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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: 1070229-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had a bruise on his/her back and days later, had a gouge on his/her arm and cuts on his/her neck that were not treated or bandaged. Date of Incident(s): Prior to October 27, 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 3, 2025, from documentation at the facility, and through five interviews conducted with the VA’s family member/legal representative (FM1), a facility management person (P1), and three facility staff persons (P2-P4). Although this investigator contacted a staff person (SP), another facility staff person (P5), and the VA’s family member/legal representative (FM2), each did not respond to requests to be interviewed. This investigator met the VA however the VA was unable to provide information due to his/her abilities. Information from the investigation showed that during the time of the alleged incidents, the VA lived with two other clients (C1 and C2), but C2 was in the hospital at the time of the alleged incident. The facility was a split-entry styled home. The VA’s Individual Information Sheet showed that some of his/her diagnoses included autism, anxiety, seizure disorder, and a developmental disability. The VA’s support plan showed that the VA enjoyed spending time with family, attending church, and “getting out in nature.” The plan showed that the VA “gets upset and can possibly be aggressive towards the staff.” Also, the plan showed that FM1 “found mysterious bruises that appear on [the VA’s] upper arms that look like grasp marks, but that hasn’t occurred in quite some time.” A review of the VA’s file did not show that the VA had a history of engaging in self-injurious behaviors (SIB). C1’s My Plan showed that C1 had a history of engaging in physical aggression, such as hitting and kicking, toward staff and clients. Regarding the bruise discovered on October 19, 2025: FM1 provided the following information: · At about 9:15 a.m. on October 19, 2025, FM1 and FM2 went to the facility to take the VA to FM1 and FM2’s home. At the time, P3, P4, and P5 were working, and the VA was “calm.” At some point, P5 was “kind of yelling” at FM2 and said that FM2 “needed” to tell the VA to “stop hitting the staff.” P5 also told FM2 that while P4 assisted the VA with a shower that morning, the VA slapped P4. · When the VA was at FM1 and FM2’s home, FM1 assisted the VA with another shower and noticed a “bruisy looking thing” on the VA’s back that looked like “finger marks.” When FM1 asked the VA what happened, the VA was unable to tell FM1 anything about the bruise. · When FM1, FM2, and the VA returned to the facility that day at about 1:15 p.m., FM1 asked P3 and P4 to look at the VA’s back. When FM1 asked P4 about the bruise, P4 stated that when s/he assisted the VA with a shower that morning, s/he did not see the bruise and P3 said that s/he did not have knowledge of the bruise. FM1 was not certain how long the bruise was visible on the VA. There was no medical care needed. A photograph, taken by FM1 on October 19, 2025, showed what appeared to be a handprint on the VA’s back. The photograph showed red marks on the outside of each finger mark. The inside part of each finger mark was not red. P4 provided the following information: · P4 began working at about 8 a.m. on October 19, 2025. Shortly thereafter, P4 assisted the VA with taking a shower, which occurred without any issues, and dressing. However, the VA did not want to put on clean clothes and while the VA sat on his/her bed, the VA slapped P4 in the face. When P4 was asked about that, P4 said that the VA “does that” type of things to staff. P4 asked P5 to go in the VA’s bedroom and talk to the VA about wearing clean clothes. While P5 talked to the VA for a couple minutes, P4 did not hear anything that was concerning and shortly after P5 went to the VA’s bedroom, the VA wore clean clothes and had calmed. · At about 9 a.m., the VA became aggressive toward C1 and “slapping” C1’s face and throwing his/her glasses, P4 did not know why the VA became upset and P4 did not see C1 become aggressive toward the VA. · When P4 assisted the VA with taking a shower that morning, P4 did not notice any bruising or injuries on the VA’s body. Also, P4 did not recall hearing anyone yelling that day. · P4 did not do anything to the VA, who did not have a history of engaging in SIB, to cause injuries and did not have concerns related to his/her coworkers. P4 also said that although C1 had a history of engaging in physical aggression toward others, P4 did not have any knowledge that C1 was physically aggressive toward the VA. P3 provided information that was consistent with the information provided by P4 and stated that s/he did not cause any injuries to the VA. The Staff Notes for the VA, dated October 19, 2025, and written by P5 prior to the VA going to the FMs’ house, stated, “[The VA] was examined for abrasion and any marks nothing was found.” Regarding injuries discovered on the VA on October 24, 2025: FM1 provided the following additional information: · At about 8 p.m., FM1 received a phone call from P1. P1 told FM1 that when staff attempted to administer the VA’s medications that night, the VA, who was typically “very compliant” with taking medications, “wouldn’t take” the medications and “got really upset.” FM1 asked P1 if s/he and FM2 should go to the facility to assist the staff and P1 said, “Yes.” · At about 8:15 p.m., FM1 and FM2 arrived at the facility and the SP and P4 were working. While P4 sat with the VA, who did not engage in SIB, in a different room, the SP thanked FM1 for coming and said that the VA “hit me” and because the SP worked “four jobs,” the SP “can’t deal with this.” The SP then said, “I’m going to slap [him/her] back,” but then the SP said, “I’m not gonna,” and “I’m going to quit this job.” FM1 asked FM2 to talk to the SP and FM1 went to talk to the VA, who was under his/her blankets. The VA showed FM1 a “gash” on one arm, “a bunch of scratches on one arm and a scratch on his/her neck that was discovered later that night. None of the injuries appeared to have been treated and were not covered in bandages. The gash was about the size of a “nickel” and the scratches were “at least a couple inches” long. When FM1 asked the VA what happened, the VA was unable to provide information. While FM1 and FM2 were at the facility, they were told that the VA had taken his/her medications before FM1 and FM2 arrived at the facility, but FM1 did not know who provided that information.
· As a result of the injuries, and because of the October 19, 2025, incident, FM1 and FM2 decided to bring the VA to their home. FM1 provided two photographs of the VA’s injuries. One photograph, taken on an unknown date, showed a red mark with what appeared to be bruising around the mark, and the other photograph showed a round abrasion about the size of a dime that was red and appeared to be relatively new. Staff Notes for the VA showed that at 7:39 a.m. on October 24, 2025, the VA took food from the refrigerator and when asked to return the food, the VA became “aggressive and attempted to hit staff.” As a result, staff “calmly approached” the VA and “allowed” the VA to keep the food. An entry that night at 9:27 p.m. showed that P1 received a call from the SP at about 7:11 p.m. because the VA was “aggressive” and “slapped” the SP because the VA “refused” to take his/her medications. When P1 went to the facility that night, the VA had already left with FM1 and FM2. P4 did not remember the date but noticed a red mark on the VA’s right arm and a couple scratches that were one inch and three inches, but P4 did not remember where they were located. P4 did not cause the injuries and did not have knowledge of how or when they occurred. P4 did not have concerns related to the SP’s interactions with the VA and did not hear any comments from the SP that were concerning. P4 did not remember if s/he, the SP or others cleaned the injuries or whether they needed to be bandaged. P1-P3 provided information that was consistent with the information provided by P4. The facility’s Summary of Internal Review showed that the VA’s “behavior had been starting to escalate since the beginning of October [2025]. Staff report that [the VA] was becoming more aggressive.” On October 19 and 24, 2025, the VA hit staff, C1, and C2. The facility’s training records showed that all staff interviewed for this investigation, as well as P5 and the SP, were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to October 19, 2025. Conclusion: Information showed that on October 19, 2025, P4 assisted the VA with showering that morning and did not notice any injuries on the VA. When P4 asked the VA to put on clean clothes, the VA slapped P4’s face. P5 intervened and talked to the VA. A couple minutes later, the VA calmed and put on clean clothes. Shortly thereafter, FM1 and FM2 took the VA to their home and FM1 noticed a bruise that appeared to look like a handprint on the VA’s back. The VA was unable to provide information regarding what happened. When FM1 and FM2 brought the VA back to the facility later that day, FM1 asked P3 and P4 if they had knowledge related to the bruise, but they did not. At about 8 p.m. on October 24, 2025, P1 called FM1 because the VA had some behavioral concerns. As a result, FM1 and FM2 went to the facility. According to FM1, the SP thanked FM1 and FM2 for coming to the facility, but the SP was upset and said that the VA slapped the SP. The SP then said that s/he “can’t deal with this,” and “I’m going to slap [him/her] back,” but then the SP said, “I’m not gonna,” and “I’m going to quit this job.” After that comment, FM1 went to the VA’s bedroom and observed some injuries and scratches on the VA that were not cleaned or bandaged. As a result, FM1 and FM2 decided to take the VA to their home. P4 did not remember the date, but saw some injuries on the VA. P4 did not know the reason the VA had the injuries and did not remember if s/he or the SP cleaned the injuries or bandaged them. Although the VA had unexplained injuries including a mark on his/her back that appeared to be in the shape of fingers and or a hand, given that there was no information regarding how any of the injuries occurred and that the VA did not require medical care, there was not a preponderance of the evidence whether the injuries were caused by 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 interview review and determined that policies and procedures were adequate, followed, and that no additional training was needed. Action Taken by Department of Human Services, Office of Inspector General: No action taken.
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