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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: 1070485-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070470-HCBS (Home and Community-Based Services) Investigator(s): Samantha Wueste 651-431-2278 Suspected Maltreatment Reported: It was reported that after a vulnerable adult (VA) displayed behaviors towards a staff person (SP), the SP responded by “punching” the VA in his/her jaw. Date of Incident(s): May 8, 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 subdivision2, paragraph (b), clause (1): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on May 22, 2025; from documentation at the facility and law enforcement records; and through five interviews conducted with two facility staff persons (the SP and P1), a supervisory staff person (P2), the VA’s guardian (G) who was also the VA’s family member, and the VA’s case manager (CM). The VA declined an interview but provided information to the CM and a law enforcement officer (LEO) that was included below. The facility was a split-level home located in a rural area, where the VA lived with three housemates (H1-H3). The facility’s front door led directly into an entry way with access to a stairway leading to the upper level, a stairway leading to the lower level, and an attached garage that was to the right of the front door and contained a staff office. The upper level had a kitchen, a living room, a dining room, a bathroom, and three client bedrooms that included H1’s, H2’s, and the VA’s bedrooms. The staircase to the lower level led directly into a common area, with H3’s bedroom located to the left of the staircase. To the right, there was a medication room, a bathroom, and a second staff office. The medication room and staff offices were only to be accessed by staff persons and kept locked when not in use. Additionally, keys to the client bedrooms were located in the medication room which included a key to the VA’s bedroom. The VA enjoyed listening to and making music, graphic design, and spending time with his/her family members. The VA’s diagnoses included major depressive disorder, generalized anxiety disorder, fetal alcohol spectrum disorder, attention deficit hyperactivity disorder, moderate intellectual disabilities, and encephalopathy (a broad term for any disease, disorder, and/or damage that alters brain function or structure). On August 5, 2024, the VA moved into the facility seeking supports and services relating to his/her diagnoses that included health and behavior management, community integration, developing independent living skills, and maintaining sobriety. The VA had 1:1 staffing during daytime hours and staff persons were to remain within auditory distance when the VA was present within the facility. The VA’s Coordinated Service Plan Addendum, Self- Management Assessment, and Individual Abuse Prevention Plan dated August 2024; the VA’s Crisis Plan dated September 9, 2024; and the VA’s Support Plan dated October 10, 2024; and the VA’s Supports and Outcome Methods updated May 19, 2025, provided the following information: · The VA had a history of self-injurious behaviors; substance abuse; verbal aggression that included “screaming, swearing, and threatening” others; physical aggression that included “intentionally hitting, kicking, grabbing, punching, and pushing” others; property destruction and throwing objects; and manipulative behaviors that included “bullying,” “coercing” others into giving the VA what s/he wanted, and using “threatening and intimidating language” for “personal gain.” Additionally, the VA had a “temper” and “at times” communicated his/her “emotions and frustrations” in a manner that was verbally and/or physically abusive towards others. · The VA also had a history of being involved in incidents of physical aggression that resulted in the response of law enforcement (LE), hospitalizations, and/or legal repercussions. The VA did not like to be told “no” to his/her “requests” or to be asked to complete daily activities that s/he did not want to do which then caused the VA to become “agitated” and engage in maladaptive behaviors. During situations when the VA was verbally/physically aggressive, staff persons were to remain “calm” and “neutral” while attempting to “redirect,” “de-escalate,” or “resolve” the situation by providing the VA with verbal prompts, coping strategies, “options” to problem solve, and “calming” activities that included allowing the VA time alone in his/her bedroom to “cool down” on his/her own. Additionally, staff persons were to contact emergency services if the VA’s behaviors were “harmful” to the VA, other facility clients, and/or staff persons. · In managing the VA’s health conditions and behaviors, the facility provided the VA with a “calm” environment, “clear expectations,” “adequate” time to process information, and the ability to make “choices” that would help the VA develop the daily life skills needed to “safely” and “successfully” live independently in the future. The VA was encouraged to make “safe” decisions, build “healthy” coping strategies, use “appropriate” communication skills, and “learn self-control.” Furthermore, the VA “liked to feel in control” and therefore, staff persons were to “avoid” particular words, body language, and “confrontational” situations that might lead to a “power struggle” when communicating with the VA. In addition to the care and supports provided by the facility, the VA also received mental health services, individual therapy sessions, community resources and support, and daily medications that included psychotropic medications (which treat mental health conditions and control, alter, and/or affect mental processes, emotions, and behavior). The SP, P1, P2, the VA’s T-Logs and Behavior Intervention Reporting Form, and the facility’s Incident Report and Internal Review provided the following information: · On May 8, 2025, the SP and P1 worked at the facility during the morning shift. At approximately 7:15 a.m., the SP knocked on the VA’s bedroom door “several times” but the VA did not open the door or respond to the SP. The VA’s bedroom door was locked so the SP tried to talk to the VA through the door to “remind” the VA that s/he needed to wake up, get dressed, take his/her morning medications, and eat breakfast prior to leaving the facility for a medical appointment that the VA had scheduled later that morning. The SP knocked on the VA’s door “a couple more” times but despite the SP’s “repeated” attempts to communicate with the VA and assist the VA with managing his/her care needs, the VA did not unlock or open his/her bedroom door and continued to “ignore” the SP. The SP then walked away from the VA’s bedroom door to provide the VA the “time, space, and opportunity” to make “responsible” decisions as directed by the VA’s care plans. · At approximately 7:25 a.m., the SP went back to the VA’s bedroom and knocked on the door but the VA still did not respond to the SP. To ensure the VA’s health and safety, the SP then went to the staff office located on the lower level, got the VA’s bedroom door key, and returned to the VA’s door where P1 was waiting for the SP. The SP then attempted to talk to the VA through the door and told the VA two times that staff were going to “enter” his/her bedroom. The SP then unlocked and opened the VA’s door and stood in the VA’s doorway with P1. The VA was “very agitated,” used “foul language,” and “yelled” at the SP to “get out” of his/her bedroom and to “close the door.” The SP told the VA that s/he was “sorry” but reminded the VA that s/he had an appointment that morning and that the VA needed to take his/her medications and eat breakfast before leaving the facility. The VA told the SP that “[the VA] did not care” and to “get the fuck out of [the VA’s] room.” The SP then closed the VA’s door and the SP and P1 walked away from the VA’s bedroom and down the stairs to the entryway towards the lower level to return the VA’s bedroom key to the medication room. · Shortly after the SP and P1 entered the lower level’s common area, they heard the VA “following” the staff to the lower level while “swearing” and being “verbally abusive” towards the SP. While the SP was returning the key, the VA entered the lower level “very upset” and walked towards the SP while “yelling” and “screaming” that “someone was going to get fucked up.” P1 stated that the VA had a history of physical aggression towards staff that included a prior incident when the VA “threatened” to “throw hot grease” on P1 and because of this prior incident, P1 “chose flight not fight” and “got out of the way” so that s/he would not be “hurt” by the VA who continued to walk towards the SP. · After the SP put the key away and locked the door to the medication room, the SP was “scared” for his/her safety and walked towards the staff office but was “approached” and “cornered” by the VA before the SP could unlock and enter the office. The SP tried to “back away” from the VA but the SP was “blocked in […] against the wall” and unable to “get away” from the VA. The VA then told the SP that s/he was going to “fuck [the SP] up” and “quickly charged” and “lunged” at the SP, “grabbed” the SP’s shirt with two hands, “pulled” the SP forward, “ripped off” the SP’s “work badge” that the SP wore on a lanyard around his/her neck, and “pushed” the SP “backwards.” The VA then “looked like [s/he] was going to harm” and “hit” the SP but the SP “quickly reacted” and “punched” the VA in his/her face before the VA was able to hit the SP. The VA then “backed up,” grabbed a chair that was nearby, started to “swing it around like crazy,” and said that s/he was “going to kill” the SP. At some point during this time, the VA was going to “throw” the chair at the SP, but the SP was able to “grab” onto the chair and told the VA to be “done.” The SP then told P1 that s/he “did not know what else to do” and P1 then tried to “diffuse” the situation by telling the SP and the VA, “Let’s just calm down.” The VA “listened” to P1 and put the chair down and P1 told the SP to go into the office and call 9-1-1. The SP immediately walked away from the VA, went into the office, locked the door, and called 9-1-1 while P1 and the VA walked up the stairs to the entryway and exited the facility to go outside, “calm down,” and wait for LE to respond to the situation. Approximately 30 minutes later, the LEO arrived at the facility and spoke with the VA, P1, and the SP about the incident from each perspective, respectively. At some point during this time, the SP also called P2 to notify supervisory staff persons about the incident and that LE was contacted. · The SP and P1 provided consistent information that the incident was approximately five minutes long and that the SP’s actions were “quick reactions” and “protective instincts” of “self-defense” after being “cornered” and physically “attacked” by the VA. Additionally, the VA had a history of verbal and physical aggression towards staff and multiple incidents where staff persons had to unlock the VA’s bedroom door using the facility’s keys to ensure the health and safety of the VA. Despite the VA’s history of being involved in similar incidents prior to this, P1 and P2 were not aware of any prior concerns regarding the SP’s interactions with clients which included the VA. Staff persons were not aware of any injuries that the VA received as a result of the incident. LE records provided the following information: · On May 8, 2025, at 7:33 a.m., the SP called LE to provide information on an incident involving physical aggression by the VA towards facility staff persons. The call was then dispatched to the LEO who arrived at the facility shortly thereafter. Upon arrival to the facility, the LEO observed the VA and P1 standing in the facility’s driveway and went to talk to each, respectively. According to the VA, the SP entered his/her bedroom at approximately 7 a.m. to wake the VA because the VA had an appointment scheduled for 9 a.m. The VA told the LEO that s/he was “very upset” that the SP entered his/her bedroom because the VA “could have been […] sleeping naked when staff came in for no reason.” Shortly after this, the SP entered the VA’s bedroom for a second time “to get [the VA] out of bed” which then resulted in “an argument” between the SP and the VA. The VA then “grabbed the keys” that were “around [the SP’s] neck” and after doing so, the SP started to “throw punches” at the VA. The VA did not receive any injuries as a result of the incident. · After talking with the VA, the LEO entered the facility to talk with the SP. The SP told the LEO that earlier that morning, the SP unlocked the VA’s bedroom door after attempting to wake the VA for an appointment and had “announced” that staff would be entering the VA’s bedroom before opening the VA’s door. After this, the VA became “very irate” towards the SP, so the SP shut the VA’s door and walked away from the VA’s bedroom while the VA “yelled” at the SP from inside the room. Shortly after this, the SP went back to the VA’s bedroom but the VA began “screaming obscenities” at the SP and being “very verbally aggressive” towards the SP. The SP then walked away from the VA’s bedroom to the lower level but was “followed” by the VA. Shortly thereafter, the VA “pushed” the SP and “grabbed” the SP’s lanyard that contained the SP’s “[work] ID.” At this time, the SP started “throwing punches towards [the VA]” in “self-defense” while the VA attempted to “throw punches back.” The VA then “backed up,” “picked up” a chair, and started to “swing it” at the SP. · After talking with the SP, the LEO then talked to P1 who told the LEO that the VA had been involved in similar incidents prior to this and was “physically violent toward staff throughout the house” which included threats of physical violence towards P1. Shortly after the LEO talked with P1, P2 arrived at the facility and the LEO provided P2 with contact information and a case number assigned to the call so that P2 could update LE with additional information if needed. The LEO then left the facility at approximately 8:35 a.m. The LEO did not take further action. The G and the CM provided the following information: · The VA “loved” listening to rap music, writing his/her own rap songs, and participating in activities that involved animals. The VA “wanted” to live independently “as possible” but due to the VA’s diagnoses and history, the VA “struggled” with managing his/her behaviors and chemical health, decision making, and “keeping [his/her] cool.” The VA also had a history of verbal and physical aggression but “tended” to be “more verbally aggressive and destructive of property than physically aggressive towards people.” For “the most part,” the VA was considered an accurate reporter of information or “tried” to be but “sometimes” the VA would not “tell the truth” if the VA was “scared of getting in trouble.” · The G and the CM were each aware of the incident and notified by the facility, respectively. Information the CM provided to this investigator was consistent to the information that was provided by LE records, staff persons, and facility documentation. Additionally, the VA told the CM that s/he responded when staff persons knocked on the VA’s bedroom door to wake him/her, but staff did not hear him/her and then used a key to unlock and enter the VA’s bedroom “without permission.” This made the VA “mad” because the VA “felt [his/her] privacy was violated” which resulted in the VA “wanting” to then “make [the SP] mad” in return. When the VA “grabbed” the SP’s lanyard, the VA’s “intent” was not to cause the SP physical harm, but the VA’s behavior resulted from the VA’s “perspective” of “if you make me mad, I’ll make you mad.” The SP “punching” the VA, hurt the VA even though the VA did not have any visible and/or physical injuries. After the incident, the VA’s mental health and behaviors “downward spiraled” and impacted the VA’s “perspectives” of the staff and care that the facility provided to the VA. · Prior to the incident, the G and the CM did not have any concerns involving specific staff persons but had general concerns with the care the facility provided to the VA that included staff knowledge, experience, and/or ability to provide a level of care that was needed when working with clients who had similar diagnoses, care needs, and history to that of the VA. There were also concerns regarding how staff persons managed and responded to the VA’s behaviors that included staff ability to effectively de-escalate situations involving the VA. According to the facility’s Program Abuse Prevention Plan updated March 7, 2025, staff persons were to use “therapeutic intervention procedures,” “negotiation techniques,” and follow client care plans to “de-escalate” client behaviors that were verbally and/or physically aggressive. If a client’s mental health and/or behaviors posed an imminent risk of physical harm to him/herself or others, staff persons were to contact emergency services for assistance in responding to and resolving the situation. The facility’s policy on the Service Recipient Rights stated that clients had a right to be free from maltreatment and to live without the fear of abuse and neglect. Additionally, clients were to have services and supports provided to them that were identified in their plans in a manner that respected clients as individuals and took into consideration the person’s preferences. Clients were to be treated with courtesy and respect. Facility documentation showed that the SP, P1, and P2 received training on the VA’s care plans; the facility’s policies and procedures, including the Program Abuse Prevention Plan and the Service Recipient Rights; and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rules and/or Statutes: Minnesota Statutes, section245D.04, subdivision 3, paragraph (a), clause (6) state that a person’s protection related rights include the right to be treated with courtesy and respect. Conclusion: A. Maltreatment Information from all sources was consistent that during the morning of May 8, 2025, there was a physical interaction between the VA and the SP. From approximately 7:15 to 7:30 a.m., the VA became “very upset” with the SP after the SP used a key to unlock and open the VA’s bedroom door when attempting to wake the VA. The VA then engaged in verbal and physical aggression towards the SP that included “yelling” at the SP, threatening the SP, and “grabbing” the SP by his/her shirt and “ripping off” the SP’s “work badge.” After the VA took the SP’s badge, the SP responded to the VA’s behaviors by “punching” the VA in his/her face. Although the SP stated that his/her response to the VA’s behaviors was “self-defense,” the SP’s action of “punching” the VA in the face was inconsistent with the VA’s support plans, the facility’s policies and procedures, and with the standards of a professional caregiver in a facility licensed by the Minnesota Department of Human Services, and were a violation of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6). Although the VA was not injured as a result of the punch, given that the SP provided consistent information to LE, within facility documentation, and to this investigator that the SP “punched” the VA in his/her face, there was a preponderance of the evidence that the SP’s conduct was not accidental or therapeutic and could be expected to produce physical pain. 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). B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. At the time of the incident, the SP was responsible for the care of the VA. The SP received training on the VA’s plans; the facility’s policies that included the Program Abuse Prevention Plan and the Service Recipient Rights; and on 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 abuse for which the SP was responsible was not recurring or serious maltreatment. It was a single incident for which the VA did not sustain a serious injury. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate but not followed by the SP. After the incident, the SP was retrained on all facility policies and no longer worked with the VA. 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. Given that the facility took immediate corrective action a correction order was not issued for the violations outlined above.
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