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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: 1073088-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Alice Percy Minnesota Department of Human Services 651-431-3970 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had a bruise under his/her right eye and when s/he was asked about the cause, the VA stated that a staff person (SP) hit him/her. Date of Incident(s): May 14 – 15, 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 June 3, 2025; from documentation at the facility and law enforcement records; and through five interviews conducted with two facility staff persons (P1 and P2), two supervisory staff persons (P3 and P4), the SP, and the VA’s guardian (G). The VA declined an interview. The VA enjoyed smoking cigarettes, going shopping, watching television, coloring, doing beading, and collecting small stuffed animals. The VA’s diagnoses included schizoaffective disorder, chronic obstructive pulmonary disease (COPD), edema, bipolar disorder, mild cognitive impairment, anxiety, and major depressive disorder. The VA typically used a walker or a wheelchair for mobility. The VA’s Individual Abuse Prevention Plan (IAPP) stated that the VA was susceptible to physical abuse and was unable to deal with verbally or physically aggressive persons. The VA had a history of self-injurious behaviors and sometimes picked on various parts of his/her body when agitated, which might cause an injury. P1 – P4 provided the following information: · P1 stated that in approximately March 2025, the VA told him/her that the SP hit the VA. When P1 told P3, P3 said that the SP would “never do that.” P1 believed that P3 and the SP were “good friends,” which was why P3 did not do anything about what the VA said. · P1 stated that in May 2025, P1 noticed swelling beneath the VA’s right eye and the VA told P1 that the SP hit him/her after the VA hit the SP on the leg. P1 took photographs of the VA’s face. P1 sent a message to all of the staff persons asking what caused the injury to the VA’s face. P3 replied that s/he believed the VA had a sunburn. · P3 stated that one morning in May 2025, s/he worked at the facility and noticed that the VA’s eye “drooped” more than it usually did in the morning. P3 believed that it looked like the VA had a sunburn. The VA did not experience any pain when P3 applied ointment to the area under his/her eye. When s/he asked the VA about his/her eye, the VA told P3 that s/he fell out of his/her bed. A few days later, a law enforcement officer (LEO) talked to the staff persons about area around the VA’s eye. P3 had no concerns about the SP’s interactions with the VA. · P2 stated that s/he did not recall any information about a March 2025 incident where the VA had “something” under his/her eye. Recently the VA again had “something” under his/her eye and P3 told P2 that the VA fell out of his/her bed. P2 never saw the SP behave aggressively with the VA or raise his/her voice to the VA. P2 had no concerns about the SP’s interactions with the VA. The VA never told P2 that anyone hit him/her. · P4 stated that s/he was unaware of any incident in March 2025 when the VA had a scratch under his/her eye. In May 2025, the VA had a “swollen and bruised right eye.” P1 took a photograph of the VA’s eye and sent it to the other staff persons. P3 told P4 that s/he believed the VA either fell out of bed or had a sunburn and P3 did not believe that the SP hit the VA. P4 had no concerns about the SP’s interactions with the VA. · P1 stated that s/he was trained to document and report any unexplained bruise or injury to a VA. P4 stated that the staff persons were not allowed to hit the clients, even if a client first hit them. If the VA attempted to hit a staff person, the staff persons were trained to redirect the VA. P4 stated that since P1 began working at the facility, there were interpersonal conflicts between the SP and P1 and P4 told P1 to “do what you can” to work with the SP. P1 stated that the VA was “very verbal” and capable of describing events. The SP stated that s/he did not know what caused the marks under the VA’s eye in March and May 2025. The SP did not hit the VA on the face or anywhere else on his/her body. On an unknown day in May 2025 the VA fell from his/her bed, but the SP did not notice any puffiness or redness under the VA’s right eye after that. When the VA first lived at the facility, his/her behaviors were “challenging,” but for the past six months, the VA had become accustomed to living at the facility and was “sweet.” The SP believed someone “fabricated” the information that the SP caused the marks under the VA’s eye. The G stated that on the day after the incident, s/he visited the VA and the VA did not tell the G that the SP hit the VA or provide any additional information about the incident. The VA told the G that s/he “wasn’t getting along with” one of the staff persons, but did not tell the G which staff person. The G did not observe any “abnormal” bruising or marks under the VA’s eye. The G believed the VA was doing “really well” at the facility. A law enforcement officer’s (LEO’s) Incident Data stated that when the LEO asked the VA what caused the swelling under his/her right eye, the VA told the LEO that “staff hit me” on two different occasions. The facility provided three photographs of the VA that were taken on unknown dates in February and March 2025 and on May 15, 2025. The photographs from February and May 2025 each showed a swollen area under the VA’s right eye. The area was not red. The facility’s Recipient Rights policy stated that the clients had the right to be free from abuse or neglect and to be treated with courtesy and respect. Facility documentation showed that the SP, P1, P2, P3, and P4 each 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 incident. Conclusion: P1 stated that the VA told him/her that the SP hit the VA in March 2025 and in May 2025. In May 2025, the VA also told the LEO that a staff person hit him/her. Inconsistent information was provided by the other staff persons about what the VA told them about the cause of the marks under his/her right eye and none of the staff persons documented any injury to the VA’s eye. P4 stated that there were interpersonal conflicts between the SP and P1. Although P1 stated that the VA told him/her that the SP hit the VA, given that the VA did not provide information to this investigator about the incident, that the SP denied hitting the VA, that P3 stated that the VA told him/her that the VA fell out of his/her bed, and that there were no witnesses to the incident, there was not a preponderance of the evidence whether any of the SP’s actions could reasonably be expected to produce physical pain to the VA. 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 and determined that the facility’s policies were adequate, but were not followed by the staff persons. After the incident, the staff persons were retrained on the facility’s policies. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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