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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: 1113760-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070450-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler jason.pehler@state.mn.us Suspected Maltreatment Reported: It was reported a staff person (SP) kicked a vulnerable adult (VA) in the leg. Date of Incident(s): June 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 subdivision2, 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 conducted on July 16, 2025; from documentation at the facility and/or law enforcement records; and through five interviews conducted with a facility staff person (P1), a facility supervisor (P2), the VA’s case manager (CM), the VA’s guardian (G), and the SP. This investigator attempted to interview the VA; however, the VA did not engage with this investigator, and had limited verbal communication. The facility was a two-level home with a front entry that led to a living room. The living room was connected to the kitchen/dining room. A hallway off the living room/kitchen led to the VA’s bedroom. There was no angle which allowed a view into the VA’s bedroom from the kitchen or living room. The facility had a video recording device in the living room/kitchen. The recording was stored for a period of two weeks before it was recorded over. The alleged incident was reviewed by the facility; however, the facility was not able to retain the video recording, and it was not provided to this investigator. Facility documentation showed the VA enjoyed spending time with the G, going on car rides, and getting drinks at a café. The VA required assistance with hygiene tasks such as brushing teeth, and bathing. The VA was diagnosed with developmental disabilities, autism, and epilepsy. The VA’s Coordinated Service Support Plan (CSSP) Addendum provided the following information: · The VA was sensitive to his/her environment including loud noises, crowded rooms, and strange smells. The VA experienced high anxiety and was hyperactive through the duration of the day. · The VA had a history of self-injurious behavior (SIB), property destruction, and physical aggression. The SIB and physical aggression included biting, head banging, punching him/her herself or others. The VA’s property destruction included throwing objects around, and kicking holes in the wall. · Staff persons should redirect the VA without using force, and should contact 9-1-1 for assistance if there was imminent danger. The VA’s Individual Abuse Prevention Plan (IAPP) showed the VA was susceptible to physical abuse. The G said s/he had minimal information related to the alleged incident, but observed bruises on the VA’s legs. The G said there may have been a staff person present when an alleged incident occurred, and the facility utilized a video recording system. The G did not have access to the recording. Pictures of the VA legs showed s/he had approximately ten bruises in total on both legs. The majority of the bruising was located around the VA’s knees, were brown in color, and were different shapes and sizes. There was no information that the VA require any medical assessment due to the alleged incident. The VA’s progress notes provided the following information: · On June 19, 2025, the SP completed a progress note. There was no information related to any alleged incident. · On June 20, 2025, it was noted the VA had showered. There was no information related to any bruising observed. · On June 22, 2025, it was documented the VA had bruising on his/her legs. The facility completed an Internal Review (IR) which provided the following information: · On June 22, 2025, it was observed the VA had bruising on his/her legs. P1 stated s/he had witnessed the SP kick the VA on June 19, 2025. · P1 said s/he observed bruising on the VA on June 22, 2025, while assisting the VA with personal cares. P1 denied observing the SP or anyone else harming the VA, but said s/he asked the SP if s/he had caused the bruising, which the SP denied. · The SP the VA was fast moving, but clumsy. The SP added that the VA would bump into furniture and stub his/her toes due to the way s/he walked. · P3 said s/he observed bruising on the VA’s legs on June 22, 2025, and took pictures of the bruising. P3 confirmed P1 had also observed the bruising. P3 believed the bruising s/he observed was SIB as the VA often bumped his/her knees and pressed on his/her legs while using the bathroom. · The facility reviewed the video recording which showed P1 and the SP at the facility on June 19, 2025. At 5:45 p.m., the SP walked down the hallway toward the VA’s bedroom. At 5:46 p.m., P1 walked toward the VA’s bedroom for a few seconds, before going to another area of the house. P1 returned to the VA’s bedroom at 5:49 p.m., the VA and P1 talked in the doorway of the VA’s room. At 5:52 p.m., the SP exited the VA’s bedroom and went into the kitchen. There was no other information related to the allegation. P1 provided the following information: · P1 denied observing the SP kick or harm the VA, but heard the VA scream. P1 responded to the VA’s bedroom and asked the SP if s/he had hit the VA, which the SP denied. P1 said the SP had moved away from the VA after the VA had screamed, and was not near the VA when P1 went into the bedroom. · P1 said the VA had recently engaged in SIB in which s/he hit and pinched his/her legs near or around the knee area. P2 provided the following information: · P2 said s/he did not witness any concerning interactions between the SP and the VA. · P2 said the injuries were not consistent with the VA’s property destruction as s/he typically would kick the wall with his/her foot, or hit the wall with a hand. P2 added that the VA had a history of SIB, but had not witnessed the VA hit him/herself in the legs near his/her knees. The SP provided the following information: · The SP denied hitting or kicking the VA, and said there was “gossip” at the facility, but tried to keep to him/herself. · The SP said the VA engaged in SIB, physical aggression towards staff persons, and property destruction. · The SP said s/he did not assist the VA with personal care such as showering and had not seen any bruising on the VA. The CM was aware the VA had bruising on his/her legs due to an incident, but was not sure how the bruising occurred. The CM said the VA was not a risk to engage in physical aggression, but had a history of SIB. The G reviewed the IR and identified multiple inconsistencies with the information. The inconsistencies noted included, but were not limited to the information below. This investigator, the facility and LE reviewed the information from their investigations, completed additional interviews, and sought to clarify the inconsistencies: · P1 witnessed the alleged abuse on June 19, 2025, and there was a delay in reporting the alleged incident until June 22, 2025. LE and the facility re-interviewed P1, and P1 denied observing the SP “strike, kick, or hit” the VA. P1 said any other documentation that stated otherwise was a miscommunication due either to language barrier or just misunderstanding. LE closed their investigation without any charges. Based on the information, there was not a reporting delay because P1 denied observing any alleged abuse. · P3 said s/he observed bruising to the VA’s legs, and contacted P2. P3 did not observe or have information related to how the bruising occurred. P3 said s/he had previously observed the VA pressing on his/her legs while going to the bathroom. · The SP stated the VA was “very fast and clumsy,” and would often bump into furniture. The G’s said the VA was not clumsy and did not “run” into things. · The IR did not show what days or times the video recording system was reviewed. The IR stated an 11-minute timeframe showed the SP’s interaction with the VA. The IR stated P1 was in a medication office (which was located downstairs) and interacted with the VA, who was in his/her bedroom on the main floor. Based on the information it was believed the facility description of the location of P1 was inaccurate, and P1 was in a doorway (not the medication office) across the hallway from the VA. · The VA did not have “skin checks” completed every shift. The skin checks were started by a previous supervisor as a best practice process, and they were not ordered by a physician. Although it was considered good practice to ensure the safety of the VA, the skin checks were not a requirement based on the VA’s programming. · The facility reimplemented skin checks as a result of the investigation, and staff persons were retrained on documentation. P1, P2, and the SP received training on the VA’s client specific plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: It was reported the SP kicked the VA in the legs on June 19, 2025. There was a video recording from inside the facility, however the recording provided limited information related to the alleged incident. The VA was unable to provide any information related to the alleged incident. P1 was working on June 19, 2025, and heard the VA scream while in his/her bedroom. P1 observed the SP and the VA in the VA’s bedroom, and asked the SP if s/he had hit the VA. P1 said s/he did not observe the SP kick or harm the VA, and therefore did not provide information that corroborated the initial information that P1 had observed the VA kick the SP. The SP denied kicking or harming the VA, and said s/he was not aware of any injuries the VA had. The VA had a history of physical aggression, property destruction, and SIB. There was conflicting information whether or not the injuries were consistent with the VA’s history of SIB and property destruction, however P1, and P3, described the VA engaging in SIB of pinching his/her legs, or pushing on his/her thigh and knee area. Although the VA had bruising on his/her legs, there was no corroborated information that showed the SP had harmed the VA, and a plausible explanation related to the VA’s SIB may have been the cause of the bruising. It should be noted it was unclear why the initial reported included information that P1 had observed the SP kick the VA. Given that, it was not able to be determined how the VA’s bruises were sustained, therefore there was not a preponderance of the evidence whether a staff person engaged in conduct that would cause the VA pain or injury or whether the VA’s bruises were caused by any other means other than accidental. It was not determined whether 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.) Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, but not followed as staff persons did not report the alleged incident for multiple days after the bruises were observed. The facility completed additional with all staff persons. The report was not similar to past events, and no additional corrective action was completed to ensure the safety of the VA. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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