SP then turned into a gas station, got out of the car, opened the back door to the car where the VA was sitting, and pulled the VA’s hair. The SP then shut the door, locked the doors with the car running, and went into the gas station leaving the VA inside the car. G2 also stated although the VA’s care plan stated that his/her designated shopping day was Wednesday, G2 noticed that the SP did not always take the VA shopping on Wednesdays. When G2 asked the SP about it, the SP told G2 that s/he did not shop with other clients and therefore would not do so with the VA. P1 provided the following information: · On May 7, 2025, around 2:30 p.m., the SP texted P1 and said that s/he was going to be late to his/her shift at the VA’s house and that even though it was the VA’s designated shopping day, the SP was not going to take the VA shopping. P1 told the SP that s/he needed to take the VA shopping unless “significant behavioral concerns” were present, and the SP responded saying that s/he was not going to do so. · Later the same day, between 4 and 5 p.m., P1 received “several” calls from the SP but s/he could not answer the calls at the time. P1’s significant other (SO), who also worked for the facility, was with P1 and answered one of the SP’s calls. The SP told the SO that the VA was “agitated” and pushed the SP. The SO then went to the VA’s house and gave the SP a soda to give to the VA as a “calming strategy.” P1 went to the facility shortly after his/her SO, and let the SP go home. P1 worked the rest of the SP’s shift until the night staff person arrived at 10 p.m. but did not ask the VA any questions about what happened earlier that day. · The next day, P1 took the VA to an appointment. On the way to the appointment, the VA pointed out a gas station parking lot and told P1 that the day before, the SP locked the VA in the car there. At that time, P1 did not ask the VA any further questions about the incident. After the VA’s appointment, P1 reviewed the SP’s log notes from May 7, 2025, which showed that the SP pulled over three times while driving due to the VA’s “behavior.” P1 stated that according to the log notes, 23 minutes past between when the SP clocked into work and when the first behavioral incident was documented. Later that day, P1 asked the VA what happened before the SP locked him/her in the car and the VA said that the SP pulled his/her hair and put his/her hand above his/her forehead. P1 then called an administrative staff person (P3) and told him/her what the VA said. · On May 12, 2025, P3 called P1 and told P1 that s/he met with both the VA and SP, and the VA and SP each claimed that the other pulled their hair so s/he was going to search the VA’s car for hair. P1 told P3 that if any hair was found, s/he would be able to tell whose hair it was because the SP and VA each had very different lengths, colors, and textures of hair. Later that day, the VA and P1 went to the facility office and met with an administrative staff person (P4) and a facility licensed practical nurse (LPN). The VA told P1, P4, and the LPN that the SP pulled his/her hair above his/her forehead, but they did not examine the VA at that time. · Later that day, P1 received another call from the P3 who said that s/he found a “clump” of hair in the back seat of the car that matched the VA’s hair length, color, and texture. P1 then called the facility nurse (LPN) to report the P3 found. The LPN said s/he would go to the VA’s house and examined his/her head. Later, P1 received a call from the LPN who said that after looking at the VA’s head, s/he saw that the VA was missing hair loss above his/her forehead, where the VA stated that the SP pulled his/her hair. The LPN also told P1 that were no other injuries or broken skin was visible. P1 stated that the VA was “never self-injurious,” and had a history of pulling other people’s hair but not his/her own. The SP provided the following information for the facility’s Internal Review: · On May 7, 2025, the VA requested to go shopping with the SP. The SP said s/he explained to the VA that it would be “faster” if s/he went alone and that the SP would purchase what the VA needed during the VA’s unsupervised time. The SP then took the VA for a car ride and told the VA that if s/he “calmed down” the SP would take him/her shopping. As the SP drove the car, the VA pulled the SP’s hair, kicked him/her, threw things in the car, and shouted “inappropriate names” at the SP. The SP pulled over three times for two to three minutes each, exited the car, and attempted to deescalate the VA from outside the car by speaking to him/her through the window. The SP denied pulling the VA’s hair or lock him/her in the car. The SP stated that s/he did not know how the VA’s hair got into the back seat of the car. · The SP stated that staff persons “sometimes” completed shopping for the VA without the VA and that although staff “typically” planned shopping with the VA, the SP “opted” to go alone to “avoid potential disruptions.” The SP added that the VA often requested to purchase “unplanned” items and if the SP denied the VA, it could “trigger outbursts.” The Daily Log Notes completed by the SP, on May 7, 2025, stated that the VA was in a “bad mood” when the SP arrived at the VA’s home. The VA was “visibly upset” because s/he was “unable” to go grocery shopping and expressed his/her frustration by swearing and “becoming increasingly agitated about the missed trip.” The SP took the VA on a car ride to attempt to deescalate the VA. The SP had to stop three times because the VA was “unable to keep [his/her] hands to [him/herself]” and pulled the SP’s hair. The SP and the VA returned to the VA’s home and the VA yelled and swore at the SP outside. The VA remained in a “heightened state” for approximately four hours until s/he fell asleep. The facility’s Internal Review provided the following information from P2, P4, P3 and a staff person (P5): · P4 stated that on May 12, 2025, the VA went to the facility office with P1 to meet with P4 and the LPN. The VA stated that the SP pulled the VA’s hair and locked the VA in the car while s/he went into a gas station. · P5 stated that on May 7, 2025, the VA came to his/her house after the incident and was “visibly upset.” The VA showed P5 a spot on his/her head where s/he said his/her hair was pulled. P5 called P2 for “guidance,” and then called P1. · P2 stated that on May 7, 2025, P5 called him/her and said that the VA came to his/her house, said his/her hair was pulled, and that the VA indicated to an area on his/her head. The next day, the VA told P2 that the day before the SP pulled his/her hair while they were in the car. · On May 12, 2025, the P3 found a “small clump of hair” in the back seat of the VA’s car that was consistent with the VA’s length of hair and inconsistent with the SP’s length of hair. The VA told P3 that s/he pulled the SP’s hair and the SP pulled his/her hair back. The SP denied pulling the VA’s hair. A law enforcement report provided the following information: · On May 7, 2025, at approximately 3 p.m. the SP pulled the VA’s hair and locked the VA in the car and that a “clump” of the VA’s hair was found in the back seat of the VA’s car. When a law enforcement officer (LEO) spoke with the SP about the allegations, s/he said s/he did not understand “what the big deal was.” The SP told the LEO that she took the VA for a car ride to calm the VA and had to stop the car because the VA was pulling the SP’s hair. The SP denied pulling the VA’s hair. The VA told the LEO that the SP was “mean” and that s/he locked the VA in the car. The VA also told the LEO that when they were outside of the gas station, the VA pulled the SP’s hair and then the SP pulled the VA’s. Although the LEO forwarded the information to the City Prosecutor’s Office for a criminal charge of assault of the VA by the SP, they declined to prosecute the SP. · Two photographs were identified as being the hair found in the backseat of the car by P3. The photographs showed two separate tufts of hair (approximately 20 strands) that appear to be consistent with the VA’s hair length, color, and texture, however, this investigator was unable to meet the SP in person to observe his/her hair. Conclusion for Allegation One: The VA’s Coordinated Services and Supports Plan stated that the VA’s designated shopping day was Wednesday and that it was “very important” to the VA that s/he was able to go shopping on that day. Consistency was also important to the VA, and s/he liked to know ahead of time any changes to his/her schedule. Information provided by P1, the VA, and G2 and the SP for the Internal Review was consistent that the SP did not take the VA shopping as outlined in the VA’s plans which was a violation of the VA’s plans and violation of Minnesota Statutes, section 245D.07, subdivision 1a, paragraphs (a) and (b), and section 245D.04, subdivision 3, paragraph (a), clause (15). The VA provided inconsistent dates, but consistent information to this investigator, G1, G2, P1, P2, P5, the LPN and the LEO that the SP pulled his/her hair. The VA told this investigator, G1, G2, P1, and the LEO that the same day the SP pulled his/her hair, s/he left the VA in a car unsupervised and went into a gas station. Regarding physical abuse: Information obtained showed that on May 7, 2025, there was an interaction between the VA and the SP while they were in the car. The SP said s/he took the VA on a car ride to help him/her “calm down,” but denied in the Internal Review that s/he pulled the VA’s hair and said that the VA pulled the SP’s hair. The VA provided consistent information to this investigator, G1, G2, P1, P2, P5, the LPN and the LEO that the SP pulled his/her hair. Information including two photos showed that hair was found in the backseat of the car that was consistent with the VA’s hair length, color, and texture. Although the SP denied pulling the VA’s hair, given that the VA provided consistent information about the SP pulling his/her hair to multiple persons on multiple occasions, that hair found in the back seat was consistent with the VA’s, and that there was no information provided that that VA had a history of pulling out his/her own hair, it was more likely that the VA’s account was more credible. Therefore, there was a preponderance of the evidence that the SP’s actions of pulling out the VA’s hair was not accidental or therapeutic conduct and would be reasonably expected to produce physical pain or injury. It was determined that 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.) Regarding neglect: The SP did not provide information for this report and although the SP denied locking the VA in the car, the SP did not provide additional information in the Internal Review regarding whether s/he left the VA unsupervised in the running vehicle when s/he went into the gas station. The VA provided consistent information about being left unsupervised in the car and the VA’s plans say that the VA had no unsupervised time in the community so the SP leaving the VA unsupervised in the car was a violation of the VA’s plans and a violation of Minnesota statutes 245D.07, subdivision 1a, paragraphs (a) and (b). However, it was a single incident, for which the car was locked to preventing any person from entering and the VA was able to open the doors in the event of an emergency. In addition, it was unknown how long the VA was in the car unsupervised, but it was most likely only a few minutes, and the VA was not harmed as a result of being in the car. Therefore, there was not a preponderance of the evidence whether there was a failure or omission to supply the VA with reasonable and necessary care. 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). 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 trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans. The SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: See Conclusion for Allegation Two, Part C. Allegation Two: It was reported that the SP was “dismissive, disrespectful, and intimidating” towards the VA on multiple occasions. The VA told this investigator that that the SP called him/her a “fucking bitch,” but could not remember when. The VA stated that s/he did not know what caused the SP to call her that or what led up to it but stated that it made him/her feel “sad.” The VA said that s/he never told anyone that the SP called her a “fucking bitch.” The VA could not remember other times that the SP called him/her names. The D stated that s/he provided transportation for the VA to and from the day program and had concerns with the way the SP interacted with the VA. On the days the SP worked with the VA, the VA was “very agitated and on edge” which was different than his/her demeanor on days that another staff person worked with the VA. The D noticed that the SP was “impatient” with the VA and “occasionally” called the VA names. The D could not remember the names the SP called the VA. The D recalled a specific incident where the VA exited the home “agitated,” the SP followed the VA and was on the phone with an unidentified person and told the person, within earshot of the VA, that the VA was a “snot,” a “brat, and “snobby.” G1 and G2 provided the following information: · On separate unknown dates, the D told G1 and G2 that the SP treated the VA “poorly” and that the SP was “rude” to the VA. G2 stated that the SP “intimidated” the VA when s/he was on the phone with G2 and/or G1 and told the VA s/he was “fake crying” or “lying” while on the phone. G1 overheard the SP tell the VA that s/he was the “boss” and the VA “couldn’t do anything about it.” · On an unknown date, the SP took VA to birthday party hosted by P2. After the party, P2 called G1 and told him/her “all of a sudden [the SP] stormed and told [the VA] ‘Get the fuck over here. We are leaving.’” The VA told the SP s/he did not want to leave, but the SP replied, “Get the fuck in the car. We are leaving now.” · G2 stated that from what P2 told them, the VA was “treated badly” in front of everyone at the party and was “very upset” afterwards. G2 added that “a number” of party guests told G2 that the SP was “rude” to the VA at the party. P6 stated that the SP was “verbally and mentally aggressive” with the VA and “talked crap” about the VA to others in front of him/her. P6 “always” worked at the VA’s house because s/he did not think the SP and VA were a “good mix.” P6 spoke to the SP about his/her concerns and had him/her apologize to the VA, but his/her behavior did not change. P6 then told P1 about his/her concerns regarding how the SP treated the VA but P1 promoted the SP to a supervisory position. P1 stated that s/he saw the SP work with the VA and did not have previous concerns about the way that the SP interacted with the VA. P1 stated that P2 called him/her and said that “the entire group” from the party wanted to make a report because of the way that the SP talked to the VA. P1 did not recall any report or any additional information other than what P2 stated when s/he called P1.
· P2 stated that “sometime in February or possibly January” 2025, P2 was on the phone with the VA and the SP and heard the SP call the VA a “bitch.” The SP then. muted the phone call for about five minutes, and when s/he unmuted the phone, P2 heard the VA crying in the background. In March 2025, the SP brought the VA to a birthday party that P2 hosted. During the party, P2 saw the VA standing by the table for cake and the SP “got in [the VA’s] face.” P2 heard the SP say to the VA, “We’re fucking leaving,” and told the VA that s/he could not have any cake. P2 attempted to deescalate the situation by offering the VA a slice of cake, and the SP responded, “No, we’re fucking leaving.” P2 said that the VA was not “acting out” and the VA repeatedly told the SP, “I’ll behave,” and “I didn’t mean to do anything wrong.” · P4 stated that an unknown community person who attended a birthday party that the VA and the SP also attended, had concerns regarding the SP’s tone of voice when speaking to the VA at the party and that the SP did not let the VA have a piece of cake at the party, even though P2 said it was okay. Facility documentation showed that on October 4, 2024, the SP received a written warning for “carelessness” and “insubordination.” The SP told the VA that two supervisory staff persons were “bitches,” which “visibly upset” the VA. Conclusion for Allegation Two: A. Maltreatment: Information provided by the VA, the D, G1, G2, and P6 and P2 via the Internal Review showed that on different occasions, the SP called the VA names including “fucking bitch” and “bitch,” and talked about the VA to others in front of the VA including saying that the VA was a “snot,” a “brat, and “snobby;” and that s/he was “fake crying” or “lying.” The SP did not provide information for this report. However, the SP’s actions as described by the VA, the D, G1, G2, and P6 and P2 via the Internal Review were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and were a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). Given the repeated nature of the SP’s verbal interactions with the VA that included calling the VA a “fucking bitch” and “bitch,” and talking about the VA to others in front of the VA including saying that the VA was a “snot,” a “brat, and “snobby;” and that s/he was “fake crying” or “lying,” there was a preponderance of the evidence that the SP’s action were not accidental or therapeutic conduct and that the SP engaged in repeated oral language that would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening and could reasonably be expected to produce emotional distress. It was determined that 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). 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: (2) 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; (3) 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 (4) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. 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 and emotional abuse for which the SP was responsible in this report was “recurring” and “serious” maltreatment. The SP was responsible for two incidents of maltreatment and pulling hair out of a head causes tissue damage. The SP was disqualified from providing direct contact services. Allegation Three: It was reported that the SP took the VA’s cell phone. The VA stated that s/he used to have a red cell phone but the SP “stole” it. The VA added that the SP “kept” his/her red phone and “never gave it back.” The VA did not have additional information regarding his/her phone. On an unknown date in early 2025, P2 told the SP to step away from the situation and encouraged the VA to use his/her alone time to calm. Later that day when P2 was working, the VA told P2 that the SP took his/her phone. When P2 asked the SP about the phone, s/he said the VA thew it and no one knew where it landed. The VA’s phone was never found. P1 stated that s/he did not know what happened with the VA’s cell phone. On an unknown date, the SP called P1 to say that the VA broke a lamp and shattered a light bulb. While P1 was on the phone with the SP, the VA was in the kitchen on the phone with G1. At some point, the SP stated that the VA threw his/her phone and later that day when P1 went to the house, s/he searched for the phone but did not find it. G1 thought that the SP took the phone, but there was no evidence that s/he did so. G1 and G2 each stated that on unknown date in 2025 the SP yelled at the VA which made the VA to “very upset” and the VA threw his/her cell phone at the SP. About a week later, G2 went to the VA’s house and the VA told him/her that s/he could not find his/her phone. G2 looked around the house and could not find the cell phone. G1 and G2 each thought that the SP took the VA’s cell phone because the SP had withheld the phone from the VA in the past The facility’s Internal Review stated that the SP denied taking the VA’s phone. The facility reimbursed the VA for the lost phone. Conclusion for Allegation Three: Information provided by the VA, G1, G2, P1, and P2 showed that in early 2025, the VA’s phone was missing and that the VA, G1, G2, and P1 “thought” that the SP took the phone. However, the Internal Review stated that the SP denied taking the VA’s phone and there was no additional information to support or refute whether the SP took the VA’s phone. Therefore, there was not a preponderance of the evidence whether the SP took the VA’s phone. It was not determined whether financial exploitation occurred (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. There was a need for additional staff training, and staff received additional training in behavioral de-escalation, conflict prevention, maintaining client dignity, and proper documentation of behavior support. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. On September 29, 2025, the facility was issued a Correction Order for the violations outlined in this report.
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