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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: 1070580-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux carla.harvieux@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) “shoved” a vulnerable adult (VA) against a wall. The VA sustained a bump that bled on the right side of his/her head. The SP applied a cold pack to the injury and contacted a supervisory staff person (P1). Date of Incident(s): December 30, 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 January 14, 2026; from documentation at the facility; and through interviews conducted with facility staff persons (P1, P2, and the SP), and the VA’s guardian (G). This investigator met the VA, but the VA communicated with short answers and did not provide information regarding the incident. Facility documentation showed that the VA was diagnosed with a moderate/severe intellectual disability, disruptive mood dysregulation disorder, anxiety, depression, low muscle tone, and expressive language deficits. The VA had poor balance and wore orthotic inserts in his/her shoes to increase his/her stability but did not wear shoes with the inserts at the facility at night. The VA’s Individual Abuse Prevention Plan (IAPP) showed that the VA was vulnerable to physical abuse and had a history of engaging in aggressive behaviors including swinging his/her arms and hands in a downward motion, slamming his/her hands on the tops of the heads of others, grabbing, scratching, kicking and biting others, spitting at others or pulling their hair, and/or grabbing their glasses to break the glasses. The VA might not realize how his/her actions affected others. When the VA had aggressive behavior, staff persons were to use the least restrictive means of de-escalation and redirect him/her to a preferred activity, including wearing comfortable gloves or his/her favorite sunglasses, using a weighted blanket, or listening to music. When necessary, staff persons were to use Effective and Safe Engagement (EASE) techniques with the VA to physically redirect him/her, remain person centered, offer the VA an as needed medication to help him/her calm, or give the VA the opportunity to spend time in his/her bedroom if s/he chose. Approved EASE techniques included using one’s arms/hands to block hits and kicks. Indicators that the VA was becoming upset included crossing his/her arms, putting his/her hands under his/her arm pits, putting his/her hands in his/her pockets, or asking for gloves. The VA loved to eat cheeseburgers and fries. Interviews with this investigator, facility documentation, and the facility’s Internal Review, provided the following: · P1, a supervisory staff person who was on call on the date of the incident, said that the SP called him/her at about 1:30 a.m. and said that the VA had just hit and scratched the SP, which left a long bleeding cut on the SP’s arm. The SP then pushed the VA against a wall. The VA sustained a bump with a small cut that bled on the right side of his/her head. P1 told the SP to assess the VA for injuries, administer first aid, and complete an Incident Report. · The SP said that on the date of the incident, s/he was scheduled to work from 3 p.m. to 11 p.m., but the staff person who was supposed to work the awake overnight shift that began at 11 p.m. called and said that s/he could not work. The SP contacted other staff persons to ask them work the shift, but no one was willing to work it, so the SP stayed at the facility and worked the overnight shift. · During the 35-45 minutes prior to the physical contact between the SP and the VA, the VA was upset and had aggressive behavior. When the VA did not calm, the SP gave the VA an as needed medication, but the medication took time to take effect, and the VA walked back and forth in the hallway between his/her bedroom and the living room, swung his/her arms at the SP, and tried to hit him/her. The VA had been wearing gloves that s/he preferred, which helped calm him/her and protected staff persons if the VA attempted to scratch them, but while the VA was walking, s/he took off a glove or it fell from his/her hand. The SP approached the VA in the hallway between the living room and the VA’s bedroom to redirect him/her, but the VA swung his/her arms toward the SP, grabbed the SP’s arm, and scratched it with his/her fingernails. The scratch was deep, and it bled. · The SP verbally redirected the VA away from him/her, placed his/her hands out in front of him/her in an instinctive reaction in the hallway, and made contact with the VA’s chest and shoulders. The VA lost his/her balance, fell backward, hit his/her head on the hallway wall, and “collapsed down” against the wall. The VA quickly stood, and the SP asked him/her to wait in his/her bedroom while the SP cleaned the cut on his/her arm. The VA went to his/her bedroom. After the SP cleaned the blood from his/her arm and bandaged it, s/he assessed the VA for injuries and observed that the VA had a small friction burn on a raised bump on the back of the right side of his/her head near the ear. The bump was not bleeding. The SP called P1 and described the incident to him/her and completed an Incident Report. · The December 30, 2025, Incident Report the SP completed was generally consistent with information the SP provided in the interview with this investigator. However, in the Incident Report, the SP documented that s/he “pushed” the VA, but during the interview, the SP stated that s/he realized that pushed was a “poor choice of words” that had given P1 the impression that the SP shoved the VA away or “sent [him/her] flying,” which was not accurate. The SP denied that s/he pushed the VA and maintained that s/he put his/her hands in front of him/herself, made contact with the VA, and moved him/her back while maintaining contact with him/her. · In addition, the Incident Report showed that the VA told the SP that the bump hurt when touched but voiced no other concerns. The VA’s pupils were normal, and the VA had no other signs of distress. The SP gave the VA an ice pack wrapped in a towel to hold on the bump for a few minutes to decrease the swelling. A little later, the VA fell asleep in his/her bed, but the SP checked on the VA several times during the shift. The next morning, the size of the bump had decreased by half. Progress Notes for the VA provided a shortened description of the incident/injury that was consistent with the Incident Report. · The SP said that s/he was very tired when the incident occurred and probably briefly lost his/her temper but in hindsight, s/he should have “swirled” his/her arms around to keep the VA from grabbing him/her and scratching his/her arm or removed him/herself from the situation. However, the SP did not feel that s/he was in danger until the VA’s glove came off. The as needed medication s/he gave the VA prior to the incident took about 20 minutes to take effect and had not calmed the VA before the incident occurred. The physical contact between the VA and the SP occurred quickly and lasted a few seconds. · The December 2025 Medication Administration Records (MARs) for the VA showed that on the date of the incident, the SP administered a medication that helped regulate mood, behaviors, and thoughts, to the VA at 9:14 p.m. and 12:49 a.m. · The VA said that s/he liked spending time with his/her family and going into the community with them. The facility’s Use of Permitted Actions and Procedures for the VA showed that staff persons were permitted to use physical contact/instructional techniques that were the least restrictive possible to meet the VA’s needs including calming/comforting the VA by holding his/her hand. Staff persons might also assist the VA when s/he walked by supporting the VA’s elbow/arm. If the VA put him/herself in danger by walking into a busy road, or had aggressive behavior toward staff persons or other individuals, staff persons were to block or redirect the VA’s limbs without holding them or limiting the VA’s movement to interrupt the VA’s actions with less than 60 seconds of contact between staff persons and the VA. When the VA was at imminent risk of harm, staff persons were to place their open palms on the VA’s shoulders and guide him/her away from risk, explain to the VA why s/he was guided, and then document the incident in the VA’s Progress Notes. However, if the VA’s actions did not pose a serious threat to him/herself or others, staff persons were not permitted to use physical contact to redirect the VA. The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procedures prior to the incident. The SP was most recently trained on EASE on August 5 and 6, 2024, which included instruction on de-escalation and approved intervention techniques. On February 25, 2025, the SP had an EASE booster class, and P2 added that incidents were reviewed as needed at team staff meetings. Conclusion: Facility documentation showed that the VA’s diagnoses included an intellectual disability, disruptive mood dysregulation disorder, and expressive language deficits. The VA had limited verbal communication and when s/he was upset, s/he might swing his/her arms and hands. When the VA’ actions were aggressive, staff persons were to use the least restrictive means of de-escalation to redirect him/her. The VA was vulnerable to physical abuse and might not realize how his/her actions affected others. Staff persons were to use EASE techniques with the VA when necessary, remain person centered, offer the VA an as needed medication to help him/her calm, or give the VA the opportunity to spend time in his/her bedroom. Information was consistent from P1, the SP, and the Incident Report that the SP completed, that there was an incident of physical contact between the SP and the VA on December 30, 2025. P1 was on call on the date of the incident and said that the SP called him/her to say that s/he “pushed” the VA against the wall after the VA hit and scratched him/her. The SP stated that s/he worked a double shift when the incident occurred and was tired. The VA was upset and behaved aggressively prior to the incident, and the SP had given the VA an as needed medication to calm him/her, but the medication had not taken effect. The VA’s MARs showed that the SP administered the as needed medication to the VA at 9:14 p.m. and 12:49 a.m. Just before 1:30 a.m., the SP attempted to redirect with VA, who was walking in the hallway between his/her bedroom and the living room, swinging his/her arms at the SP. When the SP approached the VA, the VA grabbed the SP’s arm and scratched it, causing a long scratch on the SP’s arm that bled. The SP put his/her hands out in front of him/her to move the VA away from him/her, and made contact with the VA’s chest and shoulders. The VA lost his/her balance and fell against the wall in the hallway and hit his/her head. The VA stood unassisted, and the SP redirected the VA to his/her bedroom, then went to clean the blood from the scratch on his/her arm. After the SP cleaned and bandaged the scratch, s/he assessed the VA for injuries and observed that the VA sustained a red bump with an abrasion on the right side of his/head near his/her ear, but the SP said that the bump did not bleed. The SP gave the VA an ice pack to hold against the bump and the next morning that bump had decreased in size. Initially, the SP documented and told P1 that s/he “pushed” the VA, but later s/he realized that pushed was not an accurate description of what occurred and gave the impression that s/he shoved the VA or sent him/her “flying,” which was not accurate. The SP denied that s/he pushed the VA and stated that s/he put his/her hands in front of him/her, made contact with the VA, and moved him/her back, away from him/herself. Although the VA sustained an abrasion/bump on his/her head during the incident when the SP used his/her hands to move the VA away from him/herself, given that the VA had aggressive behavior prior to and during the incident, that the SP gave the VA an as needed medication to calm him/her prior to the incident and redirected the VA several times, that the incident occurred quickly and in a narrow space, that the SP denied pushing the VA but put his/her hands up toward the VA to create space after the SP sustained a scratch from the VA, and that no information showed that there was prolonged or continued contact between the SP and the VA, there was not a preponderance of the evidence whether any of the SP’s actions were not therapeutic or whether the VA’s injury was sustained 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 which determined that its policies and procedures were adequate but were not followed. The facility felt that the SP did not follow the VA’s plans, which showed that the VA had a history of grabbing, scratching, kicking, and hitting others, and had an as needed medication protocol in place which staff persons were expected to follow. The SP did not use approved EASE techniques when s/he attempted to block the VA’s hits. When the facility became aware of the incident, it ensured that the SP no longer worked single staffed. The SP worked only when there was another staff person on shift with him/her. On January 8, 2026, the facility retrained the SP on the VA’s plans and protocols. The incident was not similar to past events, and there were no prior concerns with the SP’s work. The SP received a “formal discipline” because s/he did not follow policies and procedures. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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