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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: 1100707-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070397-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler jason.pehler@state.mn.us Suspected Maltreatment Reported: It was reported a staff person (SP) hit a vulnerable adult (VA) in the shoulder. Date of Incident(s): May 23, 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 18, 2025; from documentation at the facility and law enforcement (LE) records; and through five interviews conducted with the VA, a facility staff person (P1), a facility supervisor (P2), the VA’s guardian (G), and the SP. The VA enjoyed spending time with his/her family, and made multiple trips a year to Washington to visit family. The VA liked listening to music and audio books. The VA was described as kind and positive, and it was important for other people to identify themselves to the VA because s/he was legally blind. The VA was diagnosed with developmental disabilities, epilepsy, used a wheelchair for all ambulation, and was unable to bear weight on his/her legs. The VA required assistance with all of his/her personal hygiene/cares. The VA had a history of engaging in agitated behaviors while completing non-preferred tasks. The VA understood verbal communication, but had a stutter and had difficulty pronouncing some words. All staff persons were trained on completing personal cares with the VA, as well as the VA’s preferred interactions. The VA’s Individual Abuse Prevention Plan (IAPP) showed the VA was susceptible to physical abuse, and had a history of occasional physical aggression toward staff persons. Staff persons were trained to redirect the VA, and encourage the VA to problem solve the situation, or have the VA utilize relaxation skills. P2 said the VA had informed P1 of an incident after s/he arrived at the facility. The incident occurred when the SP was assisting the VA with brushing his/her teeth. The VA told P1 the SP made a comment that made the VA mad, and the VA responded by moving his/her hand, which hit the SP, and the SP responded by hitting the VA. The alleged incident included P1 observing a red mark on the VA’s shoulder area. A photo of the VA’s shoulder was taken, however there was no observed redness or bruising within the photo. There was no information that showed the VA developed a bruise or any other injury from the alleged incident. LE Records, the facility’s Internal Review (IR), client specific plans, and interviews completed by this investigator provided the following information which was consistent: · The VA told LE that s/he was brushing his/her teeth, and got upset with the SP. The VA hit the SP in the chest, and the SP responded by hitting the VA in the shoulder area on his/her back. · P1 told LE the VA was crying when s/he arrived at the facility on May 23, 2025. P1 said after arriving the SP told him/her the VA was having behavior problems, and the VA hit the SP in the chest. P1 said the VA tried to explain the situation to P1, however the SP started “interrupting” the VA. P1 moved the VA to his/her bedroom to further discuss what had happened. P1 said the VA informed him/her the SP hit the VA on the back by his/her shoulder. P1 observed redness where the VA said the SP hit the VA. · P1 informed a on-call supervisor of the incident at approximately 8:35 a.m., on May 23, 2025. · The SP told LE the VA got mad due to a missing cup, but the SP walked away from the situation. The SP spoke with P1 prior to leaving the facility and informed P1 the VA was upset due to a missing cup. The SP was shocked s/he was accused of hitting the VA, and denied hitting the VA. The SP felt s/he was accused of the incident because there were interpersonal issues between staff persons at the facility. · This investigator attempted an interview with the SP, however the SP decided to not be interviewed and said s/he would contact an attorney. · P1 and P2 believed the VA provided information that was accurate. · The VA could get confused or be difficult to understand due to his/her speech. The VA had previously provided inaccurate information related to a romantic relationship with a person, but there was no other information that showed the VA had a history of providing inaccurate information. · LE found that there was “probably cause” and sent the case for charging but was declined and the case was closed. The G was contacted, but did not have any first-hand information regarding the allegation. The SP, P1, and P2 received training on the VA’s client specific programming, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Information showed that the VA provided consistent information that the SP was assisting the VA with brushing his/her teeth, and during the interaction the SP hit the VA on the back near his/her the shoulder. P1 said s/he arrived at the facility and the VA told P1 that the SP had hit the VA. P1 looked at the VA’s shoulder and observed a red mark. A photo was taken of the VA’s shoulder; however, the photo did not show any mark or injury. There was no information the VA developed a bruise from the alleged incident. The SP spoke with LE and denied hitting the VA. The SP said s/he was accused of the incident as there was interpersonal issues between staff persons at the facility which likely caused the allegation. Although the SP denied hitting the VA, given that the SP had reason to minimize his/her actions for fear of consequence, that P1 witnessed a red mark on the VA’s shoulder after the VA stated the SP hit him/her, that the SP attempted to interfere in the conversation between the VA and P1 regarding the incident, and that the VA provided consistent information, there was a preponderance of the evidence that the SP engaged in conduct that was not accidental which could reasonably be expected to produce pain or injury. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP received training on the Reporting of Maltreatment of vulnerable Adults Act. The SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated physical abuse for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and the mark the VA had was transitory so did not meet the definition of serious maltreatment. Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate. The facility did not complete additional staff training, and no corrective action was completed by the facility to protect the persons that received services. The report was similar to a past incident involving the VA that was investigated, but the SP was not involved. The SP no longer worked for the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.
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