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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: 1068340-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux carla.harvieux@state.mn.us Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had two unexplained “gashes” on his/her face, scratches on the left side of the face under the eye, and bruising on a large part of the forehead. Date of Incident(s): October 19, 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 November 20, 2025; from documentation at the facility; and through interviews conducted with the VA’s residential facility staff persons (P1, P2, and P4). information provided by staff persons (P3, P5, and P6) in the facility’s Internal Review, and information from two staff persons (DPS1 and DPS2) who were employed at a day program facility the VA attended. This investigator met the VA on the date of the site visit, but s/he did not provide information regarding the allegations in this report. Three residents (R1, R2, and R3) lived at the facility with the VA, but each of the residents had a developmental disability and communicated with vocalizations and gestures. Facility documentation showed that the VA was diagnosed with a developmental disability and autism, and s/he was vulnerable to all forms of maltreatment. The VA was blind and used vocalizations and gestures to communicate. The VA received daily socialization and other opportunities at the day program. The VA’s Support Plan Addendum showed that s/he had a history of physically aggressive behavior including pushing, grabbing, kicking, hitting, scratching, or pinching others. The VA might hit his/her head with his/her hands, hit his/her head against stationary objects, or “punch” his/her face. When the VA walked, s/he held staff persons’ hands or their waists, and followed them. Staff persons were to ensure that the VA’s paths were free from items that might increase his/her risk of falling. When the VA was alone, s/he might sit on the floor or couch for long periods of time, and s/he was comfortable being sedentary. If staff persons observed the VA engaged in self-injurious behavior, they might offer him/her mittens for his/her hands to protect his/her face from injury. The headboard of the VA’s bed was covered in cloth and was padded to decrease the likelihood that the VA might injure him/herself if s/he intentionally hit his/her head on it, and the floor of his/her bedroom at the facility was carpeted. The VA’s bed was low to the floor to permit the VA to get into and out of the bed unassisted by staff persons. Some of the VA’s behaviors might irritate others, and s/he could be a target of aggression from others according to the VA’s Individual Abuse Prevention Plan. The VA enjoyed getting hugs from staff persons and liked listening to music. Interviews with this investigator, facility documentation, the facility’s Internal Review, and information from the DPSs provided the following: · P1 said that s/he worked the day shift at the VA’s residential facility on October 19, 2025, and at about 8 a.m. when assisting the VA with his/her morning cares, s/he noticed that that VA had two scratches of unknown origin on his/her forehead. P1 notified P2 (a supervisory/administrative staff person) about the scratches, provided a photograph of them to P2, and completed an Incident Report (IR). On October 20, 2025, the VA went to the day program and when s/he returned, s/he had two additional injuries that looked like abrasions on his/her forehead. According to P1 and the IR s/he completed about the VA’s injuries, the two additional marks on the VA’s forehead might have been “rug burns.” P1 applied an over-the-counter topical antibiotic to the scratches and abrasions. · An October 19, 2025, photograph of the VA’s injuries from the VA’s residential facility showed that the VA had two scratches that were slightly red, but the VA did not have abrasions when the photograph was taken. An October 20, 2025, photograph taken at the VA’s day program facility showed that the VA had two red scratches that were each about an inch and a half long and two small red abrasions that were all scabbing over. One abrasion was near the VA’s hairline on the top right side of his/her head, and the second abrasion was lower on the right side of the VA’s forehead. The abrasions were irregularly shaped, but more rounded than straight. One scratch was about an inch and a half long and was near the VA’s hairline on the right side of his/her forehead and the second scratch was near the center of the VA’s forehead and was slightly shorter than the other scratch. The scratches and abrasions were about the same color red, were superficial, and were not weeping or oozing fluid. There were no visible bruises in the photographs. · A review of the VA’s Progress Notes and the residential facility’s Internal Review regarding the VA’s injuries showed that P3, P4, P5, and P6 worked shifts with the VA prior to October 19, 2025, when P1 notified P2 of the injuries and documented them. · On October 17, 2025, P3 worked with the VA from 8 p.m. to 8 a.m. the following day, and said that s/he did not observe anything unusual about the VA, who slept well during the shift and participated with his/her morning cares. · P4 worked with the VA on October 18, 2025, from 8 a.m. to 2 p.m., and did not observe any injuries to the VA. However, P4 worked the same hours with the VA the next day and noticed scratches on the VA’s forehead. · P5 worked with the VA during the evening shift on October 18, 2025, and information s/he provided in the Internal Review showed that s/he was cooking supper at the facility but observed the VA scratching at his/her forehead in the living room and “poking” at his/her eyes which caused skin irritation to the VA’s forehead. P5 stated that s/he applied over-the-counter antibiotic cream to the VA’s forehead, but did not document the incident in the VA’s Progress Notes. According to P5, the markings on the VA’s forehead did not change during his/her shift and looked the same when s/he left the facility at the end of the shift. In hindsight, P5 realized that s/he should have documented the incident in the Progress Notes and described it to the staff person who worked the next shift. · On the overnight shift on October 19, 2025, P6 worked with the VA and said that the VA slept through the night. When the VA awoke on the morning of October 20, 2025, P6 assisted the VA with his/her morning cares, but did not notice anything unusual. · DPS1 and DPS2 provided consistent information that on October 20, 2025, when the VA was at the day program, s/he had scratches and marks on his/her forehead. The day program used a van to transport the VA and other individuals to the facility from their residences to the day program. However, on the date of the site visit, the day program no longer owned the van. DPS1 and DPS2 each stated that the van had cloth seats but no carpet on its floors. The VA sat on the first bench seat on the passenger side of the van, immediately behind the front passenger seat. · On the date of the site visit, the injuries to the VA’s forehead were healed, but some slightly pink areas remained. The VA did not require medical care for the injuries to his/her forehead. The facility’s personnel and training records showed that the staff persons at the VA’s residential facility who provided information for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procedures prior to the incident. Conclusion: Information was consistent that the VA had injuries on his/her forehead of unknown origin that were observed by P1 at the VA’s residential facility on October 19, 2025, and by DPS1 and DPS2 at the VA’s day program facility on October 20, 2025. The VA had a developmental disability, was blind, and was vulnerable to all forms of maltreatment. The VA and the Rs at the residential facility communicated with vocalizations and gestures. The VA’s plans showed that the VA might push, grab, kick, hit, scratch or pinch others and might hit his/her head with his/her hands, hit his/her head against immovable objects, or hit his/her face. To minimize the likelihood that the VA might injure him/herself, the VA’s bed was low to the floor, the bed headboard was padded, and there was carpet on the bedroom floor. Staff persons might give the VA mittens if they observed him/her hitting him/herself. P3, P4, P5, and P6 provided care to the VA at the residential facility prior to October 19, 2025, when P1 noted scratches to the VA’s face and notified P2 about them. On October 20, 2025, the VA attended the day program, and DPS1 and DPS2 observed that the VA had scratches and abrasions on his/her face. According to P5, on October 18, 2025, the VA scratched at his/her forehead and poked at his/her eyes, which caused skin irritation to the VA’s forehead. P5 applied antibiotic cream to the VA’s forehead, but did not document the incident. Later, P5 realized that s/he should have documented the incident and told the staff person who worked the next shift about it. The injuries to the VA’s forehead did not require medical care and were healed on the date of the site visit. Although the VA had unexplained injuries to his/her forehead including scratches and abrasions, given that no information showed how or when the VA sustained the injuries, that there were no witnesses to the incident, and that the VA had a history of engaging in self-injurious behaviors, there was not a preponderance of the evidence whether the VA’s injuries were sustained by any means other than accidental. It was not determined whether 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). Action Taken by Facility: The facility completed an Internal Review which determined that their policies and procedures were adequate, but documentation policies and procedures were not followed. The facility thought that the VA scratched him/herself but could not determine how the VA sustained the marks that looked like “rug burns” on his/her forehead. The facility immediately retrained staff persons on its policies and procedures and stressed that staff persons should immediately notify supervisory/administrative staff persons of injuries, marks, changes in condition, and document those concerns timely and accurately. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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