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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: 1069718-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Elisa Montgomery 651-431-6474 elisa.montgomery@state.mn.us Suspected Maltreatment Reported: It was reported that two staff persons (SP1, SP2) held down a vulnerable adult (VA) and shaved his/her pubic area. Two other staff persons (SP3, SP4) had given SP1 and SP2 permission to do so. 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 (3); 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: Use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult unless authorized under applicable licensing requirements or Minnesota Rules, chapter 9544. 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 September 22, 2025; from documentation at the facility and through seven interviews conducted with facility staff persons (P1-P3) and SP1-SP4. Interview attempts via phone and mail were not responded to by the VA’s Guardian (G) at the time of this report. Due to the VA’s diagnoses, the VA was not able to provide pertinent information related to this incident. The VA enjoyed spending time with family and going to his/her day program. The VA was diagnosed with encephalopathy, severe developmental disability, and hirsutism (excessive growth of dark or course hair). The VA attended a day program during the weekdays for eight hours per day. Due to the VA’s diagnoses, staff persons assisted the VA with shaving, showering, and grooming. SP1 provided the following information: · On August 15, 2025, SP1 was working at the facility. SP1 was concerned for the VA’s hygiene and asked SP3 if the VA’s pubic region could be or had been shaved. SP3 agreed that the VA’s pubic region could be trimmed for hygiene purposes. · SP2 was at the facility and assisted SP1 with trimming the VA’s pubic region in the bathroom of the facility with the door closed. SP2 stood in front of the VA so the VA could stand still. · SP1 did not hold the VA down and did not observe SP2 hold the VA down. The VA remained standing while SP1 trimmed the VA’s pubic hair. · The VA was prescribed a cream for in-grown hairs and directives from the VA’s physician were received a week later that identified that further trimmings of the VA’s pubic hair were not to occur. SP2 provided the following information: · SP2 arrived at the facility sometime in the afternoon on August 15, 2025, to discuss open shifts with SP3. While at the facility, SP1 asked SP2 if s/he could assist SP1 with trimming the VA’s pubic hair due to hygiene concerns. · SP2 assisted SP1 with trimming the VA’s pubic hair in the bathroom of the facility with the door closed. · SP2 stood in front of the VA so s/he would not move but did not touch the VA or hold the VA’s hand when doing so. · The VA’s legs and armpits were shaved using a regular razor and when doing so, the VA would stand up and would stand still during that time. The VA’s face was shaved with a hair and body trimmer on a daily basis. SP2 observed that SP1 used the hair and body trimmer to trim the VA’s pubic hair. · After assisting SP1, SP2 left the facility. SP3 provided the following information: · SP3 worked at the facility on August 15, 2025. SP1 asked SP3 if the VA had his/her pubic hair trimmed before and was concerned for the VA’s hygiene. SP3 recalled that the VA had his/her pubic hair trimmed in the past but “could be wrong.” SP3 told SP1 that s/he could trim the VA’s pubic hair. · SP2 was at the facility discussing open shifts with SP3 and SP2 offered to assist SP1 with trimming the VA’s pubic hair in the bathroom of the facility. SP3 left the facility before this occurred. · SP3 notified the G on August 20, 2025, and the G verbally told SP3 that the VA’s pubic hair could be trimmed again for hygiene purposes. · SP3 believed that the VA would have stood still so that s/he could have the pubic hair trimmed and was not concerned that SP1 or SP2 would have held down the VA since the VA stands or sits to have his/her legs and face shaved. SP4 provided the following information: · SP4 worked in an office in the basement of the facility and occasionally worked directly with the VA and the VA’s housemates when needed. · On August 15, 2025, SP4 had overheard SP1 asking SP3 if s/he could trim the VA’s pubic hair for hygiene purposes and SP3 agreed. SP2 was at the facility and offered to assist SP1. · When SP4 was leaving the facility, SP2 told SP4 that s/he was also leaving and that s/he had finished helping trim the VA’s pubic hair. P1 provided the following information: · P1 received a call from P2 on August 16, 2025. P2 explained that the VA’s pubic area had been trimmed. P1 went to the facility and observed that the VA’s pubic area had been trimmed. P1 observed that the VA might have had in-grown hairs and called the VA’s physician. · The VA was prescribed a cream for in-grown hairs and the physician recommended to discontinue further trimmings of the VA’s pubic hair. · P1 was concerned that the VA would not have been able to stand still while his/her pubic hair was trimmed and that SP1 and SP2 would have held the VA down but was not sure. · P1 did not have experience with shaving the VA and was not aware of the process staff persons take to shave the VA’s legs, armpits, or face. P2 provided the following information: · P2 had worked at the facility on August 14, 2025, and did not observe that the VA’s pubic hair had been trimmed. On August 16, 2025, P2 worked at the facility and observed that the VA’s pubic area had been trimmed and called P1 to inform him/her. · P2 observed that the VA might have had some in-grown hair due to shaving and P1 had called the VA’s physician and a cream was prescribed. · P2 did not know how SP1 and SP2 had trimmed the VA’s pubic hair but was not concerned that SP1 or SP2 had held the VA down to shave his/her pubic hair and that the VA might have sat down while having his/her pubic hair shaved. P3 provided the following information: · P3 worked at the facility on August 20, 2025, and observed that the VA’s pubic area had been trimmed and that s/he might have had some in-grown hairs. · P2 had talked to P3 regarding the VA’s pubic hair being trimmed by SP1 and SP2. P3 did not have concerns that the VA was held down but was not sure how the VA was trimmed because the VA did not sit or stand still for long periods of time. All staff person’s interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults and the VA’s plan of care prior to the incident occurring. Conclusion: On August 15, 2025, SP1- SP3 were working at the facility. SP1 asked SP3 if s/he could trim the VA’s pubic hair due to hygiene concerns. SP3 believed that this had occurred in the past and told SP1 that s/he could do so. SP2 was at the facility discussing open shifts with SP3 and offered to assist SP1. SP1 and SP2 went into the bathroom with the VA and closed the door. SP2 stood in front of the VA while SP1 used the VA’s hair and face trimmer to trim the VA’s pubic hair. The VA would stand still when his/her legs and armpits were shaved and SP1 and SP2 denied holding the VA down. P1 saw the VA might have ingrown hair in his/her public area so called the VA’s physician on August 16, 2025, and received a prescription cream for possible in-grown hairs. The physician also recommended not trimming the VA’s pubic area. The VA’s plan of care was updated to reflect the only areas staff persons were to assist the VA with shaving/trimming. Although there was a concern that the VA was held down to have his/her pubic area shaved, given that SP1 and SP2 each denied either of them holding the VA down and that the VA’s pubic area was shaved for hygiene purposes, and that SP3 stated that the G approved shaving for hygiene purposes, there was not a preponderance of the evidence whether staff persons engaged in conduct that would be reasonable be expected to produce pain or injury or whether there was a failure to provide the VA with reasonable and necessary care and services. It was not determined whether abuse or neglect 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: Use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult unless authorized under applicable licensing requirements or Minnesota Rules, chapter 9544). 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 that their policies and procedures were followed but were not adequate. The VA’s plan of care was updated to reflect the only areas that staff persons were to assist the VA with shaving/trimming and staff persons at the facility received training regarding the change. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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