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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: 1070610-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Neubauer-Hoffman, Deb 651-431-6567 Suspected Maltreatment Reported: It was reported that when a vulnerable adult (VA) was engaging in behaviors, a staff person (SP) was verbally aggressive and provoked the VA by asking why the VA was treating staff persons so poorly when they were nice to him/her. The VA then spat in the SP’s face and the SP responded by slapping the VA’s face and pushing the VA against a kitchen counter. Date of Incident(s): September 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 October 8, 2025; from documentation at the facility and through nine interviews conducted with the VA, facility staff persons (the SP, P1, P2, P3 and P4), two guardians (G1 and G2), and a case manager (CM). The VA liked to play Uno, watch planes take off and land at the airport, and go out to eat at Taco Bell. The VA’s diagnoses included autism, mild intellectual disabilities, and fetal alcohol syndrome. Information showed that at the time of the incident, the VA resided at the facility for 17 days. The VA’s plans showed the following: · A Self-Management Assessment (SMA) showed that the VA engaged in “behavioral episodes” that included “physical aggression, property damage, [leaving without supervision], disrobing, and rectal digging,” and staff persons were to use therapeutic interventions and if needed, physical interventions. · The Individual Abuse Prevention Plan (IAPP) stated that the VA had 24-hour awake staffing with 1:1 staffing within eyesight in the community, and 1:1 within arm’s length when displaying signs of anxiety or when around antecedents to behaviors such as loud noises or at the time of staff shift change. If the VA placed him/herself or others in imminent risk of harm, staff persons were supposed to immediately intervene using the least restrictive technique, up to and including physical intervention. The facility was a rambler-style home in a residential neighborhood and provided crisis services for individuals with a variety of challenging behaviors including self-injurious behavior, suicidal threats or attempts, physical aggression toward other people and/or property, verbal aggression, unauthorized absences, sexual behavior, non-compliance with doctor’s orders, etc. The kitchen had an induction stove that required induction-compatible cookware (when contact was made between the special cookware and stovetop, it allowed the pan to heat the food inside the pan, resulting in the cooktop remaining cool when the pan was removed). A progress note for September 27, 2025, written by P1, provided the following information: At 7:20 p.m., the VA “initiated aggressive behaviors without warning or signs of anxiety; an additional staff (determined to be the SP and then P3) assigned to [the VA’s] roommate came up to assist, as the aggression was beyond the abilities of a single staff to contain. [The VA] tried to grab and bite staff, attempted to use the oven for self-injury, and repeated (sic) removed pants and undergarments.” The VA refused as needed medications and scheduled medications. P2, a supervisory person, provided the following information: · It was the VA’s “desire” to get to a hospital and s/he used his/her behaviors to try to achieve that goal. Staff persons were supposed to redirect the VA when s/he talked about wanting to go to the hospital. · On September 29, 2025, P2 was contacted by the Department of Human Services (DHS) and heard that the SP “slapped” the VA on September 27, 2025. That same day, the SP called P2 and told him/her about an incident that occurred on the weekend. Specifically, when the SP “heard commotion” upstairs, s/he “stepped in” to support P1. The SP said that P1 was “not trying to do anything” and was “ignoring” the VA. (According to P2, because the VA was new to the facility, there was not a “universal response” regarding the best way to address the VA’s behaviors, and the VA did not have a positive support transition plan.) When the SP attempted to get the VA down or away from the stove, the VA spit at the SP and “that was all” P2 heard about the incident at that time. · P2 then spoke to P1 who stated s/he and the SP had to put their “hands on” the VA on September 27, 2025, to get him/her down from the stove. As the VA was standing next to the kitchen counter, the VA spat saliva at the SP and P1 saw the SP “grabbing” the VA’s lower jaw. When asked how staff persons were trained to respond, P2 said they should “get distance” between themselves and the client and “block” physical aggression. · P2 was not aware of any marks or injuries to the VA from the incident. On September 29, 2025, P2 asked another staff person (P5), who worked well with the VA, to see if the VA had any concerns about the weekend. P5 talked with the VA and said s/he “did not express” any problems or concerns. · Although P2 described the SP as a “louder person,” P2 had no prior concerns regarding the SP. P1 provided the following information: · On September 27, 2025, P1 was working upstairs as the VA’s 1:1 while the SP and P3 were working downstairs with another client (C). The VA was “pulling out the stove to hurt [him/herself].” P1 said that that it was “pretty common” for the VA to pull out the stove and did so that day without “a lot of warning.” The VA sometimes did this to try to burn him/herself, smash his/her hands in the door, or climb on top of the stove to jump off it. That day, the VA “started to” climb onto the stovetop and damaged the lower drawer by stepping on it to get on top. · As the VA attempted to get on top of the stove, the SP came upstairs. P1 was not sure if s/he called for assistance or if the SP “heard commotion.” After the SP entered the kitchen, they each held one of the VA’s arms with their hands for “about 30 seconds” to keep the VA away from the stove. As they were holding the VA’s arms, the VA “spat” at the SP. P1 initially said the SP “slapped” the VA’s face and later said that was not the “most accurate description” and described how the SP “really, really forcefully” brought his/her palm to just below the VA’s mouth and used his/her thumb and index finger to hold the VA’s face for “about 15 seconds” as s/he “pushed” the VA’s back against the counter. No marks or injuries occurred; however, the SP “didn’t do that to maintain safety, [s/he] did it because [s/he] was mad.” · P1 told the SP that s/he did not want the SP’s help “if this is how you are going to behave” and requested P3 come upstairs to replace the SP. P1 believed the SP was “offended” and said s/he was “trying to help” P1. When P3 came upstairs P1 told P3 what occurred and P3 said s/he believed P1. · When P1 was asked about prior concerns with the SP, P1 said they had a “friendly relationship” and “most days get along fine.” However, during times of crisis, the SP did not “keep things calm” and s/he reacted “aggressively” and was “loud.” In addition, the SP attempted to “reason” with clients at a “level [P1] did not believe they are capable of.” · P1 did not think the VA would remember the incident and believed the VA would interpret the incident as no different from “other hundreds of holds [the VA] has been in throughout [his/her] life” and would not “grasp that hitting [him/her] is something we are not allowed to do.” The VA told this investigator that staff persons treat him/her “good.” The VA said that sometimes when s/he was angry, s/he hit staff persons, took off his/her clothing, and spat at staff persons. When asked how staff persons respond when s/he spat at them, the VA said they “walk away.” The VA denied that a facility staff person ever slapped or grabbed his/her face. P3 provided the following information about September 27, 2025: · The SP and P3 were working downstairs with the C, and P1 was upstairs with the VA who was “having a behavior.” P3 heard “rumbling,” along with “feet” and “movement” on the floor upstairs and the SP went upstairs “to help.” A short time later the SP came “rushing” downstairs and P3 observed “moisture” on the SP’s shirt. The SP said when s/he went upstairs, s/he told the VA that s/he did not understand why the VA was “harming staff when they try so hard to help [him/her].” The VA spat on the SP and the SP asked P1 for help; however, the SP said that P1 “stood back and watched” and told the SP that s/he could not help the SP if the SP was “going to act like that.” P1 called for P3 and P3 went upstairs to assist. · When P3 went upstairs s/he observed the VA was in the kitchen and had pulled the stove away from the wall. P1 was also in the kitchen “keeping an eye on” the VA. P3 said they were taught the “best approach” when clients displayed behaviors was to “keep distance.” · P1 told P3 that the SP should not have asked the VA “why” s/he was “doing this” because that was “not appropriate” verbal de-escalation. P1 also said that the SP was “too aggressive” toward the VA. (P3 did not provide further clarification.) However, P3 did not see any marks, injuries, or redness on the VA. · As the VA attempted to pull the stove further, P3 attempted to get closer but when P3 did so, the VA “tried to disrobe” so P3 held one of the VA’s hands and P1 held the other hand, and they “guided” the VA out of the kitchen to a loveseat. Each time the VA attempted to bite P1, P1 let go of the VA’s hand. Once on the loveseat, the VA continued to try to bite and kick P1, disrobe, and pull down his/her absorbent adult brief but P1 and P3 pulled the absorbent adult brief “right back up.” At one point the VA was successful disrobing/getting his/her brief off, and the SP grabbed a clean absorbent adult brief while P3 held the VA. P3 said that each time the VA calmed, and they released the VA from a manual restraint, the VA “started all over again.” The VA’s behaviors continued until unidentified overnight staff persons arrived at 10 p.m. P3 said at some point the SP left the area to complete his/her charting and P3 restrained the VA by him/herself with P1 stepping in “from time to time.” P3 said “a lot” of the VA’s behaviors were “targeted” at P1 and it was “obvious” that P1 was “afraid” of the VA. · P3 said that s/he and P1 manually held the VA three to five times for “easily 15-20 minutes each time” to “keep [the VA] seated on the loveseat” because each time s/he got up, s/he tried to disrobe and went back to “kicking and flailing and scratching.” P3 said that s/he did not complete any paperwork regarding the incident and restraint and believed P1 was responsible given P1 was assigned to work with the VA that day. · Prior to the incident, P3 believed the SP worked “very good” with the VA and the C; however, the SP sometimes talked to the clients “in a manner they do not understand.” P3 “never” saw the SP use “excessive force.” P4 was not present for the incident and provided information regarding the VA’s behaviors and how staff persons were trained to address them. Regarding the VA’s access to manipulating the stove, P4 said that staff persons were trained to prevent such instances by using their body position to stop it. If the VA was able to climb on top of the stove, staff persons should “wait it out” and offer him/her a hand to help him/her down, while not giving “excessive verbal or heightened feedback” because the VA tended to “mirror” the staff persons energy. P4 believed a “hands off” approach worked best with the VA. If the VA spat on a staff person, they were trained to “ignore” that behavior and redirect while remaining neutral. If the VA’s behaviors were not a safety issue, staff persons were trained to “give space” to the VA. However, physically raising a hand to block being spat on would be a natural reaction. P4 believed P1 had “difficulties” when the VA’s behavior “gets elevated.” The SP provided the following information: · On September 27, 2025, s/he either heard P1 call for help or heard “some noise” that resulted in the SP going upstairs to see what was happening. When the SP entered the kitchen, s/he saw the stove was unplugged and pulled out from the wall, P1 was standing on the “other side” of the stove, and the VA was near the kitchen sink, leaning on the counter. When the SP told the VA if s/he broke the stove staff persons would not be able to cook, the VA grabbed the SP’s shirt and “spit on” the SP resulting in saliva landing on the SP’s face. The SP put his/her hand up cover his/her face from any further spit. · The VA continued to hold on to the SP’s shirt and the SP asked P1 to help him/her. The SP said s/he “can’t help me if I am behaving like that.” The SP did not know what P1 meant by that comment. · When the VA let go of the SP’s shirt, the SP went downstairs and P3 went upstairs. The SP denied touching the VA’s face and said s/he responded to the incident as trained. G1 and G2 provided information together over the phone to this investigator and said that the VA had “a lot of changes in a short amount of time.” Regarding the VA’s ability to accurately report events, G1 and G2 said that when the VA was “dysregulated” s/he may not remember specifics about an incident. The CM said that in the past the VA made “false reports” surrounding incidents where s/he was manually restrained; however, that had been “several years” ago. The CM said it “surprises” him/her to hear the allegations because “things were going well” at the facility and s/he believed there were “good staff” there. The SP, P1, and P3 each had a Position Description stated they were responsible for completing required documentation including case notes, incident reports, data collection, and emergency use of controlled procedures (manual restraints). Facility information showed that staff persons were trained regarding the VA’s IAPP and SMA, resident rights, person centered planning, positive behavior supports, effective and safe engagement (EASE), and were trained regarding the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information showed that the VA’s history included “physical aggression, property damage, elopement, disrobing, and rectal digging.” Information was consistent that on September 27, 2025, the VA moved the kitchen stove and when the SP attempted to intervene and asked the VA about why s/he was acting in that manner, the VA grabbed the SP’s shirt and spat on the SP. Although P1 initially said the SP slapped the VA’s face, later P1 said that was not an accurate description of what happened. P1 then stated that the SP responded “really, really forcefully” by putting his/her hand to the VA’s face and holding the VA’s face for about 15 seconds. The SP denied touching the VA’s face and said s/he held his/her hand up to cover his/her face from the VA’s spitting, and the VA denied that any staff person ever slapped or grabbed his/her face. P1 stated that the SP pushed the VA’s back against the counter, but the SP stated that the VA already was against the counter when the VA spat at the SP. Given there were no other witnesses to the incident to confirm or dispute either account and that there were no marks or injuries on the VA, there was not a preponderance of the evidence whether all the SP’s actions were therapeutic or could reasonably be expected to produce physical pain or injury or emotional distress. It was not determined whether 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 were not followed regarding the Emergency Use of Manual Restraints (EUMR) documentation. Staff persons were retrained regarding EUMR documentation and intervention techniques. Action Taken by Department of Human Services, Office of Inspector General: On January 15, 2026, the facility was issued a Correction Order for not completing required documentation or reporting emergency use of manual restraints as required.
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