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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: 1122764-H_CRS (Home and Community-Based Services-Community Residential Setting) 1072381-HCBS (Home and Community-Based Services) Investigator(s): Thomas Nixon 651-431-2155 Suspected Maltreatment Reported: Allegation One: It was alleged that a staff person (SP) kicked a vulnerable adult (VA1) causing VA1 to fall to the floor and sustain a bruise. Allegation Two: It was alleged that the SP punched another vulnerable adult (VA2). Allegation Three: It was alleged that the SP yelled at VA1, VA2, and another vulnerable adult (VA3). Date of Incident(s): Ongoing prior to January 17, 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 February 6 and 25, 2025; from documentation at the facility and law enforcement records; and through 11 interviews conducted with VA1 – VA3, another resident (R) who lived at the facility, VA1’s – VA3’s and the R’s guardians (G1 – G3 and G4 respectively), a supervisory staff person (P1), and two staff persons (SP and P3). Attempts were made via phone, text, email, and U.S. mail to contact and interview another staff person (P2), but P2 did not respond to the requests. The facility was a rambler style home. On the main level on the street side were two bedrooms separated by the primary bathroom that included an adapted walk-in shower. One bedroom had an en-suite bathroom and shower. Facility documentation showed that P1-P3 and the SP were trained on the VA1’s, VA2’s, and VA3’s care plans and on the Reporting of Maltreatment of Vulnerable Adults. Allegation One: It was alleged that the SP kicked VA1 causing VA1 to fall to the floor and sustain a bruise. VA1’s diagnoses included Prader-Willi Syndrome and intellectual disabilities. At times, VA1 was incontinent which was tracked by staff persons on the VA’s Behavior Outcome form. VA1 enjoyed collecting dolls and toys, coffee, shopping, and telling stories. VA1’s Coordinated Service and Support Plan Addendum (CSSP) stated that VA1’s incontinence was tracked as part of his/her Behavior Outcome. The CSSP also provided the following information: [The facility] provides residential services to [VA1] to meet [his/her] daily needs and activities. . . . [VA1’s] diagnosis can affect [VA1’s] ability to keep [his/her] balance when walking, running, or standing. . .
[VA1] has a history of falling when out for a run or walk, therefore staff need to assist [him/her] by standing within arm’s reach of [him/her] and offering to hold [his/her] hand if [s/he] needs additional support. . . . Due to the effects of PWS, [VA1] may display symptoms of confabulation as well as psychosis. [VA1] has a history of making up stories about people and/or events. There are times when these “stories” may include mention of violent or sexual events. In the past, when the frequency of “stories” which include violent or sexual events, [VA1] has then begun to display behaviors consistent with psychosis. . . . Prior to the incident, there was a bedroom change at the facility. VA1 moved out of the bedroom that had an en-suite bathroom and shower and VA3 moved in. What VA1 referred to as his/her bedroom at the time of the incident was VA3’s bedroom. During VA1’s interview, s/he had a difficult time answering questions and several times went back to talking about his/her health and things that happened when s/he was younger. VA1 provided the following information: · VA1 had issues with his/her knees that caused him/her to “sometimes” fall, about “two” times a week. When VA1 fell, s/he typically landed on his/her knees. VA1 then tried to find something to grab on to for help standing.
· VA1 did not remember what s/he and the SP were doing prior to the incident but VA1 was “not feeling good” and had “problems with [his/her] stomach.” VA1 was in his/her bedroom when s/he needed to use the bathroom and “tried to make it to the bathroom.” The SP told VA1, “You got to make it,” and “Go when you have to go.” The SP was “mad,” “angry,” and “holler[ed]” at VA1 that s/he was not doing things and that s/he was “wrong,” and the SP was “right.” VA1 told the SP to “stop,” and that s/he was “upsetting” VA1.
· The SP was behind VA1, got “angry,” and “kicked” VA1 on his/her butt. The kick “hurt… a lot.” VA1 fell and landed “on [his/her] butt.” VA1 told the SP s/he was “mad for what [s/he] had done,” and the SP said, “I didn’t do it.” · The SP left VA1 on the floor for “a while” and “made [VA1] sit there.” The SP “did not care” if VA1 was “safe or not safe” and “would not help [VA1] get up.” The rest of the evening was “not very good” because VA1 “ached and hurt.” VA1 denied being physically aggressive at the time of the incident. · Later on at an unknown date and time, VA1 looked at his/her buttocks, and saw “a big print.” [Note: VA1 could not provide additional details regarding the print.” The next morning, VA1 showed P3 the bruise and “as soon as [s/he] could,” VA1 also told P1 about the incident and showed P1 the bruise. The law enforcement report stated that VA1 told law enforcement that on January 17, 2024, around dinner time, VA1 was incontinent and the SP yelled at him/her for making a mess and kicked him/her and pointed to his/her right buttock. VA1 fell to the floor and was on the floor between five to ten minutes before the SP picked VA1 up. VA1 did not recall where in the facility this occurred. VA1 sustained a bruise on his/her right butt cheek that was one inch by one inch. P2 provided information to law enforcement and in the facility’s Internal Review that on January 17, 2025, P2 worked at the facility with the SP. At the time of the incident, P2 was gone with two other residents. Around 7 p.m., when P2 was back at the facility, the SP told P1 that VA1 did not earn his/her incentive reward because s/he was incontinent on the way to the bathroom. The SP said VA1 asked for a disposable brief and when the SP was about to hand it to him/her, VA1 tried to hit the SP. As VA1 was “taking a swing” at the SP, VA1 fell to the floor. The SP told P2 that s/he let VA1 sit on the floor for about 15 minutes because the SP was concerned that VA1 would “hit” the SP if s/he tried to “immediately” pick him/her up. P2 was not aware of any other instances when VA1 had been physically aggressive and did not talk to VA1 about the incident. The R provided the following information: · On the day of the incident, the SP “might” have been giving the R a shower when VA1 had an upset stomach and “might have” been incontinent. VA1 wanted the SP to help him/her get to the bathroom in his/her room but the SP told the VA that s/he “was busy” and that VA1 could “handle this yourself.” Because the SP was in the bathroom with the R who was showering, the SP “tried to get [VA1] away” despite the R not needing any assistance once s/he was seated in the shower. The SP and VA1 then left the bathroom while the R showered. · While in the shower, the R heard the SP “yelling at [VA1]” something like, “You’re not trying to get into your room.” The R heard the SP tell VA1 that s/he was “falling on purpose” and “You’re not trying to get up.” · “Five to ten minutes” later, the SP returned to help the R in the shower and appeared “very agitated.” The R asked the SP what was wrong and the SP said, “[VA1] fell and there’s a problem on the floor.” The SP used a “tone” that indicated to the R that it was “none of your concern.” While the SP helped the R finish his/her shower, the SP “concentrated more at yelling at [VA1].” Later on that evening, VA1 was “very quiet.” · At some point, the R heard from VA3 that the SP was “really mad” and “kicked [VA1] in the butt” causing VA1 to fall on his/her hands and knees. The R heard from VA3 that the SP “kicked” VA1 who “fell down on [his/her] hands and knees.” The R believed VA3 because at the time VA3 “pa[id] attention more” to what was happening. (Note: VA3 was not at the facility at the time of the incident. G3 said that when law enforcement interviewed VA1, VA3 heard the conversation through the bedroom walls.) P1 provided the following information: · In the past year, VA1’s balance and mobility had gotten “quite a bit worse” and VA1 now used a walker. One to two times a week, VA1 fell because s/he did not always lift his/her foot all the way up. VA1 typically “stumble[d] forward” and fell and did “not usually” sustain bruises. · VA1 was not formally diagnoses with dementia but had “quite a bit of memory loss.” VA1’s recall ability varied day to day. VA1 might think that staff persons were his/her family relatives, call a staff person by a different name, and/or need reminders of what was next but VA1 knew his/her routine and could recall details of the day. · P1 was not aware of any time when VA1 was physically aggressive towards any persons including staff persons. VA1 was “honest” and “very accurate” about events, even when s/he was “caught” doing something. VA1 was also a “storyteller” and “exaggerate[d] things” about people s/he knew from the past but did not say untrue things about staff persons. · VA1 wore disposable briefs and was able to use the toilet and clean his/herself independently. At times, VA1 was not able to get to the bathroom which resulted in him/her being incontinent. · The SP got along “good” with VA1, but the SP’s humor did “not really click” with the residents and it “clashed” with establishing relationships. The SP “did fine” working at the facility. When VA1-VA3 and the R learned the SP no longer worked at the facility, they seemed “bummed” and said they were “really going to miss [the SP].” · On January 17, 2025, around 9 p.m., P1 received a text message from P2 stating that the SP said VA1 did not earn his/her incentive reward that night because VA1 “hit” the SP. VA1 had been incontinent, needed a disposable brief, and was “upset and yell[ed]” at the SP. VA1 “swung at “and tried to hit the SP causing VA1 to lose his/her balance and fall. The SP did not want to be hit so s/he “left” VA1 on the floor for 15 minutes. P1 thought the rest of the shift was “good” and was not aware of any additional issues. P2 said that evening s/he needed to “encourage” VA1 to join in board games because VA1 was “quiet” and “not really having it.” The SP’s shift ended at 8 p.m. · On January 18, 2025, at 6 a.m., P1 arrived at the facility and VA1 told P1 about the incident. At that time, VA1 appeared “very with it” and “aware” and did not show any memory issues. VA1 said s/he did not make it to the bathroom in time and was incontinent. VA1 asked to use the bathroom, but since the R was in the shower in the main bathroom, VA1 went to use the bathroom in the bedroom. VA1 asked the SP to bring him/her a disposable brief and the SP followed VA1 out of the bathroom into bedroom. The SP “yelled” at VA1 and was “frustrated” and “upset” because VA1 had been incontinent · The SP then “kicked” VA1 in the buttocks causing a bruise. P1 and VA1 went to the bathroom and VA1 showed P1 a bruise on his/her “lower buttocks.” P1 had “never” seen a bruise on VA1’s “lower butt cheek.” VA1 typically had bruises on his/her hips because when s/he fell it was usually to the “side.” The bruise on VA1’s buttock was “dark” and “almost… black-ish” about the size of a “golf ball.” VA1 told P1 that the kick caused him/her to lose his/her balance and fall to the floor. The SP “left” VA1 on the floor for “10 to 15 minutes” before helping VA1 up. · P1 did not talk to the SP about the incident and the SP did not document the incident or provide any information that VA1 tried to hit the SP. P3 provided the following information: · VA1 often came to P3 to talk about his/her concerns or things that bothered him/her but never talked about having concerns with staff persons. P3 was not aware of any times VA1 was physically aggressive towards anyone. The SP was “good” to VA1 tried to help him/her when s/he was frustrated and make him/her laugh. P3 had no prior concerns with how the SP supported VA1. · VA1 was “pretty aware” of what happened around him/her but things “slip[ped] [his/her] mind.” VA1 needed reminders on what day it was and where s/he placed things at times accusing others of taking them. Sometimes, VA1 called people by the wrong name, forgot to use the bathroom, and forgot that s/he changed bedrooms. VA1 also struggled with timelines of incidents such as when they happened and how they happened. · VA1 fell “a lot.” On occasion, when VA1 was alone in his/her bedroom and fell, P3 heard VA1 say that “someone pushed” him/her. P3 then went into the room to help VA1 up, and VA1 accused P3 of pushing him/her even though VA1 was in the room by his/herself when s/he fell. VA1 also said that staff or other residents pushed or hit him/her when they were no near VA1 at the time and no one had touched him/her. · On January 17, 2024, P3 worked the overnight shift and relieved the SP. When P3 arrived, VA1 was in bed. On January 18, 2024, in the morning when P3 assisted VA1, P3 did not notice anything unusual or any bruises on VA1 and VA1 did not say anything about a bruise or an incident the previous night. VA1 appeared “good” and “relaxed.” Later that day, P2 asked P3 to look at a bruise on VA1. P3 did so and saw a “small” and in “triangular shape[d]” bruise. [Note: Information was not obtained regarding the location of the bruise.] P3 asked VA1 what happened and VA1 said s/he did not know. P3 asked VA1 if s/he fell on something, and VA1 said she did not know. P3 touched the bruise and VA1 said it did not hurt. The SP provided the following information: · VA1 was “very unsteady” and sometimes wanted assistance to walk. The SP thought this was “a behavior” because VA1 only asked for help and fell around “certain” staff persons. VA1 needed “a lot” of prompts to use the bathroom but s/he was capable of changing him/herself. At times, VA1 “acted” like s/he could not use the bathroom or change his/her disposable brief independently and wanted staff persons to do it for him/her. · On January 17, 2024, at 2 p.m., the SP and P2 were working at the facility. VA1 and the R arrived at the facility from their day programs and each used the bathroom. At 3 p.m. they each had snack and medications. P2 then brought VA2 and VA3 to the gym, while the SP stayed at the facility with VA1 and the R. · The SP planned to assist the R into shower before starting to make dinner because once into the shower, the R was independent. The SP asked VA1 if s/he needed to use the bathroom before the R showered and VA1 said s/he did not. · The SP then helped the R into the bathroom, undressed, and into the shower chair. While assisting the R, VA1 walked past the bathroom without his/her cane or walker, towards VA3’s bedroom. VA1 did not come into the bathroom or say s/he needed to use the bathroom, and the SP did not direct VA1 to use the bathroom in VA3’s bedroom. The SP left the bathroom and went to see why VA1 was going to VA3’s bedroom. · Once the SP was in VA3’s bedroom, the SP reminded VA1 that s/he needed ask a staff person before going into VA3’s bedroom. VA1 then told the SP had been incontinent. The SP was “disappointed” and told VA1 that s/he had just been asked if s/he needed to use the bathroom and that VA1 could have avoided being incontinent. VA1 asked for a disposable brief so the SP went to get one and brought it to VA1 who was still in VA3’s bedroom. · VA1 was in the middle of VA3’s bedroom walking towards the bathroom. The SP walked up behind VA1 with the brief and said, “Here.” The SP said s/he thought s/he either handed VA1 the brief to VA1 over VA1’s shoulder or might have tapped on VA1’s shoulder to get his/her attention which might have “scared” VA1. · VA1 began to turn around to face the SP and while in motion, VA1 “swung” his/her left arm out “trying to hit” the SP with his/her left hand. The SP “stepped out” of the way to avoid being hit by VA1’s hand. VA1’s swing was “awkward” and s/he became “off balance,” so as VA1 continued to swing his/her arm, VA1 “trip[ped] over [his/her own] feet” and fell to the floor on his/her right side. VA1 had never swung at the SP in the past. · As VA1 was on the floor, s/he started “yelling” and “cussing” at the SP. VA1 said s/he was “going to defend [him/herself]” and “kicked” at the SP and “threatened” to hit him/her so the SP “kept [his/her] distance” away from VA1. The SP then left VA1 on the floor and went to check on the R who was still in the shower giving VA1 time to calm because the SP’s presence with VA1 was “not working” to deescalate the situation because VA1 was “so upset” with the SP. The SP wanted to allow the VA to calm on his/her “timetable” so s/he was not kicking or cussing at the SP. · The SP walked back and forth “several times” between the R in the shower and checking on VA1 on the floor. Each time, the SP asked VA1 if s/he was ready to move on and if VA1 wanted help to stand. The third or fourth time, the SP saw VA1 “crawling” towards VA3’s bathroom. The SP walked behind VA1, placed his/her arms under VA1’s shoulders, and picked up VA1 to stand, which VA1 handled “surprisingly well.” VA1 seemed “back to normal” and was no longer “mad.” The SP then went back to the R in the shower. · The SP said VA1 was on the floor for about 10 to 15 minutes. The SP did not check VA1 for any bruises, but did not see any bleeding and VA1 did not complain of any pain. The rest of the evening was “fine” and “normal.” · At some point after P2 returned to the facility, the SP told P2 that VA1 had been incontinent and swung at him/her. The SP said it was possible s/he also told P2 that VA1 kicked at him/her and that VA1 did not earn his/her incentive program item for “non-compliance.” The SP did not document the incident because it was a “busy” shift but planned to do so the next morning. The SP also did not tell the next staff person about the incident with VA1. · The SP denied kicking VA1 and was not aware of VA1 sustaining a bruise. The SP stated that his/her stature and size it was “very difficult moving around” and was “basically impossible” for him/her to “kick high enough to kick [VA1] in the butt” without the SP “falling” him/herself. The SP did not think s/he was able to kick his/her foot “up that high, definitely not swinging it.” The SP did not know how VA1 sustained the bruise. G1 said that VA1 was “pretty well aware” of what happened around him/her and “underst[ood] quite a bit.” VA1 had been “a little more forgetful” lately, but G1 never knew VA1 to make up stories. A couple of times, VA1 fell when s/he was at G1’s home and tended to fall “sideways.” P1 told G1 about the allegation and prior to the incident, G1 had no concerns with the facility. G1 “doubt[ed]” that VA1 physically aggressed towards the SP. The SP was charged with misdemeanor abuse by a caregiver and 5th degree assault. The SP originally plead not guilty but then the case was continued for dismissal. [Note: A continuance for dismissal is a legal agreement in Minnesota where the prosecution agrees to suspend the case for a specific period. If the defendant meets certain conditions during this time, the charges will be dismissed without a conviction.] Conclusion for Allegation One: A. Maltreatment: Information was consistent that on January 17, 2025, VA1 was incontinent and asked the SP for assistance with a new brief. At some point, VA1 fell to the floor where the SP left VA1 for 10 to 15 minutes. VA1 provided consistent information during his/her interview, to law enforcement, and P1 that the SP kicked him/her causing him/her to fall to the floor and afterwards, VA1 had a bruise on his/her lower right buttocks. The SP denied the allegation and said that VA1 fell as a result of his/her swinging trying to hit the SP. Given the conflicting information provided, credibility was left as a determining factor. The SP had reason to minimize his/her interactions for fear of repercussions and although there were some concerns with VA1’s memory and possible dementia, VA1 had no history of providing inaccurate information regarding staff persons interactions and no history of being physically aggressive towards staff persons. In addition, although the R was in the shower and did not see the interaction, the R heard the SP yelling at VA1 during the incident and returned to the bathroom “very agitated,” which corroborated VA1’s account that the SP was “mad,” “angry, and “hollering” at VA1. Therefore, VA1’s account of the incident was more credible than the SP’s account. Given that kicking VA1 in the buttocks was not accidental or therapeutic and that it caused him/her to fall to the floor and sustain a bruise, there was a preponderance of the evidence that the SP’s actions produced or could reasonably be expected to produce physical 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 VA1’s care plan and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for maltreatment of VA1. 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 was not “recurring” because it was a single incident but it was “serious” because VA1 sustained a bruise. Allegation Two: It was alleged that the SP punched VA2.
VA2’s diagnoses included Prader-Willi Syndrome, moderate intellectual disabilities, obsessive compulsive disorder, and autism spectrum disorder. VA2 liked to watch movies, Disney, Veggie Tales, and spending time with his/her family. VA2’s Self-Management Assessment stated the VA might hit, pinch, kick, and push others. Staff persons were to “verbally prompt [VA2] once and suggest alternatives that would have more positive outcomes and will clearly explain those to [VA2] in a calm manner. If target behaviors persist, and those behaviors threaten [VA2’s] safety or the safety of others [VA2] will be asked by staff to move to an area where [his/her] behavior will be less of a threat.” VA2 said around “ten months ago” the SP and P3 were working. When it was “almost time to eat,” VA2 stood “close by the kitchen door” near the SP. P3 “was around.” VA2 then provided conflicting information. Initially VA2 said the SP “punched” VA2 and showed the investigation that it was to his/her chest/shoulder area, but then VA2 said that the SP “almost punched” him/her. The SP told VA2 s/he did it because s/he was “too close to the [kitchen] door.” VA2 then ended the interview and did not provide additional information. P1 and P3 were not aware of any instances when the SP punched VA2. P3 stated that the SP and VA2 got along “well,” “made lots of jokes,” and VA2 was “always laughing” when they were together. P1 and P3 had no concerns regarding the SP’s interacted with VA2. G2 stated that s/he assisted VA2 with bathing weekly and did not see any bruises or marks that might indicate that VA2 was punched. The SP denied punching VA2 or putting his/her hands on VA2. Conclusion for Allegation Two: Given that VA2 provided conflicting information regarding whether the SP punched or almost punched the VA, that P1 and P3 were not aware of any instances when the SP punched VA2 and neither had concerns regarding the SP’s interactions with VA2, and that there was no information provided that VA2 had any injuries/bruises that might appear as though s/he was punched, there was a preponderance of the evidence that the SP did not punch VA2. It was not 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). Allegation Three: It was alleged that the SP yelled at VA1, VA2, and VA3. VA3’s diagnoses included Prader-Willi Syndrome, autism spectrum disorder, and mild intellectual disabilities. VA3 liked to read books, bowl, talk with his/her family, and be outside. VA1’s-VA3’s Individual Abuse Prevention Plan stated that each had an inability to deal with verbally/physically aggressive persons. The R said the SP gave “a lot of orders” and was “really bossy.” The SP told the residents what they should and should not be doing. The SP wanted things done a certain way, told people they were doing it “wrong,” and said they were not following instructions “on purpose.” The SP was “always yelling at people” and “yelling quite a bit at “almost all of us.” The SP also “chas[ed]” VA3 causing VA3 to be “afraid” the SP. VA1 said the SP was “very pushy” and when VA1 did not complete his/her exercise workout expectations, the SP often told VA1 s/he could “do better than that.” When VA1 did “wrong things,” the SP told VA1 s/he was “doing this shit on purpose” and to “knock that off.” The SP “did not care how [s/he] reacted” towards VA1. The SP called VA1 “names” and seemed to “test us” on “how mad” s/he could make the residents. At times, other staff persons were around when the SP said this. VA1 did not provide additional details such as dates, times circumstances, or who was present at the time of the incidents VA2 said when the other residents “hurt” his/her feelings or made him/her “feel bad,” the SP helped VA2 “feel happy again” and “feel better” by saying “nice words.” VA2 ended the interview prior to obtaining any additional information. VA3 said the SP never yelled at him/her but said things that made him/her feel like s/he did not do the right things. On an unknown day in the winter 2023 or 2024, VA3 had a normal day and was reading his/her book in the living room. The SP lay on the couch and told VA2 that s/he was “going to keep an eye on you” and “going to get [VA3].” VA3 thought the SP was “teasing” as the SP had in the past. The SP then “follow[ed]” VA3 to his/her room. VA3 was “scared” so s/he “shut the door on [the SP]” and locked the door. VA3 did not know if the SP tried to open it and nothing else was said or done. P1 was not aware of any times when the SP yelled at any resident and was not aware of any concerns about the SP from VA2, VA3, or the R. P1 was not aware of any situations where VA3 locked him/herself in his/her bedroom as s/he was afraid of the SP. P3 never heard the SP yell and the SP only “raise[d]” his/her voice when the R yelled at him/her and the SP needed to be heard. The SP and VA3 got along “very well.” The SP was the main staff who brought VA3 into the community and when they came back VA3 was usually “happy and excited.” G2 had concerns with how a previous staff person, who was not the SP, spoke with VA2, but that person no longer worked at the facility. G3 heard the SP get “frustrated and upset” with the residents and “raise [his/her] voice,” but never heard the SP swear or be demeaning towards them. If VA3 was concerned or scared of a staff person, s/he would tell one of his/her family members, who would then tell G3, who would follow up with VA3. G3 was not informed by any of VA3’s family members about any concerns VA3 had with the SP. G4 had no concerns with the facility or staff persons. The SP said s/he “definitely” was “loud” and used a “firm… voice relatively frequently” when the residents were being loud. The SP did this to try to be heard over the residents when they “scream[ed]” and “slamm[ed]” items and were not listening. The SP denied screaming at the residents and did not swear at them or say anything humiliating, insulting, or derogatory at/towards them. On an unknown date, the SP and VA3 were at a walking track and VA3 went “significantly faster” than the SP could walk. The SP “joke[ed]” with VA3 that s/he “was going to get you” and tried to catch up. VA3 “laugh[ed]” when the SP said this. The SP did not recall any other times s/he told VA3 s/he was “going to get [him/her],” but if the SP did it was meant as a joke. Conclusion for Allegation Three: Although the R said the SP was “always yelling at people” and “yelling quite a bit” at “almost all of us,” and that VA1 said the SP called VA1 “names,” neither provided details of incidents including dates, times, circumstances, or who was present at the times of the incidents and there was no other information provided that any person heard the SP make derogatory comments to the residents. Information was consistent that at times the SP might be loud and raise his/her voice but it was to get the attention of the residents. Additionally, while the SP acknowledged to having made statements at times about “getting” VA3, the SP said it was done in a joking manner, and that VA3 laughed. VA3 also stated that s/he thought the SP was teasing as the SP had in the past. Given the aforementioned, there was not a preponderance of evidence whether all of the SP’s interactions with VA1, VA2, and VA3 were therapeutic conduct or whether the SP yelled at each in a manner that would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening and could reasonably be expected to produce emotional distress. It was not determined whether 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: 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 policies and procedures were adequate but not followed. Staff persons were retained on communication between shifts, to supervisors for significant behaviors and falls, and documentation policy expectations. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for serious maltreatment and that any future background studies for facilities, programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal. On November 20, 2025, the facility was issued a Correction Order for using a token reinforcement program that included a response cost or negative punishment component.
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