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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: 1118740-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Anna Parkin anna.parkin@state.mn.us Suspected Maltreatment Reported: It was reported that while a vulnerable adult (VA) was slamming his/her bedroom door, a staff person (SP) began video recording the VA. As a result, the VA ran out at the SP and the SP pulled the VA’s hair “aggressively.” Date of Incident(s): August 15, 2025 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, 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 September 5, 2025; from documentation at the facility, video footage, and law enforcement records; and through eight interviews conducted with two supervisory staff person (P1 and P2), three facility staff persons (P3, P4, and the SP), the VA, the VA’s case manager (CM), and the VA’s guardian (G). The VA was diagnosed with major depressive disorder and anxiety disorder. According to the VA’s Individual Abuse Prevention Plan: · The VA was “very outspoken” and possibly put him/herself in “dangerous” situations. If the VA put him/herself in an abusive situation, staff persons intervened to protect the VA by standing between him/her and the aggressor and asked the VA to leave the area. If the VA did not respond to the verbal request to move, staff persons called 9-1-1 to remain safe. · If the VA was “upset” or “dysregulated” in certain situations, staff persons remained calm and provided verbal directions on following safe and appropriate safety skills in neutral, informal situations. · The VA had a history of multiple physical assaults on staff persons. Staff persons provided supervision as agreed upon in the VA’s Support Plan Addendum Intensive Services and had a positive support plan. Staff persons used proactive strategies to decrease occurrences of incidents. If the VA became escalated, staff persons used positive support strategies and a crisis plan to attempt to deescalate the situation. If the situation was not safe, staff persons called 9-1-1. According to the VA’s Support Plan Addendum Intensive Services: · Staff persons encouraged the VA to walk away from situations if aggression occurred. Staff persons also encouraged the VA to practice coping skills such as deep breathing, puzzling, coloring, or listening to music. Staff persons offered “space” in heightened situations and kept the VA in sight and sound for supervision. · Staff persons provided the VA with alternative communication techniques and “stress[ed] the importance of voicing concerns” to staff persons to avoid physical aggression. Staff persons also encouraged the VA to walk away from a situation in which physical aggression could and “mostly likely” would occur. If staff persons were concerned about the VA or other persons in “imminent risk of harm” they called 9-1-1. Consistent information was provided that P3, P4, and the SP were working on August 15, 2025, at the time of the incident but P4 was outside and did not hear or see anything. The facility had a main living area that had a coffee table and sofas. From the living room there was a hall that led to the clients’ bedrooms. The VA’s bedroom was at the end of the hall. Consistent information was provided that the facility had video cameras that recorded the main areas of the facility, including the living room and hall. P5 stated by the time s/he was aware of the incident on August 19, 2025, the recording was no longer available because it auto deleted after three days. The VA stated that on the day of the incident, the SP grabbed and pulled the VA’s hair that was in a ponytail and his/her head pulled back. It hurt but s/he was not injured. P3 provided the following information: · On August 15, 2025, at approximately 6:30 p.m., the VA entered the facility. The VA was “verbally aggressive” and “having behaviors” with another client (C) and staff persons. The VA said s/he was going to his/her bedroom and when s/he entered, s/he slammed his/her bedroom door five times. · The SP followed the VA to his/her bedroom and began video recording the VA on the SP’s personal cell phone. The VA came out of his/her bedroom and told the SP s/he was not allowed to video record him/her and “charged” at the SP with his/her hands out grabbing for the phone. The SP put his/her hands up toward the VA to “block” the VA and the VA pushed the SP backwards toward the living room. · As the SP fell backwards onto the floor, s/he grabbed a “big bunch” of the VA’s ponytail “aggressively” with one hand and the VA’s head went back “a little bit.” It happened “so fast” that it was difficult for P3 to remember where each of their hands were during the incident however, it was “questionable” whether it was incidental based on where the SP grabbed the VA’s hair and how “aggressive” it was. The SP got up and went outside to call law enforcement while the VA stayed inside the facility. The VA did not have any injuries. · P3 tried calling to notify P2 about the incident but was not able to get ahold of P2 until August 17, 2025, because P3 was not available that weekend. The law enforcement report provided the following information: · On August 15, 2025, at 5:21 p.m., that there was a phone call for assistance with a disturbance. A law enforcement officer (LEO) arrived at the facility and spoke to the SP, who stated that the VA “attacked” the SP. The SP said that the VA argued with the C and the SP tried to intervene to protect the C. The VA became “upset” and slammed his/her bedroom door because the VA was “jealous” that the SP protected the C over the VA and the VA became “even more enraged.” The SP then started video recoding the VA for the SP’s own safety. When the VA saw this, s/he “charged” out of his/her bedroom and hit the SP in the chest. The SP did not want to press charges and declined medical attention. · The LEO then spoke to the VA who said s/he got into an argument over the TV with the C and when staff persons tried to intervene, the VA recognized that his/her anger “got the best of [him/her].” The VA “admitted” to charging and hitting the SP and the VA said s/he was “extremely” sorry for the incident. The VA agreed to remain calm for the rest of the night and “work it out” with the SP. [Note: There was no mention of the hair pulling or the VA or the SP receiving an injury to his/her ankle.] P2 provided the following information: · On August 17, 2025, P2 received an email from P3 that there was an incident between the VA and the SP that was “not right.” The following morning, on August 18, 2025, P2 spoke to P3 who provided consistent information as s/he did to this investigator. P2 immediately called and notified P1 and another supervisory staff person (P5) about the incident. · P3 was a “very genuine” person and P3 was “one hundred percent” accurate when providing information. The SP had a “very quick temper” and was an “instigator” at times with the clients. In the past, P2 saw documentation from the SP in the client progress notes that were not always accurate. P1 interviewed the SP as part of the internal investigation and the SP provided information to P1 that was consistent with the information the SP told this investigator. P1 said that the SP did not follow facility training including videoing the VA when in an “escalated state” resulting in the VA coming out of his/her bedroom instead of staying inside remaining calm. The SP also should not have pulled the VA’s hair and should have followed the VA’s plans. Video footage taken by the SP during the incident showed six seconds where the VA opened his/her bedroom door, ran towards the SP, put his/her hand up in front of the phone, and said to stop recording him/her.
The SP provided the following information: · On the day of the incident, the VA had “escalating behaviors” including property damage and threatening to injure the C and staff persons. The SP redirected the VA to other activities such as arts and crafts and talked the VA through the concerns the VA had with the C. The VA got “upset,” went to his/her bedroom, and slammed his/her bedroom door shut multiple times which the SP felt was a “safety risk” for the C and property damage. · The C told the SP that s/he was “scared” so the SP positioned him/herself between the C and the VA’s bedroom. The SP then began video recording the VA to “document” the VA and when the VA saw this, s/he “rushed” at the SP, grabbed the SP’s phone, pushed the SP, and the SP fell backwards. During that time, the SP felt a “pop” in his/her ankle that had been previously injured so s/he was trying not to fall onto the floor and injure it more. While trying not to fall down, the SP closed his/her eyes and “instinctively” reached out to the nearest thing and as a result “grabbed” the VA’s hair. The SP did not realize s/he grabbed the VA’s hair until the VA told the SP immediately after. The VA did not have any injuries. · The SP stated s/he was not able to provide information as to where they were at in the hall and living room area because it all “happened so fast.” The VA punched the SP in the chest and the SP used his/her forearms to block the VA and verbally redirected the VA back to his/her bedroom. The VA stopped hitting the SP, so the SP went outside and called 9-1-1. Later on, the SP went to the doctor and found out s/he tore a tendon in his/her ankle. · The SP was supposed to have crisis prevention training prior to the incident, but the facility would not schedule it since they did not have an instructor. The lack of training put the SP and the VA at risk. The VA attacked the SP on previous occasions and during that time, the SP used verbal and physical de-escalation techniques, like moving toward the VA to get him/her to release his/her grip on the SP and the SP remained calm. According to the facility’s Rights of Persons Served policy, staff persons treated clients with “courtesy and respect.” According to the facility’s Personal Electronics Policy, staff persons were prohibited from using their personal cell phones for video recording the clients. According to the facility’s Data Privacy policy, clients had protection-related right that included having their personal information kept private. Written and verbal exchanges of information regarding clients were considered “private” and were conducted in a manner that preserved confidentiality, protected their data privacy, and respected their dignity. According to the Emergency Use of Manual Restraints policy, staff persons attempted to de-escalate a client’s behavior before it posed an imminent risk of physical harm to themselves or other persons. Staff persons used the following were options to de-escalate the situation: · A calm discussion between the client and staff person regarding the situation, their feelings, their responses, and alternative methods of handling the situation. · Staff persons suggested or recommended the client participate in an activity they enjoyed as a way to self-calm. · Staff persons suggested or reminded the client had options in spending time alone, when safety permitted, as a way of self-calm. Staff persons also used the strategies in the client’s plans. · Staff persons were prohibited from using “painful techniques” including intentional infliction of pain or injury. Facility documentation showed that staff persons, including the SP, were trained on the VA’s plans, the facility’s Rights of Persons Served policy, Personal Electronics Policy, Data Privacy policy, Emergency Use of Manual Restraints policy, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes 245A.04, subdivision 14, paragraph (b), clause (3), states, in part, the license holder shall monitor implementation of policies and procedures by program staff. Minnesota Statutes, section 245D.11, subdivision 3, stated that a license holder ensured staff persons followed policies and procedures protecting clients’ data privacy rights. Minnesota Statutes 245D.07, subdivision 1a, paragraph (a) stated, in part, 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. Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), stated that a client’s protection-related right included being treated with courtesy and respect.
Conclusion: Consistent information was provided that on August 15, 2025, after the VA was “verbally aggressive” and “having behaviors,” the VA said s/he was going to his/her bedroom and when s/he entered, s/he slammed his/her bedroom door five times. The SP followed the VA to his/her bedroom and recorded the VA with the SP’s cell phone, which was a violation of Minnesota Statutes 246D.11, subdivision 3. The VA had removed him/herself from the situation to his/her bedroom and the SP’s actions caused the VA to escalate, which was not consistent with the VA’s plans and against facility policies. The VA ran at the SP with his/her hands up. The SP fell backwards as s/he put his/her hands up and pulled the VA’s hair. The SP’s actions as described during the incident were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services; inconsistent with the VA’s plans; and were violations of Minnesota Statutes 245D.07, subdivision 1a, paragraph (a); Minnesota Statutes 245A.04, subdivision 14, paragraph (b), clause (3); and Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). Pulling the VA’s hair likely caused physical pain for the VA. However, given that P3 stated that it happened “so fast” it was difficult for P3 to remember where each of their hands were during the incident and it was “questionable” whether it was incidental based on where the SP grabbed the VA’s hair and how “aggressive” it was; and that the SP stated while s/he was trying not to fall, the SP closed his/her eyes and “instinctively” reached out to the nearest thing, as a result “grabbed” the VA’s hair, and that s/he did not realize s/he grabbed the VA’s hair until the VA told the SP immediately after; there was not a preponderance of the evidence whether all of the SP’s actions were therapeutic conduct or whether the SP pulled the VA’s hair by any means other than accidental. It was not determined whether 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. Action Taken by Facility: The facility completed an Internal Review and determined that policies and procedures were adequate but not followed. The SP was retrained on the facility’s Personal Electronics Policy, Rights of Persons Served policy, Data Privacy policy, Emergency Use of Manual Restraints policy, and Reporting Incidents policy. The VA’s plans were also updated to include additional de-escalation techniques and strategies. The SP was given a final written warning. Action Taken by Department of Human Services, Office of Inspector General: On October 16, 2025, the facility was issued a Correction Order for the violations outlined in this report, lack of staff training on the VA’s plans, and failing to report maltreatment as required.
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