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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: 1073226-H_DSF (245D-Home and Community-Based Service-Day Services Facility) 1073209-HCBS (245D-Home and Community-Based Services) Investigator(s): Samantha Wueste 651-431-2278 Suspected Maltreatment Reported: It was reported that a staff person (SP) used a “squirt bottle” to “spray” water in a vulnerable adult’s (VA’s) face to “help” the VA “stay awake” during the VA’s workday. Date of Incident(s): October 16, 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 (2): 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: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. Summary of Findings: Pertinent information was obtained during a site visit conducted on October 30, 2025; from documentation at the facility; and through seven interviews conducted with the VA, the SP, two supervisory staff persons (P1 and P2), an administrative staff person (P3), and the VA’s guardians (G1 and G2) who were also the VA’s family members. The facility was located on the main level of a two-story, industrial style building that offered day services and prevocational programming to persons diagnosed with disabilities providing job-skill training and employment opportunities working on-site or within the community. The facility consisted of offices, classrooms, a cafeteria, a kitchen, a large production floor, and a warehouse. The production floor contained various “production lines” and “workstations” where clients were able to have on-site employment in packaging, assembly and/or kitting. The facility operated Monday through Friday from 7:30 a.m. to 2 p.m. and served up to 382 clients. The VA’s diagnoses included Down syndrome, intellectual disability, and sleep apnea. The VA enjoyed spending time with his/her family members and friends, playing games, completing puzzles, listening to music, and going on vacation with G1 and G2. The VA used a walker for mobility and a lift when getting on/off a bus that transported the VA to and from the facility and the VA’s home. The VA resided with G1 and G2 and worked at the facility during the weekdays. For approximately 16 to 17 years, the VA received supports and services related to his/her diagnoses from the facility which included working on the facility’s production floor Monday through Friday from 8 a.m. to 1:15 p.m. At approximately 7:15 a.m., the VA was transported from his/her home to the VA’s day program and arrived at the facility around 7:40 a.m. While the VA was at the facility, the VA had 1:8 staffing and completed a variety of prevocational tasks with a consistent group of seven other clients who worked a “production line” together under the supervision and support of a staff person. [Note: The terms “work” and “employment” used throughout this report had distinct meanings and levels of responsibilities/expectations when referencing the “work” or “employment” of a facility staff person and the “work” or “employment” of a facility client.] The VA’s Face Sheet, Coordinated Service and Support Plan Addendum, Self-Management Assessment Plan, Preliminary Service Plan, Outcome/Goal Plan, and Individualized Abuse Prevention Plan (IAPP) updated August 28, 2025, provided the following information:
· The VA was aware of his/her sleep apnea but “refused” to sleep with a continuous positive airway pressure (CPAP) device which resulted in the VA having “interrupted” sleep cycles during the night and “often” caused the VA to “feel” “exhausted” and become “fatigued” during the day. Additionally, the VA also told facility staff persons that s/he liked to “stay up late” at night to play games or watch YouTube videos on his/her phone which also contributed to the VA “feeling” tired in the mornings and throughout the day and impacted the VA’s “stamina” and ability to “focus/stay on task.” The VA’s diagnoses and ongoing behaviors also prevented the VA from having “healthy” and “restful” sleep schedule/routines resulting in the VA “frequently” falling asleep during his/her workdays. · The VA was “very social” and enjoyed working and spending time with his/her peers at the facility which were daily activities that were “important” to the VA. The VA also wanted to “feel important” to others, to be “helpful,” for his/her work tasks to have “purpose,” and to become and “feel more independent.” Staff persons were to provide the VA with opportunities to be a “leader” within his/her work groups while staff persons modeled socially appropriate interactions and “frequently” “checked in” with the VA using “gentle” reminders or prompts to help the VA remain “alert,” “engaged,” and “on task.” The VA had weekly meetings with P1 to talk about the VA’s work at the facility during the week prior and any upcoming modifications to the VA’s work week schedule, outcomes, and/or goals. · The VA’s IAPP stated that the VA was susceptible to abuse due to an inability to identify potentially dangerous situations, lacked community orientation skills, had verbally/physically aggressive interactions with others, and did not have the ability to deal with verbally/physically aggressive persons. According to the facility’s Employee Timesheets and Personnel Files, the SP worked at the facility Monday through Friday from 7 a.m. to 2:30 p.m. with a group of eight clients, including the VA. The SP was responsible for providing his/her group of clients training, support, and supervision during the workday. P1-P3; the VA’s Case Notes (CN) completed by the SP dated October 13 to 17, 2025; the facility’s Incident Report dated October 22, 2025; and the facility’s Internal Review dated November 6, 2025, provided the following information: · The week of October 13 to 17, 2025, the VA “appeared” like s/he was not “getting enough” sleep at night, “struggled” throughout the mornings in “staying on task” or awake while trying to complete his/her work, and each morning fell asleep multiple times while sitting at his/her work station. The VA told the SP that s/he “stayed up too late” at night, was “tired,” and “could not keep [his/her] eyes open.” P1 had “recently” provided the VA with an alarm/timer to use to help the VA remain “alert” and “focused” at work, but the VA did not like using it because it was “too loud.” · On October 21, 2025, at approximately 10:40 a.m., the VA and P1 had their weekly meeting and talked about the VA’s ongoing “difficulties” in staying awake while working at the facility and discuss “any new ideas” that the VA “might want to try” to help with this. During this conversation, the VA told P1 that s/he did not like using the alarm/timer that P1 had given to the VA but liked it when the SP used a “squirt bottle” “one time” to “spray” water at the VA’s face because the VA “thought” it “felt good,” was “refreshing,” and “helped [the VA] stay awake.” When P1 asked the VA for more information, the VA said that it was the SP’s “idea,” that the SP “only” “sprayed” the VA one time, and that the incident occurred the week prior on a morning when it was “still dark” and when the VA’s eyes were “heavy.” Shortly after talking with the VA, P1 contacted and notified P2 about what the VA said. · On October 22, 2025, at approximately 8:30 a.m., P2 met and talked with the VA about the incident and the VA provided P2 with information that was consistent to the information the VA provided to P1. · Then at approximately 9:20 a.m., P2 met and talked with the SP about the incident and the SP said that s/he “sprayed” the VA in the face with water “one time in order to wake [the VA] up.” · At approximately 10:10 a.m., P2 called G1 to notify him/her about the incident but G1 told P2 that the VA already told him/her and G2 about the incident the day it occurred, October 16, 2025. G1 then said that s/he “thought” that the SP’s conduct towards the VA during this incident was “odd” and “not necessarily okay” but decided to “just let it go” without further discussion or follow-up because the VA did not “seem” to be “upset” by the SP’s actions. · After P2’s phone call with G1, P2 contacted and notified administrative staff persons about the incident and the facility conducted an internal review. · According to P3, there were not any similar incidents or concerns regarding the SP’s conduct or how the SP interacted with the VA or other clients prior to the incident. The VA provided information that was consistent to the information that the VA provided to P1, P2, G1, and G2. The VA also stated that s/he “loved all [his/her] friends” at the facility which consisted of both peers and staff persons and included the SP and P1. The VA also “loved [his/her] job” and wanted to do a “good job” when s/he worked. The VA said that staff persons were “never mean” to the VA and the VA “really liked” the SP because the SP was “nice” and “funny.” The SP provided information that was consistent to the information provided by P1-P3 and facility documentation. The SP also provided the additional information: · The SP worked with the VA at the facility for “almost” two years and worked at similar programs operated by the same license holder for approximately 18 years. At the facility, the SP worked with the “same” eight clients everyday but the prevocational tasks that the SP’s clients were assigned to complete varied. Additionally, the SP’s workstation consisted of nine desks/chairs that were positioned in a “U-shape” with the SP’s desk placed in the center and at the bottom of “the U” with four client desks on each side that were positioned “to face” the SP’s desk. The SP did not work with any additional staff persons but there were multiple lines/workstations on the production floor with “groups” of clients/staff persons similar to the SP’s that each worked on their respective prevocational tasks nearby. · At the time of the incident, the SP’s clients were “doing a lot of greeting cards” and the VA was responsible for putting the cards into envelopes and then putting the envelopes into a protective sleeve. The clients would “typically” “do cards” from approximately 8 to 10:45 a.m. and then have lunch together in the facility’s cafeteria from approximately 10:55 to 11:30 a.m. After lunch, the SP and the clients returned to their workstation on the production floor and each client resumed his/her task as assigned until about 1 pm. Then at approximately 1:15 p.m., clients left the facility. · On October 16, 2025, upon the VA’s arrival to the facility, the VA “appeared” to “need more sleep” and told the SP that s/he was “tired” because s/he “only got” around six hours of sleep that night. Shortly thereafter, the VA fell asleep at his/her desk “almost immediately” after beginning his/her work which was “recently something” the VA was having ongoing “struggles” with, “especially” during that workweek. The SP walked over to the VA’s desk and said the VA’s name multiple times while “encouraging” the VA to “wake up” to do his/her work. Within “a minute or so,” the VA woke up but had “heavy eyes” so the SP asked the VA if s/he wanted to try using the alarm/timer but the VA did not want to do so, so the SP attempted to keep the VA engaged in conversation to help keep him/her awake. · At an unknown time shortly after , as the SP continued to talk with the VA and the other clients, s/he was using a “squirt bottle” to water succulent plants that the SP kept and maintained within the workstation and noticed that the VA was falling asleep again. Then “without even thinking,” the SP “playfully” called out the VA’s name while “squirting” water at the VA who was sitting in his/her chair that was near to where the SP was standing at that time. The VA opened his/her eyes and “looked shocked” and the SP “immediately” told the VA that s/he was “sorry” and “wouldn’t do that again.” The VA then started “laughing” and told the SP that it was “okay.” However, the SP’s actions “even shocked [him/herself]” and the SP stated that s/he “only squirted” the water one time but would “never do it again” because s/he “respected” and “cared about” the VA but also did not want to “get [water] on the product” (paper greeting cards). The SP said s/he would “never” try to cause the VA “any harm” and “squirted” the water at the VA “in fun” and “not as a “punishment of any sort.” The SP also had a “good rapport” with the VA and clients and “their group” would “often” make “jokes” and “kid around” to “keep the line fun” because it was important for the clients to have workdays that were “productive but enjoyable.” · The VA did not have any injuries that resulted from the SP’s actions and the SP stated that “it wasn’t a power squirter or anything” and that one “squirt” was about “two drops” of water. Additionally, the SP was not aware that the water “squirted” the VA’s face until supervisory staff persons talked with the SP the following week and that the SP “thought” that water “squirted” the VA’s right “shoulder area.” G1 and G2 each provided information that was consistent to the information provided by P1-P3, the SP, and facility documentation. G1 and G2 also provided the additional information: · On October 16, 2025, at some point during the afternoon, after the VA returned home from the facility, the VA told G1 and G2 about the incident while talking about his/her day. However, the VA was not “upset” or “particularly bothered” by the incident, “treated it as no big deal” and “more like something that got [the VA’s] attention,” and the water “just so happened to hit [his/her] face.” · G1 and G2 each stated that s/he did not have any previous concerns involving the SP’s conduct towards the VA and that the VA “actually very much enjoyed” working with the SP, that the VA and the SP were “on very good terms,” and that it “wasn’t anything malicious.” The facility’s Employee Handbook provided the following information: · According to the Code of Conduct, staff persons had a “commitment” to the clients and “working in service to” rather than “controlling” the clients. Additionally, staff persons were to interact with clients in a professional and respectful manner at “all times.” · The policies on Basic Work Rules stated that the “misuse” of property belonging to the company, “improper” conduct, and/or “any acts” that failed to maintain an environment free of “violence, hostility […] or other types of harassment” were considered “intolerable” behaviors by staff persons at “all times” resulting in “immediate discipline, up to and including discharge.”
According to the facility’s policy on Rights of Persons Receiving Services, clients were to have services and supports provided to them that were identified in their plans in a manner that respected clients as individuals and took into consideration the person’s preferences. Clients were to be treated with courtesy and respect. Facility documentation showed that the SP and staff persons who provided information for this investigation received training on the VA’s care plans; the facility’s Employee Handbook and policies that included the Code of Conduct, Basic Work Rules, and Rights of Persons Receiving Services; and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Minnesota Rules and or Statutes Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) states in part that a person’s protection related rights includes the right to be treated with courtesy and respect. Minnesota Rules, part 9544.0060, subpart 2, item N state in part that actions or procedures prohibited from use as a substitute for a behavioral or therapeutic program to reduce or eliminate behavior, as punishment, or for staff convenience included using a spray, including water mist. Conclusion: Consistent information showed that the VA’s diagnoses sleep apnea with a history of ongoing behaviors related to the VA not maintaining “healthy” and “restful” sleep schedules/routines which then resulted in the VA “frequently” falling asleep during the day. For approximately 16 to 17 years, the VA received supports and services related to his/her diagnoses from the facility including on-site employment which consisted of a variety of prevocational tasks that were completed on the facility’s production floor with the SP and seven other clients during weekdays from approximately 8 a.m. to 1:15 p.m. The VA and the SP provided consistent information that at some point during the morning of September 16, 2025, the VA fell asleep in his/her desk chair while completing prevocational tasks and that the SP attempted to wake the VA by “calling out” the VA’s name and then “squirting” the VA one time with water from a “squirt bottle.” The SP stated s/he thought the water went over the VA’s shoulder but the VA said it hit him/her in the face. Information was consistent that VA “liked” it and told P1 “it felt good;” G1 and G2 said the VA was not “upset” or “particularly bothered” by the incident, and “treated it as no big deal;” and that there were no concerns with the SP’s interactions with the VA or any other facility clients prior to the incident. The SP stated that s/he “immediately” apologized to the VA after the incident, that s/he would “never” try to cause “harm” to the VA, and that the SP’s actions were not done “as a punishment of any sort” in responding to the VA’s behaviors. The SP’s actions of “squirting” water at the VA’s face to wake the VA was inconsistent with the VA’s care plans, the facility’s policies and procedures, and with the standards of a professional caregiver in a facility licensed by the Minnesota Department of Human Services, and were violation of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6) and Minnesota Rules, part 9544.0060, subpart 2, item N. However, given that it was one squirt of water one time, there was a preponderance of the evidence that the SP’s conduct was not repeated treatment that could reasonably be expected to produce emotional distress. It was determined emotional abuse did not occur (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 the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed by the SP. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate corrective action a correction order was not issued for the violations outlined above.
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