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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: 1105162-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scout Peterson Minnesota Department of Human Services 651.431.6578 Suspected Maltreatment Reported: It was reported that a staff person (SP) slapped a vulnerable adult (VA) in the face, causing a bruise on his/her face. The SP was also “mean” and frequently yelled at the VA. Date of Incident(s): Ongoing, prior to November 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), clauses (1) and (2): 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. · 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on October 30, 2025; from documentation at the facility; and through six interviews conducted with two facility staff persons (P1 and P2), two administrative staff persons (P3 and P4), the SP, and the VA. Attempts were made to contact the VA’s guardian (G) by telephone and letter, but the G did not respond to the requests for an interview. The VA enjoyed cooking, looking at magazines, watching television, working on crafts, playing board games, listening to music, taking walks, swimming, going out to eat, going bowling, and dancing. The VA’s diagnoses included anxiety disorder, moderate intellectual disabilities, conduct disorder, major depressive disorder, and polydipsia. The VA lived alone in the facility. The VA’s Coordinated Service and Support Plan Addendum stated that the VA had 2:1 staffing from the hours of 7 a.m. to 11 p.m. daily and one awake staff person and one asleep staff person from the hours of 11 p.m. to 7 a.m. The VA had a history of self-injurious behaviors. The staff persons were trained in therapeutic strategies, de-escalation techniques, positive support strategies, and active listening. If the VA’s behaviors escalated, the staff persons were to remain a safe distance from the VA and continue to use de-escalation techniques, including asking the VA to move to a different location in the facility to calm. The staff persons were allowed to use their hands to block hits if the VA became physically aggressive. If the VA used an item to injure him/herself, the staff persons could take the item from the VA. The staff persons were to treat the VA with dignity and respect and avoid power struggles. The VA’s Individual Abuse Prevention Plan stated that the VA was susceptible to physical abuse and was unable to identify potentially dangerous situations. The facility had five rooms which were adjacent to each other. The living room and staff office were on one side of the facility and the VA’s bedroom and kitchen were on the other side of the facility. The door to the staff office opened into the living room. The VA stated that on an unknown date, the SP hit the left side of the VA’s face with his/her right hand while the VA was standing in the living room next to a bookshelf. The SP did not say anything to the VA prior to hitting him/her. On other occasions, the SP said things that were “not nice” to the VA, but the VA was unable to provide additional information about those incidents. P1 stated that on October 19, 2025, s/he and the SP worked at the facility. They took the VA to Wendy’s and then returned to the facility, where the VA watched television until 10 p.m. The SP reminded the VA that it was bedtime. The VA told the SP that s/he “didn’t like that,” which the VA did every night because s/he did not like people telling him/her what to do. The SP went to the VA’s bedroom with the VA and P1 went to the office to do paperwork. At 11 p.m., P1 went to the VA’s bedroom, turned on the VA’s light to ensure that s/he was sleeping, then turned off the light and left the facility. P1 never saw the SP hit the VA. P1 believed the VA was an accurate reporter of events. P2 stated that on October 20, 2025, P2 was sitting by the VA in the living room and the VA “randomly” told P2 that the previous night at bedtime, the SP hit the VA in the face. The VA told P2 that the SP was “mad,” but s/he did not know why the SP hit him/her. The VA did not remember what s/he said after the SP hit him/her. P2 then told P3 about what the VA told him/her. P2 stated that the VA never lied or made up stories. Prior to the incident, P2 never had any concerns about the SP’s interactions with the VA. P3 stated that on October 21, 2025, P2 told him/her that the VA told P2 that the SP hit him/her in the face. P3 went to the facility and talked to the VA and P2. The VA told them that the SP hit the VA in the face and pointed to the side of his/her face. The VA also told them that at the time of the incident, P1 was in the staff office. The VA told P3 that the SP was “mean” to the VA and yelled at him/her. P3 then told P4 about the incident. The VA was typically an accurate reporter of events. P3 had no previous concerns about the SP’s interactions with the VA. P4 stated that after P3 told him/her about the incident, s/he met with the SP and asked him/her about what occurred over the previous weekend. The SP told P4 that s/he took the VA out to get food and then returned to the house and the VA watched television. The VA napped on the couch until bedtime and then went to bed. The SP denied having an altercation of any kind with the VA and stated that s/he never hit the VA. The SP also told P4 that P1 worked with him/her that day who was with the SP “all the time.” P4 met with P1, who told him/her that s/he did not hear any altercation between the VA and the SP while P1 was in the staff office, just the SP reminding the VA that it was time for bed. The VA had a good day with no behaviors and then went to bed. In the past, the VA was happy to have the SP work at the facility. P4 stated that s/he did not see any bruising on the VA’s face. At times, the VA rubbed his/her personal items on his/her face, which might cause redness. The SP provided the following information: · On October 17, 2025, the SP took the VA to the bank and then to the grocery store. That evening, the SP made dinner for the VA, administered medications to the VA, and the VA went to bed. On October 18, 2025, the SP took the VA to the Wow Zone and then returned to the facility. · On October 19, 2025, the SP took the VA to McDonalds for lunch and the SP later made dinner for the VA. After dinner, the VA watched television in the living room. At 7 p.m., the VA was administered his/her medications. At some point the VA fell asleep on the couch and at approximately 10 p.m., the SP woke the VA and asked him/her to go to bed. The VA became upset and the SP redirected the VA by reminding him/her that it was bedtime. The VA stood across the room from the SP and the SP stated that s/he was not close enough to touch the VA. The VA took a pillow and blanket from the sofa and then went to his/her bedroom. P1 was in the staff office doing paperwork. On the days the SP worked with the VA, s/he did not see any mark on the VA’s face. · The staff persons were trained to redirect the VA when s/he became upset and suggest that s/he use one of his/her coping skills or ask him/her to do another activity. The staff persons never used a manual restraint on the SP because the VA was fragile. The SP never used “mean” words with the VA, but the VA sometimes said mean words to the staff persons. Facility documentation showed that the SP, P1, P2, and P3 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Conclusion: The VA told P2 that the SP hit the VA in the face. When P2 asked the VA about the incident, the VA told P2 that the SP hit the VA as the VA stood in the living room at bedtime and that in the past, the SP was “mean” to the VA but was unable to provide additional information about the incident. The VA also told P2 that P1 was in the staff office during the incident. P1 stated that s/he did not see or hear any altercation between the VA and the SP. The SP stated that s/he did not hit the VA at any time and did not make mean comments to the VA. Although it was reported that the VA had a bruise on his/her face, no information was provided that any of the staff persons saw a bruise. None of the staff persons previously had concerns about the SP’s interactions with the VA. Although the VA stated that the SP hit the VA and was mean to the VA, given the conflicting information provided by the VA and the SP about the incidents and that there were no witnesses to the incidents, there was not a preponderance of the evidence whether any of the SP’s actions could reasonably be expected to produce physical pain to the VA or was repeated oral conduct which would be considered by a reasonable person to be disparaging, derogatory, humiliating or threatening and could reasonably be expected to produce emotional distress to the VA.
It was not determined whether physical or emotional 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 and/or 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. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate and were followed by the staff persons. The SP no longer worked with the VA. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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