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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: 1071836-H_CRS (Home and Community-Based Services-Community Residential Setting) 1071829-HCBS (Home and Community-Based Services) Investigator(s): Anna Parkin Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had an unexplained bruise on his/her left shoulder and was diagnosed with fractured clavicle. During the internal investigation, a garden took was found at the facility that possibly matched the shape of the bruise. Date of Incident(s): October 20, 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), 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 6, 2025; from documentation at the facility and medical records; and through 11 interviews conducted with a supervisory staff person (P1), seven facility staff persons (P2-P8), an administrative staff person (P11), and the VA’s guardian (G). Attempts were made via telephone and certified mail to contact and interview two staff persons (P9 and P10) but P9 and P10 did not respond to the requests. P1-P10 were all the staff persons assigned to work at the facility. The VA was diagnosed with a profound developmental disability and consistent information was provided that the VA did not verbally communicate. The VA’s bedroom was next to the VA’s bathroom and down a hall from the main area of the facility. Consistent information was provided that the VA woke up throughout the night and used the bathroom independently. Staff persons checked the cleanliness of the VA and the bathroom and assisted with clean up if needed before the VA went back to sleep. The VA generally showered in the evenings and needed staff persons assistance with showering and occasionally with getting dressed. The VA enjoyed walking around inside the facility including down in the basement and at times was alone while downstairs. According to the VA’s Action Plan, the VA had a history of self-injurious behaviors that included biting his/her own hands and slapping his/her face. If the VA appeared escalated, staff persons encouraged calming techniques including drinking tea. If the VA bit him/herself, staff persons provided first aid cares. According to the VA’s Risk Assessment Detail: · The VA did not indicate an understanding of physical abuse so would not be able to defend or remove him/herself from the situation. If staff persons observed potential abuse, they assessed the situation and intervened with verbal statements, including asking the VA to leave the area with the staff person. · The VA had a history of biting his/her hands when “anxious and/or agitated.” When staff persons observed the VA becoming anxious, they implemented proactive steps included in his/her Action Plan. If staff persons observed the VA biting his/her hands, they offered verbal redirection to prevent injuries. According to the VA’s ISSA Assessment Detail, the VA had a tendency to not walk in straight lines and bumped into obstacles. In the past, the VA fell at night when using the bathroom. P2 and progress notes written by P2 provided the following information: · On October 19, 2025, starting at 10:30 p.m., P2 worked the overnight shift and the VA was already asleep in his/her bedroom when P2 arrived. At 1:57 a.m., the VA woke to use the bathroom and urinated on him/herself while walking into the bathroom. The VA finished using the toilet and P2 assisted the VA with changing his/her clothing before returning to bed. · Later that morning, when P2 assisted the VA with getting dressed, P2 saw a bruise on the VA’s left shoulder. P2 took a picture of the bruise and “immediately” notified P1. P2 denied causing the bruise on the VA’s shoulder. A picture taken by P2 on October 20, 2025, showed a large (though unsized) dark purple bruise in the shape of two connected triangles on the VA’s left shoulder. According to the VA’s medical records, on October 22, 2025, the VA was seen at urgent care for bruising on his/her left shoulder. X-rays were taken and the VA was diagnosed with mild displaced comminuted fracture of the distal clavicle. The VA was given a sling to wear and advised to alternate Tylenol and ibuprofen as needed for pain. P11 stated on October 22, 2025, P11 went to the facility and looked around but did not see anything that could have caused the bruises. On October 24, 2025, P11 did a “more detailed” search and saw a garden tool and machete inside a closet in the staff office. The end of the garden tool was a similar shape to the bruise on the VA’s left shoulder. P11 called law enforcement and had the LEO come look at the garden tool and the picture of the bruise. The LEO spoke to P11 who showed the LEO the bruise on the VA’s left shoulder and the garden tool. The LEO was unable to say if the bruise was the shape of the garden tool or if it caused the bruise. The LEO did not complete a report or investigate further. P1 provided the following information: · On a previous unknown date, P2 sent P1 a picture of a bruise on the VA’s left shoulder. When P1 arrived at the facility later that day, the VA already left for his/her day program so s/he did not see the VA. P1 looked around the VA’s bedroom and bathroom and did not see anything that could have caused the shape of the bruise. P1 did not know there was a garden tool and machete inside the facility prior to an P11 finding them inside the closet in the staff office. · P1 worked with P3 and P4 the evening prior and P1 did not remember anything unusual about evening. P1 did not have concerns with staff persons’ interactions with the VA or other clients. P3 stated on October 19, 2025, P1, P3, and P4 worked during the day and evening. At approximately 4 p.m., P3 assisted the VA with his/her shower and at that time P3 did not see a bruise on the VA. On October 20, 2025, P1 called P3 and told P3 about the bruise. P3 did not know where the bruise came from and said that it was possible that the VA fell and injured him/herself. P3 denied doing anything that caused the bruise and did not have concerns with staff persons’ interactions with the VA or other clients. P4 stated on October 20, 2025, P3 and P4 worked in the evening after the VA returned from his/her day program. At approximately 6 p.m., P4 assisted the VA with a shower and saw the bruise on the VA’s left shoulder. After the shower, P4 asked P3 about the bruise and P3 said s/he had not seen the bruise the day prior when assisting the VA with a shower. P4 then called P1 who was already aware of the bruise. P4 stated that the VA could have possibly sustained the bruise if s/he walked into a door frame during the night when using the bathroom. P4 denied causing the bruise and did not have concerns with other staff persons’ interactions with the VA or other clients. P5-P8 each stated that they were not aware of the bruise on the VA’s left shoulder until on or after October 20, 2025. P5 stated that the VA walked around “a lot” but did not know how the VA sustained the bruise. P6 stated that the VA had a history of falling especially at night when it was dark. P7 and P8 each stated that the VA had a history of losing balance when walking and fell. P5-P8 did not have concerns with other staff persons’ interactions with the VA or other clients. The G stated that the VA was “busy” walking around the facility and possibly bumped into objects. It was a “busy” facility with the VA and multiple other clients walking around. Facility documentation showed that P1-P4 were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. P5-P8 were trained on the Reporting of Vulnerable Adults Act but were not trained on some of the VA’s plans which was a violation of Minnesota Statutes, section 245D.09, subdivision 4a, which states in part that before having unsupervised direct contact with a person served by the program, the staff person must review and receive instruction on the requirements for the person’s support plan. Conclusion: Information obtained was consistent that the evening of October 19, 2025, P3 assisted the VA with a shower and did not see a bruise on the VA. On October 20, 2025, in the morning while assisting the VA with getting dressed, P2 saw a bruise on the VA’s left shoulder and was later diagnosed with a closed fracture of distal clavicle. On October 24, 2025, P11 found a garden tool that was a similar shape to the bruise. However, the LEO could not say if the garden tool caused the bruise. In addition, P3-P8 provided information that the VA walked around at night and could have possibly bumped into something or fallen and sustained the bruise; it was not known when and where the VA sustained the injury; and P1-P8 each stated they did not have concerns with other staff persons’ interactions with the VA. Therefore, there was not a preponderance of the evidence whether a staff person caused the injury to the VA or whether the VA sustained the injury 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 and determined that policies and procedures were adequate but it was unknown if they were followed. The garden tool and machete were removed from the facility and all staff persons received additional training on the vulnerable adult policy. P5-P8 were trained on the VA’s plans. Action Taken by Department of Human Services, Office of Inspector General: On January 5, 2026, the facility was issued a Correction Order for the violation outlined above and for one person not receiving annual mandated reporter training as required.
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