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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: 1125078-H_CRS (Home and Community-Based Services-Community Residential Setting) 1103884-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported staff persons (SP1-SP3) did not provide a vulnerable adult with care and services while s/he had a behavior in the community. Date of Incident(s): April 25, 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 (2); and subdivision 17, paragraph (a): 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. The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on May 21, 2025; from documentation at the facility and law enforcement records; and through eight interviews conducted with the VA, a facility supervisor (P), the VA’s case managers (CM1-CM2), the VA’s guardian (G), and staff persons (SP1-SP3). Facility documentation showed the VA enjoyed creating art, music, and stories. The VA also enjoyed spending time in the community, but had a history of engaging in negative behaviors while in the community. The VA’s negative behaviors included verbal and physical aggression, self-injurious behaviors, and property destruction. The VA required 3:1 staffing 24-hours a day while at the facility and in the community. The VA was diagnosed with borderline personality disorder, schizoaffective disorder, post-traumatic stress disorder, and autism. The VA had a history of being triggered by chaotic environments, and being spoken to in a stern voice. The VA’s Functional Behavior Assessment showed that verbal aggression was typically the first observable behavior that preceded all other behaviors. Staff persons negatively engaging with the VA by entering a power struggle, criticizing the VA, threatening punishment, or moving or taking away the VA’s belongings, would make the behavior worse. Additionally, using bribes such as money or gift cards for ending negative behaviors also did not work well as it reinforced the VA to engage in negative behaviors.
The VA’s Crisis Plan (CP) and Positive Support Invention Plan provided the following information: · The CP included a description of the four phases of behavior the VA engaged in during a crisis. o Phase 1: Ideal/Calm o Phase 2: Antecedent/Triggers o Phase 3: Escalation/Crisis o Phase 4: Recovery · The “Antecedent/Triggers” included, but were not limited to telling the VA, “No or that [the VA] can’t do something.” As well as, engaging in a “power struggle” with the VA. Staff persons were to support the VA by redirecting the VA to a different activity, offer the VA the use of coping skills, and inform the VA staff persons were “there to support” the VA. · The “Escalation/Crisis” included, but was not limited to verbal and physical aggression, self-harm, and intimidating behavior. During the “Escalation/Crisis” staff persons were to be aware of their surroundings, and not place themselves in a “compromising position.” Staff were also to provide the VA with space while keeping eyes on the VA. The VA’s Service Outcome and Support plan provided the following information: · The VA wanted to spend more time in the community, but had a history of negative behaviors in the community which threatened the VA’s health and/or safety during the outings. · Staff persons were to bring one or two sensory tools to help manage the VA’s anxiety during community outings. · Staff persons were to use social stories to mentally prepare the VA for community activities. · Staff persons were to inform the VA if they saw the VA engage in a negative behavior and attempt to redirect/de-escalate the VA before leaving the activity or outing. The VA’s Self-Management Assessment stated if the VA started portraying escalating behaviors, staff persons would use the least restrictive techniques/modules to help calm the VA before increasing to a more restrictive form of calming. If required, staff persons would guide the VA using his/her limbs to ensure safety for the VA and others. Prior to the alleged incident, the VA purchased food from a restaurant and went back to the facility to eat the food. However, the VA returned to the restaurant due to concerns with the food quality. Law enforcement (LE) records provided the following information: · On April 25, 2025, at 7:28 p.m., LE responded to a disturbance at a restaurant as the VA refused to leave. LE escorted the VA out of the restaurant and the VA continued to have behaviors including screaming, attempting to walk away from LE, and refusing to get into the facility vehicle. The VA repeatedly made suicidal statements, and hit his/her head against a parking sign and business window/wall. LE intervened, and the VA was placed in handcuffs. The VA was later put on a “medical hold,” and was transported to a medical facility. · The VA told LE that staff persons did not take “good care” of him/her, refused to provide the VA medication, recorded the VA’s outbursts, and laughed at the VA during outbursts. · SP1-SP3 were at the restaurant, and SP1 told LE the facility’s policy did not allow staff persons to touch the VA or contact 911. SP1 denied any staff person recorded or laughed at the VA during the incident, but said they were not equipped to supervise the VA. · LE was informed by restaurant personnel that SP1-SP3 were laughing at the VA and recording the incident. LE reviewed the restaurant’s surveillance footage which showed that SP1-SP3 remained in the restaurant booth for the majority of the incident and failed to approach the VA. LE did not observe SP1-SP3 attempt to redirect the VA, or intervene to get the VA to leave the restaurant. LE said the footage showed staff persons were laughing at times, but footage did not confirm if staff persons recorded the incident. Medical Records showed the VA was seen at a medical facility on April 25, 2025, due to “outburst of explosive behavior,” and was discharged from the medical facility with basic discharge instructions related to the VA’s mental health.
The G, CM1, and CM2 provided consistent information related to concerns that staff persons did not try to intervene during the incident, and expressed concerns with staff persons’ ability to work with the VA. The facility completed an Internal Review (IR) and an Incident Report that included the following information: · On the evening of April 25, 2025, around 5:30 p.m., the VA got fast food from a restaurant, and returned to the facility. The VA noticed a hair in the food, and returned to the restaurant to address the concern. While at the restaurant the restaurant manager offered to refund a portion of the purchase, but the VA did not believe that was fair. The VA became visibly frustrated, raised his/her voice, and insisted on a full refund. SP1-SP3 attempted to redirect the VA and assist in resolving the situation, however the VA was overwhelmed and refused to leave the restaurant per the request of the manager. The restaurant manager contacted LE. · LE arrived at the restaurant and requested the VA leave the building. The VA continued to express frustration and escalated further, which led LE to temporarily place the VA in handcuffs for safety purposes. During the interaction the VA said s/he felt suicidal and did not want to be alive. · The VA was transported to a hospital for a mental health assessment, and was discharged. The VA returned to the facility and was at baseline behavior. SP1-SP3 interviews provided the following information: · SP1-SP3 said they were present for the incident, and attempted to redirect the VA, however the VA did not respond to the de-escalation prompts. · SP1-SP3 said they remained within visual contact of the VA, but did not laugh or record the VA’s behavior. SP1-SP3 said a group of younger adults or teenagers observed the incident and they were recording the incident. Prior to the alleged incident the P, and SP1-SP3 had been trained on the facility’s policies and procedures, client specific programming, client rights, and Reporting of Maltreatment of Vulnerable Adults. After the incident the facility completed retraining on the VA’s client specific plans with SP1-SP3 regarding supporting the VA. The facility also established that staff persons have a responsibility to support the individual through difficult encounters, and should not be a passive non-actor as that was not supporting an individual. Conclusion: It was reported SP1-SP3 did not provide a vulnerable adult with care and services while s/he had a behavior in the community. On April 25, 2025, prior to the incident, the VA purchased food from a restaurant and was dissatisfied with the food quality. LE responded to a disturbance at the restaurant as the VA was refusing to leave, and due to the VA’s behaviors s/he was placed on a medical hold. The VA was later discharged from the medical facility and returned to the facility. LE reviewed the video recording from the restaurant and it showed SP1-SP3 remained in the restaurant booth for the majority of the incident and failed to approach the VA. LE did not observe SP1-SP3 attempt to redirect the VA, or intervene to get the VA to leave the restaurant. SP1-SP3 provided consistent information related to the incident, and the interactions the VA had with the restaurant personnel, and SP1-SP3’s interactions with the VA. SP1-SP3 said attempts were made to redirect the VA, however the VA did not respond to the de-escalation prompts. SP1-SP3 remained within visual contact of the VA, and stated they did not laugh or record the VA’s behavior. The VA required 3:1 staff supervision 24-hours a day, and the VA’s client specific documentation provided instruction on how to best work with the VA while in crisis and/or engaging in negative behaviors. There was contradictory information from LE and SP1-SP3 regarding whether SP1-SP3 failed to approach, redirect, or intervene with the VA’s behaviors. Although the restaurant provided video footage of the incident, the footage did not provide conclusive information on whether staff attempted to verbally de-escalate or redirect the VA, only that they did not approach the VA. Given the contradictory information, and that it could not be determined whether staff made attempts to de-escalate the VA’s behaviors, there was not a preponderance of evidence whether there was a failure to provide the VA with reasonable and necessary care and services. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct.) Action Taken by Facility: The facility completed an internal review and determined the facility’s policies and procedures were adequate, and followed. The report was not similar to past events. The facility provided additional training to staff persons, and no other corrective action was completed. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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