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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: 1111168-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Heidi Murphy 651-431-6544 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had bruises on his/her face, shoulder, and arm, a split lip, and a scratch on his/her back. A staff person (SP) stated the injuries were caused by the VA’s self-injurious behaviors. Date of Incident(s): July 7 to July 8, 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); and subdivision 17, paragraph (a): 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 failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on July 29, 2025; from documentation at the facility; and through seven interviews conducted with facility staff persons (the SP, P2, and P3), facility supervisory staff persons (P1, P4, and P5), and the VA’s guardian (G). Due to the VA’s abilities, the VA was not able to provide information for this investigation. The VA enjoyed van rides, playing outside with a yoga ball, and going for walks. The VA’s diagnoses included Down syndrome, congestive heart failure, and severe intellectual disabilities. The facility was a story and a half house with a finished basement, in a residential neighborhood. The VA’s time was spent on the main floor, which consisted of a kitchen, living room, dining room, bathroom, bedroom, and office. The VA’s Individual Abuse Prevention Plan stated, “[The VA] may display self-injurious behaviors which include banging head on objects, hitting/kicking objects, and/or picking at wounds and cuticles causing injury. Staff working with [the VA] observe for changes in [the VA’s] activity level or changes in [his/her] behavior in a way to assess for any injury or illness. If [the VA] is angry or upset, self-injuring [him/herself] staff will verbally or physically redirect [him/her] to safety. Staff will provide any first aid that may be needed or seek medical attention for [the VA].” “[The VA] would not be able to verbally or physically stop abuse if it were to occur, [the VA] is also non-verbal and would not be able to report abuse.” The VA’s medication documentation stated hydroxyzine HCL 50 milligram (mg) tablet was given three times daily as needed for anxiety or agitation and lorazepam 1 mg tablet was given every eight hours as needed for severe anxiety or irritation. These medications were given to the VA as needed (PRN). In the facility T-Log from July 7, 2025, at 10:12 p.m., P3 stated, “[The VA] was in the living room watching TV at 2 p.m. [The VA] then had a snack at 3:30 p.m. [The VA] then went on a van ride from 3:45 p.m. to 5 p.m. [The VA] then had supper at 6 p.m. [The VA] then started yelling and pacing around until 7:30 p.m. [The VA] went on another car ride till 8 p.m. and came home and staff assisted [the VA] with pm cares and [The VA] laid down but didn’t go to sleep.” In the facility T-Log from July 8, 2025, at 6:28 a.m., the SP stated, “[The VA] was in a high behavior when the night staff arrived. The behavior consisted of yelling, trying very hard to get into the cabinet to throw things. [S/he] tried to get into the hallway cabinet to throw towels and other supplies but staff was able to stop [him/her] from that each time. [S/he] threw clothes out of [his/her] closet, shoes. [S/he] would get even more upset when staff would use the restroom or shut the office door to take a breather. Staff did administer a 1 mg lorazepam at 3 a.m. but didn’t take effect until about 5 a.m. [The VA] was doing a crab walk all night from room to room and because of that walk, [s/he] ran into the corner of the chair [s/he] tipped over many times and received a bruise by [his/her] eye. [S/he] also has some scratches and bit the corner of [his/her] bottom lip.” In the facility T-Log from July 8, 2025, at 2:16 p.m., P2 noted, “[The VA] has been very good today, [s/he] has also been quiet and no yelling, even when staff used the bathroom [s/he] did not yell. [S/he] has been checking on staff every 5 minutes or so but no roaming today, [s/he] just goes from the couch to the kitchen or shutting the bathroom door. Few hugs also.” P2 provided the following information: · On the morning of July 8, 2025, P2 arrived at the facility around 6 a.m. and found the SP outside smoking. P2 sensed that the SP was frustrated and “maybe mad.” The SP told P2 it was a “bad night” and that the VA yelled and screamed all night until 5:30 a.m. The SP also stated the VA tripped over a chair s/he had thrown on the floor, ran into walls, and had bitten his/her lip. · P2 woke the VA up at 8 a.m. and the VA “looked like [the VA] was in a fight.” When P1 arrived, P1 looked at the VA and said, “[S/he] hit [her/him].” P2 assumed P1 was referring to the SP hitting the VA but P1 did not say a name. · P1 and P2 undressed the VA to check for additional injuries and found bruising and scratches on the VA’s back, bruises and scratches on the VA’s face, dried blood on his/her lip, and bruising on his/her arm. · The VA was quieter than normal during the day. Over the next few days, the VA hit P2 “a lot” more than normal. · P2 had never seen the VA have self-injurious behaviors. The VA had run into a wall but it was usually not that hard and was with the front of his/her shoulders. The VA did not hit him/herself. The only bruises P2 had ever seen on the VA were on the VA’s legs and that was “very rare.” · P2 was not sure how the VA would have gotten bruising on his/her face. P2 stated, “I couldn’t tell you how [the VA] got those scratches unless somebody did it. Maybe someone tried to get [the VA] to lay down,” and “It would have been frustrating to have [the VA] yelling all night.” P2 did not believe the VA’s injuries were caused by falling or running, as the VA had not had bruises or scratches before the incident or after the incident. “It was a lot of scratches and bruises for one night and never before or after.” · The VA was nonverbal and was not able to communicate how the injuries occurred. · The VA’s as needed medications (PRNs) were not working and P1 was working to find the right medications for the VA. P1 provided the following information: · P1 arrived at the facility on July 8, 2025, around 10 a.m. The VA was standing in the kitchen and put his/her arms up for a hug from P1. P1 saw a mark on the VA’s left cheek, “3-sided square” mark on the right temple, and a cut on the VA’s right lower lip and asked, “What the hell happened?” P1 hugged the VA, picked the VA up off the ground and the VA did not want to let go of P1. · P1 and P2 took the VA into the bathroom and took off the VA’s clothes and observed a scrape on the VA’s right back/shoulder area, a “good-sized” open scratch on the VA’s lower left back, and a “little bruise mark” on the VA’s right forearm. P1 was the last one to bathe the VA on July 7, 2025, at 10 a.m. and no injuries were present. P1 took photos of the injuries and contacted P4. · On July 8, 2025, the VA was “very clingy” and “looked so sad.” The VA would not let P1 or P2 out of his/her sight. When the VA did not see P1 or P2, the VA paced fast and went from room to room until P1 or P2 were found. The VA looked “somber” and did not laugh or clap all day, which s/he usually did. · P2 told P1 when P2 arrived for work on the morning of July 8, 2025, the SP was outside and was “frustrated” because the VA was “naughty” all night long and did not go to bed until 5:30 a.m. · The overnight shift was an awake position. The SP had worked with the VA since the VA moved into the facility in March of 2025. The VA did well with staff persons except the SP and one other staff person. At shift change with the SP or the other staff person, the VA screamed and threw furniture. · When the VA had behaviors, staff persons were supposed to administer hydroxyzine. If the behaviors did not improve, lorazepam was to be given three to four hours later. One staff person worked the overnight shift. Staff persons all agreed to call each other if they needed a break from the VA and another staff person would assist. Other de-escalation techniques for the VA included foot and head rubs, and van rides. · After the VA was found with injuries, the VA would not let staff persons open the living room curtains and got “very, very upset” when staff persons tried. · P1 felt the SP caused the injuries to the VA. P1 thought the SP “just snapped.” The SP was not reliable at providing information. · On previous occasions, the VA had bumped into walls and “thrown” him/herself down to his/her buttocks; however, never had any bruises or injuries before. · The SP did not give the VA lorazepam until 3 a.m. on July 8, 2025. The SP did not give the VA hydroxyzine. Hydroxyzine should have been given first and then lorazepam should have been given hours later if the behaviors did not improve. The medication protocol was practiced but was not specified in the VA’s plans. · The SP should have removed furniture if the VA was throwing it around or flipping it over. The chairs should have been moved to a bedroom, bathroom, or the kitchen. · The three-sided square mark on the VA’s face appeared to have been caused by the chair; however, P1 did not believe that the VA fell and struck his/her face on the chair. The SP told P5 that the VA fell off the couch “headfirst,” however the VA had never done that before. P3 provided the following information: · On July 8, 2025, P3 arrived at the facility at 2 p.m. P3 observed a scratch on the left side of the VA’s face, a palm sized bruise on the VA’s right cheek toward the ear, a bruise on the lower left side of the VA’s back and a bruise toward the top of the VA’s shoulder. · The VA was “really quiet” that day and had “more behaviors” than normal. · P3 was not aware of the VA having self-injurious behaviors. The VA had slapped his/her own hand when s/he was upset. The VA had “plopped down” on the floor on a previous occasion and hit the back of his/her head on a chair. The VA had run into things when the VA was “really upset” however, P3 had never seen any injuries from that behavior. The VA had moved the couch around and flipped chairs over on previous occasions. P3 stated the VA could bruise from those behaviors. P3 “had never seen any bruises or scratches on the VA before.” · When the VA threw things or flipped chairs, P3 gave the VA hydroxyzine. If the behaviors continued or worsened, lorazepam was given two hours later. If the VA was really agitated or his/her anxiety was “spiraling up,” P3 administered the lorazepam without the hydroxyzine. · The VA’s behaviors were worse in the afternoon and evening. P4 provided the following information: · On July 8, 2025, P4 was notified P2 arrived at the facility and the SP was outside and stated the VA had behaviors during the night. The SP stated the VA was awake until 3-5 a.m. P2 noticed a lot of bruising, scrapes, and scratches on the VA. P1 arrived around 10 a.m. and P2 told P1 about the injuries. · The SP was the only overnight staff and the VA was the only resident at the facility. · The VA was “timid to say the least” toward P1 on July 8, 2025, which was unusual. The VA “hung on for dear life” to P1 and was “very clingy.” P1 looked at the injuries and read the report from the SP and thought it was “suspicious.” “What we were told and what the bruises were was not lining up.” · The SP did not follow protocol and should have given the VA a PRN earlier than when the SP did at 3 a.m. · The VA had self-injurious behaviors that included hitting his/her head on the wall and hitting him/herself. The VA was known to “crab walk” on his/her hands and feet and defecate and urinate on the floors. The VA had a history of throwing him/herself to the ground and bumping into walls. · P1 helped bathe the VA and made notes of any bumps or bruises. P1 had bathed the VA on July 7, 2025, at 10 a.m. and there were no injuries on the VA. · There have never been injuries to that extent on the VA. P5 provided the following information: · P5 was contacted by P1 around 10:15-10:30 a.m. on July 8, 2025, and was “very upset.” The VA was “all bruised up and had dried blood on her.” P1 felt the SP abused the VA but did not state why s/he felt that. · The VA had a PRN for when the VA was irritable or the VA’s anxiety was elevated. On the night of the injuries, the VA was not given the PRN until 3 a.m. and the VA did not settle down until 5 a.m. · When P1 arrived at the facility on July 8, 2025, the VA “hung on really tight like [the VA] was scared.” · The VA had episodes of throwing things, urinating on the floor, and knocking things over. The VA had “a little bit” of self-injurious behaviors, however P5 had not heard of any incidents of self-injurious behaviors, except for this incident. · P5 interviewed the SP and the SP said, “I would never hurt [the VA],” and “It looks like I beat [the VA] up but I didn’t.” The SP also said s/he “should have called [P1] to get help or given the PRN sooner.” · P1 told P5 that when P2 arrived at the facility, the SP was outside and was “very stressed.” The SP told P2 that the VA had “been terrible” but did not say what went on. The VA was asleep on the couch and when the VA woke up, P2 was “shocked” when s/he saw the VA’s face. The G provided the following information: · The facility notified the G of the incident via email. · The VA had “high behavior” and in the past had self-injurious behaviors that included scratching his/her arm and chewing on fingers. The VA did not bruise easily and did not have a history of scratching his/her face. The VA was known to “throw” him/herself down to a sitting position onto his/her buttocks. The VA had disrobed and urinated and defecated on the floors. · The VA was nonverbal and “understands more than [the VA] is able to communicate.” The VA had been “thriving” at the facility. The SP provided the following information: · The day of the incident, the SP arrived at the facility at 10 p.m. P3 told the SP that the VA was not in a very good mood and did not want to go to sleep. The SP was usually able to get the VA to go to bed before midnight. The VA did his/her “regular yelling” and hand clapping. The SP tried to redirect the VA and was successful at getting the VA to sit on the couch for a while. The VA then tried to open the kitchen cabinets. Locks had recently been installed on the cabinets and the VA was unable to open them. The VA was upset and “plopped down” on the floor on his/her buttocks with his/her knees up, yelled, and looked around for something to throw. The VA tried to pull the curtains off the curtain rod and the threw a wire banana basket in the kitchen. The VA threw clothes from his/her bedroom, threw a garbage can, tipped kitchen chairs over, and pushed the chairs around. The VA was “jogging” around the house and was “frantic” s/he could not find anything to throw. The behavior was not constant and there were periods where the VA went and laid on the couch and the SP thought the VA was calmed down. The SP went to the office and monitored the VA on a monitor. The VA got up, went to the kitchen, tried to get into the cabinets, got upset, looked for something to throw, and continued on with that behavior and then sat down for a while. · The VA started “crab walking” on his/her hands and feet, with hands out in front of his/her head, facing the floor. The VA was not paying attention and bumped into the corner. The VA did not know how close the VA was to things like the tv stand or door frame. The VA started taking his/her clothes off and urinated and defecated on the floor. The VA flipped the kitchen chairs over and pushed them around. The VA walked on “all fours” and when the VA stood up, s/he scraped the side of his/her face on the bottom of the leg of one of the chairs. The SP could not say when the VA got any of the other marks or bruises. · On a previous occasion, the VA urinated on the floor and slipped in it. The SP feared the VA would urinate on the floor again and slip on it. The SP tied the drawstring on the VA’s pajama pants so the VA could not pull them off. The SP stated s/he thought it was a rights restriction due to restricting the VA’s freedom of movement, however, chose to do it and felt it was a safety issue if the VA took the pajama pants off and urinated on the floor. · When the SP “started seeing more marks” on the VA, the SP administered a PRN. The SP said that the PRN should have been given earlier. The SP “didn’t realize [the VA] had as many marks.” The SP stated s/he should have called P1 to come in. The SP could not “pinpoint exactly” how s/he tried to redirect the VA. The SP stated the VA was given a snack and the SP tried to get the VA to watch television. The SP thought about giving the VA a PRN but stated s/he tried “not to too often.” The SP gave the VA lorazepam around 3 a.m. The VA “ran around” for an hour and started to calm down around 4 a.m. The VA went to sleep at 5 a.m. · P2 arrived and the SP told P2, “I know what it looks like. It looks like we dooked it out,” and “It looks horrible.” · The SP documented the VA’s behavior in the facility’s client logs. The SP “regularly” saw bumps, bruises, and scrapes on the VA from “crab walking” and when the VA “throws [him/herself] on the floor.” · The SP denied that s/he hit the VA, grabbed the VA, or did anything that caused harm to the VA. Facility training records showed that the SP, P1, P2, P3, P4, and P5 had training on The Reporting of Maltreatment of Vulnerable Adults Act. The SP, P1, P2, and P3 were trained on the VA’s plans. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.06, subdivision 1, stated that the license holder was permitted from using adverse or deprivation procedures to eliminate behavior or for staff convenience. Conclusion: Information showed that on July 7, 2025, the SP worked at the facility from 10 p.m. to 6 a.m. on July 8, 2025. The VA had behaviors during the SP’s shift, which included “crab walking” and bumping into things, throwing things, trying to get into kitchen cabinets, and stripping clothes off to urinate and defecate on the floor. The SP gave the VA a PRN around 3 a.m. and the VA went to sleep at 5 a.m. On July 8, 2025, P2 arrived at the facility around 6 a.m. and found the SP outside. P2 sensed that the SP was “frustrated” and “maybe mad.” The SP told P2 that it was a “bad night” and that the VA “yelled and screamed all night” until 5:30 a.m. The SP told P2 that the VA had tripped over a chair that the VA had thrown on the floor, ran into walls, and had bitten his/her lip. P2 stated when the VA woke up, it looked like the VA was “in a fight.” The VA had bruises and scratches on his/her face, bruising and scratches on his/her back, bruising on his/her arm, and dried blood on his/her lip. The SP said s/he had seen bruises on the VA “regularly,” however, other staff persons interviewed had never seen bruises or other injuries, except for P2, who had seen bruises on the VA’s legs, which was “very rare.” The SP stated the VA scraped the side of his/her face on the bottom of a chair leg, which caused an injury to the VA’s face. The SP did not have any other explanations as to what caused the other injuries on the VA. In addition, the SP tied the VA’s pant drawstring so the VA could not remove his/her pants which was a violation of Minnesota Statutes, section 245D.06, subdivision 1. The SP stated that the VA should have been given a PRN earlier and that the SP should have called P1 for assistance with the VA. Although the VA had multiple scratches and bruises after the SP worked the overnight shift and the SP did not give the VA a PRN until 3 a.m., given that the SP provided consistent information that the VA had behaviors that night which could have caused injuries, that the VA would calm for some time after having behaviors and then start again so it was reasonable the SP did not give the PRN until 3 a.m., that the VA had a history of self-injurious behaviors, and that there was no further information to confirm or dispute the SP’s account, there was not a preponderance of the evidence whether the VA’s injuries were caused by the VA’s behaviors or by means other than accidental or whether there was a failure to provide the VA with reasonable and necessary care and services. It was not determined whether physical abuse or neglect 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; failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility’s Internal Review stated policies and procedures were adequate and were not followed, there was a need for additional staff training, the incident was not similar to past events with the person or services involved, and there was a need for corrective action by the facility. The SP received a Performance and Communication Tool that included disciplinary action. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The facility was not issued a Correction Order for the violations outlined in this report because they took immediate corrective action.
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