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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: 1071594-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) used a plastic container to hit a vulnerable adult (VA) on the top of his/her head and punched the VA two times. Date of Incident(s): August 21, 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 August 28, 2025, from documentation at the facility, law enforcement records, medical records, and through seven interviews conducted with the SP, two facility management staff persons (P1 and P2), a facility health care professional (HCP), a paramedic (P) and two facility staff persons (P3 and P4). Although this investigator met the VA, the VA was unable to provide information in an interview due to his/her abilities. The VA’s Positive Support Strategy Review showed that the VA enjoyed going on “road trips” and going to movies. The VA’s Risk Assessment Detail showed that the VA had “limited use of one arm” and “may have difficulty communicating.” The VA’s ISSA Assessment Detail showed that the VA was diagnosed with a traumatic brain injury. The VA’s Action Plan outlined behavioral concerns exhibited by the VA. When the VA engaged in “aggressive communication,” which consisted of yelling at others and the use of “posturing with [his/her] body to intimidate or threaten others,” staff were trained to provide verbal de-escalation techniques to the VA to calm down. Medications were stored in a plastic container in the staff office, which was locked. Information from the investigation showed that on August 21, 2025, the SP, P3, and P4 worked the evening shift. An interview with P1 and the facility’s Incident Report, written by P1, provided the following information: · At an unspecified time on August 21, 2025, P2, who was not working at the time, notified P1 about an incident that occurred at the facility. As a result, P1 went to the facility and interviewed staff. · At about 9 p.m., the VA and P3 returned to the facility after seeing a movie in the community. Shortly thereafter, the SP attempted to administer medications to the VA, but the VA “refused” and threw the medications in a garbage can. The SP called the HCP to advise him/her and was told to try administering the medications to the VA in about an hour. · After the call ended with the HCP, the SP took the container to the office and the VA followed the SP and “grabbed” the container. The VA then went to his/her bedroom with the container. The SP followed the VA and “tried to get the [medications] back and a tug of war ensued.” The VA “shoved” the SP and “either the box broke at that point or [the VA] says staff hit [him/her] with it.” P3 went into the room “just before this and was trying to calm [the VA] down, when [the VA] shoved” the SP. P3 saw the SP hit the VA with the container in the head. · When P1 talked to the SP, the SP said that while s/he administered medications to the VA, the VA noticed that s/he was missing one of his/her medications, but the VA was unable to communicate that to the SP. Although the SP and P3 provided information to P1 regarding the incident, the information was conflicting. P3 told P1 that s/he saw the SP hit the VA on the top of his/her head with the container, but the SP told P3 that s/he did not remember doing that. · After the incident, P1 assessed the VA, but did not see any injury on the VA’s head or anywhere on the VA. Law enforcement and ambulance personnel were called. The VA was assessed by ambulance personnel, but no action was taken, and the VA was not taken to a hospital for further evaluation. The law enforcement report, dated August 21, 2025, showed that when law enforcement talked to the VA, the VA explained that s/he “had been struck in the head tonight” by the SP. When P3 was interviewed, P3 said that s/he witnessed a part of the incident and “it appeared” that the SP and the VA were arguing over the plastic container. P3 said that “it appeared [the SP] and [the VA] both had a hand on each other where [the VA] began trying to push away from [the SP] to get some distance from [him/her].” P3 also said that when the VA “was up against the wall with nowhere to go,” the SP “picked up the plastic container and hit [the VA] over the head with it.” When that happened, P3 “stepped in” because the SP “was getting into a fighting stance.” P3 told the SP, “No and that we were done.” When the SP was interviewed, via phone, the SP said that when the VA “shoved” the SP, the container smashed on the floor. The SP denied hitting the VA. An interview with the P and the VA’s Prehospital Care Report Summary provided the following information: · When the VA was assessed, there was no apparent injury, and no care was provided. However, the VA complained of pain “while touching where [s/he] was hit.” · When the P attempted to talk to the VA, the VA was “hard to communicate with,” but was able to gesture that the SP hit the top of the VA’s head with the container, but the P did not see visible signs of injury. · When the P talked to P3, P3 said that s/he saw the SP “shove or punch” the VA and “break” the container on top of the VA’s head. P3 provided information that was consistent with the information provided in the facility’s Incident Report, but added the following additional information: · When P3 heard the SP and the VA “arguing,” P3 went to the VA’s bedroom and saw that the SP and the VA were “holding each other’s clothing” and the container was on the VA’s bed, which was about one foot away from the VA and the SP. P3 saw the VA push the SP, but did not see the SP push the VA. When P3 asked the SP and the VA what was happening, “no one responded to me.” The SP said, “You don’t mess with me or something like that.” After that, the SP “immediately” took the container and “hit [the VA] right above the head” and the container “shattered.” · At some point, P3 stepped in between the VA and the SP because the SP was in a “fighting stance,” which meant that the SP had both of his/her arms “up” and “fists closed.” When P3 told the SP, “There’s no reason for that,” the SP left the room. P4 said that although s/he was working at the time of the incident, P4 did not see or hear anything regarding the incident because P4 was outside. After the incident, P4 came inside and saw the SP sitting at a table. When P4 asked the SP what happened, the SP did not respond. Later, P4 heard the SP “saying something” and although P4 did not hear exactly what the SP said, the SP said something that “wasn’t nice.” When P4 talked to the VA, who was “pretty firm” and “visibly upset,” the VA “gestured” to P4 that the SP “hit” the top of the VA’s head with the container. The SP provided the following information: · Although the SP did not remember the date, s/he set up the VA’s medications shortly after 9 p.m. When the SP gave the medications to the VA, the VA threw them in the garbage can and appeared to be “upset.” The SP tried to understand why the VA was upset but was unable to do so. · The SP called the HCP and was told to try to administer the medications again to the VA in about an hour. After that, the SP took the container to the office, but did not realize that the VA was following behind the SP. When the SP turned around in the office, the VA took the container and began walking to his/her bedroom. The SP followed the VA. · While the SP was in the VA’s bedroom, the SP verbally tried to get the container back from the VA, but the VA did not give it back to the SP. The SP remembered that the VA grabbed the SP’s clothing and pushed the SP, but the SP denied that s/he grabbed the VA’s clothing or pushed/hit the VA. At some point, the VA threw the container on the floor, which caused it to break. The SP denied hitting the top of the VA’s head with the container or holding his/her fists up toward the VA. The SP was aware that P3 came into the room at some point, but denied that P3 got in between the VA and the SP. Shortly after P3 came into the room, the VA calmed down and the SP left the room. The facility’s training records showed that all staff 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 21, 2025. Conclusion: A. Maltreatment: At about 9 p.m. on August 21, 2025, the SP attempted to administer medications to the VA, but the VA became upset and threw the medications away in the garbage can. When the SP took the container back to the office, the VA followed the SP, but the SP did not know that initially. The VA took the container from the SP and went to his/her bedroom. When P3 heard the SP and the VA “arguing,” P3 went to the VA’s bedroom and saw that the SP and the VA were “holding each other’s clothing,” that the container was on the VA’s bed, and that the SP hit the VA’s head with the container. P4 stated that although s/he did not see the incident, the VA “gestured” to P4 that the SP hit the VA’s head with the container. The VA consistently communicated to the P and P4 that the SP hit the VA with the container. The VA demonstrated to P4 that s/he had pain after the incident. The SP stated that although the VA pushed the SP, the SP denied pushing the VA or hitting the VA on top of his/her head with the container. The SP said that the container broke when the VA threw the container on the floor. Although the SP denied hitting the VA on the head with the container, given that the SP had reason to minimize his/her actions for fear of consequences, that P3 saw the SP hit the top of the VA’s head with the container, and that the VA provided consistent information that the SP hit him/her on the head with the container, there was a preponderance of the evidence that the SP’s conduct was not accidental and would be reasonable expected to produce pain or 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. The SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to August 21, 2025. The SP was responsible for physical abuse 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 for did not meet statutory criteria to be determined as recurring or serious because it was a single incident, and the VA did not sustain an injury. Action Taken by Facility: The facility completed an Internal Investigation and determined that policies and procedures were adequate, but they were not followed. In addition, the review stated that additional training was provided to staff. The SP was no longer employed by 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.
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