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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: 1071504-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman/Alice Percy 641-431-6567 Suspected Maltreatment Reported: It was reported that a staff person (SP) posted on social media a photograph of a vulnerable adult (VA). The SP held his/her arm around the VA’s neck while they stood in front of a mirror. The VA was unclothed at the time. It was also reported that the SP posted a video on social media of the VA showing his/her underwear and stomach. Date of Incident(s): Unknown, between March 9 and May 9, 2023 (The Department of Human Services did not receive the report until May 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 for this investigation was obtained remotely, including documentation from the facility; and through one interview conducted with the VA’s guardian (G). Attempts were made by telephone to contact the SP, but the SP did not respond to the requests for an interview. Emails and letters sent to the SP were returned as undeliverable. Attempts were made by email and telephone to contact an administrative staff person (P), but the P did not respond to the requests for an interview. The VA was unable to provide information about the incident. The VA enjoyed going on van rides, playing catch, and doing art projects such as coloring. The VA’s diagnoses included Down syndrome, moderate developmental disability, and congestive heart failure. While the VA was nonverbal, s/he sometimes used screaming as a way to communicate. The VA lived at the facility from August 3, 2022, to September 26, 2024. The VA’s Individual Abuse Prevention Plan stated that the VA was unable to identify potentially dangerous situations or to deal with verbally or physically aggressive persons. The VA was nonverbal and would not be able to communicate about any abuse. The G stated that at the time the VA lived at the facility, the G had no concerns about the care the VA received from the staff persons. The SP worked at the facility from March 9 to May 9, 2023. A review of a video that was reported to have been posted on social media showed the VA walk into a room toward the camera, pull his/her shirt up briefly to show his/her stomach and then pull his/her pants down to show the top of his/her underwear. A caption on the video said, “[S/he] finna get wicked.” A review of a photograph that was reported to have been posted on social media showed the VA and the SP standing in front of the bathroom mirror in the facility. The SP stood behind the VA and had his/her right arm around the VA’s neck while s/he held a cell phone in his/her left hand so that s/he could photograph the two of them in the mirror. Although the VA’s body was blurred out in the photograph provided to this investigator, it was reported that the VA was unclothed in the original photograph posted on the internet. [Note: Information obtained showed that the video and the photograph were no longer posted on social media, but the images were reportedly still being circulated.] A comparison of a photograph of the SP provided by the facility and the photograph posted on the internet showed that the SP was the person in the photograph with the VA. The facility’s Individual Rights policy stated that the clients had the right to live without the fear of abuse, neglect, or financial exploitation. The clients also had the right to be treated with courtesy and respect and to be free from restraint. The facility’s HIPAA & Confidentiality Policy stated that the staff persons were prohibited from sharing the client’s information for any reason. Personal cell phones could not be used to take photographs or videos of the clients. Facility documentation showed that the SP 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 incidents. Relevant Rules and/or Statutes: Minnesota Statutes, section245D.04, subdivision 3, paragraph (a), clause (6), states in part that a person’s protection-related rights include the right to be treated with courtesy and respect. Minnesota Statutes, section 245D.11, subdivision 3, states in part that the license holder must establish policies and procedures that promote service recipient rights by ensuring data privacy according to the Minnesota Government Data Practice Act and the Health Insurance and Portability and Accountability Act. Conclusion: It was reported that the SP posted on social media a photograph and a video of the VA. In the photograph, the SP held his/her arm around the VA’s neck while they stood in front of a mirror while the VA was unclothed. The photograph and video were removed from the SP’s social media, but might still be available on the internet. A copy of the photograph blurred out the VA’s body, so it was unclear if the VA was unclothed in the photograph posted on social media. The SP’s actions as seen in the photo and video and posting them online, were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and were violations of Minnesota Statutes, section245D.04, subdivision 3, paragraph (a), clause (6) and Minnesota Statutes, section 245D.11, subdivision 3. However, given that there was over two years between when the incidents occurred and when the images were discovered; that the SP did not provide information; that the VA was unable to provide information; that it was unclear if the SP’s holding the VA by the neck caused physical pain or injury to the VA; and that it was unclear whether the photograph posted on social media showed the VA unclothed, there was not a preponderance of the evidence whether the SP’s actions could reasonably be expected to produce physical pain or injury or emotional distress to the VA. It was not determined whether physical and 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, but were not followed by the SP. The SP had not worked at the facility for two years. Action Taken by Department of Human Services, Office of Inspector General: Given the time frame between the incidents and the Department of Human Services’ and facility’s knowledge of the incident, a correction order was not issued for the violations outlined above.
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