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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: 1076773-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Heidi Murphy 651-431-6544 Suspected Maltreatment Reported: It was reported that over the past two years, two staff persons (SP1 and SP2) have been verbally abusive toward a vulnerable adult (VA), which triggered the VA’s mental health, paranoia, negative self-talk, and depression. Date of Incident(s): Ongoing since 2023 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (b), clause (2): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on May 14, 2025; from documentation at the facility; and through ten interviews conducted with the VA, facility staff persons (SP1, SP2, and P3), facility supervisory staff persons (P1 and P2), two facility residents (R1 and R2), the VA’s case manager (CM1), and R1’s case manager (CM2). The facility was a split entry residence in a residential neighborhood. The upper level had a kitchen, dining room, living room, bathroom, the VA’s bedroom, and a second bedroom. The lower level had a family room, office, utility room, bathroom, and two bedrooms. The VA’s diagnoses included schizophrenia (paranoid subtype), depressive disorder, personality disorder, and schizoaffective disorder. The VA enjoyed working at his/her job, making ceramics, and shopping. The VA’s Individual Abuse Prevention Plan (IAPP) stated the VA was susceptible to emotional abuse. “[The VA] did not always engage with peers appropriately, which may cause [the VA] or the peer to become upset and say hurtful things, which may cause an emotional response. Staff were to encourage residents to treat each other with respect at all times and would assist in handling conflicts as they came up respectfully.” The VA’s Relapse Prevention Plan stated things that increased the VA’s risk for relapse included stress/feeling overwhelmed and feeling people were “out to get” the VA. Staff were told to offer positive coping suggestions in a calm manner. Alone time was the best method of de-escalation for the VA. Staff were to allow the VA space until the VA went back to the staff persons. The VA provided the following information: · SP1 and SP2 “bully” the VA. SP2 said negative comments to the VA in regard to choices the VA made, “put [the VA] down,” and told the VA s/he was “acting like an idiot.” The VA stated SP1’s and SP2’s actions have been ongoing for years. · Approximately two to three months ago, the VA returned from an outing and went through the door into the facility, turned around and SP1 shook his/her finger in the VA’s face and said, “Don’t you talk about me to nobody! Don’t you talk about me to nobody!” The VA did not want to escalate the situation and shut the door in SP1’s face. The VA felt SP1 tried to get the VA to hit him/her. The VA felt SP1 always tried to provoke the VA and get the VA to fight SP1. · On an unknown holiday a “long time ago,” SP1 confronted the VA for being loud preparing food in the kitchen. The VA told SP1 s/he did not want to talk or argue and SP1 responded, “Oh you want to fight me though, don’t you?” The VA told SP1 s/he did not want to fight or hurt anyone. SP1 said, “Try me! Try me! You wanna fight me? Try me!” The conversation got “heated,” and the VA left the area. · SP2 was rude and put the VA down every time s/he could. SP1 and SP2 “both say dirty and mean things to [the VA] when nobody’s around so they don’t have any evidence of how they treat [the VA].” The VA stated SP1 and SP2 discriminated against the VA and treated him/her differently from the way they treated other facility residents. · The VA recalled an incident on an unknown date in which the VA put a pizza in the oven and told SP1 s/he was making a pizza. The VA fell asleep in a chair and woke up to the smell of something burning. SP1 sat there and did not say anything. The VA took out the burnt pizza and asked SP1 why s/he did not wake the VA up. SP1 did not answer. · The VA was scared SP1 and SP2 would retaliate against him/her. The VA believed staff persons entered the VA’s bedroom and took items. The VA mentioned a few items that had gone missing over the years, however, did not know who took them or when they disappeared. · The VA felt worthless and less confident due to the treatment by SP1 and SP2. The VA stated issues of concern with SP1 and SP2 had been told to P1 and that P1 had not done anything about it. R1 provided the following information: · R1 liked living at the facility and felt staff persons met his/her needs and offered support. R1 stated SP1 and SP2 “picked” at the VA. SP1 “tried to bait [the VA] to fight, points in [the VA’s] face, and gets in [the VA’s] personal space.” · On an unknown date within the last five weeks, SP1, the VA, and R1 walked into the facility and R1 witnessed SP1 get close to the VA, point in the VA’s face, and say, “Don’t you talk about me! Don’t you talk about me! You don’t ever talk about me!” R1 felt SP1 was “provoking” the VA. · SP1 talked aggressively toward the VA and “wants [the VA] to have some type of rage to [SP1].” SP1 “always talks about how [the VA] invited [SP1] to the backyard” to fight prior to R1 living at the facility. · SP1 and SP2 did not encourage, listen to, or support the VA. R1 felt SP1 and SP2 did those things for all the other facility residents. · Approximately one year ago, the VA and SP1 “got into it” in the kitchen and SP1 said, “You want a piece of me?” or something similar to that to the VA. R1 stated the SP1 “laid off [the VA]” until approximately four to five weeks ago. · SP2 “bullies” the VA, “verbally attacks” the VA, and tried to intimidate the VA with body language and words. SP2 “singles out [the VA] and pushes [his/her] buttons.” When there was conflict between the VA and someone else, SP2 always sided against the VA. · SP2 told R1 that s/he was “sick of [the VA],” “tired of [the VA] being here,” “wishes that [the VA] would get the hell out,” and the VA needed to “find a retirement home or nursing home.” CM1 provided the following information: · CM1 had been the VA’s case manager for 28 years. The VA was “very symptomatic and vulnerable” and always felt like s/he was in trouble. · R1 told CM1 and CM2 that staff persons were not always respectful to the VA. SP1 shook a finger at the VA and said, “Try me, try me, try me.” R1 also stated that staff persons had to “get the last word in.” CM1 felt staff persons engaged in “banter” that was not therapeutic. R1 stated s/he was treated very well at the facility however the VA was not treated well. · CM1 tried to get the VA to utilize his/her coping skills and felt the staff engaged the VA, rather than redirected him/her and that “might exacerbate the circumstances rather than relieve them.” CM1 stated “methods of de-escalation have not been followed.” · CM1 stated that staff persons seemed “attitudinal” toward the VA. · The VA was not always accurate when s/he provided information. The VA felt everyone was against him/her and had a paranoid stance. · R1 could provide accurate information. CM2 provided the following information: · CM2 was R1’s case manager. On April 21, 2025, CM1 and CM2 met with the VA and R1. R1 stated SP1 and SP2 “pick on [the VA]” and that SP1 shook a finger in the VA’s face and tried to get the VA to react physically. · The VA confirmed the information R1 told CM1 and CM2. The VA feared retaliation from SP1 and SP2. The VA did not feel as though s/he would have been able to report the incidents that involved SP1 and SP2. · Based on what R1 told CM2, SP1 was confrontational toward the VA. CM2 stated, “We don’t need anyone pushing them over the edge.” · Based on what R1 told CM2, SP2 tended to “dominate” any conversation the VA had, talked over the VA, and had to have the last word. The VA was “intimidated” by SP2’s behavior and felt “oppressed.” · The VA was diagnosed with schizophrenia and had said things that were delusional or untrue previously. However, the VA and R1 had consistent stories, which did not seem planned out and did not seem to be embellished. When the VA and R1 had lied previously, they made up “egregious” stories and this was more “subtle.” · CM2 felt staff persons needed more support and breaks when they felt “frazzled.” R2 provided the following information: · R2 had never seen staff persons be rude or disrespectful to any facility residents. Staff persons had gotten frustrated with how rude other facility residents were. · When the VA was rude to staff persons, staff persons “usually” responded in a professional manner, however, R2 stated staff persons were frustrated and did not like the way they were being treated. SP2 was the staff person the frustration was most noted with. · Staff persons tried to be as respectful as possible, “given the circumstances and the people” who “live [at the facility].” P1 provided the following information: · The VA was not considered a reliable reporter. The VA had a history of paranoia and made “assumptions about statements or actions of others that are not accurate.” · P1 tried to speak to the VA about the allegations, however, the VA was not willing to talk to P1. P1 spoke to SP1 and SP2 and both denied the allegations. · R1 was not a reliable reporter. R1 was paranoid, however less than the VA. There were many incidents in which R1 believed something to be true that was not true. · P1 had not witnessed any concerning interactions between the VA and SP1 or SP2. P2 provided the following information: · The VA called P2 a “handful” of times when the VA was frustrated with staff persons. P2 did not believe any of the incidents were maltreatment. The VA heard staff persons laughing downstairs and assumed they were speaking about and laughing at the VA. “Paranoia is a very significant symptom” for the VA. · P2 stated the VA could provide reliable information, however, it was not consistent. · After the allegations were reported, SP1 had a coach and counsel with P1 and reviewed policies related to having respectful, professional, and appropriate interactions with individuals the facility supported. SP1 read the policies but did not sign off on them, as SP1 felt it was an admission of guilt to sign off. · SP2 had performance issues in regard to interactions with others, which included negative interactions with fellow staff persons. Last year, a case manager was meeting with someone at the facility and SP2 inserted him/herself into that conversation when s/he should not have. · P2 had received similar complaints that SP2 inserted him/herself into conversations to share his/her “two cents” or opinions when it was not appropriate. SP2 struggled with what his/her role was. · After the allegations were reported, SP2 reviewed polices and received a letter of expectation, which outlined that SP2 engaged in “unprofessional interactions” with individuals the facility supported, and expectations were to follow policy moving forward. P3 provided the following information: · The VA had delusional thoughts and paranoia. The VA reported residents or staff persons stole items from the VA when the VA could not find items. The VA later found those items and apologized. The paranoia would “influence” things the VA said. · Part of the VA’s plans included staff persons assisting the VA with reality checks when issues arose to get the VA to realize the paranoia s/he was experiencing was not reality. · P3 did not witness any staff person be disrespectful to the VA or provoke the VA. The VA was disrespectful to staff persons. · P3 felt staff persons tried to support the VA according to the VA’s plans. Staff persons tried to get the VA to feel comfortable enough to share information. SP1 provided the following information: · P1 informed SP1 that the VA said that SP1 had swung his/her hand in the VA’s face and said, “Try me, try me, try me!” SP1 stated s/he did not know anything about the incident or when the incident occurred. SP1 denied the s/he ever swung a hand in the VA’s face or pointed a finger at anyone. · The VA said SP1 “always put [the VA] down.” SP1 did not know of any comments that s/he would have made that would have been viewed as a put down. · When conflict arose with the VA, SP1 would talk to the VA about his/her feelings. Many times, the VA walked away or stated s/he did not want to talk. · The VA “lies a lot,” was not reliable, and made-up stories. The VA did not like SP1 and approximately three weeks ago made a comment about getting SP1 and other staff fired for eating the facility food and using the phones and computers. · All residents were treated equally, and staff persons have never refused to take a resident anywhere. SP1 had not seen any staff person put down a resident or not be supportive of any resident. SP2 provided the following information: · The VA “doesn’t care” for SP2. The VA had complained for years that SP2 “talks over [the VA], talks for the VA, and makes decisions for [the VA].” SP2 stated those allegations were not true. · The VA “has been building up a scab for [SP2] and picking and finding little things that [s/he] feels I am triggering [him/her].” SP2 did his/her best to avoid the VA’s triggers. · The VA was angry s/he had not moved on out of the program and did not like many staff persons at the facility. · The VA had a history of providing “false” information and R1 was not an accurate reporter. · SP2 did not believe s/he “put down” the VA. “If you are trying to process things to me and you don’t like what I’m saying, how is that my fault.” “When [the VA] says stuff to me, I say [VA], you already know the answer, why are you coming to me. You already know what you need to do.” · When the VA went to SP2 with a problem or concern, SP2 tried to listen, offered a medication, encouraged the VA to talk to his/her therapist, gave the VA self-reflection, told the VA to write in a journal, or made the VA feel like s/he had a voice. · The VA was “very good at advocating for [him/herself]” and would “be the first one to tell you how to talk” to the VA. Facility training records showed P1, P2, P3, SP1, and SP2 had training on The Reporting of Maltreatment of Vulnerable Adults Act and on the VA’s plans.
Conclusion: It was reported that SP1 and SP2 had been verbally abusive to the VA for the past two years. The VA stated that SP1 shook a finger in his/her face and said, “Don’t you talk about me to nobody! Don’t you talk about me to nobody!” The VA felt SP1 tried to provoke the VA to fight SP1. R1 stated SP1 “tried to bait [the VA] to fight,” pointed in the VA’s face and got in the VA’s personal space. R1 witnessed SP1 point in the VA’s face and say, “Don’t you talk about me!” R1 felt SP1 provoked the VA. The VA stated SP2 said negative comments toward the VA, talked over the VA, and “put [the VA] down.” The VA felt that SP1 and SP2 treated the VA differently than they treated other residents. SP1 and SP2 made the VA feel “worthless” and “less confident.” R1 stated SP2 “bullies” and “verbally attacks” the VA and singled out the VA. SP1 and SP2 denied the allegations. The VA stated SP1 and SP2 did not have negative interactions when others were around and there were no other witnesses other than R1. Although R1 corroborated some of the information the VA provided, the VA and R1 did not always provide accurate information, however R2 stated s/he did not see staff persons be disrespectful toward facility residents but were frustrated with how “rude” residents were to them. Regarding SP1: Although it was likely that SP1 stood close to the VA and shook her finger which was not behavior consistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, given that SP1 denied the allegations, that the VA did not provide examples and or details of conduct that would rise to the level of emotional abuse, there was not a preponderance of the evidence whether SP1 engaged in repeated conduct which could be reasonable expected to produce emotional distress. It was not determined whether 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). Regarding SP2: Although the VA and R1 each stated SP2 made negative comments to the VA and “bullies” the VA, given that SP2 denied the allegations and that there were no specific examples or details regarding SP’s behavior that were repeated or would rise to the level of emotional abuse, there was not a preponderance of the evidence whether SP2 engaged in conduct which would reasonable be expected to cause emotional distress. It was not determined whether 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). Action Taken by Facility: The facility Internal Review stated the policies and procedures in place were adequate and were not followed. There was a need for additional staff training and SP1 and SP2 have received formal coaching and counseling along with retraining on Employee Code of Conduct and Conduct Between Staff and Individuals Receiving Supports. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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