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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: 1070488-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Elisa Montgomery 651-431-6474 Suspected Maltreatment Reported: It was reported that on June 6, 2025, a staff person (SP1) was observed punching a vulnerable adult (VA) on his/her arms and that on June 7, 2025, two staff persons (SP1, SP2) drug the VA an unknown distance and left the VA without his/her wheelchair for an unknown period of time. Additional concerns regarding administering additional medications to the VA were also reported. Date of Incident(s): June 6 and 7, 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 June 23, 2025; from documentation at the facility and medical records; and through eight interviews conducted with facility staff persons (SP1, P1-P4), the VA’s guardian (G), and the VA. SP2 agreed to meet at the facility but then declined, was contacted via phone on two attempts that were unsuccessful, and was contacted via phone at the facility but declined to provide information related to the incidents. The VA liked to gamble, go out into the community, and go out to eat. The VA was diagnosed with a traumatic brain injury resulting in paralysis on the left side of his/her body, anxiety, and depression. The VA utilized a wheelchair but was able to transfer him/herself in and out of the wheelchair with or without assistance from staff persons at times. The VA moved the wheelchair independently. The VA provided the following information: On June 6 and 7, 2025, the VA had been punched and dragged by staff person’s (SP1 and SP2). The VA went to the hospital on June 10 and 11, 2025, due to having bruises and scratches and it was found that s/he had fractured his/her back on an unknown date. Regarding the incident on June 6, 2025: The facility’s Behavioral Intervention/Emergency Use of Manual Restraint and Internal Review provided the following information: · On June 6, 2025, around 4:30 p.m., the VA was crying and saying, “No one loves [the VA] and cares about [him/her].” The VA was upset with P5, his/her parent, and that his/her hours at work were cut. The VA wanted to go to the casino and gamble and due to this, the VA was becoming increasingly emotional and physically aggressive toward staff (SP1, P1, P2). · The VA went outside and was in the driveway in his/her wheelchair. After 30 minutes, the VA went further down the driveway in his/her wheelchair and turned him/herself over in his/her wheelchair and was sitting in the yard. · P2 went outside and talked to the VA. The VA grabbed rocks from the driveway and put them in his/her mouth, spit them out, and began throwing them at P2. P2 backed away and gave the VA time to de-escalate. · 20 minutes later, staff was able to assist the VA with getting back into his/her wheelchair and back inside. Then the VA ate dinner. · Shortly after, the VA turned over a garbage can in a kitchen, tore cupboard doors off, tore parts out of a dishwasher and oven, attempted to burn him/herself on a stovetop, threw smaller kitchen appliances that were on counters at staff, and broke a coffee carafe resulting in shards of glass being accessible. · The VA was sitting in the kitchen with minimal clothing on and was threatening to cut staff if they attempted to intervene. Staff called 9-1-1 and law enforcement (LE) and paramedics arrived at the facility. The VA was assessed and transported to the hospital via ambulance. · No injuries were observed on the VA prior to him/her being transported to the hospital around 11:00 p.m., on June 6, 2025. P1 provided the following information: · On June 6, 2025, P1 was working at the facility and around 4:30 p.m., the VA went outside. P1 and P2 stayed inside to prepare dinner and SP1 followed the VA outside. P1 observed the VA outside by a tree for a while and at one point, the VA had tipped him/herself over in his/her wheelchair. P1 went outside and assisted SP1 with getting the VA back into his/her wheelchair and offered for the VA to come inside and the VA declined. SP1 remained outside with the VA. · Around 5:00 p.m., P1 went back inside and watched the VA from the window and observed that SP1 was standing outside with the VA but SP1 was on his/her cellphone and did not appear to be paying attention to the VA. The VA began to roll down the gravel driveway. When the VA’s wheelchair hit the grassy area alongside of the driveway, the VA and his/her wheelchair tipped over. SP1 did not look up from his/her phone and P1 and P2 went outside and talked to the VA. · When outside, P1 and P2 attempted to talk with the VA and offered to assist the VA with getting back into his/her wheelchair, the VA declined. After 20 – 30 minutes, P2 offered to bring the VA dinner outside but the VA declined and telling P1 and P2 to “get away” and threw rocks at P1 and P2. P1 and P2 went back inside and SP1 stayed outside with the VA. · The VA and SP1 came back inside, and the VA ate dinner. Around 9:00 p.m., the VA tipped over the garbage can in the kitchen and then tore cupboard doors off. The VA was threatening to hurt P1, P2, and SP1 with various broken objects. When the VA broke the coffee carafe, s/he was on the floor in his/her underwear threatening to hurt him/herself or others if they intervened. · Around 10:00 p.m., P1 was assisting the VA’s housemate and SP1 went into the kitchen to grab something. The VA was pulling at SP1 and attempting to cut SP1 with glass. SP1 was behind an island in the kitchen, and it looked like SP1 was punching the VA with a closed fist, six to seven times on his/her arm. P1 asked SP1 what was going on and told SP1 to get away from the VA. P1 could see SP1’s closed fist in a punching motion toward the VA’s arm but could not see SP1’s fist contacting the VA’s arm. · During that time, LE had already been contacted and LE and paramedics arrived shortly after and assessed the VA and transported the VA to the hospital. · P1 did not work at the facility until days later and observed several bruises on the VA’s left arm where SP1 had punched the VA. The VA told P1, “That’s where [SP1] hit me”. The VA did not make any other comments regarding the incident to P1. · P1 did not have concerns with SP1 hurting the VA or housemates prior but did not like that SP1 appeared “absent” and “disengaged” when working at the facility. SP1 spent most of his/her time on his/her phone compared to time engaging with the VA or his/her housemates. P2 provided the following information: · On June 6, 2024, P2 was working at the facility. Around 4:30 p.m., the VA went outside in his/her wheelchair and SP1 went outside with the VA. P2 observed that the VA was upset when s/he went outside and tried to talk to the VA for about 20 minutes. The VA did not want to go inside for dinner and wanted to remain outside. · P2 went outside again to talk to the VA and SP1 seemed to get upset and tell P2 that the VA was acting that way for “attention” and P2 insisted that they help de-escalate the VA’s heightened emotions. The VA began to throw rocks at P2 and P2 went back inside. SP1 remained outside with the VA. · P2 observed SP1 outside standing by a tree on his/her phone and the VA was in his/her wheelchair. The VA’s wheelchair started going down the driveway and SP1 remained by the tree on his/her phone. The VA hit a rock or another object and fell out of his/her wheelchair into the grass along the driveway. SP1 brought the VA into the facility after getting the VA back into his/her wheelchair and the VA ate dinner. · Around 9:00 p.m., the VA tipped over the garbage can in the kitchen and then tore cupboard doors off. The VA was threatening to hurt P1, P2, and SP1 with various broken objects. When the VA broke the coffee carafe, s/he was on the floor in his/her underwear threatening to hurt him/herself or others if they intervened. · P2 was downstairs around 10:00 p.m. and did not see SP1 punch the VA in his/her left arm but was told by the VA on June 10, 2025, that SP1 had punched the VA and that on June 7, 2025, SP1 and SP2 had drug the VA. · P2 observed three large bruises on the VA’s left arm on June 10, 2025. P2 noted that SP1 and SP2 did not typically engage with the VA or housemates unless it was necessary. P3 provided the following information: · P3 arrived at the facility on June 6, 2025, around 11:00 p.m., and was informed by SP1 that the VA was transported to the hospital. SP1 remained at the facility and was the asleep overnight staff person. SP1 did not share with P3 in detail about the events that had occurred prior to P3 arriving at the facility. · The VA returned to the facility from the hospital around 2:00 a.m. and went to his/her bedroom and went to sleep. Around or a little after 8:00 a.m., the VA woke up. P3 was assisting the VA in the restroom and when P3 was assisting the VA with standing and when P3 grabbed the VA’s left arm, the VA screamed. P3 asked the VA if s/he was okay, and the VA responded that SP1 had punched him/her. · P3 did not see bruises on the VA’s arms because the VA was wearing a t-shirt but P3 did see scratches on the VA’s back in the morning on June 7, 2025. · After helping the VA to the bathroom, the VA was in the living room and had begun “pulling stuff down.” P3 instructed one of the VA’s housemates to leave the living room because the VA was hitting his/her housemate. SP1 was outside on his/her phone at that time and P3 went outside to inform SP1 that the VA was hitting his/her housemate. · P3 and SP1 attempted to go back inside the facility through the front door but the VA had locked the door. P3 and SP1 used the basement patio door to enter the facility. P3 and SP1 started to block the VA from grabbing items and objects off the kitchen counters. · The VA continued to attempt to throw items at P3 and had undressed him/herself and pulled the vent cover off the living room floor and was attempting to hit P3 with the vent cover. P3 was able to get the vent cover from the VA. · Around 9:00 a.m., P4 and SP2 arrived at the facility and P3 left the facility. SP1 remained at the facility with P4 and SP2. LE records provided the following information: LE received a call on June 6, 2025, and a medical unit (paramedics) was called in addition to LE. The VA had minor cuts on his/her arms and legs and the VA made “suicidal comments” and was transported to the hospital via ambulance. Video footage that was recorded on a cell phone and shared with this investigator showed SP1 outside with the VA. The VA was in his/her wheelchair and SP1 was behind the VA, attempting to push the VA up the gravel driveway. The VA was holding onto his/her wheels of the wheelchair so SP1 was not able to push the VA up the gravel driveway. SP1 stepped away from the VA and was on his/her cellphone and the VA began to roll down the gravel driveway. SP1 did not move toward the VA or attempt to stop the VA from rolling away. The VA hit an unknown object on the side of the gravel driveway and fell sideways out of his/her wheelchair. When the video ended, SP1 had not moved and was still looking at his/her cellphone. SP1 provided the following information: · SP1 worked at the facility on June 6, 2025, during the time that the VA was outside in the driveway and had fallen out of his/her wheelchair. SP1 was also attempting to assist P1 and P2 with de-escalating the VA when s/he was in the kitchen throwing small kitchen appliances at them. · SP1 recalled that the VA was “naked” on the kitchen floor and was “rolling” in the broken glass and after this, the VA had “scratches all over” his/her body. 9-1-1 was called and LE and paramedics arrived at the facility around 11:00 p.m. · The VA returned to the facility on June 7, 2025, around 2:00 a.m. and during this time, SP1 was the asleep staff, and another staff person (P3) was awake and assisted the VA with getting to bed. · SP1 denied punching the VA in his/her arms but observed scratches and bruises on the VA’s body the following day (June 7, 2025). Regarding the incident on June 7, 2025: SP1 provided the following information: · On June 7, 2025, SP1 was working at the facility with the VA along with SP2 and P4. The VA wanted to go outside. SP1 was assisting the VA’s housemate with his/her shower and either P2 or SP2 went outside with the VA. · SP1 did not know what staff had come inside, but that staff said that the VA was going down the driveway and was getting close to the highway. · When SP1 went outside, the VA was in the grass and SP1, SP2, and P4 all carried the VA to his/her wheelchair and that they had “rescued” the VA. · SP1, SP2, and P4 were able to bring the VA into the facility and assisted the VA to his/her bedroom. The VA sat on his/her bed and P4 stayed with the VA in his/her bedroom. · SP1 did not drag the VA but was assisted by SP2 and P4 with carrying the VA to his/her bedroom. P4 provided the following information: · P4 arrived at the facility around 9:00 a.m. on June 7, 2025. SP1 and SP2 were outside on their phones when P4 arrived. P4 went inside the facility and observed the VA naked on the floor in the living room and P3 was holding a floor vent that the VA had removed from the floor. P4 took the floor vent from P3 and P3 left the facility. · The VA told P4 “over and over” that one of the overnight staff was “abusing” him/her and that s/he wanted to kill him/herself. Since P4 was in the facility alone and the VA’s housemates were also inside, P4 went outside quickly to tell SP1 and SP2 to come back into the facility and work with the VA’s housemates. SP1 laughed at P4 and went inside, SP2 went inside and sat on the couch. · The VA had been struggling with emotional dysregulation off and on from approximately 9:00 a.m. until 11:30 a.m. and was calm from 11:30 a.m. until around 2:00 p.m. The VA decided around 3:45 p.m. that s/he would go outside to calm down. SP1 went outside with the VA and P4 also went outside with the VA to talk to him/her but then went back inside to prepare dinner. · Around 4:30 p.m., while prepping dinner and serving dinner to the VA’s housemates, SP1 and SP2 were outside with the VA. P4 could see outside from the window that the VA was on the ground and his/her wheelchair was laying on its side. A while later, P4 heard yelling from outside and looked out the window but did not see the VA, SP1, or SP2 where they were before. P4 heard the VA yelling “let me go” and SP1 and SP2 yelling “stop having a behavior,” and “stop freaking out.” · SP1 and SP2 called out for assistance from P4 to help carry the VA up the stairs. When P4 went downstairs to meet SP1, SP2, and the VA, P4 asked the VA if s/he wanted to be carried by them up the stairs. The VA said, “Yes,” and SP1, SP2, and P4 carried the VA upstairs to his/her bedroom and put the VA in his/her bed. The VA’s wheelchair remained outside by the fence by a neighbor’s property line. · P4 sat with the VA in his/her bedroom and told the VA that s/he should calm down and that P4 would stay with the VA in his/her bedroom with him/her. P4 told the VA that s/he did not feel comfortable carrying the VA upstairs and the VA said that s/he needed to use the bathroom so that was why the VA agreed to be carried up the stairs. P4 assisted the VA to the bathroom. · The VA told P4 that s/he wanted to kill him/herself and went over to his/her bedroom window and tore the screen out. P4 talked to the VA and was able to help calm the VA. The VA laid in his/her bed from 5 until 6 p.m., and around that time, the VA’s wheelchair was brought back into the facility for the VA. · P4 observed scratches and “road rash” on the VA’s back, a cantaloupe sized bruise on the VA’s inner left bicep, a three-inch-by-three-inch bruise on center of the VA’s bicep, a bruise by the VA’s left eye and a scratch that went from near the VA’s left eyebrow to the VA’s left ear. · P4 did not confront SP1 or SP2 regarding dragging the VA because P4 did not want to create more conflict between staff when P4 observed the conflict between SP1, SP2, and the VA. P4 did not witness the VA being dragged but assumed the VA was dragged by SP1 and SP2 since P4 observed that the wheelchair was left near the fence and the VA had limited mobility and was not able to walk independently. · P4 did not feel comfortable with how SP1 or SP2 worked with the VA in the past and did not think that SP1 or SP2 provided adequate care to the VA or housemates. P5 provided the following information: · P5 received a call from P1 on June 6, 2025, regarding the incident that occurred between SP1 and the VA in addition to the items that were broken in the facility by the VA. · On June 9, 2025, P5 met with the VA and the VA told P5 that SP1 had punched the VA on June 6, 2025, and on June 7, 2025, SP1 and SP2 had drug the VA and left the VA without his/her wheelchair. · P5 observed bruises on the VA’s left arm and road-rash on the VA’s back from his/her shoulders to mid-thigh. SP1 and SP2 denied “dragging” the VA and said that they had “carried” the VA by his/her arms and legs and while doing so, the VA “fell” and scraped him/herself on his/her back. · P5 scheduled and attended doctor’s appointments with the VA on June 10 and 11, 2025, regarding the VA’s injuries. · The VA received an ultrasound of his/her left arm, and no concerns were found. The VA received X-rays and found an aged T-11 fracture that did not require further care or treatment since the fracture of the T-11 had healed and the cause was unknown. · It was typical for the VA to tip or get him/herself out of his/her wheelchair and typical for the VA to remove some or all his/her clothing when escalated. · P5 did not have concerns with SP2 but was concerned with the number of hours per week that SP1 was working at the facility. SP2 received retraining regarding the VA’s plan of care regarding carrying/dragging the VA on June 7, 2025. Medical records provided the following information: · The VA received an ultrasound of his/her right arm on June 11, 2025, and no serious injuries were found. The VA’s arm had bruising and some mild swelling that did not require further care or treatment. · The VA received an X-ray of his/her back and it was found that the VA had a T11 fracture (mid-spine fracture). The fracture appeared to be aged, and it was not able to be determined when or how the VA had sustained a fracture to his/her spine. · The VA was recommended to take acetaminophen and ibuprofen three times a day for pain and was prescribed a cream for the abrasions on his/her back and over the counter creams for abrasions on his/her back. LE records stated that on June 11, 2025, a call was received, and the caller told LE that s/he was assaulted by SP1 and SP2 on June 6 and 7, 2025. The VA remained at the residence. All staff person’s interviewed were trained on the Reporting of Maltreatment of Vulnerable Adult’s Act and the VA’s plan of care. Conclusion: A. Maltreatment: Regarding the incident on June 6, 2025: The VA, P1, P2, and P3 provided consistent information that on June 6, 2025, SP1 was working at the facility with P1 and P2. Around 4:30 p.m., the VA went outside and SP1 followed. During that time, video footage showed that SP1 attempted to push the VA up the gravel driveway but was unable to due to the VA holding onto the wheels of the wheelchair. SP1 stepped away and the VA rolled down the gravel driveway and hit an unknown object and fell sideways out of his/her wheelchair. Around 9:00 p.m., the VA threw and broke various objects in the kitchen including a coffee carafe. P1 was in the living room and SP1 went into the kitchen where the VA was sitting on the floor behind the kitchen island with broken glass and other broken objects around him/her. SP1 was behind the kitchen island and the VA was grabbing at SP1. P1 stated that SP1 punched the VA five to six times on the arm. P1 did not see SP1’s fist make contact with the VA’s arm but saw SP1’s fist clenched and making punching movements toward the VA’s arm. The VA told several people that SP1 punched his/her arm. LE was contacted due to the VA threatening him/herself and others with broken glass and the VA was transported to the hospital via ambulance. The VA returned to the facility around 2:00 a.m. on June 7, 2025. P1, P2, P4, and P5 witnessed large bruises on the VA’s arm and medical records from June 11, 2025, showed that the VA received an ultrasound of his/her right arm due to bruising. No complications were found, and the bruises did not require further medical care. SP1 denied hitting the VA and stated that the bruises could have come from the VA falling out of his/her wheelchair or another self-inflicted injury. Although P1 did not see SP1’s fist make contact with the VA’s arm and SP1 denied punching the VA, given that P1 saw SP1’s fist making punching motions toward the VA’s arm, that SP1 had reason to minimize his/her actions for fear of the consequence, and that the VA told several people consistently that SP1 punched his/her arm, there was a preponderance of the evidence that SP1’s actions were not accidental and could be reasonably expected to produce physical pain or injury or emotional distress. 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 the incident on June 7, 2025: The VA and P4 provided consistent information to this investigator that on June 7, 2025, SP1 and SP2 were working at the facility with P4. The VA had been struggling with emotional dysregulation off and on from approximately 9:00 a.m. until 11:30 a.m. and was calm from 11:30 a.m. until around 2:00 p.m. The VA decided around 3:45 p.m. that s/he would go out to calm down. SP1 went outside with the VA and P4 went outside with the VA to talk to him/her but then went inside to prepare dinner. Around 4:30 p.m., while preparing dinner and serving dinner to the VA’s housemates, SP1 and SP2 were outside with the VA. P4 could see outside from the window that the VA was on the ground and his/her wheelchair was laying on its side. A while later, P4 heard yelling from outside and looked out the window but did not see the VA, SP1 or SP2 where they were before. P4 heard the VA yelling “let me go” and SP1 and SP2 yelling “stop having a behavior” and “stop freaking out.” Once they entered the facility, P4 assisted SP1 and SP2 with carrying the VA upstairs to his/her bedroom. The VA’s wheelchair remained outside until around 6:00 p.m. Medical records indicated that the VA was prescribed a cream for the scratches on his/her back. P5 stated that SP1 and SP2 said the VA fell while they were carrying the VA causing the scratches on the VA’s back. When asked by this investigator, SP1 denied dragging the VA and said SP1, SP2, and P4 carried the VA to his/her wheelchair. However, P4 stated that SP1 and SP2 carried the VA into the facility and then P4, who was inside assisting the VA’s housemates, helped them carry the VA up the stairs. The VA consistently told several others that SP1 and SP2 dragged the VA. SP2 did not provide information to this investigator. Given that SP1 provided conflicting information and had reason to minimize his/her actions, that the VA provided consistent information and there was no information that the VA had a history of not providing accurate information, and that the VA had “road rash” and scrapes on his/her back, there was a preponderance of the evidence that SP1’s and SP2’s conduct was not accidental and could be reasonable expected to produce physical pain and 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.) 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. SP1 and SP2 were responsible for the VA’s care at the time of the incidents and were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plan. SP1 and SP2 were 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 SP1 was responsible regarding the June 6, 2025, incident was not recurring because it was a single incident and was not serious because it was not determined how the VA obtained the bruises. It was determined that the substantiated physical abuse for which SP1 was responsible regarding the June 7, 2025, incident was serious maltreatment because the VA sustained an injury. In addition, in combination with the June 6, 2025, incident, was also recurring maltreatment because SP1 was responsible for two incidents of physical abuse. SP1 was disqualified from providing direct contact services. It was determined that the substantiated physical abuse for which SP2 was responsible was not recurring maltreatment because it was a single incident but was serious maltreatment because the VA sustained an injury. SP2 was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but were not followed by SP1 and SP2. SP1 no longer worked at the facility. SP2 received retraining regarding the VA’s plan of care. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were each 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 SP1 and SP2 were responsible for maltreatment and the disqualification of SP1 and SP2 are each subject to appeal.
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