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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: 1070578-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Samantha Wueste Suspected Maltreatment Reported: It was reported that a staff person (SP) responded to a vulnerable adult’s (VA’s) behaviors by kicking the VA in his/her leg which caused the VA to sustain a bruise. Date of Incident(s): July 4, 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; from documentation at the facility; and through four interviews conducted with a supervisory staff person (P1), an administrative staff person (P2), the VA’s guardian (G) who was also the VA’s family member, and the VA’s case manager (CM). Attempts were made via phone to contact and interview an additional staff person (P3), but the attempts were not successful. However, P3 provided information for the facility’s Internal Review which is included below. Due to the diagnoses of the VA, the VA was not interviewed for this investigation but provided information to P1 and P2 which is included below. Additionally, the SP declined to be interviewed for this investigation. The facility was a single-family, two-story home in a rural area which was accessed by a gravel road that connected to a main road, where the VA lived alone. The main level of the home contained a living room, a dining/kitchen area, a laundry room that was to be kept locked when not in use, a staff office that was to be kept locked when not in use and only accessible to staff persons, two bathrooms, and two bedrooms including the VA’s bedroom. The lower level of the facility was not space that was used by the program or accessible to the VA. Due to the VA’s health conditions and history of maladaptive behaviors, the facility provided home modifications to maintain the safety of the VA and the safety of others which included installing plexiglass to the windows, security doors separating staff areas from common areas, bolting furniture and items to floor or wall, using weighted chairs and furniture, locking kitchen cupboards and cabinets, and storing refrigerated food items in a refrigerator that was secured near the staff office. Additionally, “all” medications and “sharp” or “hazardous” items were to be secured in a lockbox that was placed within a locked cabinet in the staff office and only accessible by staff persons. The VA loved animals and enjoyed outdoor activities, completing art projects, going to the zoo, spending time with family members, and watching movies. The VA’s diagnoses included diabetes, end stage renal failure, attention deficit hyperactivity disorder, generalized anxiety disorder, major depressive disorder, post-traumatic stress disorder, bipolar disorder, pervasive development disorder, oppositional defiant disorder, reactive attachment disorder, and mild intellectual disability. On July 23, 2021, the VA moved into the facility seeking supports and services relating to his/her diagnoses that included health and behavior management, medication administration, community integration, transportation, supervision, assistance to complete activities of daily living, and developing independent living skills. The VA’s Support Plan, Support Plan Addendum, Individual Abuse Prevention Plan, Self-Management Assessment, Supervision Needs, Positive Behavior Support Plan, Positive Support Strategies Plan, Use of Permitted Actions and Procedures, and Safety and Supervision Plan provided the following information: · The VA had 2:1 staffing 24 hours a day and no unsupervised time in the facility or the community. While the VA was present at the facility, staff persons were to remain within visual range of the VA at “all times” except for times when the VA used the bathroom or slept. Additionally, the VA was allowed “private time” in his/her bedroom as long as the bedroom door remained open, staff persons remained within auditory and/or visual distance of the VA, and staff persons completed health and safety checks throughout this time. Due to the VA’s diagnoses and history, the VA required a “high structured” and “calm” environment, “consistent” routines and “expectations,” and “adequate” time to process information. · The VA had a history of self-injurious behaviors; suicidal ideations; emotional dysregulation; verbal aggression that included “yelling,” “swearing,” and “threatening to harm” others; physical aggression that included property destruction and “hitting, biting, spitting, kicking, headbutting, and scratching” others; “attention-seeking” behaviors; “staff splitting” behaviors (using an “all-or-nothing” way of thinking to divide a care team into “opposing sides” and create conflict among staff); making false reports; and contacting emergency services when the VA was “unhappy” with staff persons. Additionally, the VA did not like to be told “no” to his/her “requests” or to “feel ignored” which “often” caused the VA to become “frustrated” that was then displayed through the VA’s behaviors including physical aggression towards staff. Staff persons were to be “proactive” in responding to the VA’s behaviors by understanding the VA’s “triggers” and “avoid” using language or behaviors that were known to “upset” the VA which included staff persons using their phones while working with the VA. · During situations when the VA was “agitated” and verbally/physically aggressive, staff persons were to remain “calm” while attempting to “redirect,” “de-escalate,” or “resolve” the situation by providing the VA with positive behavior supports, verbal prompts, “distractions,” “calming” activities, and “options” to problem solve. Additionally, staff persons were “permitted” to respond to the VA’s behaviors with “blocking” techniques, “escort redirection,” “holds,” and/or to “physically remove” the VA “when necessary” to maintain the safety of the VA and/or others, while using whichever response was the least restrictive intervention. P1 and P2; the VA’s Progress Notes completed by the SP dated July 4, 2025; the facility’s Incident Report completed by P1 dated July 6, 2025; a photograph of the VA’s bruise taken by P1 on July 6, 2025; and the facility’s Internal Review completed by P2 dated July 8, 2025, which contained information provided by P3 and the VA provided the following information: · On July 4, 2025, the SP and P3 were working at the facility during the afternoon/evening shift from 2 to 10 p.m. At some point between 5:30 to 6 p.m., the VA became “upset” and “kept complaining” about having “pain” in the VA’s left foot that extended into the VA’s stomach area. At the VA’s request, staff took the VA’s vital signs which were “all in normal range.” After this, staff persons encouraged the VA to lie down in his/her bed with “warm” blankets but the VA refused and was “upset” that staff persons were “doing nothing to help” him/her. The VA then exited the home and walked down the facility’s driveway while the SP and P1 followed the VA outside and provided verbal re-direction. When the VA reached the front edge of the facility’s property, the VA told staff that s/he was going to leave the facility and not return. The VA then walked onto the gravel road to the facility’s mailbox and towards the main road while the SP and P1 followed. Once the VA reached the main road, the VA walked out into the “middle of the road” and stood there for “a long time” with P3 standing beside the VA and the SP standing away from the VA at the side of the road. · At some point after this, the VA became “agitated” with the SP for an unspecified reason and told the SP that s/he was going to “kick [the SP] where it hurt” while the VA walked towards the SP. Once the VA was “near enough,” the VA attempted to kick the SP in his/her groin area. According to P3, the SP “jumped back” and it appeared that the VA may have “missed” and did not make physical contact with the SP at that time. After the VA tried to hurt the SP, the SP was “upset” and responded by “yelling” at the VA and then kicked the VA’s right leg which “upset” the VA further. P3 provided conflicting information regarding where the SP kicked the VA. P3 initially stated it was in the right thigh, but then stated it was in the back of the leg. The VA then “yelled” and “cursed” at the SP, called the SP names including “racial slurs,” and requested for the SP to leave the facility. Shortly thereafter, the SP turned away from the VA and began to walk back to the facility while the VA went to stand in the middle of the road again. P3 stayed with the VA and tried to “convince” the VA to return home but the VA told P3 that s/he did not want to “see” the SP anymore. P3 then “reassured” the VA that the SP would stay in the staff office if the VA returned to the facility.
· At an unknown time later, P3 was able to verbally “de-escalate” the situation by asking the VA to come inside the facility with him/her so that the facility’s on-call nursing staff could help with the VA’s stomach pains. The VA then agreed, but was “still agitated” that the SP had hurt him/her. After the VA entered the facility, P3 called the on-call nursing staff (N) to request help with the VA’s stomach pains and P3 gave the VA medications as directed by the N. “Eventually,” the VA was able to “calm down” and went to his/her bedroom. · On July 6, 2025, at approximately 1:30 p.m., a supervisory staff person (P4) was working at the facility during the morning shift when the VA told P4 about the incident and that the SP kicked the VA’s leg. The VA then showed P4 where s/he had been kicked by the SP. P4 saw a bruise on the backside of the VA’s right leg, behind the VA’s knee in the “inner crease” that was a “little bigger than the size of a quarter.” After talking with the VA, P4 contacted P3 to ask about the incident. P3 told P4 that s/he saw the SP kick the VA after the VA kicked the SP’s groin, which was consistent to the information that the VA had also provided to P4. At approximately 2 p.m., P1 arrived at the facility to work the afternoon/evening shift and at this time, P4 told P1 about the incident. At approximately 4 p.m., P1 called and notified P2 about the incident. After the call, P2 contacted and notified the G and the CM of the incident. · On July 7, 2025, P4 arrived at the facility to check on the VA and talk with him/her about the incident. The VA told P4 that s/he did not “feel comfortable” working with the SP after the SP kicked the VA. Shortly thereafter, the VA then began to cry and told P4 that the VA did not want the SP to “get fired” and said that s/he “felt bad” because the VA had “pushed [the SP] too far.” Additionally, the VA said that s/he became “upset” with the SP because the SP was talking on his/her cell phone while in the driveway with the VA, so the VA walked up to the SP and kicked the SP in his/her groin. After speaking with the P4 about the incident and how the incident made the VA feel, the VA told P4 that s/he was “feeling better” and then resumed his/her daily activities that were scheduled for the day. The G and the CM did not have additional information specific to the incident to provide. According to the facility’s Program Abuse Prevention Plan, staff persons were to use “positive behavioral supports” and follow client care plans when responding to incidents involving “challenging” behaviors including situations in which clients showed aggressive or assaultive behaviors towards him/herself or others. If a client’s behavior posed an imminent risk of harm to him/herself or others, staff persons were to implement an EMUR, if necessary. The facility’s policy on the Individual Rights- CBS stated that clients had a right to be free from maltreatment and to live without the fear of abuse and neglect. Additionally, clients were to have services and supports provided to them that were identified in their plans in a manner that respected clients as individuals and took into consideration the person’s preferences. Clients were to be treated with courtesy and respect. The facility’s Employee Code of Conduct policy and the SP’s Job Position Description stated that staff persons were to provide respectful and person-centered care services to the clients in a safe and therapeutic environment. Facility information showed that the SP, P1, P2, and P3 received training on the VA’s care plans; facility policies and procedures including the Program Abuse Prevention Plan, the Individual Rights- CBS, and the Employee Code of Conduct; and the Reporting of Maltreatment of Vulnerable Adults Act. The SP also received training on his/her job position prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), state in part that a person’s protection-related rights include the right to be treated with courtesy and respect. Conclusion: A. Maltreatment: Information from all sources was consistent that on July 4, 2025, there was a physical interaction between the VA and the SP. Sometime between 5:30 to 6 p.m., the VA walked down the facility’s driveway towards a gravel road with the SP and P1. At an unknown time shortly after this, the VA became “upset” that the SP was on his/her phone and the VA kicked the SP in or near his/her groin. It was not determined whether the VA made contact with the SP’s body. However, the SP responded by “yelling” at the VA and kicking the VA’s leg. Two days later, the VA told P4 who saw the VA’s leg where the VA said the SP had kicked the VA and the VA had a bruise on the backside of his/her leg that was a “little bigger than the size of a quarter.” Regardless of whether the VA made contact with the SP’s body, the SP’s actions of “yelling” at and kicking the VA were not accident or therapeutic conduct; was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services; and a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). Although the SP declined to provide information for this investigation, given the aforementioned, there was a preponderance of the evidence that the SP kicked the VA causing injury to the VA. 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 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. At the time of the incident, the SP was responsible for the care of the VA. The SP received training on the VA’s care plans; facility policies and procedures including the Program Abuse Prevention Plan, the Individual Rights- CBS, the Employee Code of Conduct, and the Job Position Description; and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for maltreatment 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 was not recurring because it was a single incident. However, it was determined to be serious. Although P3 provided conflicting information regarding the location of the kick, one of the locations, the back of the leg, was consistent with where the VA told P4 the SP kicked him/her and the VA had a bruise in that location so it was more likely that the SP kicked the back of the VA’s leg causing the bruise. Action Taken by Facility: The facility completed an internal review and found their policies and procedures adequate but not followed by the SP and P1. The SP was retained on the VA’s care plans and the facility’s policies and procedures. P1 was retrained on the Reporting of Maltreatment of Vulnerable Adults Act. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from 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. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. Minnesota Statutes, section 626.557, subdivision 3, requires mandated reporters at a facility to immediately report suspected maltreatment. The investigation determined that one individual failed to report suspected maltreatment as required. A letter from DHS was sent to the individual regarding his/her failure to report the suspected maltreatment and potential consequences for future such failures. Given that the facility took immediate corrective action a correction order was not issued for the violations outlined above.
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