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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: 1069061-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Heidi Murphy Heidi.Murphy@state.mn.us 651-431-6544 Suspected Maltreatment Reported: It was reported that a staff person (SP) assisted a vulnerable adult (VA) from a facility van using a wheelchair lift and did not have the lift in the correct position, which resulted in the VA rolling off the edge of the van on to the ground. The VA suffered a closed head injury. Date of Incident(s): October 13, 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 17, paragraph (a): 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 November 6, 2025; from documentation at the facility and medical records; and through five interviews conducted with two facility staff persons (SP and P2), a facility supervisory staff person (P1), and two of the VA’s guardians (G1 and G2). Due to the VA’s disabilities, the VA was not able to provide any information for this investigation. The VA’s diagnoses included Down syndrome and dementia. The VA had mobility difficulties and used a wheelchair. The VA enjoyed coloring, singing, dancing, and watching television. The VA’s plans stated the VA used a wheelchair for daily mobility. The VA did not use public transportation and relied on staff persons to transport the VA to appointments and activities using a van equipped with a wheelchair lift. The facility was a one-story single-family residence with a finished basement in a residential neighborhood. The main floor consisted of a living room, a dining room, a kitchen, three bedrooms, two bathrooms, and a laundry room. The lower level consisted of a living room, three bedrooms, a bathroom, and two utility rooms. The facility van was equipped with a wheelchair lift that assisted with the transportation of the VA. Staff persons opened the rear doors of the van and used the controller to unfold the lift platform from a vertical position to a horizontal position. Staff persons went back inside the van, released the seatbelt and locks on the wheelchair, unhooked the wheelchair, and pushed the VA’s wheelchair onto the lift platform. The wheels on the wheelchair were locked and the controller was used to lower the lift platform to the ground so the VA could be rolled off the lift. The controller had two buttons, one for folding and unfolding the lift and one for raising and lowering the lift. On October 14, 2025, the van was inspected and repaired for an issue unrelated to the incident. The SP provided the following information: · The SP was trained on the operation of the van’s lift and had transported the VA approximately twice a week since April of 2025 without any issues. The SP stated the correct procedure for assisting the VA out of the van was to set the emergency brake, go to the back of the van and open the back doors, unfold the lift, go back inside the van and unbuckle the VA’s seatbelt, unhook the hooks from the wheelchair, unlock the wheelchair wheels, check to make sure the lift was in place, push the wheelchair onto the lift, lock the wheelchair wheels, go outside the van and lower the lift to the ground. The VA’s wheelchair was then taken off the lift and the lift was folded back into a vertical position and the doors were closed. · On October 13, 2025, the SP took the VA to an area mall to “people watch.” The SP transported the VA in a facility van. When the SP and the VA arrived back at the facility, the SP parked the van in the driveway and put the emergency brake on. The SP got out of the van and went around to the back of the van and opened the back doors. The SP “unfolded” the lift (lowered the lift from a vertical position to a horizontal position) and lowered the lift to the ground. (The lift was operated by a controller with two buttons, one that folds and unfolds the lift from a vertical to horizontal position and one that raised and lowered the lift from being level with the van floor to the ground.) The SP stated that was the process when the VA was being assisted into the van, not off the van. The SP stated his/her “brain was working backwards.” · The SP went into the van, unbuckled the VA, unhooked the VA’s wheelchair from the straps, unlocked the wheelchair wheels and started to push the wheelchair backwards. The SP did not realize the lift was down on the ground and the VA’s wheelchair rolled backwards and fell out of the van. The VA did not scream or make any noise. The VA remained conscious and talked to the SP. · The SP ran into the facility to get another staff person for help. The other staff person called the facility crisis line for guidance and was advised to call the non-emergency number and 9-1-1. The SP did not see any bumps on the VA’s head. When the SP lifted the VA’s head, the VA said, “Ouch!” The SP did not move the VA any further. · The SP stayed with the VA until another staff person arrived for their shift. The SP left the facility and completed an incident report. · The VA was transported by ambulance to a local hospital for evaluation. Medical records showed the VA was evaluated at the emergency department of a local hospital on October 13, 2025, and was diagnosed with a closed head injury. The head injury was classified as “mild,” and symptoms had resolved. The VA was released from the hospital the same day, with the recommendation that observation continued at the facility. P1 provided the following information: · P1 was contacted by the facility crisis responder and informed that the VA had fallen out of his/her wheelchair and needed help back into the wheelchair. P1 was also told that the VA had struck his/her head. · P1 called the SP to find out exactly what happened. The SP told P1 that s/he unfolded the lift on the facility van and lowered the lift all the way to the ground. The SP went back on the van and pushed the VA backwards thinking the lift was level with the floor of the van. The lift was on the ground and the VA was pushed off the van and fell backwards, which caused the wheelchair to tip over on the lift and the VA struck his/head on the lift surface. · An ambulance transported the VA to an area hospital. The VA was evaluated and diagnosed with a head injury. The VA likely had a concussion; however, concussion testing could not be completed due to the VA’s dementia diagnosis. The VA did not have any negative long-term effects from the injury. · There were no witnesses to the incident. · The van was inspected after the incident on October 14, 2025. P2 provided the following information: · P2 was not working when the incident happened and learned about it from reading the VA’s shift notes. P2 also heard about the incident from the SP and P1. P2 was told the VA was on the lift and fell and tipped over and struck his/her head. P2 did not “pry” for any other details. · All staff persons that transport clients were trained how to use the lift to assist clients on and off the van prior to being allowed to transport a client. The SP trained P2 on how to use the van lift. · The VA was assisted on the van facing forward and it was too difficult to turn the wheelchair around and the “seatbelt isn’t designed for that.” The VA rode in the van facing forward and then was pushed backwards when being assisted on to the lift. G1 and G2 were both notified by the facility of the incident. G1 and G2 had not discussed the incident with the VA and did not think the VA would have remembered the incident. G1 and G2 understood that accidents happen and were hopeful similar incidents would be prevented in the future. Facility records showed that all staff persons interviewed were trained on the Reporting of Vulnerable Adults Act and on the VA’s plans. Conclusion: It was reported that on October 13, 2025, the SP returned to the facility with the VA after an outing. The SP went to the back of the van, unfolded the lift from a vertical position to a horizontal position and lowered it to the ground. The SP went back in the van and went through the procedures to unsecure the VA’s wheelchair from restraints and pushed the wheelchair backwards towards the rear of the van. The SP continued to push the wheelchair to where the lift should have been. The VA fell to the ground and landed on his/her back on the lift. The VA struck his/her head during the fall. The SP was trained on the proper operation of the lift and had used the lift with the VA many times since April of 2025. The SP acknowledged that a mistake was made, and the lift should not have been lowered to the ground until the wheelchair was secured on the lift. The SP stated his/her “brain was working backwards.” The VA was transported to the hospital and was evaluated and diagnosed with a closed head injury. The VA did not have any known long-term injuries from the fall. The VA’s plans stated the VA used a wheelchair for mobility and depended on staff persons for transportation in a facility lift equipped van. Although the SP had been trained on transporting the VA and the use of the van lift and had followed this procedure many times in the past, the SP acknowledged s/he forgot to properly observe and confirm the lift was in the proper position prior to pushing the VA onto the lift. Minnesota Statutes, section 626.5572, subdivision 17, paragraph (c), clause (5), states, A vulnerable adult is not neglected for the sole reason that an individual makes an error in the provision of therapeutic conduct to a vulnerable adult that results in injury or harm, which reasonably requires the care of a physician; and: (i) the necessary care is provided in a timely fashion as dictated by the condition of the vulnerable adult; (ii) after receiving care, the health status of the vulnerable adult can be reasonably expected, as determined by the attending physician, to be restored to the vulnerable adult's preexisting condition; (iii) the error is not part of a pattern of errors by the individual; (iv) if in a facility, the error is immediately reported as required under section 626.557, and recorded internally in the facility; (v) if in a facility, the facility identifies and takes corrective action and implements measures designed to reduce the risk of further occurrence of this error and similar errors; and (vi) if in a facility, the actions required under items (iv) and (v) are sufficiently documented for review and evaluation by the facility and any applicable licensing, certification, and ombudsman agency. Given that medical care was obtained for the VA in a timely manner; that the VA was expected to return to his/her preexisting condition; that there were no past similar incidents with the SP; and that the facility reported the incident, identified what corrective actions needed to be completed, provided retraining to the SP, and sufficiently documented their actions for review and evaluation; therefore, it was determined that the SP’s actions were an error in the provision of therapeutic conduct. This error in the provision of therapeutic conduct to the VA by the SP was not maltreatment. It was determined that neglect did not occur (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’s Internal Review stated related policies and procedures were adequate and were not followed by the SP. Additional training was needed and the SP was retrained on operating the van’s lift system and vulnerable adult training. The incident was not similar to past events and no further corrective action was needed to protect the health and safety of vulnerable adults. The van was inspected and it was determined that the lift was in proper working condition. The VA’s wheelchair was inspected and found to be free from damage or defect. Action Taken by Department of Human Services, Office of Inspector General: No further action.
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