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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: 1068431-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that a staff person (SP) hit a vulnerable adult (VA) and that the VA had marks on his/her back, chest, and arm and redness on his/her back. Date of Incident(s): August 29, 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 22, 2025; from documentation at the facility; and through three interviews conducted with the SP, a staff person (P1), and a facility management staff person (P2). The VA was unable to provide information due to his/her disability. The VA’s Annual Plan-Support Plan Addendum showed that the VA enjoyed riding his/her bike, accessing the community and spending time with family members. The VA’s Person Served Profile showed that the VA had a severe developmental disability and was diagnosed with autism and attention deficit-hyper disorder (ADHD). The VA and one other client (C) lived at the facility, and both had one to one staffing during waking hours. At the time of the alleged incident, the SP and P1 were working at the facility. The SP was the VA’s one-to-one staff person and P1 was the C’s one-to-one staff person. The VA lived at the facility less than 45 days. P1 provided the following information during his/her interview and in the facility’s Investigative Summary: · P1 said that on the morning of August 29, 2025, when s/he began working, the VA “did not have bruises or marks” on his/her body. While P1 and the C were in the C’s bedroom, P1 “heard a loud banging noise, and the sounds of [the VA] crying.” P1 told the C to remain in his/her bedroom and “remain calm.” P1 then left the C’s bedroom to see what was happening and “slipped” because the VA had thrown water on the floor. The SP told P1 that the VA was “throwing things and damaging the house.” P1 assisted moving items to minimize the VA’s access. While doing so, P1 heard the SP say, “If you do it again, I will hit you again.” P1 had moved out of the SP’s sight but was still within visual range of the VA and the SP, when s/he saw the SP use a “closed fist” to hit the VA on his/her back “multiple times.” P1 did not remember which hand the SP used. When that happened, the VA was “crying” and said, “Sorry,” “many times.” P1 did not remember if the SP said anything but P1 told the SP, “What’s going on?” and “You’re not supposed to do that,” but the SP “did not listen.” The SP said, “Sorry,” to the VA and then told the VA to relax in a chair. P1 then “came back into” the SP’s sight and the VA approached P1. P1 redirected the VA by saying “backup” and the VA complied and calmed. · P1 then went outside to “take a breather” because s/he “was in shock of what [s/he] had witnessed” and shortly thereafter, left the facility with the C for a few hours. Later at an unknown time, P1 and the C returned to the facility and the VA asked P1 to take him/her to the bathroom. Once the VA and P1 were in the bathroom, the VA “pointed” to his/her body and P1 “discovered all the marks.” When the VA showed P1 his/her injuries, the VA was able to communicate, through hand gestures, to P1 that the SP caused the injuries. P1 took photographs of the marks and called P2 to say that s/he “couldn’t work the rest of the day.” P1 was “afraid to call the police and feared retaliation” from the SP. On September 3, 2025, P1 told P2 about the incident. The SP provided the following information during his/her interview and in the facility’s Investigative Summary: · When the VA engaged in behavioral incidents, the SP provided verbal redirection, offered various foods, or offered the VA the opportunity to talk to family members on the phone. The SP did not remember the specific incident or what transpired but denied hitting the VA or saying that s/he would hit the VA again. · The SP described the VA as “wild.” Because of that, the SP tried to “study” the VA to determine “triggers” for the VA but was unable to do so. When the VA engaged in behavioral concerns, the VA “will not watch where [s/he] is walking and will bump into things.” The facility’s Investigative Summary and photos taken by P1 after the incident provided the following information: · During the investigation, management interviewed five additional staff persons and some staff noted that the VA had a history of having bruises and red marks due to the VA’s behavioral incidents. · Photographs taken by P1 after the incident were reviewed by management. The VA “appeared to have redness on [his/her] upper right side and middle of [his/her] back. Visible scratches are present on [his/her] back area and appear new. There were also a few circular red marks on [his/her] mid-upper back, two on the left side and two on the right side. A few small scratches were present on [the VA’s] arm, however, from the photos taken, it was unsure whether those were new or older injuries.” t [Note: The photographs were reviewed for this investigation and marks observed where consistent with the above information.] · The facility reviewed documentation related to the VA’s behavioral incidents between August 25 and September 7, 2025, and noted that the VA engaged in nine behavioral incidents, such as physical aggression to staff, the C and property destruction. P2 said that on September 3, 2025, P1 told P2 that s/he witnessed the SP hit the VA, but did not provide additional details to P2. P2 had no prior concerns related to the SP’s interactions with clients. The facility’s training records showed that all persons interviewed for this investigation were trained on the reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to August 29, 2025. Conclusion: A. Maltreatment: P1 provided consistent information to P2, this investigator, and for the facility’s Investigative Summary that on August 29, 2025, the SP hit the VA multiple times on his/her back. The VA was unable to provide information and the SP did not specifically remember the incident but denied hitting the VA. Later that day after the incident at an unknown time, the VA showed P1 red marks and scratches on the VA’s body. Although the SP denied hitting the VA, P1 provided consistent information to multiple people regarding the incident, the SP had reason to minimize his/her actions for fear of repercussions, and there was no information provided to discredit P1. Therefore, P1’s accounts were considered more credible and, there was a preponderance of the evidence that the SP used a closed fist to punch the VA on the back multiple times. 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. The SP was responsible for the care of the VA at the time of the incident and 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: 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 did not meet statutory criteria to be determined as recurring or serious because the SP hit the VA multiple times during a single incident and although the VA sustained red marks and scratches on various parts of his/her body, it was not determined whether any injury was a result of the SP’s actions. Action Taken by Facility: The facility completed an Internal Review and determined that although policies and procedures were adequate, they were not followed. P1 received additional training and a “corrective action form.” The SP no longer worked at the facility. 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. Minnesota Statutes, section 626.557, subdivision 3, requires mandated reporters at a facility to immediately report suspected maltreatment. The investigation determined that one staff person failed to report suspected maltreatment as required. A letter from DHS was sent to that individual regarding his/her failure to report the suspected maltreatment and potential consequences for future such failures.
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